X-traordinary at Södra Älvsborgs Hospital

X-traordinary at Södra Älvsborgs Hospital - Going beyond ready-made solutions Good medical outcomes with the SÄH process model Green Cross a method for reducing medical injuries Page 4 Page 7 Being as visible and present as possible as a manager should be a consistent feature at every level in the organisation Staff-initiated improvement work a key feature of the X-Matrix at SÄH Page 2 Walk and Talk meetings more time spent in the departments promotes better leadership Page 3 Diabetes process results in fewer complications for the patient and use of cutting-edge technology Page 5 HIFA high-intensity improvement programme builds momentum Page 6

I would like to extend a warm welcome to Södra Älvsborg Hospital, which over the years has been characterised by development work in various forms although with a consistent theme. Organisational reviews, the LIFT programme and process orientation in medical development are the tools that have laid the foundation for the model that is being used today the X-Matrix. What these methods have in common is a clear management and control perspective coupled with the ambition to involve all members of staff in the improvement process. During the study visits you will have the opportunity to find out more about our management system, the X-Matrix, the development of care processes and how we lead and control them, and the high-intensity improvement work that is taking place. You will also hear about the Green Cross patient safety tool and patient involvement in both the care process and operational improvement. I hope that you will feel inspired by the study visits, during which you will see first-rate examples of development work by management and co-workers. We look forward to meeting you and to sharing our experience. Learning from each other is an important and fruitful means of development. Thomas Wallén, Chief Executive Officer Staff-initiated improvement work a key feature of the X-Matrix at SÄH SÄH uses the X-Matrix which is unique in Swedish healthcare to present the hospital s operational plan. The X-Matrix demonstrates in visual terms the link between SÄH s focal areas, goals and improvement programmes. The strategic support employed to achieve the goals takes the form of two improvement programmes linked directly to care provision and the development of working methods for inpatient and outpatient care. The metrics are followed up and discussed on a monthly basis using the hospital management s control board. The X-Matrix is used at all departments and units. Once the overall plans have been decided, the different operating areas break down the goals and adapt them to their work at the unit level. In effect each area creates its own X-Matrix. The metrics are followed up on a regular basis. The X-Matrix is a simple and easily understood means of following up the department s common goals, which we then break down into a series of objectives at the unit level, said Stefan Magnusson, Medical Director at the Orthopaedic Department. By breaking down the objectives to the unit level and conducting regular follow-ups, it is possible for staff to see the significance of the work they do and the impact it is having on How well do improvement programmes deliver in relation to the metrics? IMPROVEMENT PROGRAMMES How much do the improvement programmes contribute to our success in the focal areas? departmental goals. When objectives are achieved, high-quality patient care can be delivered with good access to healthcare and increased patient safety. For the staff, the working environment is improved as operational mix-ups and stoppages are reduced. OPERATIONAL PLAN 2016 GOALS AND METRICS SÄH my hospital FOCAL AREAS How do your activities contribute to achieving the aims and metrics? CLINICS AND UNITS How does your unit work in relation to the focal areas? 2 1998 1999 2000 Organisational review Policy Document Operational Development Unit Quality Adviser Training

Walk and Talk meetings more time spent in the departments promotes better leadership The underlying concept behind Walk and Talk can be described in simple terms as more time spent in the departments and less time in meetings. The aim is for managers and co-workers to share the same first-hand information about the work that is being done as well as the outcomes. It is important not to lead from the office but to maintain a physical and mental presence, said Thomas Wallén, Chief Executive Officer. You need to have a sense of awareness, be attentive and feel the atmosphere. It is popular nowadays to use the expression management by and I feel that management by presence describes very well how I view SÄH leadership. This is extremely valuable as it gives me direct feedback on whether the decisions reached by the hospital management are guiding us in the right direction. We also receive input from the staff prior to making decisions. Before saying any more, I would like to state categorically that we are not out to check how the managers are discharging their duties. It is crucial that we work together to identify opportunities to make improvements in the system, concludes Thomas Wallén. Being as visible and present as possible as a manager should be a consistent feature at every level in the organisation. Walk and Talk has therefore become a permanent item on the agenda at hospital management meetings. All managers attend the meetings and afterwards they come together to discuss what has emerged. This includes proposals about what could be improved and how the goals at the unit, the department or the hospital as a whole can be achieved. The staff have up to now taken a positive view of the Walk and Talk visits and they feel that on-site dialogue with members of the hospital management is certainly a move in the right direction. Daily improvement work The interest shown by the members of the hospital management in what we are doing and in our improvement work, and the fact that they are listening to our thoughts and ideas, are reflected very clearly in the team spirit at the hospital, said Hanna Hermansson, assistant nurse at the medical rehabilitation unit. Daily improvement work, basic hygiene rules and the Green Cross method are all included in SÄH standards. These three concepts are considered vitally important and will be introduced in all departments. - Increased patient benefit and safety - Transform problems into improvements - Reduce the number of mix-ups and eliminate time-stealers from the work process - Benefit from the collective involvement of the group - Greater job satisfaction 2001 2002 2003 Lean introduced Breakthrough project well received Vision document, SÄH model LIFT Leading the way in improvement and application LIFT guides Quality leaders in each department 3

