Value Development

and Productivity as

Keys in

modernizing and

co-designing health

and care

Quality as Business

strategy.

When art meet science, Singapore Sep 2016

http://www.marinabaysands.com/museum/future-

world/town.html#BfIhrXsybsKFxAPQ.97

• Thank you!

• Singapore

• Iceland

• Sweden

Alexandra Primary’s

RJL fantastic colleagues… in different microsystems

They love their work as complexists and futurists

www.catalhoyuk.com

Neolithic (≈ 6-7000 BCE) Catalhoyuk, Turkey

Work with the work!

• From volume to value

• Focus on

experiences and

outcomes and

reducing cost

• Search for new

models

2016-10-28

The new ideas ……

• Individuals and families are partners in

their care and care processes

• Competition about value , with continuous

reduction in operating costs

• Reorganize services to align with new

incitaments ideas and process redesign

• Everyone is an improver/learner

2016-10-28

Professor in Resilience

• ‘It is not enough to do your best; you

must know what to do,

and then do your best’ W. Edwards

Deming

• "Organising is a form of leadership that

enables a constituency to turn its

resources into the power to make

change." Marshall Ganz

• "The goal is to turn data into

information and information into

insight." Carly Fiorina

Assurance: The Four Leadership Questions

• Do you know how good you are?

• Do you know where you stand relative to the

best?

• Do you know where the variation exists?

• Do you know the rate of improvement over time?

Region

Jönköping

County

1)More engaged,

activated patients and

better health outcomes

2)Better knowledge of

one’s illness and

capacity for self-

management

3)Health systems

adopting processes

and achieving

outcomes that matter

to patients

4)Find ways of

managing healthcare

costs

Redefining Health Care – Creating

value based Health Care, p 376-377,

Porter,Teisberg

• ”In tertiary care Sweden has national

competition…….Swedish hospitals vigorously pursue

quality improvement, with ongoing benchmarking ,

against world best hospitals. The results of this

competition on value are striking. In one of the most

progressive lans, Jönköping, for example, the rates of

infection and mortality from errors are about one-fifth

of those leading American hospitals for patients with

the same conditions”

• Easy to have a healthy lifestyle here

• Healthcare at the top of the league

• Clean air

• Green areas

• Healthy food

• Excellent public transport

According to this report:

One of ten

healthiest areas

in the world

Ranking list,

County Hospitals:

1. Ryhov

4. Värnamo

Höglandet, strongest

”runner up”

Please see me

https://www.youtube.com/watch?v=380MiMDoddI&app=desktop

Anette Abrahamsson, Annmargreth Kvarnefors and Göran Henriks

……

Treat me like a fellow human being

Give me knowledge

Look into my eyes

and imagine you are me

Listen to me

Talk with me, not to me

Let my family

be part of my health care

Meet me with respect

……

Let me be a part of my own care

Don’t let me be reduced

Change the Balance of Power • Ryhov Hospital in Jönköping had traditional hemodialysis

and peritoneal dialysis center.

• But in 2005, a patient, Christian, asked about doing it

himself.

Autonomy and authority

Easy to come in easy to get out

• Dörr här

Taking ”self-management” to the edge

Patrik Blomqvist, patient supporter Eje Grennborg, rehab instructor

New ways of making the consultations

Koloncancerprojekt

The Microsystem Festival March 1–4 2016 plus.rjl.se/microsystemfestival

Referens Patrik Sundström

Care Care as a distance- and imaging business

• https://vine.co/v/iTPjpdYWWXn

2016-10-28

2016-10-28

(ange enhet via Infoga sidfot)

To create a better everyday life for the many people/IKEA.com

Amount of deaths in different ages

Amount of deaths in different ages

In percent, increased amount of citizens and the

demographic demand in Sweden

Patient focused ”activities and part of processes

are organized after Prioritated patient values"

Pat söker primärvården

Undersökning primärvården

Undersökningar Sjukhuset

Diagnos & beslut om åtgärd PV/ Sjukhuset

Rehabilitering Primärvården

Behandling Sjukhuset

Rehabilitering Kommunen

Esther Primary care areas (6)

Rehab Akuten Medicin

Högland hospital

Communities (6)

Traditional "functional"

patient

treated pat

ill

Lab

Pharmacy

Esther From traditional healthcare to Process thinking

Hospital admissions fell from approximately 9,300 in 1998 to

prognostic 7,300 in 2003.

