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© Mats Bojestig Jönköping county council
Making system wide improvement in health care
Mats Bojestig MDJönköping County Council, Sweden
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© Mats Bojestig Jönköping county council
© Mats Bojestig Jönköping county council
When results get public�
© Mats Bojestig Jönköping county council
If people want take responibilty for their care �
are we with them?
© Mats Bojestig Jönköping county council
Balansen förskjuts
© Mats Bojestig Jönköping county council
© Mats Bojestig Jönköping county council
JönköpingEksjö
Värnamo
11 municipalities330 000 inhabitants
3 hospitals 34 primary care centers35 Dental care centers
9 800 employees
Regional development support Europe
Sweden
Jönköping County
Health Care in Jönköping County
© Mats Bojestig Jönköping county council
Value
Value =
Clinical result + Service quality
Resources
© Mats Bojestig Jönköping county council
Improving clinical performance while reducing unnecessary cost
� Variation
� Access� Flow
� Medication� Patient safety
� System view
� Patient as a source� Prevention
� Microsystem� New thinking
© Mats Bojestig Jönköping county council
Purpose
MissionBeliefsVision
System for obtaininginformation
(Customer focus)
PlanningStrategic objectives
Improvement efforts
Resources
Managingimprovement
efforts
Three basic questions
Act Plan
DoStudy
Organization viewed as a System
ProductsServicesTools
BSC: 4 perspectives
Economic
Process/Production
Learning and renewal
Patient / Customer
Normann, API
© Mats Bojestig Jönköping county council
� Safe � Knowledge based
and Efficient � Patient focused � Effective � Equal � Timely
A Regulation from The Swedish National Board of Welfare
What Swedish Health Care must be
© Mats Bojestig Jönköping county council
0
10
20
30
40
50
60
70
80
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100
Worst hosptial Average hospital Best hospital
AC
E /
AA
CE
/ A
-- II
inhb
itor
at
disc
harg
e II
inhb
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at
disc
harg
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iks-
HIA
199
9
Proportion of �ideal-patients�treated at discharge
Focus on potential for improvement
Focus on poor performance
Focus on differences
© Mats Bojestig Jönköping county council
Access Diagnoses, Treatment and decision support
Define ongoing relationship
Main-stay Delivery system
design
Patient´s/ Customer´s homeNursery home
SupportAdministration
Competens-development
Safety-work ITX-Ray. Lab, Rehab and care
Technical supp
DriversLearning and renewal
Planning for leading and improvement
Leadership-meetings
The surrounding world
Mission / Catch the need in society
Follow up and feedback
© Mats Bojestig Jönköping county council
100% 1%Current activities
Continuous improvements
New activities
It is the Outcome of the Whole System that Counts!
Jönköping health care services
Annual Planning and Budget Document
© Mats Bojestig Jönköping county council
Professional knowledge Subject knowledge Personal skill Values, ethics
Improvement knowledge Appreciation of a System Understanding variation Psychology Theory of Knowledge
Improvement of diagnostic and treatment
Improvement of processes and system in healthcare
Higher value for the patients
© Mats Bojestig Jönköping county council
IT
Envir.
Adm
V a l u e f o r p a t i e n t i n c r e a s e s
AccessHow we receive
Coopera-tion/flow
Clinical improvement
work
Patient safety
Medication
Learning and innovation
Good financiesReliability
�The Diamond�: Strategic Improvement Areas
