Whole System Transformation

Transcription

1 Whole System Transformation Intentional Design Sven-Olof Karlsson, CEO Göran Henriks and Mats Bojestig Jönköping Healthcare Services Sweden Who are we? Bridging the Gaps Sven-Olof Karlsson Göran Henriks Mats Bojestig 1

2 In this interactive session You will be presented key ideas and concepts for moving whole system transformation beyond the experimentation phase to intentional design, including the core principles conceptual framework leadership support needed We will also describe How to establish mission values Creating the necessary processes and structural design elements How to develop the best possible clinical results After this presentation you will be able to: Present a framework and key concepts in system thinking for leading innovation work Recognize what is needed from management perspective to develop the capacity to transform your system Initiate a framework for spread of new ideas in your system 2

3 Sweden Europe Jönköping county Jönköping County Council is responsible for the public health care services 3 Hospitals 34 Primary care centers 9,500 employees 350,000 inhabitants visits per day visit a specialist/day visit to g.p./day (300 visits to private doctors/day) Jönköping Värnamo Höglandet 160 new patients staying over night at the hospitals/day 9 newborns/day 3

4 Jönköping County 11 municipalities Beside health prevention, health and medical care the County Council is responsible for: Jönköping Värnamo Eksjö Höglandet Dental care - 35 clinics for general dentistry - 10 for specialist dentistry Education and research Culture & education Regional support & activities - County Theatre and Music - Public transportation - Regional development The Health Care in Sweden Health Care in Sweden is financed through taxes The County Council Assembly 81 elected politicians Elected every fourth year Public meetings four times a year The politicians are deciding the work of the County Council at a general level and the tax rate 4

5 Evaluation grid: Integrating Improvement into business Just beginning Aware Informed Integrating Understanding Successful and renewing Area Score = 0 Score = 2 Score = 4 Score = 6 Score = 8 Score = 10 1 Purpose No written statements Statements exists Mission and tenets Communicated and Used in align and Fully integrated into the defined and visible understood by guide the business structure employees 2 System Work as a process is not understood 3 Family Financial data is of measures viewed periodically 4 Information Information is gathered on ad hoc, reactive basis 5 Planning No formal planning, for reactive culture improve ment Major processes and products have been documented Financial and other operational measures are used System is based on passive information Planning for improvement is done on an informal basis 6 Managing No system exists to Improvements improve ment manage improvements recognized on an asneeded basis and resources assigned efforts 7 Model No standard approach Various approaches for to improvement efforts are used for improve improvement ment 8 Manage ment system Structure does not exist to make improvement a focus Relationships between processes are documented Family of measures is assembled System is well documented and includes active sources A formal documented process exists for planning improvement Leaders provide formal guidance for individuals and teams Training on the Model for Improvement and expectation of its use The need for A formal system for improvement is improvement is recognized and defined responsibility assigned System thinking and language is common Balanced set of measures reported graphically Information is documented and communicated Integrated process identifies objectives, efforts, and resources Improvements are guided by planning; leaders are learning Theory behind the Model for Improvement is understood Top management assumes responsibility for integrating improvement Systems diagrams are used in business Set of measures aligned and variation understood Comprehensive system with analysis and synthesis for decision making All other planning processes are defined and linked The impact of improvement is understood and managed Management systems have integrated the system view Measures are integrated into management systems Marketing leads and integrates information system Planning system is improved and integrated in all areas Improvement system is integrated in business and regularly improved Improvements are The Model is routinely managed as PDSA used by all cycles Improvement is linked to planning and other key business activities Improvement is completely integrated into all aspects of operating & developing the business Score your org./unit: (Source: API) Our inhabitants should get care when they need it Improvements based on knowledge 5

6 Population based health care 6

7 2000 Scatterplot of Diff i Kr vs Summa index Diff i Kr Summa index Scatterplot of Diff i Kr vs Summa index Stockholm 1500 Gotland 1000 Västmanland Blekinge Diff i Kr Dalarna Västernorrland Norrbotten Västerbotten Örebro Jämtland Uppsala Jönköping Värmland Kalmar Gävleborg Kronoberg Skåne Halland Östergötland Västra Götaland Sörmland Summa index

8 ...Change the outcome Comparison between counties in Sweden The lower the rate is the better score Serie Stockholm Sörmland Uppsala Västmanland Örebro Värmland Jämtland Kalmar Dalarna Vnorrland Gävleborg Blekinge Kronoberg Jönköping Gotland Östergötland Skåne Halland Västra G. Norrbotten Vbotten Comparison between counties in Sweden - Lower points is better ranking Total score 8

