Jönköping County

Sweden

Jönköping Eksjö Europe

Värnamo

A good life in an attractive region

“Look up” not up But out – start a movement of new integration!

How can I do the best for the patient and facilitate for my care neighbour?

Traditional Exampel 1: Traditionell Patientfokuserad ”functional” Patient focused Esther "funktionell" ”activities"aktiviteter and part och of delprocesser processes organizedorganiserade after prioritated efter patient prioriteradevalues” patientvärden" Pharmacyapotek 6 municipalitieskommuner (6) Investigate Diagnosis & desitionRehabilitation Prim. care about care/P.c. Prim. care and hospital Esther 6 primaryPV-områden care units (6) Patient pat with treatm disease finished HöglandsjukhusetHospital in Eksjö

Medicin E R Rehab Lab Pat asks for treatment Treatment Rehabilitation © Göran Henriks prim. care hospital hospital Municipality Jönköping County Council www.lj.se/qulturum ” Esther and a Better life for elderly’’

a lot of opportunities for improvement and redesign

”More days with energy, happiness and vitality”.

”You listen to my needs and together we find out what is important for me”.

”We put focus on preventive actions”.

Ref Susanne Lundblad, Senior Alert Lilly, 95

Safe care is for me.. - Knowledgeable - Meetings with professional people and feel that I'm welcome -To have a key relationship - Be seen for who I am - A personal approach - Have a linkage to life

Book: ”A Taste of Water” © Göran Henriks A Jönköping County Council www.lj.se/qulturum A poet Tomas Tranströmmer wrote Further In On the main road into the city, When the sun is low The traffic thickens, crawls It is a sluggish dragon glittering. I am one of the dragon’s scales. Suddenly the red sun is right in the middle of the windshield streaming in. I am transparent and a writing becomes visible inside me - words in invisible ink That appear when the paper is held to the fire!

© Göran Henriks Jönköping County Council www.lj.se/qulturum Further in I know I must get far away straight through the city and then further until it is time to go out and walk far in the forest. Walk in the footprints of the badger. It gets dark, difficult to see. In there on the moss lie stones. One of the stones is precious. It can change everything It can make the darkness shine. It is a switch for the whole country. Everything depends on it. Look at it, touch it…

Ludwig Wittgenstein

Creating Shared Value We get the care we need when we need it

Costs

• 13 basic values • Vision and mission • 6 overall strategic aims • A systemmap • A map of the patients process • Balanced scorecard • Patiens safety annual plan • System to obtain information • 6 strategic improvement areas • Actionplan for improvement work

Processer Befolkning/patienter

Ekonomi

© Göran Henriks Jönköping County Council www.lj.se/qulturum Munici- Average Percentage of Percentage Percen- Children Percen- Percen- pality days on 19 years old of 4 year tage of per 1000 tage of tage of sick without dental olds with pregnant births inhabitants inhabitants leave caries overweight women with low with good with high (paid 2008 and obesity smoking birth self- alcohol sick Born 2002- 2006 weight perceived consumpti days) 2004 2005-2007 health on (W/M) July (W/M) 2009 Jönköp- 31,5 30%-53% 14,6% 5,8% 32,7 65/73 7/14 ing Habo 28,4 35% 12,9% 9,2% 21,6 73/74 6/15 Mullsjö 37,7 30% 16,4% 9,6% 28,1 73/67 7/14 Tranås 39,0 42% 12,6% 9,1% 20,3 69/73 7/22 Aneby 34,5 48% 16,3% 10,9% 58,8 68/70 7/13 Eksjö 35,0 48%-59% 13,8% 9,3% 22,8 67/70 5/14 Nässjö 35,4 28%-30% 13,9% 9,8 % 21,7 68/75 6/15 Sävsjö 35,2 41%-54% 12,5% 8,4% 20,4 70/67 8/8 Vetlanda 33,4 35%-42% 15,8% 8,8% 39,2 72/73 9/14 Gislaved 31,3 33%-35% 16,9% 13,6% 33,8 71/73 7/14 Gnosjö 29,2 29% 15,8% 8,9% 32,9 74/72 10/12 Vaggeryd 29,0 28% 14,3% 6,7% 35,6 72/70 9/14 Värnamo 26,7 27-38% 15,3% 8,8% 23,4 76/75 5/11 © Göran Henriks CountyJönköping County Council32,0 38% 14,7% 8,1 30,1 70/73 7/14 www.lj.se/qulturum Sweden 34,1 -** - 7,5 31,1 67/69 10/16 Mothers that smoke while pregnant (in procent)