PreventionTaking care of oneself
Leadership
More than 5.000 participants in collaboratives so far
© Mats Bojestig Jönköping county council
Primary Care
Speciality Care
AccessDiagnosis, treatment and
Decision Support
Support Self Management
Delivery system designDefine Ongoing
Relationship
Participate in Jonkoping Executive Meeting
Design and redesign the
system
Conduct Business Planning
Conduct Council
Business Meeting Obtain
Feedback
Conduct Research
Customers
Patients
Nursing Homes
Participate in County Council
Assembly
County Council
Learning how to betterserve our Patients
HR IT Transportation EconomyMaintain
Buildings & Security
Clinical Physiology
Public Relations
Systems View of County Council of Jonkoping
Governance for Spread of Change
Provide nursing Care
Ear, nose, throat
diseases
Surgical diseases
Women
Provide Pediatric
care
Provide Psychiatric
care
Provide care for Medical diseases
Neuromuscular
Manage Infection controll
Ophtal-mology
Derma-tology
Telephone triage
Drop in visits
Schedulingappointments
Conduct Home
care visits
Provide Palliativ
care
Provide E-learning
Conduct Surgical
care
Provide care in ER
Conduct Ambulance
care
Provide care for In patients
Provide care for
Out patients
Provide Intensiv
care
Provide Group visits
Conduct evaluation
Planning for follow up
Conduct Social planning
Provide radiology
Provide labratory
Provide Diagnoses support
Attending professional
meeting
Information system
Manage drop in visits
Support IT information
systems
20 people
SpreadAccess Collaboratives
Primary care 3 2 6 9 16 16 25 10 16 15 19
Hosp. care 2 6 3 6 26 18 16 13 9 18
in 255 team s
# of teams: 5 7 9 15 42 34 41 23 25 15 37
Team fr Jonk: 5 7 6 10 9 9 4 5 7 1 5 =75
BM1 BM2 BM3 BM4 BM5 BM6 BM7 BM8 BM9 BM1S BM10
1999 2000 2001 2002 2003 2004
1500
© Bra mottagning, Qultrurum, Margaret a S trindhal l
20 people
SpreadAccess Collabora tives
Primary care 3 2 6 9 16 16 25 10 16 15 19
Hosp. care 2 6 3 6 26 18 16 13 9 18
in 255 teams
# of teams: 5 7 9 15 42 34 41 23 25 15 37
Team fr Jonk: 5 7 6 10 9 9 4 5 7 15 =75
BM1 BM2 BM3 BM4 BM5 BM6 BM7 BM8 BM9 BM1S BM10
1999 2000 2001 2002 2003 2004
1500
© Bra mottagning, Qultrurum, Margareta Strindhall
20 people
SpreadAccess Collaboratives
Primary care 3 2 6 9 16 16 25 10 16 15 19
Hosp. care 2 6 3 6 26 18 16 13 9 18
in 255 teams
# of teams: 5 7 9 15 42 34 41 23 25 15 37
Team fr Jonk: 5 7 6 10 9 9 4 5 7 15 =75
BM1 BM2 BM3 BM4 BM5 BM6 BM7 BM8 BM9 BM1S BM10
1999 2000 2001 2002 2003 2004
1500
© Bra mottagning, Qult rurum, Margareta Strindhall
20 people
SpreadAccess Collaboratives
Primary care 3 2 6 9 16 16 25 10 16 15 19
Hosp. care 2 6 3 6 26 18 16 13 9 18
in 255 teams
Teams total: 5 7 9 15 42 34 41 23 25 15 37
Teams fr Jonk: 5 7 6 10 9 9 4 5 7 15 =75
BM1 BM2 BM3 BM4 BM5 BM6 BM7 BM8 BM9 BM1S BM10
1999 2000 2001 2002 2003 2004
1500
© Bra mottagning, Qultrurum, Margareta Strindhall
© Mats Bojestig Jönköping county council
Move steps closer together Wards and open care for different
specialties are put together, everything
under one roof.
Extend the time of specialists Using the whole team. Nurses and
assistant nurses are doing things that they can do as good as or better than the doctor is.
Nurse receptions Patients in need can get an appointment
with in two-week and if it is acute during the same day.
Not regular put up patients for return-visits
Use pull system Easy for patient to contact the teams.
Always access by phone. People with need, can come directly the
same day for some teams and within two weeks for the rest of the special teams.
