Uppsala Academic Hospital Context Kildal

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Implementing High Value Care in Europe Implementing Value-Based Health Care in Europe Public hospitals Public Hospital Uppsala AcademicUppsala Academic Hospital Context Kildal. To increase efficiency, pathway coordinators were appointed to manage patient flows across departments Hospital Uppsala University Hospital is a large academic hospital with interprofessional teams focused on improvements in Sweden. With 8,300 employees and nearly 360,000 within units. Uppsala’s plan-do-study-act approach and outpatient visits annually[114], it provides highly specialised breakthrough programmes are now integral to a culture of care for complex and rare pathologies in a catchment area organisational change. Uppsala’s implementation Matrix is Context of over 2.2 million Swedes (20% of the population). In 2013, presented on the left. Uppsala launched its VBHC transformation plan. “With Uppsala University Hospital is a large academic the implementation of quality registries, we’ve had outcome hospital in Sweden. With 8,300 employees and nearly data for twenty years, but to achieve an in-depth, value- Internal forces 360,000 outpatient visits annually1, it provides highly driven transformation, you also need process,” said Professor specialised care for complex and rare pathologies in Morten Kildal, Lead for VBHC. This dialogue between process In 2015, Per Andersson, an Uppsala nurse, headed the a catchment area of over 2.2 million Swedes (20% and Achievements outcomes empowers teams to lead change across a ambulance unit and took over the dispatch centre, which had broad array of departments such as maternity, ambulance been outsourced to a private company. Andersson worked of the population). In 2013, Uppsala launched its Two years after launching its HVC programme, the and surgery. with his team to take full advantage of the control they now HVC transformation plan. “With the implementation ambulance unit succeeded in reducing the number of had over their unit in order to improve performance through of quality registries, we’ve had outcome data for unnecessary dispatches by 17% and time to dispatch a new software they designed in-house. For example, teams twenty years, but to achieve an in-depth, value-driven Achievementsby nearly 19% without affecting patient outcomes. have 90 seconds from alarm to dispatch for top priority transformation, you also need process,” said Professor Furthermore, the maternity care unit reduced the missions. To improve efficiency, the team modified the Morten Kildal, Lead for HVC. This dialogue between Twonumber years of after induced launching births by its26% VBHC and, with programme, unchanged the dispatch process so that the ambulance received information process and outcomes empowers teams to lead change ambulancepatient outcomes, unit succeeded it saved in850 reducing bed days theper year. number of on the way to the emergency site. In this way, they unnecessary dispatches by 17% and time to dispatch by nearly succeeded in reducing response times by 19%. They further across a broad array of departments such as maternity, Lastly, surgery department nurses designed a digital 19% without affecting patient outcomes. Furthermore, the reduced the total number of ambulances dispatched by 17% ambulance and surgery. tool to optimise, in real-time, the allocation of staff maternity care unit reduced the number of induced births by through replacing non-clinical phone operators with nurses, 26% resourcesand, with unchangedaccording to patient the evolution outcomes, of patient it saved status. 850 bed whose clinical training enabled them to understand when an days per year. Lastly, surgery department nurses designed a ambulance was truly necessary. To ensure these changes digital tool to optimise, in real-time, the allocation of staff added value, they monitored 1,000 patients to whom resources according to the evolution of patient status. ambulances were not dispatched under this new process, and verified that none experienced negative outcomes. This Implementation PDSA approach validated the implementation of these new operational processes and engaged the team in successive 2. Internal forces 3. Scorecard With a clear long-term endorsement from the • Board endorsement • CROMs improvement cycles. • Cohesive clinical team • PROMs board, Uppsala decided to implement its HVC • Patient involvement • PREMs transformation plan by focusing on 43 of 230

care pathways across the hospital. “Departments 9. External collaborations 4. Data platform Data platform R G E C • SVEUS initiative IN O • Outsourced R R E D N I are vertical silos, but if you move everything to T N • Peer hospitals R G • Inter-county platform A P Early patient discharge from the maternity ward is valuable processes, you create horizontal silos,” asserted