9,7

9,7 9,1

8,5 6,3 5,2 8,2

10,5 8,6 13,7 8,1

12,9 7,6 5,7 8,1 12,6 8,2 11,5

6 9,8 9,4 9,2

8,9 11,6 8,8 6,3 8,7 11,1 9,5

8,7 12,2 12

11,9 9 Andel (%) rökande bilvande mödrar 7,3 5,2-8,1 (10) 12,6 8,2-11,5 (19) 5,5 11,6-14,1 (9) 14,1

Sweden •Few young •A lot of elderly

USA •Many young •Elderly

2011: 1.75 million people over 65, approx 800 000 over 75 2020; 2,1 million people over 65 och 995 000 over 75

’’In a European perspective Sweden are in the top in self perceptive health among people over the age 85’’

Resource;Salar

From planning and talking to… it is the systems results that counts in a complex content

Many Co-Integrators: O Co - dependent A modernized Municipality Model w n e r Independent inter Independent s h i p Dependent Horisontal Integration Network Model

Vision,Vertical Principles, Integration Collaborative, Trustable Arrangements © Göran Henriks Jönköping25 County Council Source:www.lj.se/qulturum Stephen Covey and Bill Tolbert, Adapted Gaps challenges but also opportunities

• Public health and prevention • Integrated care elderly, children, chronic care • Primary care reform – Inhabitant choice • Advanced access • Individualization • Reliability and “Open comparison” • Patient safety • Practice to research and back

- To reach young people - The amount of men that do the test should increase compared with men at the hospitals office - Easy reachable from our web. - Do a good design in marketing that support the new way.

Completed actions

© Göran Henriks Jönköping30 County Council www.lj.se/qulturum © Göran Henriks Jönköping County Council www.lj.se/qulturum © Göran Henriks Jönköping County Council www.lj.se/qulturum A Care preventive process

Using evidence-based instruments for each patient ≥ Patients at risk are 65 years to diagnose investigateed and a plan risk of pressure sores, for preventive measures malnutrition or fall

All patients registered in Evaluation of results the registry - Senior Alert - is done in a clinical which is available in all registry - Senior alert hospitals, primary care and in the municipality .

Risk assessment, preventive actions and outcomes are registered in the clinical register “Senior alert”. This is done by professionals at the ward, homes for elderly etc; in the healthcare (hospitals, primary care) and in the community.

In the future John can And he will register his data by meet us on himself at home. the web!

Vad vill vi åstadkomma? Mål !

IT-support Hur vet vi att en förändring är en förbättring? Mått !

Fascilitation Vilka förändringar kan leda till en förbättring? Idéer ! Manuals

5P Agera Planer a Test ! PGSA- cirkeln Purpose Stude Göra Patient ra People - personal Processer Patterns - mönster Systematic

approach in daily work Reflections and outcomes Amount of careplan in patients with risk

100% 80% 60% 40% 20%

jul-10 jul-11

jan-10 feb-10 jun-10 jan-11 feb-11 jun-11

apr-10 okt-10 apr-11 okt-11

nov-10 nov-11

maj-10 aug-10 sep-10 dec-10 maj-11 aug-11 sep-11 dec-11

mar-10 mar-11

Hospital 1 Hospital 2 Hospital 3 County council Target Risk? Actions? Results? Learning from results

© Göran Henriks Jönköping County Council www.lj.se/qulturum ACTIVITIES Zone of Colonoscopy? Biopsy? greatest Staging? attention Surgery? Colostomy? Colostomy care? Radiation? Cancer activity? Palliative care? Diet? Chemotherapy? Pt. education? Pt. education? Risk assessment? Pt. education? Shared decision- Shared decision- Screening? Shared decision-making? making? making? Pt. education? Diagnosis & Follow-up & End of Pre-diagnosis treatment monitoring life care

Screening events? Stage at diagnosis? Survival length? Pain control? Prevalence? Treatment algorithm? Activities of daily living? Good death? Pt. awareness? Complications? Monitoring algorithm? Family help? Pt. understanding, Complications? satisfaction? Pt. understanding, Q,S,V measures? satisfaction?