9 Results, annual report 2005 and prognosis for 2006 Per cent shares of net costs Average for Sweden Jönköping Increasing self-government gives us new questions The demand for competence increases in the daily work Organizations are becoming dependent of that the staff really does understand their working tasks The leaders possibilities to develop the work and business is totally dependent of the employees possibilities to develop their understanding People act from their understanding of reality 9

10 Some problematic assumptions 1. Customer relationship focus on the individual treat, access, equity 2. Problems with the performance Headline: Patients with cancer have to wait in line 10

11 3. 100% 100 % 1% Current activities New activities Continuous improvements New technology Medication Special competence 4. New employees Center periphery New working hours Patient safety Social movement 11

12 1 2 3 Improvements are being done as projects Infrastructure to lead/manage and improve A new level is created daily with improvements and a new design Design - development Improve project III II I Management - infrastructure 12

13 How to integrate improvements in your organization Integrating Improvement into business evaluation grid for Jönköping Integrating Improvement into business evaluation grid, API 13

14 Design - development Improve project III 100% participation in II I breakthrough activities Identify/prioritize possibilities: -What does the patient/customer say? -What does the process say? Rapid improvement cycles Widespread training Learn new habits and ways of working Project to project, process to process Development within units Management - infrastructure Basic strategies for improvement work Increased access is reached by: 1 2 The activity has a balance between capacity and demand No waiting list Increase the capacity Reduce the demand Manage variations Work to get rid of the rucksack Ref: Murray 14

15 Access Most Common Changes Start a reception for district nurses where patients can book a visit Make it possible for physiotherapists to do first exams Start infection receptions with reg nurses Schedule planning to balance capacity to demand Telephone routines - more time for telephone calls, more staffing - standardize and document advice giving Ref:Strindhall Collaboratives on Access called Bra mottagning Spread in Sweden Participating teams: more then 300 Participants: more then 2000 Värmland 2001 Västra Götaland 2000 Halland 2004 Västerås 2003 Skåne 2001 Blekinge 2002 Norrbotten 2006 Gävleborg 2005 Västmanland 2001 Uppsala 2001 Stockholm 2002 Östergötland 2001 Jönköping 1999 Gotland 2000 Kalmar 2000 Kronoberg

16 Collaboratives about Access Bra mottagning Units in Jönköping County Council Hospital clinic 1 Primary care centre 1 Primary care centre 2 Waiting time before start of BM1-3 ( ) 2 months 4 months 1,5 months Result after participating in BM 1-3 ( ) 1 week 1-3 days 1-3 days Result weeks 1-3 days 14 days Results from participating units in collaborative 1 3; Hospital clinic 2 Physio therapy at primary care centre 3 3,5 months 3 months 13 days 3 days 17 days 10 days Result before, after and six years later Logopedic unit/ hospital clinic 3 6 months 0 2 months Hospital clinic 4 12 months 6 months 2 weeks Primary care centre 4 1,5 months 6 days 3 days Primary care centre 5 1 month 13 days 6 days Primary care centre 6 1 month 1 month 3 days Hospital clinic 5 3 months No progress 2,5 months Median 3 months 1 week 14 days Min Max 1 month 12 months 3 days 6 months 3 days 2,5 months QUICC Important improvements to national guidlines - the result of the Swedish improvement work called Quality Improvement in Cardiac Care (QUICC) project Bertil Lindahl, Gunilla Lindström, Anette Peterson*, Christina Åberg, Mats Bojestig* and the QUICC study group, Uppsala Clinical Research Center and Dept of Cardiology, Uppsala, and *Dept of Internal Medicine, Eksjö, Sweden. Economic support from Federation of Swedish County Councils Ref Quality Management in Health care Jan 2007, AM Heart J. 2006:152:

17 45 40 Exact increase of how they follow (%) Exact increase of how they follow (%) p= p=0.001 p=0.01 p= p= ACE-inh C Q Lipid low C Q Clopido. C Q L.m.w. hep C Q Corai C Q Number of of hospitals that reach 70 % following in in 4/5 and 5/5 treatments Control 4/5 5/5 QUICC 17

