06/11/2012
"Designing and managing
care integration in the County
of Jönköping
Welcome to
Jönköping County Council
and Health care services
24 October
Pernilla Söderberg
Qulturum Jönköping Sweden
Sweden
Norway
Jönköping
County
UK
Jönköping
Jönköping
district
Germany
Eksjö
Eksjö
Highland
district
To meet the future
or to create the future
Welcome to Qulturum
Jönköping County Council
France
Italy
Spain
Värnamo
Värnamo
district
Europe
Jönköping County:
Population: 330 000
13 cities/municipalities
Mission
Best possible care all the time
How to create a culture where everyone is
inspired to give the best possible care all
the time. And also to create an evironment
of curiosity for how to make today’s work
even better tomorrow.
The true journey of discovery is not to
search for new sites, but to see the
old, familiar one with new eyes.
Marcel Proust 1871- 1922. French Novelist
1
06/11/2012
Put on different lenses
Drive the train at 200 km/h
. . . and lay the rails
for the future
And look closely at the microsystem. . .
Every one looking at the same thing at
the same time
Very close
Some examples of lenses
Economic,
political,
anthropological,
information,
psychological,
mechanical/physical,
sociological and
biological
To think about….
• Equal care is NOT that all employees CAN
do the same thing…
• Equal care means that all employees both
SEE and DO the same thing!
•
•
•
•
If something works – do not break it
Do more of what works
If something does not work – do it differently
If it is too slow – go slower
2012-11-06
Pernilla Söderberg
2
06/11/2012
Improvement in Our Heart
WILL
with the patient’s perspective
-Attitudes
-Driving force
IDEAS
-Conrete ideas about
how something could
be better. Inspiration
from good examples
-Methods and tools
EXECUTION
Science + context = result
-Go from word into action
Our GPS
-Measure results and
make it visible
Ref; IHI Tom Nolan
To develop a culture of improvement :
From “theory” to “praxis”…
and back again
Better patient,
population outcome
Better professional
development
You have two jobs: to do your job and to improve it!
Professional knowledge
Improvement knowledge
- Professional knowledge
- Personal skills
- Values, ethics
- System
- Variation
- Psychology
- Knowledge
Everyone
Our GPS
Improving diagnosis,
treatment, care,
rehabilitation and
follow-up
Better system
performance
Our GPS
Ref; Paul Batalden
+
Improvement in
processes and systems
in health care
Increased Value for the Patients
Paul Batalden
Batalden et al.
Simple Rules
• Health care always emanates from the patient’s
value, need and whishes
• We protect the patients and ourselves
• It is the system’s result that counts
• We share the results from our development and
improvement work with others
• Either solve the problem or take responsibility for the
handing over to next step
Our GPS
• Feedback to the step before
• Work with guidelines
Imagine yourself as a learner!
In a time of drastic change,
it is the learners who inherit the
future. The learned find
themselves equipped to live in a
world that no longer exists
Eric J. Hoffer
Social Writer: 1902 –1983
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06/11/2012
The
P’s
M5ik
roof
sythe
stemicrosystem
mets fem P
LEAN
Purpose
Purpose
/syfte
Patienter
Patients
• What value
shall we
Vilket värde
accomplish?
 • Who
Vilkaare
är they?
de?
ska vi
åstadkomma?
• How well do we
 know
Hur their
väl känner
needs?vi
deras behov?
• How do we
involve them more?
 Hur involverar vi
dem mer?
People/
People/colleagues
medarbetare
• How do w e use and
 take
Hurcare
nyttjar
och
of the
tillvaratar ofviour
competence
medarbetarnas
colleagues
in the best
wkompetens
ay?
på bästa
• sätt?
How do w e involve
 them
Hurmore
involverar
in the vi
improvement
dem mer i w ork?
• utvecklingsarbetet?
How do w e increase our
 colleague’s
Hur ökar vi
understanding
of our
medarbetarnas
mission?
förståelse för sin
uppgift?
Processer/
Processes
flöden
• How do we
Patterns/
Patterns
mönster
• How do we
learn more about
evaluate
Hur the
variations in the
utvärderar vi
clinical work?
variationer i
det kliniska
arbetet?
 our
Hur
lär vi oss
processes?
mer om våra
• How
do we use
processer?
the result?
 • How
Hur do
använder
we
vi oss av
improve
our coresultatet?
operation?
 Hur blir vi
bättre på
länkning/samv
erkan?
Att out,
kartlägga,
reflektera,
och
försöka systematiskt
förbättra
To map
reflect,
discuss samtala
and try to
systematically
improve
Ref: Godfrey,
Nelson,Batalden
Ref; Henriks, Nilsson, Bojestig, Edvinsson, Berger
Every system is
perfectly
designed to
achieve the
results it gets
Tools and Methods
Donald Berwick
Ref:Caroline Fruberg
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06/11/2012
Activity is not always change
Breast cancer process
Surgeon
Time in the old days
42 days.