I M 1. Condition when longer hospital stays do not improve outcomes. To

P N R I Kildal. To increase efficiency, pathway O Maternity care R V A 8. Learning community P 5. Benchmarks I N M achieve this goal, the maternity unit designed an early G O coordinators were appointed to manage patient • Knowledge sharing C • Internal • PDSA cycles • External: 3 counties / discharge pathway including midwife homecare visits for • Weekly quality reviews 9 hospitals flows across departments with interprofessional REWARDING 30% of non-complex cases. Compared to the standard care teams focused on improvements within units. cycle, the new pathway showed equal patient outcomes with Uppsala’s plan-do-study-act approach and 7. Incentives 6. Investments 850 bed days saved per year. The Uppsala maternity unit • Reduced LOS • Platform development breakthrough programmes are now integral to a • Outcome accountability • Project management also succeeded in reducing induced births from 23% to 17% • Peer recognition • Internal team training (below the national average). To accomplish this, each week, culture of organisational change. Uppsala’s the team analyses data, stratifying the population, assessing Implementation Matrix is presented on the right. individual risk and adjusting care accordingly. They also developed a new tool populated with EMR data – a series Implementation of connected wheels displaying the patient profile, medical - HVC Implementation Matrix procedure, patient outcomes and experience six hours With a clear long-term endorsement from thePAGE board, 1 OF 3 after giving birth. This segmentation of patient profiles and Uppsala decided to implement its VBHC transformation plan outcomes enables the team to tailor pathways to maximise by focusing on 43 of 230 care pathways across the hospital. results. With an estimated development cost of SEK 527,000 “Departments are vertical silos, but if you move everything (€50,000), they then had this digital wheel custom-made for to processes, you create horizontal silos,” asserted internal benchmarking[115] (Figure 14).

44 Internal forces Case Studies

In 2015, Per Andersson, an Uppsala nurse, headed the Figure 1 ambulance unit and took over the dispatch centre, which FigureMaternity 14: case mix segmentation Investments had been outsourced to a private company. Andersson Maternity case mix segmentation tool at tool at Uppsala Academic Hospital In 2018, surgery followed the example of the burn unit who worked with his team to take full advantage of the Uppsala Academic Hospital had earlier pioneered a colour-coded magnet board detailing control they now had over their unit in order to improve patient status, the care schedule and nurses in charge. performance through a new software they designed spontaneous Every morning, during the five-minute team meeting, the psychosocial balloon catheter vaginal >5 in-house. For example, teams have 90 seconds from magnet board enabled nurses and practitioners to visualise workload, detect bottlenecks, optimise team communication alarm to dispatch for top priority missions. To improve and allocate resources according to patient needs. Inspired efficiency, the team modified the dispatch process so Patient experience by this device and the outcomes achieved, the surgery unit that the ambulance received information on the way to Patient outcomes initiated the in-house development of a digital tool to adjust the emergency site. In this way, they succeeded in Medical procedure nurse resources according to care intensity. The interactive Patient profile flat screen facilitates flexible assignments, so that the most reducing response times by 19%. They further reduced experienced nurses can manage the most complex cases. It the total number of ambulances dispatched by 17% also increases team adaptability, defuses stress, schedules through replacing non-clinical phone operators with breaks, and distributes appropriate resources according to nurses, whose clinical training enabled them to patients’ evolving needs. understand when an ambulance was truly necessary. To ensure these changes added value, they monitored Learning community 1,000 patients to whom ambulances were not dispatched under this new process, and verified that For external benchmarks, the Uppsala team compares its none experienced negative outcomes. This PDSA 5.70% of total outcomes to eight other obstetric departments using a 96.3% of parent common scorecard. Data are shared on an open source data approach validated the implementation of these new Amount: 26.0 platform financed by the Swedish National Collaboration for operational processes and engaged the team in Value-Based Reimbursement and Monitoring of Health Care successive improvement cycles. (SVEUS). In 2017, the maternity unit at Gothenburg University Hospital contacted Uppsala’s colleagues to understand how they succeeded in achieving lower post-delivery infection rates. For other quality indicators, the Uppsala team Data platform contacted Malmö and Lund University Hospitals, which demonstrated superior outcomes in 2019. This peer-to-peer Early patient discharge from the maternity ward is dialogue is the result of the SVEUS platform that publishes valuable when longer hospital stays do not improve nominative aggregated data across the nine hospitals. In this way, they form a learning community that establishes outcomes. To achieve this goal, the maternity unit baseline data and fosters competitive collaboration. designed an early discharge pathway including midwife homecare visits for 30% of non-complex cases. Compared to the standard care cycle, the new pathway showed Highlights equal patient outcomes with 850 bed days saved per “Dissemination of quality management is greatly facilitated year. The Uppsala maternity unit also succeeded in if you connect with people and with the support of reliable reducing induced births from 23% to 17% (below the and transparent quality data”, says Kildal. “VBHC is about national average). To accomplish this, each week, the empowering teams to take change by the hand.” Uppsala’s team analyses data, stratifying the population, assessing commitment to incremental change and PDSA culture stimulates team inspiration, leadership and outcome individual risk and adjusting care accordingly. They also accountability. developed a new tool populated with EMR data – a series of connected wheels displaying the patient profile, This case was written with contributions from Kildal M, Hallberg G, medical procedure, patient outcomes and experience six Wærnér H and Andersson P, from Uppsala University Department. hours after giving birth. This segmentation of patient profiles and outcomes enables the team to tailor pathways to maximise results. With an estimated development cost of SEK 527,000 (€50,000), they then had this digital wheel custom-made for internal 2 (Figure 1) benchmarking . Image by Steffan Claesson