Draft © Göran36 Henriks JönköpingMEASURES County Council Jan, 2010 www.lj.se/qulturum pbb Promises by the board of the “Regional Cancer Center South East” WE PROMISE THAT: GOAL GOAL 2012b

You do not have to wait more than Contact with healthcare T ½ 4 weeks the most before investigation - diagnosis 2 weeks and adequate treatment for cancer T ½ Diagnosis – treatment 2 weeks You are offered diagnostic and We must have Care program (CP) for T ½ treatment for your cancer according 90 % of tomours. to ”best practice” T ½ Commitment to the CP we have 80% You are well informed / taking part Time schedule to next step shall be 80 % in the whole care chain offered at every healthcare contact

You who are in the end of life will h Access to palliative care. T ½ have the same good care where 24 hours after breakpoint ever you live in the region No difference between different Smoking reduced in youth groups T ½ inhabitant groups in the region when getting cancer Coverage screening program X % T ½

Health care prioritizes patient close Share/part of cancer patients that T ½ research within the area cancer. will enter into research projects

T½= Halving the gap from to day’s result to the goal. E.g. current status 30 d, goal14 d. © Göran Henriks JönköpingT½ =County 22 days Council before Dec. 31th 2012. www.lj.se/qulturum © Göran Henriks Jönköping County Council www.lj.se/qulturum The patient’s The Patient’s Process individual preferences Patient’s context First symtom Patient’s context First contact

PPaattiieenntteennss ssaammmmaannhhaanngg FFöörrssttaa ssyymmttoomm PPaattiieenntteennss ssaammmmaannhhaanngg FFöörrssttaa kkoonnttaakktt

Patienters individuella preferenser

Undersökning bedömning uppföljning

Information Behandling/ åtgärd

Kompetens

Symtom

Patient Patient

Patientcentrerad processkartläggning för ______Patientcentrerad processkartläggning för ______Patientcentrerad processkartläggning för ______

PPaattiieenntteennss ssaammaannhhaanng FFöörrssttaa ssyymttoom PPaattiieenntteennss ssaammaannhhaanng FFöörrssttaa kkoonnttaakktt PPaattiieenntteennss ssaammaannhhaanng UUttrreeddnniinngg PPaattiieenntteennss ssaammaannhhaanng BBeesslluutt oom ååttggäärrdd PPaattiieenntteennss ssaammaannhhaanng BBeehhaannddlliinngg//ååttggäärrdd PPaattiieenntteennss ssaammaannhhaanng UUppppfföölljjnniinngg PPaattiieenntteennss ssaammaannhhaanng

Patientens fysiska, psykiska, sociala och existentiella behov

Undersökning bedömning uppföljning

Information Behandling/ åtgärd

Kompetens

vvililkkaa y ytttteerrlliiggaarree kkoommppeetteennsseerr bbeehhöövvss i i d deettttaa sstteegg??

Symtom

Patient Patient Patient Patient Patient © Göran Henriks Patient Jönköping39 County Council www.lj.se/qulturum • Multi discipline Team • Design the process with everybody involved • Patient’s diary • Start data analyze

Tid från remiss för utredning på grund av misstänkt koloncancer till behandling (operation, onkologisk behandling, palliativ vård) Landstinget i Östergötland, Regionalt cancercentrum Sydöst 2011 120

100

medel=49 dagar

0 sep sep sep okt okt okt okt nov nov nov nov dec dec dec dec dec

DVT No - premed prophylaxis Pre-op councelling No bowel prep

Early CHO - loading/ mobilisation ERAS no fasting

Perioperative Incisions Nutrition

Bairhugger No NG tubes Prevention Oral analgesics/ of ileus/ Early removal NSAID’s prokinetics of catheters/drains © Göran Henriks Jönköping County Council www.lj.se/qulturum Lassen et al, Arch Surg, 2009 © Göran Henriks Jönköping County Council www.lj.se/qulturum ”Matchmaking”

What is best Same need? care for each Same situation? of them Same individual choice?