Hospital days for heart failure patients decreased from

approximately 3,500 in 1998 to 2,500 in 2000.

Waiting times for referral appointments with neurologists

decreased from 85 days in 2000 to 14 days in 2003.

Waiting times for referral appointments with

gastroenterologists fell from 48 days in 2000 to 14 days in

2003.

Esther-results

2016-10-28

I have access to the care I need

2016-10-28

There are reasonable waiting times at the care centers

2016-10-28

My trust for the health and care centers in my region

2016-10-28

Overall trust for health and care services in your

region

2016-10-28

Your impression as a whole – largest amount of

positive answers in the whole of Sweden: Rydaholm

2016-02-09 Regionlednigskontoret

Net cost development accumulated adjusted

Region Jönköping lower than average

average

Health Care as a complex system

2016-10-28

• A large number of interactive units

• The interactions are nonlinear, small changes can

have major consequences

• The systems are dynamic, the whole is greater

than the sum of its parts, and the solutions can

not be imposed

• The systems have a history, and the past is

integrated with the present, the units changed,

and the changes are irreversible

• Wisdom does not lead to proactivity because

external conditions and systems change all the

time

Challenges that changed the roles and

functions of doctors and nurse

• Before 1910 Craftsmen and apprentices

• 1920 Scientific bases grows

• 1980 Understanding of system

performance

• 1990 Costs

• 2000 Accountability and transparency

• 2010 The care you receive depends on

where you live, not what you need

• 2015 Health - what generates health

Health and Care

Wellness Prevention

Diagnostics Treatment

http://www.svd.se/en-trist-trappa-forvandlas-till-ett-piano-leklust-och-fortrollning

Peoples actions are not directed by external

factors as rules and instructions

Instead the actions seems to be based on

peoples own understanding of the situation

Sandberg, J. & Targama, A. (2013). Ledning och förståelse Lund: Studentlitteratur

For both professionals and patients - Essence of co-learning

What matter´s to you?

”All services are in one or the

other way co-produced, co-

designed”

- We need new models of care!

2016-10-28

Utvecklingskraft 2016

Maureen

Defining Patient Involvement

Image courtesy of Region Jönköping

County

Thepa entinthecenter Thepa entasapartoftheteamandtheirneedsandpreferencesatthecenter

Pa entneedsandpreferences

A new way of thinking – value logics

• We develop value by better meeting the

wholeness of the patients and relatives needs

– Different groups have different needs

– The same citizen have different needs during

the toal lifecycle

• How do we collaborate to meet the different

patients groups needs and increase the value of

the services?

2016-10-28

(ange enhet via Infoga sidfot)

• Normann R. Reframing business: when the map changes

the landscape. Chichester, UK: Wiley, 2001.

• Bate P, Robert G. Bringing user experience to health care

improvement: the concepts, methods and practices of

experience-based design. Oxford: Radcliffe Publishing,

2007.

• Armstrong, Lisa Opipari-Arrigan and Hans Hartung Maren

Batalden, Paul Batalden, Peter Margolis, Michael Seid, Gail

Coproduction of healthcare service BMJ Qual Saf published

online September 16, 2015

Promote health and prevent illness

Parents

education

Palliative

care

Children with

different care

needs

Fragile elderly

multi disease

Now

Tomorrow

Value models

2016-10-28

Utvecklingskraft 2016

Karl, 62

• Earlier totally healthy

• Active sportsman

• Last 3 years pain in the hip

• X-ray shows a bad hip

• Need to get a new hip quickly

Hip fracture processes

Funktionella resultat Kliniska resultat Resultat patienterfarenheter

Resourcescosts

Regional medicinsk programgrupp ortopedi Resultatrapport utifrån Värdekompass

Sydöstra sjukvårdsregionen

• Funktionella resultat EQ5D i samband med

höftledsplastikkirurgi och ryggkirurgi

(diskbråckskirurgi och spinal stenoskirurgi)