Punction och
cytology
2-3 hours
Mammography
and ultrasound
This IS change
• Increase phonetimes
• Change schedule
based on needs
• 5 S pharmacy stock
• Feedback (measures)
an compliance to
standards
• Reduce no of steps in
a care process
This is NOT Change
• Planning
• Having a meeting
• Educate staff
• Do a protocol
• Point out a responsible
person
• Write on the intranet
Surgeon
Find the gap, analyze the problem, do tests
To measure and analyze over time
2.
3.
vecka
Plan small tests (goal, measure and time)
5 P to understand your
setting.
antal dagar
Väntetider sjukgymnastik
18
5
antal dagar
do test
Describe the process from the
patient’s perspective.
study results
decide – new test?
Fishbone
Define the problem
Ask why, why, why
Brainstorm
Sort and group
Multi-vote
•
•
•
•
•
Act
Plan
Study
Do
20
18
16
14
12
10
8
6
4
2
0
v 20
where are the largest gaps?
How do we measure?
v 20
v 35
TEST fr o m v 26
Havregrynsgrötsfrukost
HYPOTES
Ökad effektivitet på dagtid ger kortare väntetid
v 35
1.
vecka
Most problems are found in processes
not in people
antal dagar
Väntetider sjukgymnastik
v 34
v 32
v 30
v 28
v 26
v 24
20
18
16
14
12
10
8
6
4
2
0
v 22
18
10
2
8
14
5
14
6
20
4
11
17
3
9
15
5
v 20
v 20
v 21
v 22
v 23
v 24
v 25
v 26
v 27
v 28
v 29
v 30
v 31
v 32
v 33
v 34
v 35
antal dagar
vecka
vecka
TEST fr o m v 26
Havregrynsgrötsfrukost
HYPOTES
Ökad effektivitet på dagtid ger kortare väntetid
5
06/11/2012
Success is achieved through meeting
the needs of those we serve
You must be the change you
want to see in the world
Ghandi
Defining Quality
Background/Project application
The study presented in the report "A national cancer strategy for the
future" - SOU 2009:11
Their aim is to go from words into action.
Regional Colon Cancer Project.
In their improvement work, the region aims to focus on ’the patient’s
pathway through health care’’
”More patient-centered and more cohesive cancer treatment”
The approach covers the entire health care chain; from colon cancer
prevention to the palliative care, in order to create a whole from the
different parts.
RCC’s promises to the patients
•
All patients with cancer in the region should receive treatment within four weeks
•
All patients with cancer should be offered diagnosis and treatment of Best Practice
•
All patients with cancer should be informed and involved throughout the entire
healthcare chain
•
All patients with cancer in palliative care should receive equally good palliative care
services no matter where they live
•
All patients with cancer should be offered the best possible health promotion
measures and efficient screening program
•
Regional Cancer Centre South East should prioritize patient-oriented research in
oncology
Symptoms of the individual
Diagnosis
Die of cancer
Live with cancer
Measures
Treatment decisions
Healthy
Symptom
Diagnostics=good basis
for decision
Healthy
Involvement, making own decisions,
feeling safe, being informed,
symptomatic relief
Getting
worse
Identifying current patient
Relaps/Generalising
Prevention within the
population
6
06/11/2012
Method
•
•
•
Research Approach
Three multi-disciplinary teams from each county council were formed in
order to, together with the patients and relatives representatives, develop
and improve the process of colon cancer treatment.
The improvement work integrates an interactive learning approach for
systematic monitoring i.a. through the existing data records in the open
quality registries
The learning part throughout the process begins with listening to the
experiences of the patient and relatives and ends with examining the actual
needs.
The researchers contribute with the feedback analysis, the theory and
methods for the improvement work. Both quantitative and qualitative data
will be used
The Value Compass will be the measuring instrument throughout the work.
Impact Analysis for a good colon cancer treatment
©IHI
Action plan
An action plan has been developed with the following focus areas:
• Overall/General
• Development of measurements and performance indicators
• Patient Involvement
• Primary, secondary and tertiary prevention
• Early detection
• Investigation, treatment and rehabilitation
• Multidisciplinary collaboration
• Palliation
Primary Impact
’’What’’
Secondary Impact
’’How’’?
Will be given an adequate
treatment within the four
weeks’ time
Investigation / Treatment
Goal /
Objective
Will be offered the diagnosis
and treatment of 'best practice'
Will be well-informed and
involved in the entire health
care chain
Our promises to the
patients with a colon
cancer
In the end of their life will be
given equally good palliative
care regardless of place of
residence
Good Care
Each area of the Action Plan has a number of objectives and actions identified.