© Mats Bojestig Jönköping county council
Patients waiting more than 90 days
0
500
1000
1500
2000
2500
3000
3500
jan
-07
feb
-07
ma
r-0
7
ap
r-0
7
ma
j-07
jun
-07
jul-0
7
au
g-0
7
sep
-07
okt
-07
no
v-0
7
de
c-0
7
jan
-08
feb
-08
ma
r-0
8
ap
r-0
8
ma
j-08
jun
-08
jul-0
8
au
g-0
8
sep
-08
okt
-08
no
v-0
8
de
c-0
8
jan
-09
feb
-09
ma
r-0
9
ap
r-0
9
ma
j-09
jun
-09
jul-0
9
au
g-0
9
sep
-09
okt
-09
no
v-0
9
de
c-0
9
Besök Jönköping
Operation/åtgärd Jönköping
VisitsSurgery
© Mats Bojestig Jönköping county council
mar-11
Vårdutbud Organisationsenheter Totalt antal väntande
Andel som väntat längre än 90 dagar exkl PvV och MoV
Andel med PvV längre än 90 dagar
Beräkning enligt Kömiljard 2011, (Kortare än 60 dagar exkl MoV / Totalt antal exkl MoV)
Besök Kronoberg 3310 2,84% 1,96% 88,75%
Kalmar 5451 6,30% 0,79% 87,32%
Halland 6251 2,74% 1,84% 86,25%
Västra Götaland 30348 4,46% 1,82% 85,27%
Norrbotten 5563 5,66% 2,10% 84,25%
Jönköping 6347 8,62% 0,25% 82,80%
Västerbotten 6535 5,96% 2,23% 81,49%
Jämtland 2255 6,08% 2,44% 80,71%
Gävleborg 8369 6,58% 1,06% 80,61%
Skåne 38452 11,33% 0,18% 80,22%
Riket 214679 9,68% 1,88% 79,04%
Blekinge 3384 8,95% 1,86% 77,96%
Uppsala 7951 10,01% 1,72% 77,66%
Östergötland 8975 10,75% 2,40% 76,56%
Gotland 1660 15,09% 1,21% 76,48%
Stockholm 38060 14,42% 3,20% 75,58%
Västernorrland 5834 8,84% 1,78% 75,21%
Västmanland 5679 9,19% 2,72% 73,45%
Sörmland 7425 11,94% 2,80% 72,33%
Dalarna 7936 15,31% 2,45% 72,14%
Värmland 6434 10,88% 2,37% 71,24%
Örebro 8460 11,78% 4,08% 70,86%
© Mats Bojestig Jönköping county council
Safe Health Care � Every time
© Mats Bojestig Jönköping county council
� Safe � Knowledge based
and Efficient � Patient focused � Effective � Equal � Timely
Open comparison of Swedish 21 counties
© Mats Bojestig Jönköping county council
National Med. Registers in Sweden
© Mats Bojestig Jönköping county council
How do we work today? Analysis of current work/routines and make Action plans
� Show the current work Process, patient population, what personnel are involved� Use different tools : flowchart
diagram, fishbone/Ichikawa diagram, brainstorming, baseline measure � Make plans using PDSA -
test in small scale
© Mats Bojestig Jönköping county council
ACE-blockers at discharge after heart infarction, age <80
Optimal level?
Measure for others and annual report
Let the teams develop their own capacities and performances
Hospitals in Sweden
Wallentin, Lindahl, UCR -04
© Mats Bojestig Jönköping county council
Control Chart: Coronarangiografi 1999
Sigma level: 2
121110987654321
,8
,6
,4
,2
0,0
Coronarangiografi
UCL
Center = ,29
LCL
Wallentin, Lindahl, UCR -04
© Mats Bojestig Jönköping county council
Protocol
© Mats Bojestig Jönköping county council
Number of hospitals that reach 70 % following 4 or 5 out of 5 treatments
Number of hospitals that reach 70 % following 4 or 5 out of 5 treatments
0123456789
10111213141516171819
Hospitals in Control group
Hospitals participating in QUICC
0
4/5
5/5
(QUICC) Quality Improvement in Cardiac Care project
© Mats Bojestig Jönköping county council
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
Change in Incidence (events/100 patient years)
between pre- and post interventions period
© Mats Bojestig Jönköping county council
KnowledgeableCustomer knowledge - knowledge about the customer - the customer�s knowledge
Variation
Support to take care of yourself
Decision support
Care programs
- National guidelines
Reliable
- updated- safe- equipment
StandardisedSpecific
© Mats Bojestig Jönköping county council
Inter Mountain Health System Inter Mountain Health System Clinical Programs System WideClinical Programs System Wide
© Mats Bojestig Jönköping county council
Deaths at hospital in colon cancer
2010 2009
Number of deaths 37 38
Avoidable 1 5
Potential avoidable 4 5
Unavoidable 32 28
About 20 %
5-10/250,000
150-400 i Sweden??Professor Rune SjProfessor Rune Sjöödahldahl
UniversitetssjukhusetUniversitetssjukhusetLinkLinkööping ping
� What is the burden of the treatment today?
© Mats Bojestig Jönköping county council
© Mats Bojestig Jönköping county council
Andel patienter utan rapporterad postoperativ komplikationur INCA kolorektalregistret
Syd飉tra sjukv緳dsregionen 2010 - 2011
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Q1 2010 Q2 2010 Q3 2010 Q4 2010 Q1 2011 Q2 2011 Q3 2011 Q4 2011
J霵 k鞿 ing
Kalmar
珺 terg飆land
.
