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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
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Global Health Care Challenges Health Care costs vs BNP per capita
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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
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The Doctor. Sir Luke Fildes, 1891. The Tate Gallery, London.
Bilaga E, The Doctor. Sir Luke Fildes, The Tate Gallery, London.
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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
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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
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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
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If we want different results – we have to do things differently
Lean Method in University Hospital Setting. Helsinki April 2013
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Huddinge University Hospital 1995-2003
Lean Method in University Hospital Setting. Helsinki April 2013
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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
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Capio S:t Görans Hospital 2003-2007
Lean Method in University Hospital Setting. Helsinki April 2013
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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
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Prototype for a new work procedure
Lean Method in University Hospital Setting. Helsinki April 2013
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Karolinska University Hospital 2007-2013
Lean Method in University Hospital Setting. Helsinki April 2013
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Karolinska University Hospital 2007-2013
Solna Huddinge
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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
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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
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How should we bring about CHANGE ?
Strategic plattform Leadership Lean transformation Lean Method in University Hospital Setting. Helsinki April 2013
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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
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Where do we start to improve?
Emergency flow Imperative flow Planned flow
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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
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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
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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
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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
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How to lead the improvement work?
Lean Method in University Hospital Setting. Helsinki April 2013
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Systematic approach to establish, standardize and improve work procedures
Q 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
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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
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Waiting for doctor, 5 days a week, 08-16, in Huddinge
Mål Lean Method in University Hospital Setting. Helsinki April 2013
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Turn-around time <4hrs 5 days a week, 08-16, in whole hospital
Lean Method in University Hospital Setting. Helsinki April 2013
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% of patients in ward within 4hrs from arrival to E&A, 12 wards
Lean Method in University Hospital Setting. Helsinki April 2013
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% discharged before 12 AM,12 wards
Lean Method in University Hospital Setting. Helsinki April 2013
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Saved time in comparison with prioritized time (24h) 2010 to 2013, mars
Lean Method in University Hospital Setting. Helsinki April 2013
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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
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Three important challenges
Values Flow efficience/ resource efficiency Leadership Lean Method in University Hospital Setting. Helsinki April 2013
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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
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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
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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
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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
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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
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Flow efficiency versus resource efficiency
High Low Start Low High Flow efficiency Lean Method in University Hospital Setting. Helsinki April 2013 40
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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
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Systems for learning, continuous improvement and long-term sustainability
Q 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
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”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
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Decrease in outpatient waiting times
Totalt utbetalt vite 2012: 18,9Mkr Mål < Mål <
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Decrease in outpatient waiting times - Pediatrics 2010- 2012
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Patient satisfaction, E&A
% Lean Method in University Hospital Setting. Helsinki April 2013
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Development of leadership 2006-2011
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Bilaga E, Staff satisfaction Lean Method in University Hospital Setting. Helsinki April 2013 48
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Karolinska University Hospital – economic results 2005 - 2012
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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
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Karolinska University Hospital Stockholm Sweden
Contact information Birgir Jakobsson, CEO Karolinska University Hospital Stockholm Sweden Lean Method in University Hospital Setting. Helsinki April 2013
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