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© Mats Bojestig Jönköping county council

Making system wide improvement in health care

Mats Bojestig MDJönköping County Council, Sweden

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When results get public�


If people want take responibilty for their care �

are we with them?


Balansen förskjuts



JönköpingEksjö

Värnamo

11 municipalities330 000 inhabitants

3 hospitals 34 primary care centers35 Dental care centers

9 800 employees

Regional development support Europe

Sweden

Jönköping County

Health Care in Jönköping County


Value

Value =

Clinical result + Service quality

Resources


Improving clinical performance while reducing unnecessary cost

� Variation

� Access� Flow

� Medication� Patient safety

� System view

� Patient as a source� Prevention

� Microsystem� New thinking


Purpose

MissionBeliefsVision

System for obtaininginformation

(Customer focus)

PlanningStrategic objectives

Improvement efforts

Resources

Managingimprovement

efforts

Three basic questions

Act Plan

DoStudy

Organization viewed as a System

ProductsServicesTools

BSC: 4 perspectives

Economic

Process/Production

Learning and renewal

Patient / Customer

Normann, API


� Safe � Knowledge based

and Efficient � Patient focused � Effective � Equal � Timely

A Regulation from The Swedish National Board of Welfare

What Swedish Health Care must be


0

10

20

30

40

50

60

70

80

90

100

Worst hosptial Average hospital Best hospital

AC

E /

AA

CE

/ A

-- II

inhb

itor

at

disc

harg

e II

inhb

itor

at

disc

harg

e R

iks-

HIA

199

9

Proportion of �ideal-patients�treated at discharge

Focus on potential for improvement

Focus on poor performance

Focus on differences


Access Diagnoses, Treatment and decision support

Define ongoing relationship

Main-stay Delivery system

design

Patient´s/ Customer´s homeNursery home

SupportAdministration

Competens-development

Safety-work ITX-Ray. Lab, Rehab and care

Technical supp

DriversLearning and renewal

Planning for leading and improvement

Leadership-meetings

The surrounding world

Mission / Catch the need in society

Follow up and feedback


100% 1%Current activities

Continuous improvements

New activities

It is the Outcome of the Whole System that Counts!

Jönköping health care services

Annual Planning and Budget Document


Professional knowledge Subject knowledge Personal skill Values, ethics

Improvement knowledge Appreciation of a System Understanding variation Psychology Theory of Knowledge

Improvement of diagnostic and treatment

Improvement of processes and system in healthcare

Higher value for the patients


IT

Envir.

