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  1. The Strategic Advisory Board Alex Williamson David Stevens Fiona Moss Helen Bevan Jane Smith Nellie Yeo Ross Wilson Rosa Sunol Philippe Michel Penny Carver Wim Schellekens Piera Poletti

  2. Every case tells a story Whole system transformation – the case of JönköpingTo change a system you need a system ”we are learning - fellows and we do it all together”

  3. Merci Paris! Merci France! • From 1789 to 2008 – more than 200 years with big impact…

  4. Merci Paris! Merci France! • From Bernadotte to Björn Borg – from battlefield to kingdom, from sand to grass Jean Baptiste Bernadotte (Karl XIV Johan)King of Sweden and Norway 1818-1844

  5. Merci Improvement Explorers! • From Batalden to Berwick and Bisognano – from practice to theories, from theories to practice

  6. Esther – the patient’s focus Lack of coordination and integration causes complicated solutions

  7. Access in Sweden Specialist Care Access over time 30% 20%

  8. The staff – used as a machine, sheep or engaged individuals

  9. Helth Care Costs 1993 – 2006 (in 2006 level, Billion SEK)

  10. The Changing Landscape of Global Economic Development Robert K Crone, MD

  11. The Changing Landscape of Global Economic Development 1 billion people have a PC and 3 billion people have a cell phone. In India you can buy a car cheaper than anywhere else and a cell phone for 25 Euro!

  12. Better professional development Better patient (population) outcome Everyone Better system performance Ref: Batalden et al

  13. Michael Porter has a different perspective looking at effects of Health Care • Survival • Degree of recovery/health • The time the recovery has taken back to normal activities • Missed access to diagnostic, care or treatment • Durability of the recovery or health over time • The long time effect of therapy/treatment Ref: Porter

  14. We are here to create Value! …and develop-ment strength!

  15. Improvement strength to execute ? Staff Influence and Recognition • Value in Health Care develops over time with Good ideas

  16. Everything starts with a provocation • Let’s develop sustainability and transformation at the same time… Turning Torso in Malmö, Sweden

  17. Our journey Whole system transformation – to change a system you need a system

  18. To Pursue Perfection Secure the delivery of health care and its sustainable and reliable outcome in the perspective of the inhabitants Build a bridge between improvement outcome and reliable outcome Better understand and manageour “unwished” variations in the system of health care in Jönköping

  19. Expected Outcome • Best possible effectfulness on both micro and macro level by having systems for integration and coordination

  20. Health Care in Jönköping County Jönköping County Sweden 11 municipalities 330 000 inhabitants 3 hospitals 34 primary care centers 35 Dental care centers 9 800 employees Regional development support Jönköping Eksjö Värnamo Europe

  21. Improve everything at the same time

  22. Dental Care: Caries-free young people, age 19, in % 1990 – 2006 Andel kariesfria 19-åringar i procent åren 1990 - 2006 Jönköping35 % 2006 Sweden 25% 2005 Ref: Koch, Hugoson

  23. Children with asthma - hospitalization Ref: Gäre, Oldheaus

  24. Responsibility, competence and authority in my work Influence Development in work Work climate/participation Our activities/operations Psychological problems Physical environment Physical problems /stress Summary: satisfaction score Staff and patient satisfaction Summary7,691 answers Negative Positive

  25. Swedish National Quality Award 3 times to Jönköping The Swedish Malcolm Baldridge Award • Dep. of Internal Medicine, Eksjö, 2002 • Dep. Of Technical and Support Services, Jönköping, 2004 • Dep. of Gynecology and Women’s diseases, Jönköping, 2006

  26. Outcome 2007 Part of netto costs Results, annual report 2005 and prognosis for 2006, Counties in SwedenPercent shares of net costs Million SEK Stockholm Uppsala Sörmland Östergötland Jönköping Kronoberg Kalmar Blekinge Skåne Halland Västra Götaland Värmland Örebro Västmanland Dalarna Gävleborg Västernorrland Jämtland Västerbotten Norrbotten Sum Gotland 1 008 182 -6 61 356 1 62 54 475 231 184 18 151 210 26 131 70 42 -16 15 3 515 73 2,2% 2,9% -0,1% 0,7% 5,2% 0,0% 1,3% 1,6% 1,9% 4,1% 0,6% 0,3% 2,5% 4,0% 0,4% 2,2% 1,3% 1,5% -0,3% 0,3% 1,8% -2,0% Outcome 2005 Prognosis 2006 Average for Sweden Jönköping

