1 Collaboration between blood services and hospitals Gent, November 17, 2006 Jukka Rautonen Tiina Mäki

1

Collaboration between blood services and hospitals

Gent, November 17, 2006

Jukka RautonenTiina Mäki

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2

Conventional focus of blood service management

Donorselection

Asepticcollection

Screeningtests

Productionprocess

Adequatestorage+transp.

Usagepattern

Ris

k

Donorrecruitment

Contents of the bag, i.e.,”technical quality”

• All improvements cost money• What about the cost of stock-outs, delays,...

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3

"New" issues to consider

Donorselection

Asepticcollection

Screeningtests

Productionprocess

Adequatestorage+transp.

Usagepattern

Donorrecruitment

Purchasing Logistics

Forecasting

Ris

k

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4

Security and safety of the steps

Donorselection

Asepticcollection

Screeningtests

Productionprocess

Adequatestorage andtransp.

Usagepattern

Secu

rity

Donorrecr.

ILLUSTRATIVE

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Some neglected areas

Purchasing

Logistics

• Savings potential >10% of purchasing costs• Influence the standards• Create alliances with key suppliers

• Savings potential >10% of total supply chain costs• Do not re-invent the wheel• Do not accept the present day constraints• Create alliances with key customers

Forecasting• Required for adequate SCM• Finding the right tools may prove to be difficult• Value judgements are tricky

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Managing a blood service

• Maximize technical quality

• Everything else is secondary

• Improving quality is expensive

• Functional quality matters!

• Make informed trade-offs

• In many cases, improving quality saves money

• Re-design the value chain together with your customers

Purchasing

Logistics

Helpingcustomers

Servicemarketing

IT

HRD

Financialskills

Fromconventionalwisdom...

… to modernthinking...

… by acquiringa new skill set

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Choosing the approach

Multiple dimensions driving high value chain complexity, e.g. tough requirements on delivery times, large variety of products

The nature of the opportunities make these difficult to address by one function/ player alone

Rapid sourcing focusing on supply

side levers

Strategic sourcing focusing on supply and

demand side levers

Collaborative approach addressing the entire

value chain

Complexity of value chain/

benefits capture


benefits capture

Level of criticalness for own business, e.g. total cost impact and operational impact

Value and growth potential of joint business

Supplier strength and market share

Strategic importance of category/ supplier


Low

Medium

High

HighLow Medium

Incremental value

Vs. effo

rt to capture va

lue Mutual willingness to

participate is a prerequisite for collaboration

Mutual willingness to


Source: Booz Allen

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Blood Service view




side levers


demand side levers


value chain


benefits capture


benefits capture






Low

Medium

High

HighLow Medium

Incremental value

Vs. effo

rt to capture va





Blood bags

Office supplies

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9

Hospital view




side levers


demand side levers


value chain


benefits capture


benefits capture






Low

Medium

High

HighLow Medium

Incremental value

Vs. effo

rt to capture va





RBC

Office supplies

PlateletsFFP

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10

Cost of blood to a hospital

52,3

1,24,5

5,0 0,2

1,4

3,2

1,16,8

2,14,0

6,2

10,0

3,6

2,5

39,5

0,3

12,8

0,2

0

10

20

30

40

50

60

Materials

Blood donation

Manufacturing

Transportation

Screening tests

Custom

er service

N.A

.

N.A

.

N.A

.

BS

total cost

Transp. to hosp.

Receiving and storing

Post-storage

Distrib. to other hosp.

Hospital laboratory

Hospital adm

N.A

.

Hospital total cost

Value chain total cost

FRC Blood ServiceFRC Blood Service HospitalsHospitalsM€

39.539.576% of total 24% total

52.352.3

Source: Disguised data from a joint project by FRCBS and several hospital districts

12.812.8

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Cost of outpatient blood transfusion

Supplies

19 %

Variablelabor cost

17 %

Fixedlabor cost

18 %

Other46 %

Crémieux et al. Cost of outpatient blood transfusionin cancer patients. J Clin Oncol 2000;18:2755-2761

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Goals of the "Ketju" SCM programme

• Cost efficient and reliable supply chain of blood products controlled by FRCBS

• Compatible information systems between FRCBS and hospitals – Inventory levels in different stages of the supply chain and

traceability of blood products, taking into account the information security and privacy issues

• Deliveries that match demand: FRCBS manages the inventories also in hospitals and delivers blood according to the need – blood product availability secured

• Cost efficient, optimized, and consistent internal operations in hospitals related to the management of blood products

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Improved distribution 24/7

On-call hours

Office hours

Today In the future

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Original three-year plan

20042004 20052005 20062006 20072007

MayMay JuneJune JulyJuly Aug.Aug. Sept.Sept. Oct.Oct. Nov.Nov. Dec.Dec. 1-31-3 4-64-6 7-97-9 10-1210-12 1-31-3 4-64-6 7-97-9 10-1210-12 1-31-3 4-64-6 7-97-9 10-1210-12