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45 Investments Learning community

In 2018, surgery followed the example of the burn unit For external benchmarks, the Uppsala team compares its who had earlier pioneered a colour-coded magnet board outcomes to eight other obstetric departments using a detailing patient status, the care schedule and nurses in common scorecard. Data are shared on an open source charge. Every morning, during the five-minute team data platform financed by the Swedish National meeting, the magnet board enabled nurses and Collaboration for Value-Based Reimbursement and practitioners to visualise workload, detect bottlenecks, Monitoring of Health Care (SVEUS). In 2017, the optimise team communication and allocate resources maternity unit at Gothenburg University Hospital according to patient needs. Inspired by this device and the contacted Uppsala’s colleagues to understand how they outcomes achieved, the surgery unit initiated the in- succeeded in achieving lower post-delivery infection house development of a digital tool to adjust nurse rates. For other quality indicators, the Uppsala team resources according to care intensity. The interactive flat contacted Malmö and Lund University Hospitals, screen facilitates flexible assignments, so that the most which demonstrated superior outcomes in 2019. experienced nurses can manage the most complex cases. This peer-to-peer dialogue is the result of the SVEUS It also increases team adaptability, defuses stress, platform that publishes nominative aggregated data schedules breaks, and distributes appropriate resources across the nine hospitals. In this way, they form a according to patients’ evolving needs. learning community that establishes baseline data and fosters competitive collaboration.

“Dissemination of quality management is greatly facilitated if you connect with people and with the support of reliable and transparent quality data”, says Kildal. “HVC is about empowering teams to take change by the hand.” Uppsala’s commitment to incremental change and PDSA culture stimulates team inspiration, leadership and outcome accountability.

References: 1. https:/www.akademiska.se/om-oss/om-akademiska-sjukhuset/ arsredovisningkvalitetsbokslut- och-korta-fakta/ (accessed on December 10, 2019). 2. Interview with Dr Gunilla Hallberg, Head of the Obstetric Department, Uppsala University Hospital, November 19, 2019.

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