Good medical outcomes with the SÄH process model SÄH is a process-oriented hospital. Process work is regarded as a vital part of the hospital s development work and many of the care staff are involved. The long-term work conducted within the various processes has resulted in value-based and evidence-based patient care. The level of quality has been raised and patient waiting times have been reduced. There are currently ten patient processes, divided according to diagnostic group or symptoms that require care and treatment that extend across departmental boundaries. The hospital s two deputy chief executives are the process owners. Each process is led by a process leader, who is also an experienced medical specialist. The process leader has a process team made up of individuals who represent the areas of expertise that are critical to the success of the process work. The process leader also has operational insight that is of significance to the process and the authority to sanction process control documents for the whole hospital. Follow-up of the results takes place at process management meetings attended by hospital executives, medical directors and process leaders. Decisions are made at these meetings regarding target levels and task allocation in order to ensure the established goals are achieved. Below are the results from a number of processes. Stroke process patients that are ADL-independent after three months Hip fracture process number of persons operated on within 24 hours Cardiac arrhythmia process number of patients who have received anticoagulation treatment 4 2004 2005 2006 Healthcare Strategy Unit Processes for the entire hospital Process organisation with process owners, process teams and process guides

Diabetes process results in fewer complications for the patient and use of cutting-edge technology The diabetes process has developed guidelines for diagnosis, expanded the use of cutting-edge technology and increased the level of patient involvement in the care system. Around 80 per cent of the patients who were followed up at the hospital now have continuous monitoring using blood glucose meters and insulin pumps. These are stateof-the-art aids that simplify the monitoring of blood glucose levels and insulin dosage. In just three years, blood glucose levels have improved. The target for 2015 was for more than 20 per cent of patients to have a blood glucose level below 52 mmol/mol. The most recent figures show that 27 per cent of patients have a blood glucose level below 52 mmol/mol. Patients with type I diabetes are always monitored at the hospital. If there are signs of complications, the patient can receive help rapidly. This has been made possible by the increased collaboration that has resulted from the process. It is reassuring to be able to mediate a feeling of security to the patients, who know they will always receive the correct care and treatment, said process leader Detlef Hess. No-one needs to agree to treatment-intensive changes as a result of lack of control. Our patients undergo eye tests well in advance. Patients with foot ulcers are taken care of by multidisciplinary teams, which is not entirely self-evident in other parts of the country. Patients are invited to annual diabetes seminars and a diabetes school and they have their own patient representative on the process team, said nurse Lars Berg. Overall, the patient s motivation to follow the recommended treatment strategy is improved. The hospital takes care of 1,500 diabetes patients, of whom 230 are children. Diabetes process results, diabetes in adults Diabetes process results, diabetes in children 2007 2008 2009 Start-up of five processes covering the entire hospital Lean Game played by the Executive Management Team Training of Lean coaches 5

