E.O. Galliera di Genova (essentials)

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4 E.O. Galliera di Genova (essentials) 450 beds (40% surgery) 1700 employees 10 op. rooms 8 types of surgery (NCH incl.) interventions/ year 12% out of schedule admissions/yr H. is reference for center Genova ( populat.) 4

5 Today s hospitals.. Wardsand clinicsare untidy and chaotic Queues are everywhere Le corsie sono caotiche Code dappertutto Processes are unplanned and of byzantine complexity Physical layouts and monoliths prevent a smooth flow of work Le linee di attività non sono pianificate e sono complicate L aspetto fisico degli ospedali e dei reparti separati impedisce lo scorrere del flusso

6 Berlin 11:00 h 10 pts!!! Ottobre 2006 Ordinary Hosp 11:00 h 10 pts Ottobre 2006 CHARITE HOSPITAL Em. Dept Ordinary Hosp. Em. Dept 6

7 we came across several problems Economic problems Hospital congested and overcrowded 7

8 we came across several Economic problems problems Hospital congested and overcrowded We tried to provide general overcapacity on beds 8

9 we came across several Economic problems problems Hospital congested and overcrowded We tried to provide general overcapacity on beds The setting was more destabilized 9

10 we came across several Economic problems problems Hospital congested and overcrowded We tried to provide general overcapacity on beds The setting was more destabilized Adding resources unmanaged is worse than doing nothing 10

11 We needed to do something different 11

12 Lean Approach at the Galliera Hospital - GE francesco.nicosia@galliera.it 12

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14 The current health system is supposed to face five main issues: 1. Difficult compliance with emergency access 2. Delayed access to elective surgery 3. Cost reduction 4. Unacceptable variations in length of stay 5. High rate of Hospital Acquired Infections, and unacceptable rate of errors (leading to avoidable suffering and even death) London

15 The current health system is supposed to face five main issues: 1. Difficult compliance with emergency access 2. Delayed access to elective surgery 3. Cost reduction 4. Unacceptable variations in length of stay 5. High rate of Hospital Acquired Infections, and unacceptable rate of errors (leading to avoidable suffering and even death) London

16 Lean Model Factories (thousands) Toyota 1970 Honda... Porsche dal 1995 Ducati 1999 BTicino 2001 Tesco 1998 Whirlpool 2004 Pirelli 2008 Kimberley Clark 2003 Aermacchi Hospitals (few hundreds) Seattle VMH dal 2001 Pittsburgh 2005 ThedaCare H 2004 Bolton RH 2006 and many within the NHS Rotterdam 2005 Charitè H Berlin 2005 Mayo Clinic ASL 10 FI 2006 Galliera-GE 2008 (Vimercate MI?)

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19 12 December 2008 Royal Bolton Hosp. 19

20 Stream Map flow: lumbar pain, sciatic pain pz. (2009) 20

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22 So we formed a Team We taught ourselves about Lean Thinking and process redesign Set up a program governance structure And got on by supporting the operators in trying to redesign the patients flow systems, using: The principles of Lean Thinking A basic insight An implementation methodology 22

23 Lean G.E.N.O.V.A. We simply focused on the progression of care to the patients The patients make horizontal journey through vertical structures Many processes have waste on them We eliminated part of the waste 23

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27 Lean G.E.N.O.V.A. Group Galliera (H) Empowered by New Organization and Value Analysis Patient care is really nothing more than a process. We experimented the lesson of Lean in our Hospital Start up on May

28 Four Steps to Lean Approach 1. Any line of activity is put into a plan map Value Stream (identifying value and non value activities at current state) build the future state by eliminating non value 2. Gather similar intensity of care activities and share resources 3. Keep flowing value and pt. journey (checking out changing level) 4. Permanent education (Lean training courses, Visual Management, VSM,..) 28

29 DATI di partenza Anno 2009 Stato attuale Per individuare possibili errori e sprechi Stato futuro 29

30 Lean G.E.N.O.V.A. We eliminated part of the waste: The patient care improved! The care cost declined! 30

31 What s Waste Medication errors When the nurse is going around to find things (supplies, documents..) Infections Waiting time More blood tests than needed... Learning to see waste 31

32 Un percorso snello per i pazienti obesi. 32 Marco De Paoli

33 Process flow add value add costs, etc etc 33

34 The Value flow (eliminating waste) process speed in a surgical activity add value Pre Operative Useless tests PRC Pre-admission visit intervention Patient Doesn t move For pain First Recovery (R.Room) late FKT Recovery add costs, morbility etc etc Postoperative time 34

35 Reducing no-value activity, improves the process quality and lowers costs Add value Pat doesn t Move for pain FKT Fast Track OUT Preop Useless tests Preop visit IN add costs, 35

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37 Emicholectomy: Actual State Giorni 40 Tempo attività a valore (contatto) Tempo attività necessarie Tempo di attesa 0,55 Tempo Utile [gg] 30 6,72 7,27 Tempo Totale [gg] 20 30, ,86 0 % sul totale 75,9% 22,3% 1,8% L incidenza del Tempo di attesa pari al 75,9% del tempo totale è molto elevata. La riduzione di questo tempo è attuabile con azioni di migliormanto avviate dalla Chirurgia Generale. Esistono però tempi di attesa legati ad attività svolte da altri enti che non erano presenti in aula e che quindi non è stato possibile progettare; E possibile ridurre anche il Tempo attività necessarie agendo sulla riduzione delle giornate di degenza postopratorie grazie ad un miglioramento di tipo clinico e non organizzativo; 37 37