Basic study and

preliminary improvement hypothesis

Basic study and

preliminary improvement hypothesis

Planning of operating

model expansion

Planning of operating

model expansion

Implementation in large hospitalsImplementation in large hospitals

Implementation in medium-sized hospitals

Implementation in medium-sized hospitals

Implementation in small hospitals

Implementation in small hospitals

Agree on pilot supply chain

project

Agree on pilot supply chain

project

Pilot 1:

TAYS and KSKS

Pilot 1:

TAYS and KSKS

Pilot 2:

HUS

Pilot 2:

HUS

TAYS: Part of Pirkanmaa Hospital District ; KSKS: Part of Central Finland Hospital District; HUS: Hospital District of Helsinki and Uusimaa

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Two pilot projects were completed

Customer + Central unitCustomer + Central unit

Order-delivery model

Inventory management

Demand forecasting

Internal transportation and deliveries to hospitals

Administrative routines

Allocation of overlapping activities between Blood Service and hospital


Inventory management

Demand forecasting

Internal transportation and deliveries to hospitals

Administrative routines

Allocation of overlapping activities between Blood Service and hospital

CustomerCustomer

Demand forecasting


Deliveries

Demand forecasting


Deliveries

Customer + ProductionCustomer + Production

Inventory management and control

Demand forecasting

Allocation of research responsibilities between Blood Service and hospitals

Deliveries

Allocation of production volumes between local units and central unit in Helsinki

Inventory management and control

Demand forecasting

Allocation of research responsibilities between Blood Service and hospitals

Deliveries

Allocation of production volumes between local units and central unit in Helsinki

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1a1a

1b1b

Pilot 1

Pilot 2

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Rigorous project management was used

Project plan and timetable

Key activitiesKey activities 3 4 5 6

Week

1 2 7 8 9

Kick-off

Description of current situation

Cost driver identification

Identification of improvement opportunities

Assessment of the size of improvement potential and prioritization

Description of new operating model

Development of implementation plan

Steering groupSteering group

Esa Leppänen/KSKS Erkki Seppälä/TAYS Jukka Rautonen/FRCBS Tiina Mäki/FRCBS Pertti Heinonen/Booz Allen

Esa Leppänen/KSKS Erkki Seppälä/TAYS Jukka Rautonen/FRCBS Tiina Mäki/FRCBS Pertti Heinonen/Booz Allen

TAYS project groupTAYS project group

Tomi Koski/TAYS Terttu Lehtiniemi/TAYS Tiina Mäki/Veripalvelu Päivi Gröndal/ FRCBS Mika Häkkänen/ FRCBS Tomi Ere/ Booz Allen

Tomi Koski/TAYS Terttu Lehtiniemi/TAYS Tiina Mäki/Veripalvelu Päivi Gröndal/ FRCBS Mika Häkkänen/ FRCBS Tomi Ere/ Booz Allen

KSKS project groupKSKS project group

Esa Leppänen/KSKS Leena-Kaisa

Mäkinen/KSKS Kaisu Känsälä/KSKS Tiina Mäki/FRCBS Päivi Gröndal/ FRCBS Mika Häkkänen/ FRCBS Tomi Ere/ Booz Allen

Esa Leppänen/KSKS Leena-Kaisa

Mäkinen/KSKS Kaisu Känsälä/KSKS Tiina Mäki/FRCBS Päivi Gröndal/ FRCBS Mika Häkkänen/ FRCBS Tomi Ere/ Booz Allen

Booz Allen support / Janne Näränen

Support resourcesSupport resources

Martti Pysäys/ KSKS Leila Ahtiala TAYS Tuija Kärppälä/TAYS Riitta Lahti/TAYS Mika Räsänen/FRCBS Outi Boman/ FRCBS Maarit Laakkonen/FRCBS

Martti Pysäys/ KSKS Leila Ahtiala TAYS Tuija Kärppälä/TAYS Riitta Lahti/TAYS Mika Räsänen/FRCBS Outi Boman/ FRCBS Maarit Laakkonen/FRCBS

Project organization & resourcesKey factsKey facts

TAYSTAYS KSKSKSKS

Part of Pirkanmaa Hospital District:– 34 member municipalities – 7 hospitals

Population in the area: 457 000 Blood product demand (10% of the

total in Finland):– Red cell demand: 9% – Platelet demand: 14%

Blood Service regional center is located in close proximity to the main hospital





Part of Central Finland Hospital District:

– 30 member municipalities – 7 hospitals



Blood Service does not have regional centre in the city of the main hospital






Key factsKey facts

TAYSTAYS KSKSKSKS



















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Roll-out – current status

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1a1a

1b1b

Central hospitals (8-10,000 RBC/year)

• Order placement and fulfilment practices

University hospitals(15-40,000 RBC/year)

• Consolidated warehousing (by FRC) within hospital premises

• VMI? Outsourced blood bank?

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Key lessons learned

• Costs are decreasing and quality is increasing!• Must use top level SCM expertise• Outsourcing (parts of) logistics may be necessary• Hospitals have been extremely positive – current

bottleneck is our own resources• Need to tailor the partnership agenda• IT systems are the biggest challenge – how to make three

(or more) systems talk with each other. This will introduce at least a 1-2 year delay to the program

• Probably must modify our own organisational structure

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Use of red cells in primary hip replacement operations in Finnish hospitals (2002)

Red

cell

un

its/

pati

en

t over 7-fold difference ???