© Göran Henriks Jönköping County Council www.lj.se/qulturum Ref Per-Anders Heedman Current status The transition of the ward round from a “parade” The “ward round” is a central activity of a to a round table consultation hospital ward. It is often proceeded by the doctor and the responsible nurse, in the corridor or in an office before meeting the patient bedside. This was also the tradition Economics of the gastroenterological ward at the In tests the time 41 min Highland Hospital in Eksjo, Jonkoping County, Sweden. We perceived that this needed for the format did not fulfil the requirements for ward round was high quality care. Each patient was to decreased with been seen individually in a separate office, when needed, by a multi professional approximately 8 team. minutes. The aim of the redesign is to enhances patient privacy, empowerment and inter- Upscaled to a 33 min professional communication. By this Department level increasing the value of the care offered as well as lowering the cost for this central this equals 300- activity of hospital care. 400000 dollars a

Baseline for proportion of patients having their medical plan year of savings outwritten in their record note of the Medical Department in Eksjö, Jönköping County, Sweden 1,20 1,00 Percent 0,80 p-bar 0,60 LCLp

Fraction 0,40 UCLp Fraction of record 0,20 0,00 notes about “Today every one in the staff knows what Handover (se below) is going to happened the coming day” staff 14-03-201116-03-201118-03-201122-03-201124-03-201128-03-201130-03-201101-04-201105-04-201107-04-2011 according Date was measures: to SBAR

Baseline for proportion of patients beeing assessed bedside at the Medical plan Medical Department in Eksjö, Jönköping County, Sweden New status Rapid improvement cycles were 1,00 Social plan 0,80 Percent adapted in a multifaceted strategy. 0,60 p-bar Care level Hand overs were structured according

0,40 LCLp fraction fraction 0,20 UCLp to SBAR. Baseline measures for notes 0,00 about the assessment of medical, social and care level was performed as 14-03-201116-03-201118-03-201122-03-201124-03-201128-03-201130-03-201101-04-201105-04-201107-04-2011 well as for the time needed for the two datum ward round formats. The intended redesign became the daily routine of the ward. Preliminary Baseline for proportion of patients having their care level assessent and noted in their record at the Medical Department in Ekjsö, results show possible improvements Jönköping County, Sweden. for the value of the offered care as well 1,00 as time savings. 0,80 Percent Staff reports “Today every one in the 0,60 p-bar

0,40 LCLp staff knows what is going to happened Fraction 0,20 UCLp the coming day” pointing to a better 0,00 interprofessional communication.

14-03-201116-03-201118-03-201122-03-201124-03-201128-03-201130-03-201101-04-201105-04-201107-04-2011 Date

Följsamhet till riktlinjer basala hygienrutiner Punktprevalensmätning Vårdrelaterade infektioner (PPM VRI) Följsamhet Område 3 Förebygg läkemedelsfel vid 20 vårdens övergångar. Mål:100 procent 100

100 15 90 90

85 80

10 70

80 Procent

60 75 50

5 Procent 70 40

65 30

0 20 60

Maj 2008 November 2008 April 2009 November 2009 April 2010 November 2010 sep-08 okt-08 nov-08 dec-08 jan-09 feb-09 mar-09 apr-09 maj-09 jun-09 jul-09 aug-09 sep-09 okt-09 nov-09 dec-09 jan-10 feb-10 mar-10 apr-10 maj-10 jun-10 jul-10 aug-10 sep-10 okt-10 nov-10 dec-10 jan-11 feb-11 mar-11 apr-11 maj-11 jun-11 jul-11 aug-11 sep-11 okt-11 nov-11 dec-11 10

