1. Birgir Jakobsson CEO Karolinska University Hospital 2013-04-25
Change management at the Karolinska University Hospital using Lean transformation
Birgir Jakobsson CEO
Karolinska University Hospital

2. Global Health Care Challenges Health Care costs vs BNP per capita

3. Insufficient clinical
Bilaga E,
Local Health Care Challenge
Some challenges are Health Care inhouse challenges
Restricting rules
and regulations
Differences in
culture and conflicts
of interests
Lack of integration
between academia,
industry
and health care
Demography
Lack of quality
Inefficiency
Rearranging our products and services into main and supporting
Do we have any additional products/services that is not yet sold
Categorise products and label: M(ain) and S(upporting)
What products and services are we NOT handling.
Accidents and
mistakes
Insufficient clinical
pathways
Lean Method in University Hospital Setting. Helsinki April 2013

4. The Doctor. Sir Luke Fildes, 1891. The Tate Gallery, London.
Bilaga E,
The Doctor. Sir Luke Fildes, The Tate Gallery, London.

5. Lean Method in University Hospital Setting. Helsinki April 2013
Bilaga E,
Source: accessed
Cardiac surgery. (Foto 2003 © Johan Garsten, Karolinska Universitetssjukhuset).
Lean Method in University Hospital Setting. Helsinki April 2013 5 5

6. Sir Cyril Chantler:
“Medicine used to be simple, ineffective, and relatively safe. Now it is complex, effective, and potentially dangerous.”
Lancet. 1999; 353(9159): , p
Lean Method in University Hospital Setting. Helsinki April 2013

7. according to Amalberti, R. Safety Science, 2001.
Bilaga E,
High Risk Organizations
Health care organizations with high risk profile
according to Amalberti, R. Safety Science, 2001.
René Amalberti är doktor inom medicin samt professor i medicin, fysiologi och ergonomi. Han har även en doktorsexamen i kognitiv psykologi. Han gick med i flygvapnet 1977 och tog där examen i flygmedicin. Mellan 1980 och 1992 arbetade han med flera stora europeiska forskningsprogram med inriktning på flyg och komplexa arbetssituationer.
Han bedriver forskning kring Patient Safety and Medical Error
tillsammans med Don Berwick, Lucian Leape och Charles Vincent i Storbritannien.
Lean Method in University Hospital Setting. Helsinki April 2013 7 7 7

8. If we want different results – we have to do things differently
Lean Method in University Hospital Setting. Helsinki April 2013

9. Huddinge University Hospital 1995-2003
Lean Method in University Hospital Setting. Helsinki April 2013

10. LEAN – a strategy for improvement
See the whole picture
Focus on patient value
Eliminate waste A B C D R
Flow-
Principles
Principles of
Improvement R A A B B C C D D
Lean Method in University Hospital Setting. Helsinki April 2013

11. Capio S:t Görans Hospital 2003-2007
Lean Method in University Hospital Setting. Helsinki April 2013

12. Lean Method in University Hospital Setting. Helsinki April 2013
Where is the waste?
Flow Chart of Emergency Surgery
2. 30 min
Parts of patient’s way through the E & A
where waste (time) can be identified and refused by us
Konsult
Rtg
Important decisions
Remiss
4. 15 min
Svar
Ord
Prover
Identified waste = 130 min
Am-
bulans
Ord
Svar
Beh
Prover
EKG
Inl. 10
Ny bed
av läkare 40
1. 55 min
Hem 29
Reg.
Kassa
SpotCheck
Triage
Disken
bed prio.
av ssk
Läkare
unders.
Leaves
E&A
Klar * *
3. 30 min *
Wait for dr 1:19
Nr of pat kl 16: 3,7
Treatment time 2:43
Nr of pat kl 16: 7,5
Lean Method in University Hospital Setting. Helsinki April 2013

