ISOC Santiago de Chile October 2011 On gains in efficiency, quality and safety in orthopedic hospitals ISOC CEO Meeting Santiago de Chile, October 14,

ISOC Santiago de Chile October 2011ISOC Santiago de Chile October 2011

On gains in efficiency, quality andsafety in orthopedic hospitals

ISOC CEO MeetingSantiago de Chile, October 14, 2011

Peter Hoppener

Sint Maartenskliniek, The Netherlands

Pelle Gustafson

Skåne University Hospital, Sweden


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


Our most important problems:

- The economy

- Quality issues

- Safety issues

- Accessibility

- Future recruitment


1900 1950 2000

% of GDP$ per inhabitant

What healthcare has cost / will cost

What society has paid / will pay

Year

(adapted from WHO 2000)


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?


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)



If a commercial airline operated with the same level of safety as

healthcare (10 %) …



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…



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?...


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?


Future recruitment

Who will do the work?

A global shortage of 5 million healthcare workers is

estimated in the coming 10 to 15 years.


1304/20/23

Lean Healthcare

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

Pelle Gustafson MD, PhD, COO

Department of Orthopedics

Skåne University Hospital

1504/20/23

INTRODUCTION – what is Lean?

1604/20/23

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!

1704/20/23

What is Lean (2)?

1. Find out what to do (know your demand)

2. Find out how to do it (agree on standard)

3. Do what is supposed to be done

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

5. Improve process step-wise by using flaws

1804/20/23

What Lean really is

Value setsAttitudesMindset

Value setsAttitudesMindset

Methods, tools

Principles

1904/20/23

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

2004/20/23

Our common core valuesOur common core values

- The patient comes first- The patient comes first

- Respect the individual- Respect the individual

- Continuously better- Continuously better

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

2104/20/23

CENTRAL OPERATION WARD

2204/20/23

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…)

2304/20/23

Method

• Analysis of demand

• Correct planning

• Mapping of processes

• As much parallel work as possible

• Working group

• External facilitator

2404/20/23

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

2504/20/23

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

2604/20/23

Mapping/designing of process

• Done by working group

• Swim-lane diagram useful

• Remove sequential work, replace with parallel work

• Make role descriptions

2704/20/23

07:15 07:20 07:25 07:30 07:35 07:40 07:45 07:50 07:55 08:00 08:05 08:10 08:15 08:20 08:25 08:30 08:35 08:40 08:45 08:5007:55 op start 08:40 Op-slut

VårdavdFörbereda pat

inför op07.30 Pat 1 till

slussFörbereda nästa pat

Op uskSprita salen, ställa ass-

bord

Hämta opvagn + extrainstr o

ev impl

Assistera dukning

Assistera tvätta och klä

07:55 Operation

Beställa pat 2 + op-vagn + med tek bitr

Fika

Op ssk Läsa in sig på patient

Tvättar sig Duka Tvätta och klä07:55

OperationRäkna ner instrument

Fika

An uskStarta alla

datorerDuka fram till

anestesiHämta MT-utr

Ta emot pat i sluss

Förberda pat 1

Sövning pat 1

Hämta ev MT-utrustn pat 2

FikaInstrument t

sterilenMellanstäda Pat in på sal

An sskKontr av

apparat + Primus

Läsa in sig på pat och dra lm

x 5 pat

Ta emot pat i sluss

Förbereda pat i förb.rum

Sövning pat 1

Kopplar upp och övervakar pat. Dokumenterar

07:55 Operation

Koppla loss allt pat 1

Pat 1 till UVA, rapport

Fika

An läk Fika Pat in på sal

OperatörAnländer och

kollar checklista

Tvättar sig07:55

OperationKoppla loss

allt pat 1Diktera

Op ass Tvättar sig07:55

OperationKoppla loss

allt pat 1Pat 1 till UVA,

rapport

Med tekn biträde

Förbereda och markera op

bord

Opbord till sluss pat 1

Säng parkeras COP?

Förbereda och markera op

bord

Säng pat 1 till slussen

Opbord pat 2 till sluss

Städ

SterilenLeverera op-vagn pat 1 till

sterilförråd

Packa op vagn, pat 2

UVA

Rapport fr operatör och an ssk

07:15 07:20 07:25 07:30 07:35 07:40 07:45 07:50 07:55 08:00 08:05 08:10 08:15 08:20 08:25 08:30 08:35 08:40 08:45 08:50

Testdag 1, 18 maj, ortopedmodulen på COP (en sal)

Beräknad knivtid ca 230 minuterAnvänd modultid (minus lunch o fika): 400 minuterAndel knivtid per använd modultid: 58%Andel knivtid per 510 minuter (dvs max tillgänglig modultid): 51%

2804/20/23

DESCRIPTION

2904/20/23

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

3004/20/23

3104/20/23

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

3204/20/23

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

3304/20/23

Planning 1 - 3 days before surgery

3404/20/23

Planning during surgery

3504/20/23

Feed-back after surgery

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

• Afterwards in working group (systematic)

3604/20/23

RESULTS

3704/20/23

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 35Total 139 235 average 78

• Afterop 1 08.16 08.38 22 32op 2 09.10 09.50 40 50op 3 10.40 11.04 24 94 (incl lunch 30 min)

op 4 12.38 13.42 64 50op 5 14.32 15.05 33Total 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-backIncreased safety

Historical comparison

3804/20/23

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?”

3904/20/23

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)

4004/20/23

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

4104/20/23

4204/20/23

4304/20/23

4404/20/23

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…

4504/20/23

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

4604/20/23

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)

4704/20/23

”Don't have time, got work to do!!”

4804/20/23

DISCUSSION, QUESTIONS

ISOC Santiago de Chile October 2011 On gains in efficiency, quality and safety in orthopedic hospitals ISOC CEO Meeting Santiago de Chile, October 14,

Documents

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harmedisoc santiago

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patient safety issuesif

level of safety

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