38 Emicholectomy: Future State Giorni 30 Tempo attività a valore (contatto) Tempo attività necessarie Tempo di attesa 0,55 Tempo Utile [gg] 5,28 Tempo Totale [gg] 20 4,73 23, ,57 0 % sul totale 71,9% 26% 2,1% Ridurre il Tempo Utile, agendo sui tempi di degenza post-operatoria, ha un triplice impatto primo aumenta la soddisfazione dei pazienti secondo riduce i costi ospedalieri per paziente terzo incrementa la disponibilità dei letti; Ridurre i Tempo di attesa ha un impatto positivo sulla soddisfazione dei pazienti; 38 38

39 Key point: Value Stream Mapping We mapped the process of many patient s care and found out that often 90% of the process was waste We also found that half of that we could remove Delivering more patient benefits in less time and lower costs We eliminated waste by redesigning work process 39

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41 By minimising nurses work travel we reduce patient wait time Nurses learned to put supplies in designated places that creates additional capacity to provide more value (and same work) So we grow the business without adding people 41

42 Key for change Medicine is a Team Work today. It has different kind of leadership style that it was exhibited in the past. Collaborative groups get better patient satisfaction and lower cost The key for success in Lean Implementation is that Managers have to change 42

43 Key for change For the manager: be facilitator be teacher ready to learn helper be communicator be humble 43

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45 Patient status At a glance A Plan for Every patient 45

46 Visual Management Patient status At a glance A Plan for Every patient 46

47 Galliera Intensive Care Year beds beds beds N. pts 385 N. pts 445 N. pts 460 lenght of stay 6.8 Possib. di accogliere pz. 75% dei giorni dell anno Pazienti con deg. Max > 30 gg 17 Lenght of stay 4.9 Possib. di accogliere pz. 86% dei giorni dell anno Pazienti con deg. Max > 30 gg 8 Lenght of stay 4.09 Possib. di accogliere pz. 92% dei giorni dell anno Pazienti con deg. Max > 30 gg 6 47

48 Strategy Deployment A process that starts from the top, goes to the frontline activities, and comes back to the top A management system that aligns an organization function and activities with its strategic objectives 48

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53 Orthogeriatric flow starts in 2009 A ) Orthopedic 46 pl costumer base Hip fracture (21 days LOS) B ) Flusso ortogeriatrico (orthogeriatric flow) 24 pl 22 pl post-surgical recovery Livello 2 di assistenza Livello 3 di assistenza 4 days max LOS 10 days max LOS 54

54 Ortogeriatria per intensita di cura Attività clinica distinta in due aree a diversa intensità di cura ma in continuità assistenziale (stessa equipe multidisciplinare): LIVELLO 2: acute care LIVELLO 3: post-acute care Patients n. 371 pt. 362 pt. Mortality 30 days

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57 Promising Results: Just by improving patients flow Ridotti del 45% i pazienti rinviati (45% reduction of patients put off in the Op. Theatre) 40% space floor reduction in the Op.Theatre Ridotte del 90% le sedute extraorario (90% reduction extra work in O.T. and same production) Increased unplanned surgical daily activity from 11 to 16%, (2009) 35-45% reduct postop hip fruct mortality in the elderly 20% reduct Length of Stay in Gastroenterology (2010) 58

58 Promising Results: Just by improving patients flow Seven days waiting-time-reduction in Radiation Oncology Imaging vs paper for Radiology Gen. Surgery: decreased preop time for unplanned surgeries (3 to 2 days) Twenty to 25 % reduction LOS in gastroenterolory Improved (10 to 50% waiting time reduction) twelve administration processes Ninety % waiting time reduction for patients to get test response. 850 out of 1700 Operators (all levels of responsibility) trained on Lean Approach along the period

59 - 90% waiting time 90% waiting time reduction for patients to get tests response Dr. Berutti SIET- Galliera 60

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61 Patient centredness We are convinced that Lean Thinking and true patient centredness are not just compatible they are the same thing J. Toussant Thedacare H

62 Variazione dei costi di produzione in Aziende Sanitarie a confronto A parità di prodotto e di finanziamento -10 % - 15/20 % standard Galliera Galliera aspettativa

63 10000 Variazione dei costi di produzione in Aziende Sanitarie a confronto A parità di prodotto e di finanziamento -10 % /20 % standard Galliera Galliera Riduz. costi

64 Traffic lights Round-about At the beginning of xx century was considered democratic, for the pause and activity alternance (redgreen) for everybody First traffic light was working with gas 1868 The first electric traffic light 1912 Salt Lake City Detroit 1920 Automatic model 1924 Berlino Spread out in UK over 70-80s thanks to John Blackmore innovative proposal. New roules RESULTS Less accidents. As less as 40% compared with TL Queues decline every where round-about are built. 65

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66 INTERNSHIP MIHMEP Hospital Within the National Health System, 450 beds, admission/year, all specialities except Cardiosurgery and pediatrics. Innovative Lean management approach is on the way since Educational programs research and its impact into the Hospital are under implementation Requirements: Basic experience in healthcare lines of activity and process analysis. Standard English (Italian language basic knowledge preferable) 67

67 INTERNSHIP MIHMEP Expected Period of Time: Three 6 months internship available on the field of Lean Healthcare Expenses coverage: No grant available at the moment. 68