Change management at the Karolinska
University Hospital using Lean transformation
Birgir Jakobsson CEO
Karolinska University Hospital
2013-04-25
Global Health Care Challenges
Health Care costs vs BNP per capita
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
Accidents and
mistakes
Insufficient clinical
pathways
Källa: Value guided healthcare, The Boston Consulting Group, AB 2009
Lean Method in University Hospital Setting. Helsinki April 2013
The Doctor. Sir Luke Fildes, 1891. The Tate Gallery, London.
Cardiac surgery. (Foto 2003 © Johan Garsten, Karolinska Universitetssjukhuset).
Lean Method in University Hospital Setting. Helsinki April 2013
5
Sir Cyril Chantler:
“Medicine used to be simple, ineffective, and relatively safe. Now
it is complex, effective, and potentially dangerous.”
Lancet. 1999; 353(9159):1178-81, p. 1181.
Lean Method in University Hospital Setting. Helsinki April 2013
High Risk Organizations
Health care organizations with high risk profile
according to
Amalberti, R. Safety Science, 2001.
Lean Method in University Hospital Setting. Helsinki April 2013
7
If we want different results –
we have to do things differently
Lean Method in University Hospital Setting. Helsinki April 2013
Huddinge University Hospital
1995-2003
Lean Method in University Hospital Setting. Helsinki April 2013
LEAN – a strategy for improvement
See the whole picture
Focus on patient value
A B C
D
Eliminate waste
R
FlowPrinciples
Principles of
Improvement
A
B
C
Lean Method in University Hospital Setting. Helsinki April 2013
D
R
Capio S:t Görans Hospital
2003-2007
Lean Method in University Hospital Setting. Helsinki April 2013
Where is the waste?
Flow Chart of Emergency Surgery
Parts of patient’s way through the E & A
where waste (time) can be identified and refused by us
Important decisions
2. 30 min
Konsult
Rtg
Remiss
Svar
4. 15 min
Ord
Prover
Identified waste = 130
min
Svar
Ambulans
Ord
Beh
Prover
EKG
40
*
Ny bed
av läkare
1. 55 min
Reg.
Kassa
SpotCheck
Triage
Disken
bed prio.
av ssk
Wait for dr 1:19
Nr of pat kl 16: 3,7
Inl. 10
Läkare
unders.
Hem 29
Leaves
E&A
Klar
*
3. 30 min
Treatment time 2:43
Nr of pat kl 16: 7,5
Lean Method in University Hospital Setting. Helsinki April 2013
*
Prototype for a new work procedure
Lean Method in University Hospital Setting. Helsinki April 2013
Karolinska University Hospital
2007-2013
Lean Method in University Hospital Setting. Helsinki April 2013
Karolinska University Hospital 2007-2013
Solna
Huddinge
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
Patient flow to and from an in ward unit
Inpatients
arrive to
E&A
Lean Method in University Hospital Setting. Helsinki April 2013
Patients
leave ward
unit
Patients
arrive to
ward unit
How should we bring about CHANGE ?
Strategic plattform
Leadership
Lean transformation
Lean Method in University Hospital Setting. Helsinki April 2013
What did we want to improve?
To improve patient value
Method (EBM)
R&D
1. Create more effective processes
with better patient flow, shorter lead
times, less faults and less waste
2. Create effective team work with
safer communication
3. 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
Where do we start to improve?
Emergency flow
Imperative flow
Planned flow
In which order should we improve?
1
2
3
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
Goals and KPI’s?
E&A
1. Wait for doctor: 40 min
2. Through time E&A 4hrs: 90%
3. Nr of patients at 16 PM: 80
Ward
1. Patients to ward <4hrs: 90 %
2. Discharge before 12 AM: 33 %
3. Shorter AVLOS: 15 %
Lean Method in University Hospital Setting. Helsinki April 2013
Early involvement of support processes
X-rays/
lab
X-rays/
lab
E&A
Wards
Surgery
Lean Method in University Hospital Setting. Helsinki April 2013
How to create a mixture of top-down and
bottom-up?
Management
team
Flow leader
Improvement groups
X-rays/
lab
X-rays/
lab
E&A
Wards
Surgery
Lean Method in University Hospital Setting. Helsinki April 2013
How to lead the improvement work?
Lean Method in University Hospital Setting. Helsinki April 2013
Systematic approach to establish,
standardize and improve work procedures
Q
FAS 3
Ständiga
förbättringar
FAS 1
Framtagning
och test
FAS 0
Överenskommelse
Lean Method in University Hospital Setting. Helsinki April 2013
FAS 2
Implementering
Tid
How to avoid too much focus on results?