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What was done since 2002:

– a database was created of transfusions in Finland– ~70% of Finnish blood product use is currently in the

database – data is updated 2x/year

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All major (university-linked) hospitals are included + 5 other central hospitals, more coming

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What data are collected from where?

Only existing hospital databases are utilized administrative registers laboratory databases hospital blood bank registers FRC Blood Service database (Progesa)

The data collected: surgical operations main diagnoses selected laboratory results the blood products given

The patient identification information (unique social

security number is coded)

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Selection of the patients included in the database

Included are

patients who have blood orders

AND patients undergone surgical operations

AND patients with selected diagnosis (hematological, pregnancy or childbirth, trauma)

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Optimal Use of

Blood, what do we do with all that data?

Reports published in web (by BS) Benchmarking

meetings (arranged by BS; doctors, nurses)

Hospitals' own analysts (trained by BS)

Publications, theses Recommendations,

guidelines?

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Standard reports available in internet

published on Blood Service home page (www.bts.redcross.fi) (some examples in english as well)

Overall information on blood usage

Patient group comparisons between hospitals

TURPHoitojaksojen osuus, joilla annettu punasoluja

0

5

10

15

20

25

30

%

2002

2003

2004

2005

Transurethral prostathectomy, percentage of patients receiving red cells

http://www.bts.redcross.fi/

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Benchmarking days

• Personnel teams (doctors, nurses) treating, e.g., hip operations or cardiac surgery or childbirths etc. from different hospitals are invited

• The groups look for differences in their practices with a background list, most important differences are named

• The actions to be taken are agreed

• A follow-up session is organized 1.5 years later

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Preoperative tests (blood counts etc), how controlled?Treatment of preoperative anaemiaAmount of blood reserved for routine coronary surgeryHb-triggers for red cell transfusion (preop., periop., postop.)B-Trom triggers for platelet transfusionFFP-transfusion triggersOperative techniquesAnesthesia-techniques, hypothermiaUse of blood savers/washersHow to reverse warfarin-treatment?Use of haemosthatic medicationLaboratory follow-upHospital guidelines on transfusionPatient's opinion (refuse/demand) on transfusionPatient discharge criteria

An example of a background list from heart surgery meeting

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Use of the database by hospitals

• Hospitals are given an internet-connection to their own data

• One person / hospital is trained to use the analysis-tool (Ecomed)

• She/he can further analyse hospital's own data

own reports for personnel

recommendations

publications, thesis etc

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What happened in the "high use" hospital

• Routine blood order for hip replacement was reduced to 2 units of RBC

• Preoperative iron was recommended • Restrictive fluid consumption preoperatively

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Mean use of red cells in primary hip replacement HOW DOES IT LOOK LIKE NOW?

0

0,5

1

1,5

2

2,5

3

3,5

4

4,5

5

Yksik

kö

ä

2002200320042005

Difference reduced to 2.4 fold

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16 %

16 %

13 %

12 %

11 %

32 %

Verenkiertoelintensairaudet

Veren pahanlaatuisetkasvaimet

Vammat,myrkytykset jaulk.syyt

Muut pahan- jahyvänlaatuiset kasvaimet

Ruuansulatuselintensairaudet

Muut diagnoosit

Where does all the blood go anyway?Use of blood according to the main diagnosis

Diseases of the circulatory system B

Malignant diseases of the blood B

Injury and poisoning

Other neoplasms

Diseases of the digestive system B

Other

B=Benchmarking day organized

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28 %

20 %

18 %

9 %

4 %

4 %

17 %Tuki- ja liikuntaelimet

Ruuansulatuskanava ja senoheiselimet

Sydämen ja rintaontelon suuretsuonet

Verisuonet ja imusuonijärjestelmät

Rintaontelon muut osat

Virtsatiet, miehen sukupuolielimet javatsaontelon takaiset kudokset

Muut toimenpiteet

Use of blood according to the surgical operation

Musculoskeletal system B

Digestive system and spleen B

Heart and thoracic vessels B

Peripheral vessels

Other thoracal operations

Urinary systems, male genitals, retroperitoneal

other (gynecology etc) B

B=Benchmarking day organized

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Sex and age of transfused patients

0

2000

4000

6000

8000

10000

12000

Alle 17v 17v-30v 31v-44v 45v-64v 65v-79v yli 80v

Naiset

Miehet

A benchmarking day of blood use in elderly is under consideration

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Should recommendations be given?

• IDEA: Experts from hospitals gather, discuss, write and publish recommendations

• FRC Blood Service could bring the experts together, but we would avoid making clinical recommendations

• Under consideration

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Challenges

• Taking the project inside the hospitals • (Surgeons etc.)• How to study the clinical OPTIMUM?• How to avoid overreacting and too restrictive

attitudes towards blood use?

Documents

1 Collaboration between blood services and hospitals Gent, November 17, 2006 Jukka Rautonen Tiina Mäki