18 Quality index 2005 comp. to 2003 QUICC-hospital Kvalitetsindex Kvalitetsindex 2003 Figur 29d. Sjukhusens kvalitetsindex 2005 jämfört med 2003 (minst 10 patienter i målgruppen), med Göran antal Henriks, sjukhus Mats Bojestig bredvid cirkeln och referenslinje längs oförändrat index. Red line = reference line for no change in index Promising ideas and concepts Senior alert Your care Care prevention More time near the patient 18

19 The Care Prevention Project Four teams created four care programs; for Prevent falling, Nutrition, Ulcers and Pain (2004/2005) Create a better process for the preventive work in the whole county and better cooperation Create a way of working for all elderly people, for everybody in the county and for the whole care chain Target group for Care prevention: Patients age 70 or elder! Prevention work for population/ Individuals before getting ill. Help them live healthier Inpatients at the hospitals having risk getting ulcers, falling and malnutrition Special risk groups Patients with need of treatment and care 19

20 The Care prevention process Number of Risk patients in the process 20

21 Number of Risk patients where something was done Number of patients in the process 21

22 Number of patients where something was done A new national register: Med. treatment and care for elderly people 22

23 Business Case: Pressure Ulcer Now Patient enrolled Pr. ulcer Yes develops? Treatment of pr. ulcer Patient dicharged No Value Assessment episods of care/year New At 8 % of episodes pressure ulcer develops Treatment of pressure ulcers costs 7.6 million dollars Total cost 7.6 million dollars Pat enrolled Assessment acc. to Norton Risk? Yes No Preventive treatment Pr. Ulcer Yes develops? No Treatment of pr. ulcer Patient discharged Value assessment Sven-Olof episodes Karlsson, of Jönköping care/year ALL patients are assessed dollars 8 % of patients has a risk acc. to assessment dollars Assume that half of the pressure ulcers can be prevented 4 million dollars Total cost 5 million dollars Design - development Improve project III 100% participation in II I breakthrough activities Identify/prioritize possibilities: -What does the patient/customer say? -What does the process say? Rapid improvement cycles Widespread training Learn new habits and ways of working Project to project, process to process Development within units Management - infrastructure Build needed infrastructure Identify key processes Measure and follow outcome. Learn how to assess Quality control How we organize Early warning signals Prioritize what to do System understanding/how we do The Diamond Picture Strategic compasses New arenas: Big Group HC 23

24 There is a lot of exciting things going on and think when we can promise a Health Care that is Good Health Care Swedish Board of Healthcare and welfare safe knowledge based and efficient patient focused effective equal timely What is leadership? A group of people going in the same direction by the will and the conviction of their own 24

25 The New leadership Economic requirements How? Breakthrough of what is good What? Clinical improvements Organizational changes Swe: Capitering 1 physician per 1500 inhab Cue-money etc Now Coop. Good access Breakthrough Logistics From indoor to outdoor From physician to other category From readmission to new visit etc Future Good exemples Enthusiasm Safety Medication etc What does it take? To get a group of people, go in the same direction by the will and the conviction of their own, you have to have... a dialogue that... creates participation letting people grow allows many to become winners 25

26 A good leader is recognized by a strong will courage persistence A good leader is recognized by a strong will - to have this, you need knowledge and a conviction of your own courage persistence 26

27 A good leader is recognized by a strong will - to have this, you need knowledge and a conviction of your own courage - requires that you don t hesitate or bend when you meet resistance persistence A good leader is recognized by a strong will - to have this, you need knowledge and a conviction of your own courage - requires that you don t hesitate or bend when you meet resistance persistence - means that you for long time stick to your strategy 27

28 A learning organization has to have a learning leadership. Jönköping s group of leaders have spent more than hours/year since 1998 on Quality work! Six challenges for leaders: The maintenance of purpose 6. and organization/ business idea 1. The Basic Values The development of more 2. profound knowledge and capacity in improvement work 5. The leadership of system results rather than project results Cooperation over unit-, 3. preserve- and competition boarders 4. The creating of a work (a business) that generates reliability, good economizing and value for the inhabitants 28

29 Budget plan and Plan for : The important of relations Vision and goal: Best possible life - the whole life! Develop Value The Region Cooperation routines and resources Well trained and prepared care teams Health care Support self care Offer different kind of health care Deliver diagnostics, caring and rehab IT-support Best possible value and clinical results for the patient! Well informed active inhabitants/ patients 29