13. Prototype for a new work procedure
Lean Method in University Hospital Setting. Helsinki April 2013

14. Karolinska University Hospital 2007-2013
Lean Method in University Hospital Setting. Helsinki April 2013

15. Karolinska University Hospital 2007-2013
Solna
Huddinge

16. Number of patients per hr
Bilaga E,
Patients way through E & A
Number of patients per hr
Number of patients seen by doctor per hr
Lean Method in University Hospital Setting. Helsinki April 2013

17. Patient flow to and from an in ward unit
Patients leave ward unit
Inpatients arrive to
E&A
Patients arrive to ward unit
Lean Method in University Hospital Setting. Helsinki April 2013

18. How should we bring about CHANGE ?
Strategic plattform
Leadership
Lean transformation
Lean Method in University Hospital Setting. Helsinki April 2013

19. To improve patient value
What did we want to improve?
Method (EBM)
To improve patient value
R&D
Create more effective processes with better patient flow, shorter lead times, less faults and less waste
Create effective team work with safer communication
Secure that we use effective methods (EBM)
R&D
R&D
Teamwork
Process
Staffing and rules
Lean Method in University Hospital Setting. Helsinki April 2013

20. Where do we start to improve?
Emergency flow
Imperative flow
Planned flow

21. We wanted to improve the processes with an ”end-to-end”-perspective
In which order should we improve? 1 3 2
E&A
Ward
We wanted to improve the processes with an ”end-to-end”-perspective
- but one step at a time
Lean Method in University Hospital Setting. Helsinki April 2013

22. Goals and KPI’s? E&A Ward Wait for doctor: 40 min
Through time E&A 4hrs: 90%
Nr of patients at 16 PM: 80
Patients to ward <4hrs: 90 %
Discharge before 12 AM: 33 %
Shorter AVLOS: 15 %
Lean Method in University Hospital Setting. Helsinki April 2013

23. Early involvement of support processes
Bilaga E,
Early involvement of support processes
X-rays/
lab
X-rays/
lab
E&A
Wards
Surgery
Lean Method in University Hospital Setting. Helsinki April 2013

24. How to create a mixture of top-down and bottom-up?
Bilaga E,
How to create a mixture of top-down and bottom-up?
Management
team
X-rays/
lab
X-rays/
lab
E&A
Wards
Flow leader
Improvement groups
Surgery
Lean Method in University Hospital Setting. Helsinki April 2013

25. How to lead the improvement work?
Lean Method in University Hospital Setting. Helsinki April 2013

26. Systematic approach to establish, standardize and improve work proceduresQ
FAS 1
Framtagning
och test
Tid
FAS 2
Implementering
FAS 3
Ständiga
förbättringar
FAS 0
Överenskommelse
Lean Method in University Hospital Setting. Helsinki April 2013

27. How to avoid too much focus on results?
Values
Principles
Way of working
Results
Flow rules
Flow-
principles
Go and see
Standards
Lean Method in University Hospital Setting. Helsinki April 2013

28. Waiting for doctor, 5 days a week, 08-16, in Huddinge
Mål
Lean Method in University Hospital Setting. Helsinki April 2013

29. Turn-around time <4hrs 5 days a week, 08-16, in whole hospital
Lean Method in University Hospital Setting. Helsinki April 2013

30. % of patients in ward within 4hrs from arrival to E&A, 12 wards
Lean Method in University Hospital Setting. Helsinki April 2013

31. % discharged before 12 AM,12 wards
Lean Method in University Hospital Setting. Helsinki April 2013

32. Saved time in comparison with prioritized time (24h) 2010 to 2013, mars
Lean Method in University Hospital Setting. Helsinki April 2013

33. Change of culture Future Present Values Principles Way of working
Mutual values
For whom are
we here
Wright from beginning
Standardisation
Visualisation
Silos
Hierarcies
Principles
Teamwork
Wright competence in wright time
Continuous improvement
Single work
Sequensial
Way of working
Safety
Quality
Accessability
Working environment
Efficiency
Variation
Unpredictable
Results
Predictable
Lean Method in University Hospital Setting. Helsinki April 2013
Peter Alvarsson och Anna Rasmuson

