Improving patient flowswith an End-to-End approach

Mikael ForssDeputy CEO

Katarina Andersson, Gustav Hjelmgren, Olof VallinChange agents, Operations Management

Karolinska University Hospital- one of the largest hospitals in Europe

Solna Huddinge

15 miles

600 patients/day in our ED:s1,680 beds109,000 admissions/year1,7 million patient visits/year

County council owned• Patient care• Research• Education

15 000 employees

Karolinska´s main strategies

Change culture and daily routine work– Create safety culture– Improve leadership

Lean transformation– Process orientation and continuous improvements– Develop process oriented management– Change in culture as a result

Create Academic Health Care System in Stockholm– Strengthen clinical research– Increase cooperation between health care, academy and industry

3

4

Learning by doing 1993-2007

1993-1996

Outpatient ClinicDpt of Cardiology

1997 – 2004

End-to-End approachMaternity care

Top down & bottom up

2005-2007 2007

120 improvement projectsTQM, Six Sigma, SPC, LEAN85 % success rate short term

Long term?

Huddinge Hospital St Görans HospitalKarolinska

The merger

+

End-to-End approachED/Ward

Top down & bottom up

Days

2010

Delivery ward Maternity ward BA

Maternity ward A

A

Labour painsReferral to first assessment

End-to-End approach

ED Ward

X-rayLab

X-rayLab

OR

Our improvement modelQ

Phase 1RedesignTest/Learn

Phase 2Implementation

Phase 3ContinuousImprovement

Time

Value stream management system

ED Ward

X-rayLab

X-rayLab

ORValue stream leaderImprovement team

Value streammanagement team

Value stream management in practice

Current status

ED*(16)

Ward*(19)

X-ray* (5)Lab* (2)

X-ray (5)Lab (2)

OR(2)

16 patient flows:•Internal Medicine•Surgery•Orthopeadics•Gynecology•Ear-Nose-Throat•Pediatrics•Infectious diseases•Neurology95% of ED patient flow

* Statistically significant changes in patient oriented measures

Improved ED patient experience

%0 20 40 60 80 100

”Always/Almost always” got help when needed

Should ”on the whole” recommend Karolinska University Hospital

” On the whole” organised in a good way

”Acceptable” waiting time to see a physician

See a physician within 30 minutes

”Acceptable” waiting time to see a physician

”On the whole” satisfied with information about the medical condition

Was given information about expected waiting time to physician evaluation

Cooperation of the work force ”Very good”

Left the ED within 3 hours

20072009

All significant changes in the patient inquiry 2007 to 2009 are presented above

End-to-End LoS for admitted patients

jul 20

10

jan 20

10

jul 20

09

jan 20

09

jul 20

08

jan 20

08

jul 20

07

jan 20

07

jul 20

06

jan 20

06

78:00

72:00

66:00

60:00

54:00

48:00

Months (jan 2006 to oct 2010)

End-

to-E

nd L

oS (

mea

n)

Before Impl ED:s Impl first ward

Arrival at the ED until leaving the hospital for admitted patients10 wards at Karolinska 24/7

Door-to-doctor time

30 min reduction 24/7

40 min reduction weekdays 8 AM – 4 PM

2010

-42

2010

-17

2009

-45

2009

-20

2008

-47

2008

-22

2007

-49

2007

-24

2006

-51

2006

-26

2006

- 1

2:00

1:40

1:20

1:00

0:40

0:20

0:00

Week (2006-1 to 2010-42)

Doo

r-to

-doc

tor

(mea

n)Before Tests Implementation

Door-to-doctor time16 ED:s at Karolinska 24/7

Number of patients waiting for doctor each hour

Patients

Hour

Discharged before 12 AM

2010

-18

2009

-45

2009

-20

2008

-47

2008

-22

2007

-49

2007

-24

2006

-51

2006

-26

2006

- 1

40%

30%

20%

10%

0%

Week (2006-1 to 2010-42)

Dis

char

ged

befo

re 1

2 A

M (

mea

n)

Before Tests Implementation

10 wards att Karolinska University Hospital 24/7

X-ray total turn-around time

jul-se

p 201

0

jan-m

ar 20

10

jul-se

p 200

9

jan-m

ar 20

09

jul-se

p 200

8

jan-m

ar 20

08

jul-se

p 200

7

jan-m

ar 20

07

jul-se

p 200

6

jan-m

ar 20

06

3:20

3:00

2:40

2:20

2:00

1:40

Quarter (jan 2006 - sep 2010)

Tota

l tur

n-ar

ound

tim

e (m

ean)

Before Significant change

Time from first doctor asessment to avaliable X-ray result CT Brain at all ED:s in Karolinska Solna 24/7

Clinical Chemistry total turn-around time

okt 2

010

aug 2

010

jun 20

10

apr 2

010

feb 20

10

dec 2

009

okt 2

009

aug 2

009

jun 20

09

apr 2

009

feb 20

09

dec 2

008

okt 2

008

2:10

2:00

1:50

1:40

1:30

Months (oct 2008 - oct 2010)

Tota

l tur

n-ar

ound

tim

e (m

ean)

Before Significant change

Time from first doctor asessment to last available test-result at visitClinical Chemistry testing at all ED:s in Karolinska Solna 24/7

Financial results at Karolinska 2005 - 2010

18

Learning by doing 1993-2010

1993-1996

Outpatient ClinicDpt of Cardiology

1997 – 2004

End-to-End approachMaternity care

Top down & bottom up

2005-2007 2007

120 improvement projectsTQM, Six Sigma, SPC, LEAN85 % success rate short term

Long term?

Huddinge Hospital St Görans Hospital Karolinska

The merger

+

Swedish LEAN AwardSt Görans Hospital

End-to-End approachED/Ward

Top down & bottom up

End-to-End approachED/Ward

Top down & bottom upSupport processes

Days

2010

Delivery ward Maternity ward BA

Maternity ward A

A

Labour painsReferral to first assessment

Sustainableimprovements

2512262011761511261017651261

1:50

1:40

1:30

1:20

1:10

1:00

Week (2006 - 2010)

Doo

r-to

-doc

tor

Sustainable improvements

Challenges from the CEO`s perspective• Other projects

• Make priorities• Continuous productivity improvement

• To involve the whole organisation• Leadership• Staff involvement

• The change agents risk become ”burned”

• Why lean transformation – only to become more effective?

We have set up a value stream management system which sits parallel toour line management structure. We have also put in place supporting structuresincluding an operations management team, improvement teams consistingof staff members, written work standards, procedures for handling deviations,visual management as well as comprehensive data support.

BUT our senior management team is not yet fully committed and has notinvested enough time in learning of LEAN principles and the design of aLEAN transformation. They also do not invest enough time at the ”Gemba” to learn, or intheir managements team meetings to follow up. As a result, some of theirdirect and indirect report areas are also less than fully committed.

The situation is starting to change, but we would like your advice how we can inspireand engage the senior management to get more involved and committed to make the LEAN transformation a core part of their agenda?

Current problem