30 QUALITY AS A BUSINESS STRATEGY Overall strategic aims of Jönköping County Council: With Good financing we mean activities that create values leading to satisfied customer/-patients with high quality of life. This requires that health care... has access. is based on a overall view regarding patient flow and processes. reaches/performs the best clinical results with the best safety. is performed to lowest possible costs. To live up to this demand it is of necessity to have motivated and participated employees. Improvement collaboratives, 2007 Work in a smarter way! Balanced scorecard Learning/Renewal Economy 100% 80% 60% 40% 20% 0% Customer/patient Process/productivity Activities, Breakthrough series etc 30

31 Overall Strategic Aims of Jönköping County Council/Health care services: With Good financing we mean activities that create values leading to satisfied customer/-patients with high quality of life. This requires that health care... has access. is based on a overall view regarding patient flow and processes. reaches/performs the best clinical results with the best safety. is performed to lowest possible costs. To live up to this demand it is of necessity to have motivated and participated employees. Strategic areas that we are working with in Jönköping Strategic aims for the County council of Jönköping Legislation from the Swedish National Board of Health with IOM aims and Deming methods! Value compass 31

32 System measures for Jönköping County Council/Health care services Sick leave Staff turnover Actual year worker SF-6 TM Patient with Health Need Process of Providing Services Patient with Health Need Met Mortality Clinical Outcomes Functional Outcomes Satisfaction Access End of life Reimbursement within 30days 3rd Available Appointment Number of care days during the last 6 months of life Numbers dying in Hospital HSMR Mortality ADE Reports to PSR Costs Costs per discharge Costs per capita Inpatient Satisfaction Success factors Customer Citizens Process/ Production Learning & Innovation System measures Economy Development areas Tillgänglighet Access / How och bemötande we treat patients Prevention/Egenvård / Self-care Cooperation Developing areas Clinical result improvements Kliniskt förbättringsarbete 32

33 1,50 HMSR, hospitals per county in Sweden HSMR Reducerat, sjukhusvårdtillfällen samt endast verifierade överföringar 1,40 1,30 1,20 1,10 1,00 0,90 0,80 0,70 0,60 0,50 Stockholm Dalarna Kronoberg Västerbotten Jämtland Västra Götaland Halland Jönköping Östergötland Västernorrland Skåne Gotland Norrbotten Kalmar Värmland Gävleborg Blekinge Uppsala Örebro Södermanland Västmanland HMSR, hospitals in Sweden 33

34 Strategic Improvement areas Learning and innovation Leadership IT Envir. Adm. Access How we receive Prevention Self-care Cooperation/flow 350 team 30 team 21 team Big Group Healthcare Clinical improvement work 60 team + 43 team i National Quality Registers Patient safety Medication 80 team 60 team Transformation in depth and width Good finances Reliability More than 550 teams and 4,000 employees have participated in programs V a l u e f o r p a t i e n t i n c r e a s e s Open comparisons Perspectives A. Med. Results (35) - Clinical results - Evidence based care - Safe care - Cooperation - Prevention B. Patient experiences (9) - Patients view of the HC - Populations view of HC C. Assess (4) - Waiting times - Telephone access D. Costs and productivity (9) - Costs per inhabitant - Productivity 34

35 Competence Center for Swedish National Registers on Heart Failure From one of the largest daily newspapers in Sweden: Best intensive care units Hospitals Worst intensive care units Hospitals Best hospitals in Stockholm 35

36 Expectations towards QI Patient results QI work Quality Management in Health Care submission, Improvements for patients? Findings from an independent case study of the Jönköping improvement program John Øvretveit, Director of Research, Medical Management Centre, The Karolinska Institutet, Stockholm, and Professor of Health Management, Faculty of Medicine, Bergen University, Norway. Anthony Staines MBA, MHA, MPA, researcher, IFROSS, University Lyon III; France Vice-Chairman of sanacert, Accreditation Body for the Swiss Hospitals. Literature review. No evidence of patient results through QI Patient results QI work Quality Management in Health Care submission. Improvements for patients? Findings from an independent case study of the Jönköping improvement program John Øvretveit, Director of Research, Medical Management Centre, The Karolinska Institutet, Stockholm, and Professor of Health Management, Faculty of Medicine, Bergen University, Norway. Anthony Staines MBA, MHA, MPA, researcher, IFROSS, University Lyon III; France Vice-Chairman of sanacert, Accreditation Body for the Swiss Hospitals. 36