34. Three important challenges
Values Flow efficience/ resource efficiency Leadership
Lean Method in University Hospital Setting. Helsinki April 2013

35. Karolinska´s strategic plattform
Our assignment
Our Vision
Present
state
Long term strategies
Our values
Long term
goals
Använd “Visa” menyn och “sidhuvud och sidfot” för att ändra eller ta bort texten under strecket.
Lean Method in University Hospital Setting. Helsinki April 2013 35

36. Our vision The patient always first
We provide care of excellent quality and safety
We are accessible, effective and provide individual care to our patients
We are role models within R&D and education
Lean Method in University Hospital Setting. Helsinki April 2013 36

37. Our values Accountability Humanity Holistic attitude
Vi tar ansvar för våra patienter, uppgifter och varandra. We speak up if we think something is wrong.
Vi möter våra patienter och varandra med omtanke och respect. Vi utgår från varje patients unika behov.
Vi arbetar tillsammans över gränser för att ge bästa möjliga vård. We value each others work and ask for help when needed.
Lean Method in University Hospital Setting. Helsinki April 2013 37

38. Values = tools to change culture!
Performance
Använd “Visa” menyn och “sidhuvud och sidfot” för att ändra eller ta bort texten under strecket.
Attitudes and behaviour
Lean Method in University Hospital Setting. Helsinki April 2013 38 38

39. New Karolinska? Resource efficiency Flow efficiency VC/Resources
VC/Flows
Quality/Cost/Health
Quality/Cost/Health
Lean Method in University Hospital Setting. Helsinki April 2013

40. Flow efficiency versus resource efficiency
High
Low
Start
Low
High
Flow efficiency
Lean Method in University Hospital Setting. Helsinki April 2013 40

41. Lean and leadership Accountable for reaching goals
1. Esatablish best standard
2. Standard should be folowed
3. Challence and support imrovement of standard
Educates and motivates
Lean Method in University Hospital Setting. Helsinki April 2013

42. Systems for learning, continuous improvement and long-term sustainabilityQ
Patient value
Problemlösning på rätt nivå
Värdeskapande aktiviteter
Medarbetare
Ständiga förbättringar och dagligt lärande
Visualisering
1:a linjechef
Eskalering av
problem som ej kan lösas på egen nivå
Efterfråga
resultat och skapa förutsättningar
Tillämpa alla delar att börja fungera i ett system
Verksamhetschef
Divisionschef
Sjukhusdirektör
Lean Method in University Hospital Setting. Helsinki April 2013

43. ”Coninuous improvement”
Karolinska will not only focus on results – we also have to build ”Health”
Health
Results
What do we achieve, production of care at the wright quality within balanced economy
Our ability as an organisation to continously question and challenge ourselves in order to reach sustainable results
”Coninuous improvement”
Lean Method in University Hospital Setting. Helsinki April 2013
STH-LLQ MPE-budgetbalans

44. Decrease in outpatient waiting times
Totalt utbetalt vite 2012: 18,9Mkr
Mål
<
Mål
<

45. Decrease in outpatient waiting times - Pediatrics 2010- 2012

46. Patient satisfaction, E&A%
Lean Method in University Hospital Setting. Helsinki April 2013

47. Development of leadership 2006-2011
Lean Method in University Hospital Setting. Helsinki April 2013 47

48. Bilaga E,
Staff satisfaction
Lean Method in University Hospital Setting. Helsinki April 2013 48

49. Karolinska University Hospital – economic results 2005 - 2012
Mkr 49 49

50. Conclusion
Standardisation Transparence – visualisation Patient value Learning from errors Continuous improvement The developing leadership Focus on quality/cost
Lean Method in University Hospital Setting. Helsinki April 2013

51. Karolinska University Hospital Stockholm Sweden
Contact information
Birgir Jakobsson, CEO
Karolinska University Hospital
Stockholm
Sweden
Lean Method in University Hospital Setting. Helsinki April 2013