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2012-09-19
1
Centre for Healthcare Improvement (CHI)
Chalmers and Healthcare in Collaboration
For Sustainable Healthcare
CENTRE FORHEALTHCARE IMPROVEMENT
Andreas Hellström, Assistant Professor Svante Lifvergren, M.D. Co-Director, Centre for Healthcare Improvement Co-Director, Centre for Healthcare Improvementandreas.hellstrom@chalmers.se svante.lifvergren@chalmers.se
www.chi.chalmers.se
Centre for Healthcare
Improvement (CHI)• a research and education centre at the Department of Technology and
Economics, Chalmers University of Technology
• organizes cooperation between researchers from different discipline and led by two directors.
• conducts research and education in improvement, innovation and transformation of health care.
• our goal is to collaborate with Swedish Healthcare to create, translate and disseminate research-based and action-oriented knowledge.
• to achieve this goal, CHI focuses on two parts - research and education.
ApproachesOrganizing and managing
• Principles for organizing, organizational learning, how to deliver value, organizational change…
Data-driven operational development• Applied statistics, ”from data to improvement”,
visualization…
Processes and flow• Value focus, capacity planning, coordination,
integration…
Improvement knowledge• Variation, systems understanding, psychology…
Sustainability• Social, financial, environmental…
Action oriented • Action research – interactive research
• Experiential learning
2012-09-19
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CENTRE FORHEALTHCARE IMPROVEMENT
Management research
Healthcare practice
Learning about healthcare developmentLearning about healthcare development
Action research – with (not on) carepractitioners
”The knowledge that is generated shall be both scientifically relevant, and relevant for practitioners. You must be able to use it, and act on it.”
Collaboration throughresearch
• Patient oriented and integrated cancer care processes
• In Search of Sustainable High Quality Health Care
• Decision support system for Warfarin treatment
• Experienced Based Co-Design – to involve patients, relatives and staff in a joint improvement work
• Patient complaints as a basis for improvement work
• Chest-pain – variation in quality, safety and cost
• System dynamics at a Dermatology Department
• Learning micro systems in healthcare processes
• The application of Lean Six Sigma in a healthcare context
• When process orientation meets the functional structures
• Analyses of medication processes
• Prognosis and and tactical planning within surgery
• Reimbursement models and process effectiveness
Action research with interdisciplinary staffing
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Collaboration througheducation
Professional education
• Quality driven organizational development (30 credit)
• Quality Management for senior managers (7,5 credit)
• Advanced improvement knowledge (30 credit)
• Lean healthcare (7,5 credit)
• Improvement knowledge for residents (7,5 credit)
PhD education
– Reflexiv action research (7,5 credit)
– Quality Management (7,5 credit)
– + other courses at Technology Management and Economics
CHI has trained more than 250 managers and improvement leaders within Region Västra Götaland
Education as a catalystfor change
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ApproachesOrganizing and managing
• Principles for organizing, organizational learning, how to deliver value, organizational change…
Data-driven operational development• Applied statistics, ”from data to improvement”,
visualization…
Processes and flow• Value focus, capacity planning, coordination,
integration…
Improvement knowledge• Variation, systems understanding, psychology…
Sustainability• Social, financial, environmental…
Action oriented • Action research – interactive research
• Experiential learning
Reduce variation in INR of patients undergoing warfarin
treatment as a way to eventually decrease mortality
and morbidity
Warfarin treatment• Warfarin – an oral anticoagulant (blood thinning) treatment
effective for the prevention of thromboembolic events in various clinical contexts.
• Serious risks related to Warfarin treatment, thus requiring great care and caution when ordinating Warfarin pills to patients.
• Patients undergoing Warfarin treatment are therefore monitored regularly by blood testing.
• International Normalized Ratio (INR) is usually used to measure the effect of Warfarin treatment.
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International Normalized Ratio (INR)
coagulation time of patient plasma
coagulation time of normal plasma
ISI
INR
• The standard INR range (also called the therapeutic range) for most clinical situations is 2.0-3.0.