Will be offered the best
possible health promotion
measures and effective
screening programs
Regional cancer center will
prioritize patient-oriented
research in Oncology
Promise 1 – Will be given an adequate treatment within the
four weeks’ time
Early detection
Investigation
phase
Patient involvement
Investigation / Treatment
Patient involvement
Patient and
family
experiences
Multidisciplinary
collaboration
Palliation
Prevention
Interactive research
approach in several
aspects of the project
Palliative
phase
Prevention
Research
Functional status / health status
Patientupplevt funktionellt status vid första besök efter operation i samband med koloncancer
resultat av enkätsvar
Sydöstra sjukvårdsregionen
2011 - 2012
100%
Quality of life
90%
80%
Agitation / anxiety
70%
60%
50%
appetite
40%
Survival
30%
Jag klarar av mina huvudsakliga aktiviteter (andel svar Ja, helt och hållet)
20%
Aptit (andel svar 0-3, 0=bästa möjliga aptit, 10=ingen aptit)
Oro/ångest (andel svar 0-3, 0=ingen oro/ångest, 10=värsta tänkbara oro/ångest)
10%
Livskvalitet (andel svar 0-3, 0=bästa möjliga livskvalitet, 10=sämsta tänkbara livskvalitet)
0%
Coverage ratio
It is important that we identify the improvement areas locally and that we make
sure that they are improvements and not just changes.
jan-jun 2011 (n=15)
jul-dec 2011 (n=21)
jan-jun 2012
jul-dec 2012
main activities
Clinical Status
Patient/Customer’s needs
Welcoming attitude
Complications
Good care
Colon cancer
Involvement
Information
Stage after
diagnosed
Resources / Costs
competence
hospitalization
lead time
investigation costs
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06/11/2012
Patients’ experience
Patients with colon cancer
Results of the survey related to visits following diagnosis
and starting treatment, the proportion of answers: yes, completely
South East health district
2011-2012
Coverage/Ratio in a Colon Cancer Registry
The percentage of planned colon cancer surgery reported in INCA within five months after surgery
2011-2014
Results of the survey related to the visits following diagnosis and surgery of colon cancer
South East healthcare region
2011-2012
Percentage of post operative MDK-colon cancer(non-emergency surgery)
From INCA-registry
South East Health District
2012-2012
Ur rapport nr 3 från Kolorektalcancerregistret, perioden jan –
apr, 2012
Percentage of post-operative MDK-colon cancer
(elective and emergency surgery)
From INCA-registry
South East Health District
From diagnosed cancer to the treatment
(Diagnosis to the start of treatment)
Medianen
Östergötland
Jönköping
Kalmar
80:e perc.
22
22
22
Medianen
47
41
43
Östergötland
Jönköping
Kalmar
80:e perc.
25
16
18
50
31
38
8
06/11/2012
Reflections of a 59 year-old woman.
From diagnosed cancer to the treatment
(Diagnosis to the start of treatment)
Antal dagar från diagnos till behandlingsstart
Koloncancer
(n=137
patienter), Östergötlands
län, Diagnosår
2011
Colon cancer
(n=patients),
Ostergotland
County Council,
year of diagnosis
2012
• ’’It was a very long waiting time for the x-ray results; I
100
90
80
70
60
50
80:e percentilen=50 dagar
40
30
Median=25 dagar
20
10
0
Jan
Feb
Patient’s
individual
preferences
Mars
April
Maj
Juni
Juli
Aug
Sept
Okt
Nov
Dec
Patient’s process
Patient’s context
First symptom
Patientens
Patientens sammanhang
sammanhang
Patient’s context
Första
Första symtom
symtom
First contact
Första
Första kontakt
kontakt
Patientens
Patientens sammanhang
sammanhang
Patienters
individuella
preferenser
Undersökning
bedömning
uppföljning
Information
Behandling/
åtgärd
Kompetens
Symtom
Patient
Patientcentrerad processkartläggning för ____________________________________
Patientens
Patientens sammanhang
sammanhang
Patientcentrerad processkartläggning för ____________________________________
Första
Första symtom
symtom
Patientens
Patientens sammanhang
sammanhang
Första
Första kontakt
kontakt
Patientens
Patientens sammanhang
sammanhang
Patient
Patientcentrerad processkartläggning för ____________________________________
Utredning
Utredning
Patientens
Patientens sammanhang
sammanhang
Beslut
Beslut om
om åtgärd
åtgärd
Patientens
Patientens sammanhang
sammanhang
Behandling/åtgärd
Behandling/åtgärd
Patientens
Patientens sammanhang
sammanhang
Uppföljning
Uppföljning
Patientens
fysiska,
psykiska,
sociala och
existentiella
behov
Undersökning
bedömning
uppföljning
Information
had to wait 4-5 weeks
• ’’I’ve met many different physicians
• This can be very confusing
• Maybe it would be more efficient if I could have
registered a day before the surgery and just stayed at
the hospital.’’
• Once I should have had my surgery in the morning but I
didn’t leave the hospital until 5 pm. It’s quite tough to be
without food for such a long time.’’
Patientens
Patientens sammanhang
sammanhang
How to support these processes
In our region we have 8 process leaders
• Palliative care
• Prostate cancer
• Head and neck cancer
• Brain tumor
• Breast cancer
• Gynecological cancer
• Lung cancer
• Malignant lymphoma
Behandling/
åtgärd
Kompetens
vilka
vilkaytterligare
ytterligare
kompetenser
kompetenser
behövs
behövsiidetta
detta
steg?
steg?
Symtom
Patient
Patient
Patient
Patient
Patient
Patient
Support
• Coaches
• Education – process leader program
• Learning by doing
Thank you!
Pernilla Söderberg
Qulturum Jönköping Sweden
9