HIFA high-intensity improvement programme builds momentum High-intensity improvement work, HIFA, is aimed at rapidly analysing and implementing improvements related to how the hospital satisfies patient needs on their journey through the system. The idea is to achieve results more quickly than would be the case with daily improvement work when there is an explicit wish to develop a particular area. Peter Häyhänen is Head of Development: The model of bringing together a group of representatives from different professions for a number of very intensive days started back in 2013. What is unique about this method is that it moves from analysis to testing and implementation within just a few days. The methodology is founded on activity-based learning. In general terms, the arrangement is as follows: Five working days, including a short theory session and practical work. Interviews with patients on day 1, detailed mapping and analysis of the current situation on day 2, and a workshop on days 3-5. HIFA at the Adult Outpatient Psychiatric Clinic. Staff at the city centre Adult Outpatient Psychiatric Clinic have introduced a multidisciplinary assessment and care plan for new appointments, an open electronic time book, improved telephone access, an improved structure for therapy conferences and a new form of training for patients and relatives. Evaluations show that staff feel that they have achieved more than they had expected and that job satisfaction has increased. HIFA at the Rehabilitation Department Improvement work has been incorporated into day-to-day life at the central Physiotherapy and Occupational Therapy Unit. A total of 36 improvement tasks have been concluded since the beginning. Examples include use of the SBAR communication tool for internal and external handover reports, undisrupted ADL (Activities in Daily Life) training, compliance with basic hygiene routines and follow-up of physical activity on prescription and patient questionnaires. Meetings where the focus is on the improvement board take place three times a week to maintain momentum in the development process. Read more in the blog http://blog. vgregion.se/rehabiliteringsklinikenshifa/ (in Swedish) HFIA at the Orthopaedic Department, Anaesthetics Department and Accident and Emergency Department HIFA in relation to emergency operations has recently commenced at three departments and cooperation has already improved. At the Surgery Department, new routines have been introduced that will lead to an improved flow in the surgical process. One example is that after an operation the operating surgeon writes out a prescription stipulating various activities, such as return visit, that the patient will need to do after the operation. This reduces the amount of post-operative work and the patient only needs to visit one department. At the same time it frees up beds at the Orthopaedic Department. 6 2010 2011 2012 Patient safety initiative Appointment of a Development Controller at each department The majority of managers at SÄH attend a national Lean Conference Lean training for managers and co-workers

Green Cross a unique method for reducing medical injuries From having begun as an improvement idea at the Surgery Department in 2011, the Green Cross model has become an established method at SÄH. Green Cross is a simple tool used to identify medical risks and injuries and to prevent them from occurring. It is also part of SÄH standards. As an SÄH standard, the aim is for all departments and outpatient clinics to use the method to reduce the number of medical injuries and to promote a patient safety culture. The strength of the model is that it is simple and visual. Each month a cross is displayed containing boxes for each day of the month. The boxes are filled in each day in Better for the patients - Improved information - Increased security during the night - Fewer falls - The right medicine is given more often - Better sleep during the night - Less pain following an operation 1 4 2 5 3 6 different colours. A cross that is entirely green means that there were no medical risks or injuries during the month. Other colours indicate medical injuries that have occurred or where there was a risk of occurrence yellow (risk of injury occurring), orange (medical injury occurred) and red (serious injury occurred). The colours show the patient safety status at the unit. During brief daily reconciliation meetings, the staff at the unit come together, regardless of profession, to discuss Green Cross. When shortcomings in patient safety are noted, these are rectified as part of day-to-day improvement work and are followed up on a monthly basis. Patients and relatives are also offered the opportunity to be involved in a dialogue when an injury has occurred. Better for staff - Open climate for discussion - Less searching for scapegoats - Safer working methods - Increased expertise in patient safety - Daily patient safety discussion - Managers and co-workers have access to the same tools Green Cross, which was developed at SÄH, received the Innovation of the Year Award in 2014, by Swedish Institute for Quality, SIQ. I am extremely pleased and very honoured to receive the award, said operational development specialist Katherina Hansson, who was responsible for developing the model. The staff have taken on board the Green Cross working method and it has become an integral part of day-to-day work at the hospital. I would also like to take the opportunity to thank all my co-workers for their contribution to achieving the current level of patient safety. SÄH is on the right path in terms of patient safety. In recent years the hospital has achieved a tangible reduction in the number of pressure ulcers and care-related infections. This work will be intensified even further in the future. Read more about Green Cross and view the film online. Better for the hospital - Fewer medical injuries - Improved skills and knowledge of patient safety - Improved patient safety culture - Greater inclination among co-workers to report deviations - Systematic support in patient safety work - Part of the departments operational planning process 7 14 21 8 15 22 9 16 23 28 31 10 17 24 29 11 12 13 18 19 20 25 26 27 30 2013 2014 2015 X-Matrix replaces the operational plan Improvement programme High-intensity improvement programme (HIFA) Revised model for SÄH patient processes 7

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