Höglandets Sjukvårdsområde Jönköpings Sjukvårdsområde Värnamo Sjukvårdsområde Mål 0 Jönköpings sjukvårdsområde Höglandets sjukvårdsområde Värnamo sjukvårdsområde Folktandvård Oktober 2008 April 2009 Oktober 2009 April 2010 Oktober 2010 Medicinsk diagnostik Primärvård Mål Jönköpings Sjukvårdsområde Höglandets Sjukvårdsområde Värnamo Sjukvårdsområde Mål

Primära drivkrafter Sekundära drivkrafter Patientskador per 1000 vårddagar (AE) Följsamhet Basala Följsamhet riktlinjer ”KAD bara när det behövs” 40 Hygienrutiner och Rätt Klädd Undvik 100 Vårdrelaterade 35 Följsamhet område 4, 5, 6, 8, 90 infektioner 10 och 13 80 30 Följsamhet omr 1 70 25 Tillförlitlig 60

20 Hjärtsjukvård Följsamhet område 2 och 11 50 Mål: Säker Vård 40 15 alla gånger andel Procentuell Undvik Följsamhet område 3 och 7 30

Patientskador per tusen vårddagar tusen per Patientskador 10 Läkemedelsrel Övergripande 20 patientskador resultatmått: 10 5 Antal patientskador Undvik Fall och Följsamhet område 9 och 14

per 1000 patientdygn trycksår 0

juli juli

maj juni maj juni

april april

mars mars

0 mars

januari januari januari

augusti augusti

oktober oktober

februari februari februari

november december november december september 2008 Tertial 1 Tertial 2 Tertial 3 2009 Tertial 1 Tertial 2 Tertial 3 2010 Tertial 1 Tertial 2 september n=6 n=4 n=8 n=7 n=10 n=8 n=6 n=8 n=14 n=13 n=11 n=16 n=19 n=18 n=20 n=26 n=26 n=21 n=18 n=20 n=26 n=29 n=31 n=30 n=31 n=26 n=24 Månad 2009-2011 (n=antal mätande enheter i Landstinget) Höglandets Sjukvårdsområde Jönköpings Sjukvårdsområde Värnamo Sjukvårdsområde Landstinget Höglandets Sjukvårdsområde Jönköpings Sjukvårdsområde Värnamo Sjukvårdsområde Stödjande Följsamhet omr 12 ledarskap

Läkemedelsrelaterade patientskador (ADE), genomsnitt 3,1 ADE per 1000 doser Vårdprevention – Riskbedömning av fall, nutrition och trycksår Förebyggande bedömningar före operation 2003 2004 2005 2006 2007 2008 2009 2010 110% 1 100% 0,006 90% 100% 1 1 UCL=0,005282 1 80% 0,005 1

90% 70% s

o 0,004

d 60%

r _

e 80% p

U=0,003058 % 50%

0,003

E D 40% A 70% 0,002 30% 0,001 60% LCL=0,000835 20%

10% 0,000 50%

jan-09 feb-09 mar-09 apr-09 maj-09 jun-09 jul-09 aug-09 sep-09 okt-09 nov-09 dec-09 jan-10 feb-10 mar-10 apr-10 maj-10 jun-10 jul-10 aug-10 sep-10 okt-10 nov-10 dec-10 jan-11 feb-11 mar-11 apr-11 maj-11 jun-11 jul-11 aug-11 sep-11 okt-11 nov-11 dec-11 n g t c b r n g t c b r n g t c b r n g t c b r n g t c b r n g t c b r n g t c b r n g t c k e e p k e e p k e e p k e e p k e e p k e e p k e e p k e 0% ju au o d f a ju au o d f a juau o d f a juau o d f a juau o d f a j uau o d f a ju au o d f a ju au o d

jul-10

jan-10 jun-10 jan-11

okt-10

feb-10 feb-11

apr-10

nov-10

sep-10 dec-10

maj-10

aug-10 mar-11 Jönköpings sjukvårdsområde Höglandets sjukvårdsområde Värnamo sjukvårdsområde mar-10 Tests Jönköpingperformed with une qCountyual sample s izCounciles Totalt i länet Mål Höglandets sjukvårdsområde på op enhet Jönköpings sjukvårdsområde på op enhet Värnamo sjukvårdsområde på op enhet Mål www.lj.se/qulturum Resultatmått Processmått