Freq
uenc
y
87654321
5000
4000
3000
2000
1000
0
Histogram over INR-values at SkaS in 2005
Probable causes of variation in INR
30%
17%
11%
11%
7%
7%
6%
4%2%
5%
At start up
Drugs added/withdrawn
Ordination routines
Dr doesn't know of ordination
Concurrent disease
Information to patient
Patient compliance
Interruption routines
Lab variation
Other
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VCHEN (INR: 60%)
SiF (INR: 70-75%)
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160140120100806040200
5
4
3
2
1
0
Time in days
Y-D
ata
INRTablets/day
Variable
Plot of INR and number of tablets/day
Hemolysis
Vacutainer canula
constant dimension
2012-09-19
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Venflon with Vacutainer adapter
Note all dimensional changes
Datum
And
el h
emol
ys
2007
-10-1
3
2007
-10-0
7
2007
-10-0
1
2007
-09-2
5
2006
-10-0
9
2006
-10-0
3
2006
-09-2
7
2006
-06-1
3
2006
-06-0
7
2006
-06-0
1
2006
-05-2
6
0,20
0,15
0,10
0,05
0,00
_X=0,0317
UCL=0,0808
Före förändring Efter förändring uppföljning efter 1 år
1
Andel hemolys före och efter förändring
” The Skaraborg Hospital Group (SkaS)……..//……. Using an action research approach, thisarticle describes the lessons thatwere learned from the first 22 Six Sigma projects, completedbetween 2006 and 2008 and having a success rate of 75%.”
Net cost savings per project = 40 000 €
Lifvergren S, Gremyr I, Hellström, ChakhunashviliA, Bergman B(2010) Lessons from Sweden’s firstlarge-scale implementation of Six Sigma in healthcare. Oper Manag Res 3:117–128. DOI 10.1007/s12063-010-0038-y
2012-09-19
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ApproachesOrganizing and managing
• Principles for organizing, organizational learning, how to deliver value, organizational change…
Data-driven operational development• Applied statistics, ”from data to improvement”,
visualization…
Processes and flow• Value focus, capacity planning, coordination,
integration…
Improvement knowledge• Variation, systems understanding, psychology…
Sustainability• Social, financial, environmental…
Action oriented • Action research – interactive research
• Experiential learning
A physician-led, and learning driven approach to the regional
development of 23 cancer pathways in Sweden
The cancer challenge• Every third person in Sweden at some point in their lives has experience
of cancer. That amounts to 50 000 patients a year = one new admission every ten minutes.
• Projections suggest that the number of men with cancer in 2030 will be almost 130 % more than today - the corresponding increase for women is around 70 %.
• Cancer care is:– highly decentralized – involves most levels of care. – highly multi-professional activity– fragmented– long and varying delays – a general lack of patient orientation.
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• 4 Patient centred criterias• 3 Criterias regarding training, knowledge
management and research• 3 Criterias regarding the organizing of RCCs
National cancer strategy
Learning about healthcare developmentLearning about healthcare development
”The knowledge that is generated shall be both scientifically relevant, and relevant for practitioners. You must be able to use it, and act on it.”
Centre for Healthcare
Improvement
Regional Cancer Centre West
Project Design
Agreed-upon core principles… so far
• Patient focused• Physician-led• Learning driven• Systems approach• Positive and opportunity-driven• Research informed
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Bladder cancerBrain tumorBreast cancerCervical cancerCervical cancer preventionChildhood cancerColorectal cancerColorectal cancer screeningCorpus cancerEarly detectionEsophageal cancer
Gastric cancerHead and Neck cancerKidney cancerLeukemiaLiver cancerLung cancerLymphomaMalignant skin tumorsOvarian cancerMammography
MyelomaPalliative carePancreatic cancerPenile CancerPrimary tumor unknownProstate cancerSupportive careThyroid cancerVulvar and vagina
A process oriented viewPatient process
Care team
Regional process group
Regional cancer centre
Community Control
CureCare
Customer
4 + 1 C
Glouberman & Mintzberg 2001
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Customer involvement• Experience-based codesign (patients and close relatives)• Patient Associations• Patient diaries• Young Cancer• …
Appreciative Inquiry: 4 + 1 C
• Different ways of creating value (value logics)• Resource consumption (CPP-data)• Effectiveness and production planning• Developmental dialogues• Early detection• Palliative care• Support for cancer survivorship• Patient diaries• KPI for tumour processes• …
