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On gains in efficiency, quality and safety in orthopedic hospitals ISOC CEO Meeting Santiago de Chile, October 14, 2011. Peter Hoppener Sint Maartenskliniek, The Netherlands Pelle Gustafson Skåne University Hospital, Sweden. ISOC Santiago de Chile October 2011. Agenda.

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On gains in efficiency, quality and

safety in orthopedic hospitalsISOC CEO MeetingSantiago de Chile, October 14, 2011

Peter Hoppener

Sint Maartenskliniek, The Netherlands

Pelle Gustafson

Skåne University Hospital, Sweden

ISOC Santiago de Chile October 2011


Agenda

  • Introduction and background 10.30 – 10.45

  • Short description 10.45 – 11.00

    • Lean

    • ToC

    • Six Sigma

  • Cases presented 11.00 – 12.00

    • Sweden

    • The Netherlands

  • Discussion 12.00 – 12.30

ISOC Santiago de Chile October 2011


Our most important problems:

- The economy

- Quality issues

- Safety issues

- Accessibility

- Future recruitment

ISOC Santiago de Chile October 2011


% of GDP

$ per inhabitant

What healthcare has cost / will cost

What society

has paid / will pay

(adapted from WHO 2000)

1950

2000

Year

1900

ISOC Santiago de Chile October 2011


Quality issues

  • How do we know:

    • how good we are (absolute measure)?

    • if we are good enough (relative measure)?

    • where we are not good enough?

    • where we are better than good enough?

ISOC Santiago de Chile October 2011


Patient safety issues

  • Those who measured found:

  • In around 10 % of all contacts with healthcare, the patient was either in risk of harm or de facto harmed

  • The fraction of care-related infections is around 10 %

  • Swedish orthopedic department: 15 % of patients experienced some kind of care-related harm (e.g. infection, DVT, overfull urinary bladder)

ISOC Santiago de Chile October 2011


Patient safety issues

If a commercial airline operated with the same level of safety as healthcare (10 %) …

ISOC Santiago de Chile October 2011


Patient safety issues

If a commercial airline operated with the same level of safety as healthcare (10 %) …

we would consider it acceptable that during an ordinary domestic flight 10 to 15 passengers were either at risk of being harmed, or were de facto harmed…

ISOC Santiago de Chile October 2011


Patient safety issues

In 2010, one of 1 600 000 commercial flights ended in a crash…

How many of 1 600 000 elective operations ended in a crash?...

ISOC Santiago de Chile October 2011


Accessibility

Swedish healthcare has results and outcomes among the best in the world…

Still, we were ranked 22nd in the world in 1999, and 16th in Europe in 2006.

Why?

ISOC Santiago de Chile October 2011


Future recruitment

Who will do the work?

A global shortage of 5 million healthcare workers is estimated in the coming 10 to 15 years.

ISOC Santiago de Chile October 2011



Lean Healthcare- what is it and how can it be used during surgery? -

Pelle Gustafson MD, PhD, COO

Department of Orthopedics

Skåne University Hospital


INTRODUCTION – what is Lean?


What is Lean (1)?

  • Know your demand

  • Separate “true demand” from “failure demand”

  • Identify “value” and “non-value”

  • Design against demand

  • Eliminate waste

  • Use the expertise of the employees

  • Make sure learning is reintroduced into work

  • Continuous improvement

  • Keep customer in focus!


What is Lean (2)?

  • Find out what to do (know your demand)

  • Find out how to do it (agree on standard)

  • Do what is supposed to be done

  • Make it possible to identify flaws (why? x 5)

  • Improve process step-wise by using flaws


What Lean really is

Value sets

Attitudes

Mindset

Principles

Methods, tools


Our Lean history

  • Serious work since 2007

  • Done in line-of-command by chiefs/heads

  • Internal staff- and education support

  • Facilitators but no external consulting

  • 5S in wards and outpatient clinic

  • Hip fracture line

  • Section of artroplasty

  • Central operation ward

  • Emergency department


  • Our common core values

    • - The patient comes first

    • - Respect the individual

    • - Continuously better

      • All we do should be based on these 3 principles!