37 Patient results Situation of Jönköping County Council Jönköping QI work Quality Management in Health Care submission. Improvements for patients? Findings from an independent case study of the Jönköping improvement program John Øvretveit, Director of Research, Medical Management Centre, The Karolinska Institutet, Stockholm, and Professor of Health Management, Faculty of Medicine, Bergen University, Norway. Anthony Staines MBA, MHA, MPA, researcher, IFROSS, University Lyon III; France Vice-Chairman of sanacert, Accreditation Body for the Swiss Hospitals. Hypothesis suggested by this case. A threshold (t) in QI work (zone of noise below which results will not show) Patient results t QI work Quality Management in Health Care submission. Improvements for patients? Findings from an independent case study of the Jönköping improvement program John Øvretveit, Director of Research, Medical Management Centre, The Karolinska Institutet, Stockholm, and Professor of Göran Health Henriks, Management, Mats Bojestig Faculty of Medicine, Bergen University, Norway. Sven-Olof Anthony Karlsson, Staines Jönköping MBA, MHA, MPA, researcher, IFROSS, University Lyon III; France Vice-Chairman of sanacert, Accreditation Body for the Swiss Hospitals. 37

38 What does it take to become a leader? How to establish mission values Creating the necessary processes and structural design elements How to develop the best possible clinical results Lean Design Value chain analysis (Toyota Prod. System) Micro system Design development Everyone is creating from their position Drive both outcome and responsibility for resources Working without borders From chain to unbounded Improve project III 100% participation in II I breakthrough activities Identify/prioritize possibilities: -What does the patient/customer say? -What does the process say? Rapid improvement cycles Widespread training Learn new habits and ways of working Project to project, process to process Development within units Management - infrastructure Build needed infrastructure Identify key processes Measure and follow outcome. Learn how to assess Quality control How we organize Early warning signals Prioritize what to do System understanding/how we do The Diamond Picture Strategic compasses New arenas: Big Group HC 38

39 Interviews in Jönköping Nov 2007 John Black, Lean consultant and Gary Larson, Parc Nicolett Healthcare system vision 2010 Everyone works to optimize processes in the system Staff participation Easy to use Health care system 39

40 The Challenge! Level of ambition Successful project Transformation Good enough Strategic improvements Strength in cooperation Cooperation over boundaries Conflicts How to support the force of development Renewed roles and tasks Status quo Small changes in current design Permission to test new things 40

41 Challenges: To become as good as you can The big steps in science have not always been the result of a specific discovery they have emerged from changing reference frameworks and looking at things in another light/from another perspective. Edward de Bono The oldest symbol for mind in the Chinese written language is an outline of a heart to view things with a heart is maybe more than a metaphor, it is Chin. Heart extension of awareness that characterizes seeing from the whole Peter Senge 41

42 CHAIN provides an opportunity to find out what is happening within health & social care regionally and nationally, a source of e-networking, exchange if ideas, and not having to re-invent the wheel web: enquiries@chain-network.org.uk Nod for Scandinavia: Qulturum, anette.nilsson@lj.se Learning focus yesterday Learning focus we need more of The thing that counts... My performance We teach and do together Knowledge through The knowledge... We manage through... Seminars, lectures Saved in stores until asked for Goal! We act into the new Spread directly everywhere Result! For this we need other form of support What? We look for the knowledge... At the libary On Google It is all about... My development The Customer s development 42

43 For this we need other form of support What? Good websites Intranet and extranet for competence development Video conferences Web access Telephone conferences Measures Presentation techniques Simple papers Peter Senge The tools and ideas in this book (The 5th discipline) are to destroy the illusion that the world is created of free-standing focuses without relations in between. When we abandon this illusion we can built Learning organizations organizations where - people continuously increase their ability to accomplish the results they really pursue, - new and expansive mind patterns are nourished, - common ambitions at let loose and - people continuously learn how they can learn together (Senge 1990:3) 43

44 How can we learn from other high performing systems? Service Excellence SCANIA (GREAT BRITAIN) LIMITED 44

45 Putting the customer first SCANIA (GREAT BRITAIN) LIMITED Everything Speaks SCANIA (GREAT BRITAIN) LIMITED 45

46 Everything Speaks SCANIA (GREAT BRITAIN) LIMITED Everything Speaks SCANIA (GREAT BRITAIN) LIMITED 46

47 SCANIA (GREAT BRITAIN) LIMITED Customer Service Training and Education SCANIA (GREAT BRITAIN) LIMITED 47

48 Scania Production System (Scania Performance System) SCANIA (GREAT BRITAIN) LIMITED SPS Whiteboard Local Teams Whiteboard for issues Everything speaks Measurement Local remedies Intranet system to raise profile Intranet system of good practice SCANIA (GREAT BRITAIN) LIMITED 48

