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Improving Patient Flows with an End to-End Approach

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- mikael forss - karolinska university hospital - ls10 - 02.11.10 - pptshown at the Lean Summit 2010 - New Horizons for Lean Thinking on 2/3 November 2010

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Improving Patient Flows with an End to-End Approach

  1. 1. Improving patient flows with an End-to-End approach Mikael Forss Deputy CEO Katarina Andersson, Gustav Hjelmgren, Olof Vallin Change agents, Operations Management
  2. 2. Karolinska University Hospital - one of the largest hospitals in Europe Solna Huddinge 15 miles 600 patients/day in our ED:s 1,680 beds 109,000 admissions/year 1,7 million patient visits/year County council owned • Patient care • Research • Education 15 000 employees
  3. 3. Karolinska´s main strategies Change culture and daily routine work – Create safety culture – Improve leadership Lean transformation – Process orientation and continuous improvements – Develop process oriented management – Change in culture as a result Create Academic Health Care System in Stockholm – Strengthen clinical research – Increase cooperation between health care, academy and industry 3
  4. 4. 4 Learning by doing 1993-2007 1993-1996 Outpatient Clinic Dpt of Cardiology 1997 – 2004 End-to-End approach Maternity care Top down & bottom up 2005-2007 2007 120 improvement projects TQM, Six Sigma, SPC, LEAN 85 % success rate short term Long term? Huddinge Hospital St Görans Hospital Karolinska The merger + End-to-End approach ED/Ward Top down & bottom up D a y s 2010 Delivery ward Maternity ward B A Maternity ward A A Labour painsReferral to first assessment
  5. 5. End-to-End approach ED Ward X-ray Lab X-ray Lab OR
  6. 6. Our improvement model Q Phase 1 Redesign Test/Learn Phase 2 Implementation Phase 3 Continuous Improvement Time
  7. 7. Value stream management system ED Ward X-ray Lab X-ray Lab OR Value stream leader Improvement team Value stream management team
  8. 8. Value stream management in practice
  9. 9. Current status ED* (16) Ward* (19) X-ray* (5) Lab* (2) X-ray (5) Lab (2) OR (2) 16 patient flows: •Internal Medicine •Surgery •Orthopeadics •Gynecology •Ear-Nose-Throat •Pediatrics •Infectious diseases •Neurology 95% of ED patient flow * Statistically significant changes in patient oriented measures
  10. 10. Improved ED patient experience %0 20 40 60 80 100 ”Always/Almost always” got help when needed Should ”on the whole” recommend Karolinska University Hospital ” On the whole” organised in a good way ”Acceptable” waiting time to see a physician See a physician within 30 minutes ”Acceptable” waiting time to see a physician ”On the whole” satisfied with information about the medical condition Was given information about expected waiting time to physician evaluation Cooperation of the work force ”Very good” Left the ED within 3 hours 2007 2009 All significant changes in the patient inquiry 2007 to 2009 are presented above
  11. 11. End-to-End LoS for admitted patients jul 2010 jan 2010 jul 2009 jan 2009 jul 2008 jan 2008 jul 2007 jan 2007 jul2006 jan 2006 78:00 72:00 66:00 60:00 54:00 48:00 Months (jan 2006 to oct 2010) End-to-EndLoS(mean) Before Impl ED:s Impl first ward Arrival at the ED until leaving the hospital for admitted patients 10 wards at Karolinska 24/7
  12. 12. Door-to-doctor time 30 min reduction 24/7 40 min reduction weekdays 8 AM – 4 PM 2010-42 2010-17 2009-45 2009-20 2008-47 2008-22 2007-49 2007-24 2006-51 2006-26 2006- 1 2:00 1:40 1:20 1:00 0:40 0:20 0:00 Week (2006-1 to 2010-42) Door-to-doctor(mean) Before Tests Implementation Door-to-doctor time 16 ED:s at Karolinska 24/7
  13. 13. Number of patients waiting for doctor each hour Patients Hour
  14. 14. Discharged before 12 AM 2010-18 2009-45 2009-20 2008-47 2008-22 2007-49 2007-24 2006-51 2006-26 2006- 1 40% 30% 20% 10% 0% Week (2006-1 to 2010-42) Dischargedbefore12AM(mean) Before Tests Implementation 10 wards att Karolinska University Hospital 24/7
  15. 15. X-ray total turn-around time jul-sep 2010 jan-m ar 2010 jul-sep 2009 jan-m ar 2009 jul-sep 2008 jan-m ar 2008 jul-sep 2007 jan-m ar 2007 jul-sep 2006 jan-m ar 2006 3:20 3:00 2:40 2:20 2:00 1:40 Quarter (jan 2006 - sep 2010) Totalturn-aroundtime(mean) Before Significant change Time from first doctor asessment to avaliable X-ray result CT Brain at all ED:s in Karolinska Solna 24/7
  16. 16. Clinical Chemistry total turn-around time okt2010 aug 2010 jun 2010 apr 2010 feb 2010 dec 2009 okt2009 aug 2009 jun 2009 apr 2009 feb 2009 dec 2008 okt2008 2:10 2:00 1:50 1:40 1:30 Months (oct 2008 - oct 2010) Totalturn-aroundtime(mean) Before Significant change Time from first doctor asessment to last available test-result at visit Clinical Chemistry testing at all ED:s in Karolinska Solna 24/7
  17. 17. Financial results at Karolinska 2005 - 2010
  18. 18. 18 Learning by doing 1993-2010 1993-1996 Outpatient Clinic Dpt of Cardiology 1997 – 2004 End-to-End approach Maternity care Top down & bottom up 2005-2007 2007 120 improvement projects TQM, Six Sigma, SPC, LEAN 85 % success rate short term Long term? Huddinge Hospital St Görans Hospital Karolinska The merger + Swedish LEAN Award St Görans Hospital End-to-End approach ED/Ward Top down & bottom up End-to-End approach ED/Ward Top down & bottom up Support processes D a y s 2010 Delivery ward Maternity ward B A Maternity ward A A Labour painsReferral to first assessment Sustainable improvements 2512262011761511261017651261 1:50 1:40 1:30 1:20 1:10 1:00 Week (2006 - 2010) Door-to-doctor Sustainable improvements
  19. 19. Challenges from the CEO`s perspective • Other projects • Make priorities • Continuous productivity improvement • To involve the whole organisation • Leadership • Staff involvement • The change agents risk become ”burned” • Why lean transformation – only to become more effective?
  20. 20. We have set up a value stream management system which sits parallel to our line management structure. We have also put in place supporting structures including an operations management team, improvement teams consisting of staff members, written work standards, procedures for handling deviations, visual management as well as comprehensive data support. BUT our senior management team is not yet fully committed and has not invested enough time in learning of LEAN principles and the design of a LEAN transformation. They also do not invest enough time at the ”Gemba” to learn, or in their managements team meetings to follow up. As a result, some of their direct and indirect report areas are also less than fully committed. The situation is starting to change, but we would like your advice how we can inspire and engage the senior management to get more involved and committed to make the LEAN transformation a core part of their agenda? Current problem

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