Values
Flow rules
Principles
Go and see
Flowprinciples
Standards
Way of working
Results
Lean Method in University Hospital Setting. Helsinki April 2013
Waiting for doctor, 5 days a week, 0816, in Huddinge
Före
Fas1 Fas2
Fas3
Väntan på läkare
2:00
UCL=1:03
_
X=0:49
1:00
Mål
LCL=0:35
0:00
1
25
49
73
97
121
145
169
193
217
241
Konsekutiva veckor 2006-2010
Lean Method in University Hospital Setting. Helsinki April 2013
Turn-around time <4hrs 5 days a week,
08-16, in whole hospital
Lean Method in University Hospital Setting. Helsinki April 2013
% of patients in ward within 4hrs from
arrival to E&A, 12 wards
%
Lean Method in University Hospital Setting. Helsinki April 2013
% discharged before 12 AM,12 wards
%
Lean Method in University Hospital Setting. Helsinki April 2013
Saved time in comparison with
prioritized time (24h) 2010 to 2013, mars
Lean Method in University Hospital Setting. Helsinki April 2013
Change of culture
Future
Present
For whom are
we here
Silos
Hierarcies
Single work
Sequensial
Variation
Unpredictable
Values
Principles
Way of working
Results
Lean Method in University Hospital Setting. Helsinki April 2013
Mutual values
Wright from beginning
Standardisation
Visualisation
Teamwork
Wright competence in wright
time
Continuous improvement
Safety
Quality
Accessability
Working environment
Predictable
Efficiency
Three important challenges
Values
Flow efficience/ resource efficiency
Leadership
Lean Method in University Hospital Setting. Helsinki April 2013
Karolinska´s strategic plattform
Our assignment
Our
Vision
Lean Method in University Hospital Setting. Helsinki April 2013
35
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
Lean Method in University Hospital Setting. Helsinki April 2013
36
We are role
models within
R&D and
education
Our values
Accountability
Vi tar ansvar för våra
patienter, uppgifter
och varandra. We
speak up if we think
something is wrong.
Humanity
Vi möter våra patienter
och varandra med
omtanke och respect.
Vi utgår från varje
patients unika behov.
Lean Method in University Hospital Setting. Helsinki April 2013
37
Holistic attitude
Vi arbetar tillsammans
över gränser för att ge
bästa möjliga vård. We
value each others
work and ask for help
when needed.
Values = tools to change culture
Performance
!
Attitudes and behaviour
Lean Method in University Hospital Setting. Helsinki April 2013
38
New Karolinska?
Quality/Cost/Health
Lean Method in University Hospital Setting. Helsinki April 2013
Quality/Cost/Health
Flow efficiency
Resource efficiency
VC/Flows
VC/Resources
Flow efficiency versus resource efficiency
Resource efficiency
High
Low
Start
Low
Lean Method in University Hospital Setting. Helsinki April 2013
40
High
Flow efficiency
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
Systems for learning, continuous improvement
and long-term sustainability
Q
Patient value
Problemlösning
på rätt nivå
Värdeskapande
aktiviteter
Medarbetar
e
Visualisering
1:a linjechef
Eskalering av
problem som ej kan
lösas på egen nivå
Verksamhetschef
Divisionsch
ef
Sjukhusdirekt
ör
Lean Method in University Hospital Setting. Helsinki April 2013
Ständiga
förbättringar och
dagligt lärande
Efterfråga
resultat och skapa
förutsättningar
Karolinska will not only focus on results – we also have to build ”Health”
Results
What do we achieve, production of
care at the wright quality within
balanced economy
Health
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
Decrease in outpatient waiting times
Mål
2013
2015
<300
0
2013
<400
Mål
2015
0
Patient satisfaction, E&A
Patienten lämnade akuten inom 3 timmar
Personalens samarbete "Utmärkt", "Mkt bra"
2007
2009
Fick info om beräknad väntetid till läkare
"Helt och hållet" tillräcklig info om tillstånd
"Acceptabel" väntetid för att träffa specialist
Fick träffa läkare inom 30 minuter
"Acceptabel" väntetid för att träffa läkare
"Helt och hållet" organiserat på ett bra sätt
"Helt och hållet" rekommendera K
"Alltid/nästan alltid" hjälp vid behov
0
20
Lean Method in University Hospital Setting. Helsinki April 2013
40
60
80
100
%
Development of leadership 2006-2011
Lean Method in University Hospital Setting. Helsinki April 2013
47
Staff satisfaction 2006-2011
Lean Method in University Hospital Setting. Helsinki April 2013
48
Karolinska University Hospital – economic results 2005 - 2012
Mkr
300
200
100
0
-100
-200
-300
-400
resultat
år 2005
-54
år 2006
-191
år 2007
-358
år 2008
-250
år 2009
115
år 2010
181
år 2011
58
år 2012
35
49
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
Contact information
Birgir Jakobsson, CEO
Karolinska University Hospital
Stockholm
Sweden
E-mail: birgir.jakobsson@karolinska.se
Lean Method in University Hospital Setting. Helsinki April 2013