• Promenad – diff preop/1 år postop (spinal

stenoskirurgi)

• Upplevd bensmärta - diff preop/1 år postop

(diskbråckskirurgi)

• Oönskade händelser inom 30 dagar efter

knä- eller höftprotesoperation,

• Djupa infektioner (Infektionsverktyget)

• Höftledsplastikkirurgi

- Reoperationer < 2 år

• Höftfraktur

- Andel protesopererade

- Väntetid akutmottagning – operation

• Relativ revisionsrisk 10 år knäprotes

• Andel i höftartrosskola

• Tillgänglighet

Aktuellt väntetidsläge ur Väntetider i

vården

• Patientnöjdhet

- Upplevd nöjdhet ett år efter

höftledsplastikkirurgi

- Delaktighet, bemötande, information,

tillgänglighet, upplevd nytta, för-

troende, ur NPE – nationella

patientenkäten

M Bergeling/2012

• Average length of stay in connection with the hip and knee

surgery

• Average length of stay associated with spinal disc surgery

and stenos-surgery

Resurser resultat

Motala har ej system som möjliggör

uppdelad data (höft/knä) 2010

M Bergeling/2012

Kommentar: En klar minskning av vårdtid över tid. Fortfarande stora variationer. Elektiva enheter kortaste vårdtiderna.

Hip replacement

Resurser resultat

Motala har ej system som möjliggör uppdelad

data (höft/knä) 2010

M Bergeling/2012

Kommentar: En klar minskning av vårdtid över tid. Fortfarande stora variationer

Knee replacement

M Bergeling/2012

Kommentar : Klart minskande trend. Ingen skillnad. Lika som riket.

Spinal stenos surgery

Elsa, 86

• Diabetes and heart failure for many years

• Many visits at the hospital

• Need

– Trust and good life quality in the home

situation

– Avoid acute visits to the hospital

– Contact with other patient with similar

experiences

Anette Abrahamsson, Annmargreth

Kvarnefors and Göran Henriks

Mobile Geriatric Team

• Film: youtube….

https://www.youtube.com/watch?v=lTfzq5FqATs

Reference: Daniel Gustavsson and Marina Sumanusova

Senior alert - Care prevention for elderly

and a Swedish national quality registry

Prevention in several areas

simultaneously

Risk

of

fall

Risk of

pressure

ulcer

Risk of

mal-

nutrition

In hospital, primary health care, nursing home etc

Risk of

bad oral

health

Risk of

inconti-

nence

Care

prevention

Risk-

assess-

ment

Team

based

analysis

Preven-

tive

inter-

vention

s

Evalu-

ation

Dis-

charged

/

informa

-tion

Register in Senior alert

020406080

Oral ealth

0102030

Pressure ulcers

0

10

20

30

40Weightlosses

0

10

20 Falls

Actions

It´s getting better! Systematic care prevention in Swedish nursing

homes

2011 2015 100%

Reduction of falls

An example from a municipality

Pressure ulcers are reduced

Municipalitie

s

County councils

%

Region

Jönköping county Regions and

county councils Municipalities

Weightlosses >5% are reduced

2011-2015

municipalitie

s

County councils

• Municipalities: 14%→ 12%

• County councils: 5%→ 4%

Better oral health

Less oral problems

with

- oral mucosa

- teeth

- saliva

- gum

County councils

Municipalities

Percentage with at least one ”2” or ”3” in ROAG

Follow the preventive care online with Senior alert

Get started Follow

the process The outcome

Sweden knows more about risks

among the elderly (age 65+)

• Risk of fall 66%

• Risk of malnutrition 59%

• Risk of bad oral health 48%

• Risk of pressure ulcers 23%

• No risk 17%

Support to the citizens

2016-10-28

(ange enhet via Infoga sidfot)

Learning cafe for young Tomorrows open care

for young

Work to people with mental handicap

Passion for life

Health ambassadors

Dancing with young

And Parkinson

Value center

Surgent

Specialist

nurse

Oncologist

Contact

nurse

Radiologist

Socail

worker

Pathologist

Diagnostics and

treatment plan

Anna, 40

• Previously healthy

• Have in her breast that´s worrying her

• Need

– Need a diagnoses very quickly

– Clear information

– When treated?