Problems

  • Capacity; 1 200 annual elective operations not enough

  • Staffing; not fully staffed, high turnover

  • Organization; recent change (2008-01-01)

  • Quality, safety; not good enough

  • Effectiveness; bad use of resources

  • Many improvement projects tried over the years

  • Giant frustration (expressed in many ways…)


Method

  • Analysis of demand

  • Correct planning

  • Mapping of processes

  • As much parallel work as possible

  • Working group

  • External facilitator


Analysis of demand

  • We have to:

    • do 1 600 elective orthopedic operations per year

    • do all kind of orthopedic operations

    • increase quality and safety

    • incorporate continuous improvement in process

    • do this in the same facilities and with the same staff


Correct planning

  • We need to:

    • 2 months ahead

      • know how many theatres we can use

    • 3 weeks ahead

      • make coarse planning (name, operation, equipment)

    • 1 - 3 days ahead

      • make detailed planning (process planning)

    • during day

      • know what happens so we can plan next surgery


Mapping/designing of process

  • Done by working group

  • Swim-lane diagram useful

  • Remove sequential work, replace with parallel work

  • Make role descriptions



Description

  • Description of process:

    • Planning in several steps (early, 1-3 days before, during day)

    • Preoperative meeting and planning

    • The working group

    • Deal, not order

    • Descriptions of various functions

    • Continuous improvement


Early planning

  • Estimated need 1 600 elective operations per year

  • COP gives note of capacity at least 2 months in advance

  • 3 weeks before surgery

    • coarse planning (name, planned operation, need of equipment)

    • how many operations (how much do we need or dare?)

    • confirmed communication

    • information spread to those who need:

      • Central Operation Ward

      • Unit for sterile goods


Planning 1 - 3 days before surgery

  • Detailed planning

  • What to do, when to do it

  • Deal (not order!) is made

    • on paper

    • displayed on the walls in the theatre

    • shared with those who now need to know:

      • wards

      • unit for sterile goods

      • postoperative ward

      • assistants / cleaning




Feed-back after surgery

  • Directly during / after the day (“quick-fixes”)

  • Afterwards in working group (systematic)



Historical comparison

  • Start Finish Op-time (min) Change-over (min)

  • Before

    • op 1 08.34 08.52 18 79

    • op 2 10.11 11.07 56 116 (incl lunch 30 min)

    • op 3 13.03 13.33 30 70

    • op 4 14.43 15.18 35

    • Total 139 235 average 78

  • After

    • op 1 08.16 08.38 22 32

    • op 2 09.10 09.50 40 50

    • op 3 10.40 11.04 24 94 (incl lunch 30 min)

    • op 4 12.38 13.42 64 50

    • op 5 14.32 15.05 33

    • Total 183 196 average 49

  • Feed-back 15 minutes

  • Op-time + 31 % (183/139)

  • Change-over - 17 % (196/235, however one extra change)

  • Average change-over - 38 % (49/78)

  • Time for feed-back

  • Increased safety


Soft results

  • ”it's fun to work!”

  • ”what a teamwork!”

  • ”today we worked as a team!”

  • ”intense but fantastic day”

  • ”we have stopped waiting for each other”

  • ”horrible, so stressing!”

  • ”good to hear what has been done from the surgeon!”

  • ”much cooler and softer work, I wonder why?”


Experiences

  • The productivity can be increased by at least 30 %

  • The patient safety can be increased

    • common picture of what should be done

    • less open doors, shorter communication chains

  • Large improvement potential by team-work

  • Several small improvements can quickly be found

  • The predictability can be dramatically increased:

    • large improvements for cooperating units

    • large internal gains (eg. lunch breaks can be planned)


Lessons learned…

  • Improvement not loved by everyone!

  • Management needed!

  • Frustrating to know it is possible but not see it happen!

  • More behavioral science that technical solutions

    • what should the cost be for not making / keeping a deal?

    • take the ego out of the equation

    • some people simply do not think in processes


More lessons learned…

  • Standardization needed (positioning, draping, etc)!

  • Computer or paper?

  • Time not to be chased, but used to improve!

  • Deals have to be kept!

  • Do not forget to learn from what happened!

  • Use the walls!

  • Find balance between bosses involvement and not…


Present status

  • At present halted due to renovation and ventilation works

  • Restart in November 2011

  • Most important changes:

    • planning meeting same morning to enhance team-work

    • more discipline throughout

    • more feed-back to staff


What is it really about?

  • Gather the group!

  • Make deals about why, what, who, when, and how!

  • Keep the deals!

  • Make sure experiences are reintroduced!

  • Be persistent!

… there is no such thing as a Lean project – only Lean work …

… to carve mistakes in sand, and success in stone…(B Franklin)




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