- mikael forss - karolinska university hospital - ls10 - 02.11.10 - pptshown at the Lean Summit 2010 - New Horizons for Lean Thinking on 2/3 November 2010

1. Improving patient flows
with an End-to-End approach
Mikael Forss
Deputy CEO
Katarina Andersson, Gustav Hjelmgren, Olof Vallin
Change agents, Operations Management

2. Karolinska University Hospital
- one of the largest hospitals in Europe
Solna Huddinge
15 miles
600 patients/day in our ED:s
1,680 beds
109,000 admissions/year
1,7 million patient visits/year
County council owned
• Patient care
• Research
• Education
15 000 employees

3. Karolinska´s main strategies
Change culture and daily routine work
– Create safety culture
– Improve leadership
Lean transformation
– Process orientation and continuous improvements
– Develop process oriented management
– Change in culture as a result
Create Academic Health Care System in Stockholm
– Strengthen clinical research
– Increase cooperation between health care, academy and industry
3

4. 4
Learning by doing 1993-2007
1993-1996
Outpatient Clinic
Dpt of Cardiology
1997 – 2004
End-to-End approach
Maternity care
Top down & bottom up
2005-2007 2007
120 improvement projects
TQM, Six Sigma, SPC, LEAN
85 % success rate short term
Long term?
Huddinge Hospital St Görans Hospital
Karolinska
The merger
+
End-to-End approach
ED/Ward
Top down & bottom up
D
a
y
s
2010
Delivery ward Maternity ward B
A
Maternity ward A
A
Labour painsReferral to first assessment

5. End-to-End approach
ED Ward
X-ray
Lab
X-ray
Lab
OR

6. Our improvement model
Q
Phase 1
Redesign
Test/Learn
Phase 2
Implementation
Phase 3
Continuous
Improvement
Time

7. Value stream management system
ED Ward
X-ray
Lab
X-ray
Lab
OR
Value stream leader
Improvement team
Value stream
management team

8. Value stream management in practice

9. Current status
ED*
(16)
Ward*
(19)
X-ray* (5)
Lab* (2)
X-ray (5)
Lab (2)
OR
(2)
16 patient flows:
•Internal Medicine
•Surgery
•Orthopeadics
•Gynecology
•Ear-Nose-Throat
•Pediatrics
•Infectious diseases
•Neurology
95% of ED patient flow
* Statistically significant changes in patient oriented measures

10. Improved ED patient experience
%0 20 40 60 80 100
”Always/Almost always” got help when needed
Should ”on the whole” recommend Karolinska University Hospital
” On the whole” organised in a good way
”Acceptable” waiting time to see a physician
See a physician within 30 minutes
”Acceptable” waiting time to see a physician
”On the whole” satisfied with information about the medical condition
Was given information about expected waiting time to physician evaluation
Cooperation of the work force ”Very good”
Left the ED within 3 hours
2007
2009
All significant changes in the patient inquiry 2007 to 2009 are presented above

11. End-to-End LoS for admitted patients
jul 2010
jan
2010
jul 2009
jan
2009
jul 2008
jan
2008
jul 2007
jan
2007
jul2006
jan
2006
78:00
72:00
66:00
60:00
54:00
48:00
Months (jan 2006 to oct 2010)
End-to-EndLoS(mean)
Before Impl ED:s Impl first ward
Arrival at the ED until leaving the hospital for admitted patients
10 wards at Karolinska 24/7

12. Door-to-doctor time
30 min reduction 24/7
40 min reduction weekdays 8 AM – 4 PM
2010-42
2010-17
2009-45
2009-20
2008-47
2008-22
2007-49
2007-24
2006-51
2006-26
2006- 1
2:00
1:40
1:20
1:00
0:40
0:20
0:00
Week (2006-1 to 2010-42)
Door-to-doctor(mean) Before Tests Implementation
Door-to-doctor time
16 ED:s at Karolinska 24/7

13. Number of patients waiting for doctor each hour
Patients
Hour

14. Discharged before 12 AM
2010-18
2009-45
2009-20
2008-47
2008-22
2007-49
2007-24
2006-51
2006-26
2006-
1
40%
30%
20%
10%
0%
Week (2006-1 to 2010-42)
Dischargedbefore12AM(mean)
Before Tests Implementation
10 wards att Karolinska University Hospital 24/7

15. X-ray total turn-around time
jul-sep
2010
jan-m
ar 2010
jul-sep
2009
jan-m
ar 2009
jul-sep
2008
jan-m
ar 2008
jul-sep
2007
jan-m
ar 2007
jul-sep
2006
jan-m
ar 2006
3:20
3:00
2:40
2:20
2:00
1:40
Quarter (jan 2006 - sep 2010)
Totalturn-aroundtime(mean)
Before Significant change
Time from first doctor asessment to avaliable X-ray result
CT Brain at all ED:s in Karolinska Solna 24/7

16. Clinical Chemistry total turn-around time
okt2010
aug
2010
jun
2010
apr 2010
feb
2010
dec
2009
okt2009
aug
2009
jun
2009
apr 2009
feb
2009
dec
2008
okt2008
2:10
2:00
1:50
1:40
1:30
Months (oct 2008 - oct 2010)
Totalturn-aroundtime(mean)
Before Significant change
Time from first doctor asessment to last available test-result at visit
Clinical Chemistry testing at all ED:s in Karolinska Solna 24/7

17. Financial results at Karolinska 2005 - 2010

18. 18
Learning by doing 1993-2010
1993-1996
Outpatient Clinic
Dpt of Cardiology
1997 – 2004
End-to-End approach
Maternity care
Top down & bottom up
2005-2007 2007
120 improvement projects
TQM, Six Sigma, SPC, LEAN
85 % success rate short term
Long term?
Huddinge Hospital St Görans Hospital Karolinska
The merger
+
Swedish LEAN Award
St Görans Hospital
End-to-End approach
ED/Ward
Top down & bottom up
End-to-End approach
ED/Ward
Top down & bottom up
Support processes
D
a
y
s
2010
Delivery ward Maternity ward B
A
Maternity ward A
A
Labour painsReferral to first assessment
Sustainable
improvements
2512262011761511261017651261
1:50
1:40
1:30
1:20
1:10
1:00
Week (2006 - 2010)
Door-to-doctor
Sustainable improvements

19. Challenges from the CEO`s perspective
• Other projects
• Make priorities
• Continuous productivity improvement
• To involve the whole organisation
• Leadership
• Staff involvement
• The change agents risk become ”burned”
• Why lean transformation – only to become more effective?

20. We have set up a value stream management system which sits parallel to
our line management structure. We have also put in place supporting structures
including an operations management team, improvement teams consisting
of staff members, written work standards, procedures for handling deviations,
visual management as well as comprehensive data support.
BUT our senior management team is not yet fully committed and has not
invested enough time in learning of LEAN principles and the design of a
LEAN transformation. They also do not invest enough time at the ”Gemba” to learn, or in
their managements team meetings to follow up. As a result, some of their
direct and indirect report areas are also less than fully committed.
The situation is starting to change, but we would like your advice how we can inspire
and engage the senior management to get more involved and committed to make
the LEAN transformation a core part of their agenda?
Current problem