49 Scania Performance System Measure Find the obstacle Remove the obstacle Measure again Move on Keep it simple SCANIA (GREAT BRITAIN) LIMITED Staff Recognition Launched at the conference Supported with posters Internal & external nominations 30 plus nominations per month All acknowledged Good news published SCANIA (GREAT BRITAIN) LIMITED 49

50 Communication SCANIA (GREAT BRITAIN) LIMITED Patient safety = Eng: Many scarcities Excerpt from a patient register discussed in Swedish court. 50

51 Develop MIG-team Evidence based care in heart failure Plan and do medication tunings Prevent central line infections Preventwound infections after operation Prevent ventilatorassociated pneumonia Prevent harms with potential dangerous drugs Prevent surgical complications - introduce SCIP (Surgical Care Improvem. Project) Prevent ulcers Prevent MRSA infections Evidens based care for patients with heart failure Engage board Prevent unary tract infections Prevent falls Management force for patient safety Risk and Safety wheel Patient s direct channel Areas Measures Meetings and methods Risk and Action analysis Improvem ents in mediciation Access +Balance Counter Nationla registers Measures for leading Leadership programs IT-support HSMR Mortality AE - Glober Trigger Tool ADE (medication incidents) Reinbursments Infections Senior Alert nat. register Cost per capita Safe health care every time! Patient safety activities 14 areas 1. Develop MIG-teams 2. Improved care for pat with congestive heart failure 3. Prevent adverse drug events 4. Prevent central line infections 5. Prevent surgical site infections 6. Prevent ventilator associated pneumonia 7. Prevent harm from high-alert medications 8. Reduce surgical complications 9. Prevent pressure ulcers 10. Reduce methicillin resistant infections 11. Improved care for acute myocardial infarction 12.Governance leadership Boards on board 13. Prevent unary tract infections 14. Prevent harms caused by falls

52 In Jönköping 14 interventions 12 interventions same as the 5 million Lives Campaign in US: 1. Deploy Rapid Response Teams at the first sign of patient decline 2. Deliver Reliable, Evidence-Based Care for Acute Myocardial Infarction to prevent deaths from heart attack 3. Prevent Adverse Drug Events (ADEs) by implementing medication reconciliation 4. Prevent Central Line Infections by implementing a series of interdependent, scientifically grounded steps 5. Prevent Surgical Site Infections by reliably delivering the correct perioperative antibiotics at the proper time 6. Prevent Ventilator-Associated Pneumonia by implementing a series of interdependent, scientifically grounded steps 7. Prevent Harm from High-Alert Medications... starting with a focus on anticoagulants, sedatives, narcotics, and insulin In Jönköping: 14 interventions, cont.: 8. Reduce Surgical Complications... by reliably implementing all of the changes in care recommended by SCIP, the Surgical Care Improvement Project 9. Prevent Pressure Ulcers... by reliably using science-based guidelines for their prevention 10.Reduce Methicillin-Resistant Staphylococcus aureus (MRSA) infection by reliably implementing scientifically proven infection control practices 11.Deliver Reliable, Evidence-Based Care for Congestive Heart Failure... to avoid readmissions 12.Get Boards on Board by defining and spreading the best-known leveraged processes for hospital Boards of Directors, so that they can become far more effective in accelerating org progress toward safe care Two more in Jönköping: 13. Prevent urinary infections 14. Prevent falls connected with caring 52

53 Mortality Period: In Jönköping we have been working with reducing mortality Getting the question on the agenda in Swedish healthcare and clarifying what this is all about Results: Appr 130 lives saved Rapid response teams have been created ADE Clinical infections reduced: The Orthopedic departments at two of our hospital has become among the best in Sweden HSMR/ Mortality Inpatients satisfaction SF6 Jönköping System measures Cost per capita Palliative mortality ADE LÖF Reimbursements within 30 days Average number of care days the last 6 months 3rd Available Time Hospital costs per patient Primary Sick leave POMS Actual yearly workers Secondary Source: Peter Kammerlind 53