  27. Ledningsgrupp och sven-olof på bild

  28. Improvement is Work on the Work The knowledge and skills of man are dependent on, and based on, the understanding of ones work. Targama, Sandberg 3 2 Tools and methods help us work on the work • To Act into a New Thinking instead of Thinking about a New Acting: • Project • Infrastructure • Design 1

  29. Step I) Improvement = projects • 100% participate in Breakthrough activities • Identify and prioritize possibilities – what does the patient, customer say? – what does theprocess say? • Rapid improvement cycles • Training for everybody • Learn new habits and ways of working • Project to project, process to process • Development within the units

  30. 1 2 The unit has a balance between capacity and need/demand No waiting list Increase capacity Handle variations Get rid of the back log Reduce need/demand Access Improved Access is Reached by… Ref: Mark Murray

  31. Access Most Common Changes made • Scheduled District nurse receptions • Possibilities to get a first exam from a physiotherapist • Nurse based infection receptions • Better Schedule Planning – capacity and need/demand that fits • Telephone routines - More possibilities to phone, more staff - standardized and documented advices Ref: Strindhall, Henriks

  32. Access Spread of Breakthrough Program “Bra mottagning”1999-2006 Participating teams: 300 Participants: 2000

  33. Available Time within 7 days 0-7-90-90 Health Care Services in Jönköping County

  34. 19 18 17 16 15 14 13 12 4/5 11 10 9 8 7 6 5 5/5 4 3 2 0 1 0 Hospitals in Control group Hospitals participating in QUICC (QUICC) Quality Improvement in Cardiac Care project Number of hospitals that reach 70 % following 4 or 5 out of 5 treatments

  35. 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

  36. Esther BSC Access Pursuing Perfection QBS Care prevention Influenza vaccination QUICC (Heart failure program + Nat. registers) Passion for life Microsystem Quality Awards (QUL) Qulturum Leadership Finances Bridging the Gaps Health promoting primary care centers Dentistry for children Health care for children Measure for management Triple Aim Improve everything at the same time

  37. Result • 122.300 lives were saved • More than 3.100 hospitals participated • Rapid response teams 60 % • AMI Care reliability 77 % • Changes in medication: 73 % • Clinical infections / Bundle of actions 72 % • Ventilator associated pneumonia; bundle of actions: 67 % • Central venous Line, bundle of actions: 65 %

  38. Step 2) Building infra structure • How we get organized!

  39. A Regulation from The Swedish National Board of WelfareWhat Swedish Health Care must be • Safe • Knowledge based and Efficient • Patient focused • Effective • Equal • Timely

  40. Best ICU in Sweden As reported in newspaper and website

  41. National Med. Registers in Sweden

  42. It is the Outcome of the Whole System that Counts! 100% 1% New activities Current activities Continuous improvements Annual Planning and Budget Document Jönköping health care services

  43. “The Diamond”: Strategic Improvement Areas Learning and innovation IT PreventionTaking care of oneself AccessHow we receive Clinical improvement work Coopera-tion/flow Patient safety Envir. Medication Adm Good financesReliability V a l u e f o r p a t i e n t i n c r e a s e s Leadership More than 5.000 participants in collaboratives so far (2007)!

  44. System measures Development areas Development Areas and System Measures as reported in the Budget: Tillgänglighet och bemötande Prevention/Egenvård Kliniskt förbättringsarbete

  45. Measures and Management • 26 teams program 1 • 20 teams program 2 • 16 CEO leadership teams • 44 participants in ”Improvement Advisor” • 80 participants in our own training program • Basic statistics and analysis

  46. Health of the Population Experience of Care Per Capita Cost Ref: Nolan, Whittington Participants from Counties/ Regions in Sweden • Jönköping • Kronoberg • Kalmar • Region Skåne • Blekinge • Värmland • Halland • Norrbotten • Östergötland • Sörmland • Västmanland • Stockholm • Västernorrland • Västerbotten • Jämtland • Dalarna 16 out of 20 counties and The Board for Promoting Society Analysis at the Swedish Association of Local Authorities and Regions