Adm

V a l u e f o r p a t i e n t i n c r e a s e s

AccessHow we receive

Coopera-tion/flow

Clinical improvement

work

Patient safety

Medication

Learning and innovation

Good financiesReliability

�The Diamond�: Strategic Improvement Areas

PreventionTaking care of oneself

Leadership

More than 5.000 participants in collaboratives so far


Primary Care

Speciality Care

AccessDiagnosis, treatment and

Decision Support

Support Self Management

Delivery system designDefine Ongoing

Relationship

Participate in Jonkoping Executive Meeting

Design and redesign the

system

Conduct Business Planning

Conduct Council

Business Meeting Obtain

Feedback

Conduct Research

Customers

Patients

Nursing Homes

Participate in County Council

Assembly

County Council

Learning how to betterserve our Patients

HR IT Transportation EconomyMaintain

Buildings & Security

Clinical Physiology

Public Relations

Systems View of County Council of Jonkoping

Governance for Spread of Change

Provide nursing Care

Ear, nose, throat

diseases

Surgical diseases

Women

Provide Pediatric

care

Provide Psychiatric

care

Provide care for Medical diseases

Neuromuscular

Manage Infection controll

Ophtal-mology

Derma-tology

Telephone triage

Drop in visits

Schedulingappointments

Conduct Home

care visits

Provide Palliativ

care

Provide E-learning

Conduct Surgical

care

Provide care in ER

Conduct Ambulance

care

Provide care for In patients

Provide care for

Out patients

Provide Intensiv

care

Provide Group visits

Conduct evaluation

Planning for follow up

Conduct Social planning

Provide radiology

Provide labratory

Provide Diagnoses support

Attending professional

meeting

Information system

Manage drop in visits

Support IT information

systems

20 people

SpreadAccess Collaboratives

Primary care 3 2 6 9 16 16 25 10 16 15 19

Hosp. care 2 6 3 6 26 18 16 13 9 18

in 255 team s

# of teams: 5 7 9 15 42 34 41 23 25 15 37

Team fr Jonk: 5 7 6 10 9 9 4 5 7 1 5 =75

BM1 BM2 BM3 BM4 BM5 BM6 BM7 BM8 BM9 BM1S BM10

1999 2000 2001 2002 2003 2004

1500

© Bra mottagning, Qultrurum, Margaret a S trindhal l

20 people

SpreadAccess Collabora tives

Primary care 3 2 6 9 16 16 25 10 16 15 19

Hosp. care 2 6 3 6 26 18 16 13 9 18

in 255 teams

# of teams: 5 7 9 15 42 34 41 23 25 15 37

Team fr Jonk: 5 7 6 10 9 9 4 5 7 15 =75


1999 2000 2001 2002 2003 2004

1500

© Bra mottagning, Qultrurum, Margareta Strindhall

20 people


Primary care 3 2 6 9 16 16 25 10 16 15 19

Hosp. care 2 6 3 6 26 18 16 13 9 18

in 255 teams

# of teams: 5 7 9 15 42 34 41 23 25 15 37

Team fr Jonk: 5 7 6 10 9 9 4 5 7 15 =75


1999 2000 2001 2002 2003 2004

1500

© Bra mottagning, Qult rurum, Margareta Strindhall

20 people


Primary care 3 2 6 9 16 16 25 10 16 15 19

Hosp. care 2 6 3 6 26 18 16 13 9 18

in 255 teams

Teams total: 5 7 9 15 42 34 41 23 25 15 37

Teams fr Jonk: 5 7 6 10 9 9 4 5 7 15 =75


1999 2000 2001 2002 2003 2004

1500

© Bra mottagning, Qultrurum, Margareta Strindhall


Move steps closer together Wards and open care for different

specialties are put together, everything

under one roof.

Extend the time of specialists Using the whole team. Nurses and

assistant nurses are doing things that they can do as good as or better than the doctor is.

Nurse receptions Patients in need can get an appointment

with in two-week and if it is acute during the same day.

Not regular put up patients for return-visits

Use pull system Easy for patient to contact the teams.

Always access by phone. People with need, can come directly the

same day for some teams and within two weeks for the rest of the special teams.


Patients waiting more than 90 days

0

500

1000

1500

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2500

3000

3500

jan

-07

feb

-07

ma

r-0

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ap

r-0

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jun

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au

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sep

-07

okt

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de

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jan

-08

feb

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jun

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sep

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feb

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sep

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Besök Jönköping

Operation/åtgärd Jönköping

VisitsSurgery


mar-11

Vårdutbud Organisationsenheter Totalt antal väntande

Andel som väntat längre än 90 dagar exkl PvV och MoV

Andel med PvV längre än 90 dagar

Beräkning enligt Kömiljard 2011, (Kortare än 60 dagar exkl MoV / Totalt antal exkl MoV)

Besök Kronoberg 3310 2,84% 1,96% 88,75%

Kalmar 5451 6,30% 0,79% 87,32%

Halland 6251 2,74% 1,84% 86,25%

Västra Götaland 30348 4,46% 1,82% 85,27%

Norrbotten 5563 5,66% 2,10% 84,25%

Jönköping 6347 8,62% 0,25% 82,80%

Västerbotten 6535 5,96% 2,23% 81,49%

Jämtland 2255 6,08% 2,44% 80,71%

Gävleborg 8369 6,58% 1,06% 80,61%

Skåne 38452 11,33% 0,18% 80,22%

Riket 214679 9,68% 1,88% 79,04%

Blekinge 3384 8,95% 1,86% 77,96%

Uppsala 7951 10,01% 1,72% 77,66%

Östergötland 8975 10,75% 2,40% 76,56%

Gotland 1660 15,09% 1,21% 76,48%

Stockholm 38060 14,42% 3,20% 75,58%

Västernorrland 5834 8,84% 1,78% 75,21%

Västmanland 5679 9,19% 2,72% 73,45%

Sörmland 7425 11,94% 2,80% 72,33%

Dalarna 7936 15,31% 2,45% 72,14%

Värmland 6434 10,88% 2,37% 71,24%

Örebro 8460 11,78% 4,08% 70,86%


Safe Health Care � Every time


� Safe � Knowledge based

and Efficient � Patient focused � Effective � Equal � Timely

Open comparison of Swedish 21 counties


National Med. Registers in Sweden


How do we work today? Analysis of current work/routines and make Action plans

� Show the current work Process, patient population, what personnel are involved� Use different tools : flowchart

diagram, fishbone/Ichikawa diagram, brainstorming, baseline measure � Make plans using PDSA -

test in small scale


ACE-blockers at discharge after heart infarction, age <80

Optimal level?

Measure for others and annual report

Let the teams develop their own capacities and performances

Hospitals in Sweden

Wallentin, Lindahl, UCR -04


Control Chart: Coronarangiografi 1999

Sigma level: 2

121110987654321

,8

,6

,4

,2

0,0

Coronarangiografi

UCL

Center = ,29

LCL

Wallentin, Lindahl, UCR -04


Protocol


Number of hospitals that reach 70 % following 4 or 5 out of 5 treatments

Number of hospitals that reach 70 % following 4 or 5 out of 5 treatments

0123456789

10111213141516171819

Hospitals in Control group

Hospitals participating in QUICC

0

4/5

5/5

(QUICC) Quality Improvement in Cardiac Care project


QUICC Hospital

Not QUICC Hospital

-6 -4 -2 0 2 4 6 -20 -10 0 10 20

Incidence death Incidence morbidity

*Adjustment made for all the factors in table 1

Change in Incidence (events/100 patient years)

between pre- and post interventions period


KnowledgeableCustomer knowledge - knowledge about the customer - the customer�s knowledge

Variation

Support to take care of yourself

Decision support

Care programs

- National guidelines

Reliable

- updated- safe- equipment

StandardisedSpecific


Inter Mountain Health System Inter Mountain Health System Clinical Programs System WideClinical Programs System Wide


Deaths at hospital in colon cancer

2010 2009

Number of deaths 37 38

Avoidable 1 5

Potential avoidable 4 5

Unavoidable 32 28

About 20 %

5-10/250,000

150-400 i Sweden??Professor Rune SjProfessor Rune Sjöödahldahl

UniversitetssjukhusetUniversitetssjukhusetLinkLinkööping ping

� What is the burden of the treatment today?