© Mats Bojestig Jönköping county council
Koloncanceropererade patienter Landstinget i J霵k鞿 ings l鄚
2010
0
2
4
6
8
10
12
14
16
18
20
Januari Februari Mars April Maj Juni Juli Augusti September Oktober November December
anta
l
Landstinget i J霵 k鞿 ings l鄚
H鐷 landet svo
J霵 k鞿 ing svo
V酺namo svo
© Mats Bojestig Jönköping county council
Ref. Bergeling, Fruberg
© Mats Bojestig Jönköping county council
Esther � the patient�s focus
Lack of coordination and integration causes complicated solutions
© Mats Bojestig Jönköping county council
Pat asks for primary care
InvestigatePrimary care
Treatment hospital
Diagnosis & desitionabout care/P.c.and hospital
Rehabilitation
Primary care
RehabilitationMunicipality
EstherPV-områden (6)
RehabE RMedicin
kommuner (6)
Patienttreatmentfinished
Patient withdisease
Lab
apotek
Traditional�Functional�
Patient focused�Activities and part of processes
organized after prioritized patient values�
Pharmacy6 municipalities
6 primary care units
Hospital in Eksjö
Treatment hospital
© Mats Bojestig Jönköping county council
Concept of Esther
� What do you want to accomplish for Esther?
� Who needs to cooperate?� Any changes?
� Map the process of today
© Mats Bojestig Jönköping county council
© Mats Bojestig Jönköping county council
NowPatient enrolled
Pr. ulcer develops?
Treatment of pr. ulcer
Patient dicharged
Yes
No
Value Assessment
53 000 episods of care/year
At 8 % of episodes pressure ulcer develops
Treatment of pressure ulcers costs 7.6 million dollars
NewPat enrolled
Pr. Ulcer develops?
Treatment of pr. ulcer
Patient discharged
Yes
No
Value assessment
53 000 episodes of care/year
Assume that half of the pressure ulcers can be prevented
4 million dollars
Risk?Preventive treatment
Assessment acc. to Norton
Yes
No
ALL patients are assessed 572 000 dollars
8 % of patients has a risk acc. to assess-ment
572 000dollars
Total cost
7.6million dollars
Total cost
5million dollars
Business Case: Pressure Ulcer
© Mats Bojestig Jönköping county council
© Mats Bojestig Jönköping county council
I want�.
� Optimal individualized dialys treatment� Run it by my Self� Dialys 5 days a Week� Influence over my regim� Support by knowledgeble professionals
© Mats Bojestig Jönköping county council
© Mats Bojestig Jönköping county council
Clinical Micro-system
and arelentless ambition
to pursue perfection
© Mats Bojestig Jönköping county council
� Resultattavlor i vården
© Mats Bojestig Jönköping county council
The need of �hudles�
The local use of measures strengthen the learning and innovation approach
© Mats Bojestig Jönköping county council
New management system
� Dialog: � Improvement ideas� Action plans� PDSA� Transparency� Learning together
Exempel
© Mats Bojestig Jönköping county council
Health of the Population
Experienceof Care
Per CapitaCost
Ref: Nolan, Withington
Triple aim
© Mats Bojestig Jönköping county council
Jönköping i topp i öppna jämförelser
-35
-25
-15
-5
5
15
25
35
Jönk
öping
Halland
Västman
land
Kronob
erg
Kalmar
Västerb
otten
Östergö
tland
Dalarna
Uppsala
Sörmlan
dÖrebro
Bleking
e
Västern
orrlan
d
Norrbott
en
Gävleb
org
Gotlan
d
Västra Götaland
Skåne
Värmlan
d
Stockho
lm
Jämtlan
d
Landsting
Poäng 2008
15 000
16 000
17 000
18 000
19 000
20 000
21 000
22 000Kostnad (kr/inv)
At the top in a total ranking of 101 indicatorsamong 21 HC systems in Sweden
© Mats Bojestig Jönköping county council
Staff and patient satisfactionSummary7,691 answers 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
Negative Positive
© Mats Bojestig Jönköping county council
Swedish National Quality Award 4 times to Jönköping
� Dep. of Internal Medicine, Eksjö, 2002
� Dep. Of Technical and Support Services, Jönköping, 2004
� Dep. of Gynecology and Women�s diseases, Jönköping, 2006
� Dep of Pediatric, 2009
The Swedish Malcolm Baldridge Award
© Mats Bojestig Jönköping county council
Mesosystem
Microsystem
Macrosystem
System levels
© Mats Bojestig Jönköping county council