Support for innovations- ongoing initiatives
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Value logic – production logic• We need different production logics to create value for
our patients–”How we organize people, competences, services,
standards and procedures at at a certain time in the system”
Sven, 62• No earlier diseases• Former football player• Accelerating pain from left hip• Severe arthrosis• Needs:
–New hip prosthesis including a swift, efficient and safe process
Process: Hip replacement
Diagnos Preparation Operation
Rehabilitation Final evaluation
Need:•New hip
Output:•Improvedfunction•No pain
•Arthrosis
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Anna, 40• Discovered a tumor in left breast• Needs:
–Immediate diagnos –Plan for futher treatment–Relieve anxiety
(One-stop) Solution workshop – Patient center
Specialist-läkare
Specialist-ssk
Specialist-läkare
Specialist-ssk
Specialist-läkare
Specialist-ssk
Specialist-läkare
DiagnosCare plan
Örjan, 76• Diabetes and congestive heart failure for many years• Severeal visits to in- and outpatient clinics• Needs:
–Safety and good quality of life at home–No admittances to the hospital–Be able to monitor and ”treat” exacerbations at
home–A trustworthy contact nurse, easy to get hold of–Be able to meet other patients with similar
experiences
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Network logic
• Self monitoring• Patient co-produces care• Coordinating centre• Mobile teams
Healthy elderly people
Elderly people withone or two stable chronic
diseases and taken care of by the ’ordinary’ care system
Elderly people with multiple chronic diseases but in stable condition and taken
care of by the ’ordinary’ care system
Elderly people with multiple chronic diseasesin unstable condition and taken care of by the
integrated mobile care team
7% of elderlypopulation
0.2%
Figure 2. Conceptual figure developed by the team together with the researchers that illustrates the different proportions of elderly people with different care needs in the actual area
Lifvergren et al. (2012) Learning microsystems in Healthcare
Different business models
• High volume, high quality, low cost
• Unique service, one stop shop
• Health promotion, prevention, upstream, behavioral aspects
2012-09-19
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Primär prevention
Screening hälsokontroll
Palliativ vård
Symptom-utredning
Diagnos
Behandlings-utredning
Primär behandling
Tilläggs-behandling
Individuell vårdplan
Rehabilitering
Kronisk sjukdom
Psykosocialt stöd
Uppföljning behandling
ApproachesOrganizing and managing
• Principles for organizing, organizational learning, how to deliver value, organizational change…
Data-driven operational development• Applied statistics, ”from data to improvement”,
visualization…
Processes and flow• Value focus, capacity planning, coordination,
integration…
Improvement knowledge• Variation, systems understanding, psychology…
Sustainability• Social, financial, environmental…
Action oriented • Action research – interactive research
• Experiential learning
2012-09-19
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0
25
50
75
100
125
150
175
200
225
# o
f d
ea
th-f
ree
ca
se
s b
etw
ee
n
Death case #
g-chart
# of death-free cases between UCL CL LCL
Deaths, Miami Children
-0,20000
-0,10000
0,00000
0,10000
0,20000
0,30000
0,40000
0,50000
0,60000
1 110 219 328 437 546 655 764 873 982 1091 1200 1309 1418 1527 1636 1745 1854 1963 2072 2181 2290 2399 2508 2617 2726 2835
EW
MA
Surgery #
EWMA chart
EWMA
UCL
2012-09-19
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t-chart (övervakning av hjärtstoppsförekomst) - utan HIVA
0
10
20
30
40
50
60
70
80
90
HjS1
HjS2
HjS3
HjS4
HjS5
HjS6
HjS7
HjS8
HjS9
HjS10
HjS11
HjS12
HjS13
HjS14
HjS15
HjS16
HjS17
HjS18
HjS19
HjS20
HjS21
HjS22
HjS23
HjS24
Hjärtstopp nr
Tid
me
llan
hjä
rtst
op
ps
fall
(an
tal d
agar
)
t Sö CL Su
Önskvärd riktning
ApproachesOrganizing and managing
• Principles for organizing, organizational learning, how to deliver value, improvement work…
Data-driven operational development• Applied statistics, ”from data to improvement”,
visualization…
Processes and flow• Value focus, capacity planning, coordination,
integration…
Improvement knowledge• Variation, systems understanding, psychology…
Sustainability• Social, financial, environmental…
Action oriented • Action research – interactive research
• Experiential learning
For more info:
www.chi.chalmers.se
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