Andel patienter utan rapporterad postoperativ komplikationur INCA kolorektalregistret

Syd飉tra sjukv緳dsregionen 2010 - 2011

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Q1 2010 Q2 2010 Q3 2010 Q4 2010 Q1 2011 Q2 2011 Q3 2011 Q4 2011

J霵 k鞿 ing

Kalmar

珺 terg飆land

.


Koloncanceropererade patienter Landstinget i J霵k鞿 ings l鄚

2010

0

2

4

6

8

10

12

14

16

18

20

Januari Februari Mars April Maj Juni Juli Augusti September Oktober November December

anta

l

Landstinget i J霵 k鞿 ings l鄚

H鐷 landet svo

J霵 k鞿 ing svo

V酺namo svo


Ref. Bergeling, Fruberg


Esther � the patient�s focus

Lack of coordination and integration causes complicated solutions


Pat asks for primary care

InvestigatePrimary care

Treatment hospital

Diagnosis & desitionabout care/P.c.and hospital

Rehabilitation

Primary care

RehabilitationMunicipality

EstherPV-områden (6)

RehabE RMedicin

kommuner (6)

Patienttreatmentfinished

Patient withdisease

Lab

apotek

Traditional�Functional�

Patient focused�Activities and part of processes

organized after prioritized patient values�

Pharmacy6 municipalities

6 primary care units

Hospital in Eksjö

Treatment hospital


Concept of Esther

� What do you want to accomplish for Esther?

� Who needs to cooperate?� Any changes?

� Map the process of today



NowPatient enrolled

Pr. ulcer develops?

Treatment of pr. ulcer

Patient dicharged

Yes

No

Value Assessment

53 000 episods of care/year

At 8 % of episodes pressure ulcer develops

Treatment of pressure ulcers costs 7.6 million dollars

NewPat enrolled

Pr. Ulcer develops?

Treatment of pr. ulcer

Patient discharged

Yes

No

Value assessment

53 000 episodes of care/year

Assume that half of the pressure ulcers can be prevented

4 million dollars

Risk?Preventive treatment

Assessment acc. to Norton

Yes

No

ALL patients are assessed 572 000 dollars

8 % of patients has a risk acc. to assess-ment

572 000dollars

Total cost

7.6million dollars

Total cost

5million dollars

Business Case: Pressure Ulcer



I want�.

� Optimal individualized dialys treatment� Run it by my Self� Dialys 5 days a Week� Influence over my regim� Support by knowledgeble professionals



Clinical Micro-system

and arelentless ambition

to pursue perfection


� Resultattavlor i vården


The need of �hudles�

The local use of measures strengthen the learning and innovation approach


New management system

� Dialog: � Improvement ideas� Action plans� PDSA� Transparency� Learning together

Exempel


Health of the Population

Experienceof Care

Per CapitaCost

Ref: Nolan, Withington

Triple aim


Jönköping i topp i öppna jämförelser

-35

-25

-15

-5

5

15

25

35

Jönk

öping

Halland

Västman

land

Kronob

erg

Kalmar

Västerb

otten

Östergö

tland

Dalarna

Uppsala

Sörmlan

dÖrebro

Bleking

e

Västern

orrlan

d

Norrbott

en

Gävleb

org

Gotlan

d

Västra Götaland

Skåne

Värmlan

d

Stockho

lm

Jämtlan

d

Landsting

Poäng 2008

15 000

16 000

17 000

18 000

19 000

20 000

21 000

22 000Kostnad (kr/inv)

At the top in a total ranking of 101 indicatorsamong 21 HC systems in Sweden


Staff and patient satisfactionSummary7,691 answers Responsibility, competence

and authority in my work

Influence

Development in work

Work climate/participation

Our activities/operations

Psychological problems

Physical environment

Physical problems /stress

Summary: satisfaction score

Negative Positive


Swedish National Quality Award 4 times to Jönköping

� Dep. of Internal Medicine, Eksjö, 2002

� Dep. Of Technical and Support Services, Jönköping, 2004

� Dep. of Gynecology and Women�s diseases, Jönköping, 2006

� Dep of Pediatric, 2009

The Swedish Malcolm Baldridge Award


Mesosystem

Microsystem

Macrosystem

System levels


Documents

Making system wide improvement in health care€¦ · E-learning Conduct Surgical care Provide care in ER Conduct Ambulance care Provide care for In patients Provide2 ... baseline