– Quick and safe

– How long will the treatment last?

The patient's path through ERAS* *Enhanced recovery after surgery

Contact

and

decisions about

surgery

Preoperative Intraoperative Postoperative Follow-up

Preoperativ tarmrengöring

Antibiotika-profylax

Trombos-profylax

Förberedande information/rådgivning till

patient

Pre-

medicinering

Vätske- och kolhydrat-belastning

Näringsintag och

näringsstatus

Fasteregler

Förebygga illamående/kräkningar

Ventrikelsond

KAD-rutiner

Mobilisering

Tarm-stimulerande

medel

Epidural anestesi - EDA

Förebygga illamående/kräkningar

Vätske-behandling

Näringsintag (näringsdryck,

iv näring)

Läkemedel för smärtlindring

Förberedande information/rådgivning till

patient

Hemskrivnings

kriterier

Förberedande information/rådgivning till

patient

Granskning av följsamhet till riktlinjer och

resultat

Uppföljning efter

utskrivning/operation

Inregistrering i EIAS

Sweden ERAS

Prevention Screening

Health c.

Symptom

investigation

Diagnos

Treatment

investigation

Primary

treatment Added

treatment Follow-up

Individual

careplan

Psychological and

social support Rehabilitation

Chronic

disease

Palliative

care

2009 2010 2012

Patrik

From patient to employed

From patient to patient support

Update

• Now calculated costs at 50% of costs in other

hemo-dialysis units

• Complications dramatically reduced and

subsequent expensive care avoided

• Measuring success by “number of patients

working”

Ejje https://vimeo.com/55094566

Good life close

Reference:

Österstad Ulf ulf.osterstad@rjl.se

Carlsson Johan johan.carlsson@rjl.se

Larsdotter Charlotta <charlotta.larsdotter@rjl.se>

Café House of Health – about life,

autonomi and authority

• For patients with chronic diseases and

relatives

• Focus on health and well-being

• Supports the living of life with chronic

conditions , maintaining autonomy

• The possibility of support and hope through

conversations with other people experience

Exnovation and resilience

• The day-to-day practice unfolds in

a space as normal to illegal, Ref:

Amalberti and colleagues

• A way the employees develops

collective competence (Boreham

et al., 2000) so they together can

make it possible for them to design

a net of safety procedures.

Learning and change

among the players,

and growth in their

sophistication about

each other, about the

issues, (Innes and

Booher, 1999: 12).

For a Good Life in an Attractive Region

Ve

rsio

n 2

5 S

ep

tem

be

r 2

01

5

Very good Best possible

Patient satisfaction

Take care of the problems

Person centered care

Prevention and plan for the next

step

Reduce over, under and misuse

Standardize work and

specialization

Run faster/more resources

Everything everywhere

Good examples Faster diffusion – equal

care

Strategic principles

Healthier life

Radical

individualism

and social

trust

Together for best possible and equal care

All parts optimize health issues

Microsystem Patients and professionals

Meso

Primary care Medicine

Surgical

Psychiatric

Makro Governance

Before Tomorrow

Primary care is the entrance – specialty care on demand

• https://vimeo.com/163250855

• http://plus.rjl.se/infopage.jsf?childId=15028&nodeId=31716

Improved learning platforms

2016-10-28

Learning on the away

court

(within the platform)

Learning at home

Learning at home

and away Tests

(acting)

Tests

(acting)

Reflection

(dialogues)

Reflections

(dialogues)

Tests

(results)

Tests

(results)

Support knowledge

development

(for examples concept

renewal

Arbetsplatsresultat ur

ett patientperspektiv

Reference: Ellström

A way to transform the culture?

Change the

whole culture

of the

company

Change the

attitude of

individuals

Change

behaviour

Nya arbetssätt

metoder& verktyg

New way to work and to use

methods and tools

”We act into a new

way of thinking”

Deming, Norman