Making system wide improvement in health care Mats Bojestig MD Jönköping County Council, Sweden When results get public 1
If people want take responibilty for their care are we with them? Improving clinical System performance view while reducing unnecessary cost Prevention Variation Access Flow Medication Patient as a source Microsystem Patient safety New thinking 2
Purpose Mission Beliefs Vision System for obtaining information (Customer focus) Planning Strategic objectives Improvement efforts Resources Products Services Tools BSC: 4 perspectives Patient / Process/ Customer Production Learning and Economic renewal Organization viewed as a System Three basic questions Act Plan Study Do Managing improvement efforts Normann, API A Regulation from The Swedish National Board of Welfare What Swedish Health Care must be Safe Knowledge based and Efficient Patient focused Effective Equal Timely 3
It is the Outcome of the Whole System that Counts! 100% 1% Current activities New activities Continuous improvements Jönköping health care services Annual Planning and Budget Document Drivers Learning and renewal Planning for leading and improvement Leadershipmeetings The surrounding world Mission / Catch the need in society Follow up and feedback Mainstay Access Diagnoses, Treatment and decision support Delivery system design Define ongoing relationship Patient s/ Customer s home Nursery home Support Administration Competensdevelopment Safety-work IT X-Ray. Lab, Rehab and care Technical supp 4
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 Open comparison of Swedish 21 counties Safe Knowledge based and Efficient Patient focused Effective Equal Timely 5
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 6
Let the teams develop their own capacities and performances Measure for others and annual report Optimal level? Hospitals in Sweden ACE-blockers at discharge after heart infarction, age <80 Wallentin, Lindahl, UCR -04 Protocol 7
(QUICC) Quality Improvement in Cardiac Care project Number of hospitals that reach 70 % following 4 or 5 out of 5 treatments 19 18 17 16 15 14 13 12 11 10 9 8 7 6 5 4 3 2 1 0 0 Hospitals in Control group 4/5 5/5 Hospitals participating in QUICC Change in Incidence (events/100 patient years) between pre- and post interventions period 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 8
Customer knowledge - knowledge about the customer - the customer s knowledge Variation Support to take care of yourself Decision support Care programs Knowledgeable Reliable - updated -safe - equipment - National guidelines Standardised Specific Esther the patient s focus Lack of coordination and integration causes complicated solutions 9
Traditional Functional Patient focused Activities and part of processes organized after prioritized patient values Pharmacy apotek 6 kommuner municipalities (6) Investigate Primary care Diagnosis & desition about care/p.c. and hospital Rehabilitation Primary care 6 primary PV-områden care units (6) Patient with disease Esther Patient treatment finished Hospital in Eksjö Medicin E R Rehab Lab Pat asks for primary care Treatment hospital Treatment hospital Rehabilitation Municipality Concept of Esther What do you want to accomplish for Esther? Who needs to cooperate? Any changes? Map the process of today 10
Clinical Micro-system and a relentless ambition to pursue perfection 11
Resultattavlor i vården The need of hudles The local use of measures strengthen the learning and innovation approach 12
Exempel New management system Dialog: Improvement ideas Action plans PDSA Transparency Learning together System levels Microsystem Mesosystem Macrosystem 13
14