How can the Microsystem Concept Contribute to Best Performance in Primary Care Office Practice

Transcription

1 How can the Microsystem Concept Contribute to Best Performance in Primary Care Office Practice An overview for the day

2 A good day for a joyfull healthcare We do it together!

3 If we keep doing what we have been doing we ll keep getting what we always gotten The health care needs to be redesigned» Paul Batalden 2006

4 How Microsystem concepts increase values to a new level of performance - Empowerment to the patient empower the team to redesign for best possible results - How a valuebased management and curiosity define new challenges - What can we learn from practical experiences?

5 Europe

6 The pillars of English and Swedish Health Care Equitable/loyal financing Political government Responsibility for the population Healthcare on equal terms

7 International comparison I:

8 International comparison II:

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10 An introduction of our sources What are you proud of based on the work you do in HC?

11 Can.everybody have the empowerment to stop the line and bring people together if something is wrong? Vitality Better performance No waste Effectiveness Standardized way to work The science of improvement We measure every day A joyfull care

12 Toyota in Health Care? An organization which creates value for their customers and Produces products/services that are highly reliable, and consistently meets the user s expectations Builds success from making quality the central business strategy Continuously develop the core process of learning and innovation for a sustainable and reliable result Establishes a culture that values input and ideas In health care, this means: safe, effective, efficient, patient centered, timely and equitable

13 Eugene Nelson Paul B. Batalden Marjorie Godfrey how to redesign health services processes to improve quality, add value, reduce variation, and improve morale, in such a way that frontline caregivers lead the process of change, rather than obey it.

14 High Performing Clinical Microsystems Leadership Leadership Organizational support Staff Staff focus Education & Training Interdependence of care team Information & Information Technology Performance Performance results Process improvement Patients Patient Focus Community & Market Focus

15 We believe all improvement must start with the purpose Our mission.. people and patients should get the care they need when they need it We are here to increase value for our inhabitants Source:Budget 2007, The

16 Tell a story from a situation with a patient Tell the story What was important for the patient? What needs and values can you identify? What causabilities was important for you and the team? Key Words: Time, open access, working together, knowledge, joint working with other speciality, Work with,

17 Where is the need?

18 It is about giving the patient a true initiative precedence It is about listening and giving feedback to enable ever more insightful teaching from the patient. Pedagogical contents Pedagogical structures Pedagogical methods Pedagogical environments Ref: Bodil Jönsson

19 An outcome measure hierarchy, Porter, Teisberg Survival Degree of recovery/health Time to recovery or return to normal activities Disutility of care of treatment process (treatment related discomfort, adverse effects, diagnostic errors, treatment errors) Sustainability of recovery or health over time Long term concequences of therapy (care induced illness)

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21 A Case study from real life This happened in the summer of The names and facts have been slightly altered to make it apply to the conditions faced by many senior leaders of hospitals and health systems in the Unites States and elsewhere. Jack Candoo, CEO of Memorial Hospital and Health System (MHHS), returned from his summer vacation and received some very bad news from his chief financial officer (CFO).

22 A Case study from real life While Candoo had been enjoying a much-needed beach holiday with his family, MHHS had been informed by its largest purchaser that they were a Tier 2 health system and that reimbursement levels would be cut to reflect their suboptimal performance. Initially, Candoo felt that the decision had come out of the blue and that the data were wrong. On further reflection, however, he roughly confirmed that the data were right. He started to think that this Tier 2 placement by one purchaser posed a much greater problem for the long-term future of MHHS than it did for the next fiscal year. His reasoning behind this conclusion developed into the following internal monologue: Jack Candoo s dilemma

23 A Case study from real life 1. Looking at data from the core measures from the Joint Commission on Accreditation of Healthcare Organizations and being honest about them I realize that some of our numbers are excellent, some are average, and some are, frankly, shameful. 2. Patient satisfaction scores reflect a successful service excellence campaign we now consistently rank above the 80th percentile, way up from the 45th percentile attained three years ago but improving satisfaction has done nothing to improve clinical quality, costs per discharge, or costs per visit. 3. There is an aggravating and large gap the Institute of Medicine (IOM) even called it a chasm between the MHHS mission, vision, and rhetoric and actual, honest-to-goodness, measured performance. Jack Candoo s dilemma

24 A Case study from real life 4. The performance gap is not just embarrassing and aggravating but has financial implications as well. Now the public view this gap because both the Joint Commission and the Centers for Medicare & Medicaid Services (CMS) publish our results, along with everybody else s in the United States, in the name of transparency. Our purchases, who are getting serious about pay-for-performance and value-based purchasing programs, also use those results. 5. Today s gap could cause us huge problems tomorrow with the everincreasing number of gold-standard quality measures being published by the National Quality Forum (NQF) hundreds of very specific quality measures are currently in development and CMS leading the charge for all of the pay-for-performance schemes. Unless things change for the better and for real at MHHS, I could be out of a job, MHHS s bond rating could plummet, and the survival of our whole organization that we have worked so hard to build up during the past decade could be mortally threatened. Jack Candoo s dilemma

25 So this was Jack Candoo s dilemma What should you do? What recomendations can you give to Jack if you were his consult? Jack Candoo s dilemma

26 A Case study from real life Candoo thought that his reflections on current reality and future trends were fundamentally correct and deeply disturbing. He began to think what he needed was a whole new way of thinking, acting, and leading. He knew from experience that MHHS could run a quality improvement project on this or that condition or item. Recently, it had been successful in improving emergency department (ED) and inpatient satisfaction, decreasing length of stay and improving clinical quality for pneumonia and heart failure patients. But his general observation was that MHHS s work to improve quality and cut costs had been based on carrying out projects. These projects often succeeded in the short run but sometimes failed to hold the gains in the long run and never did spread to other clinical areas or give rise to new, collateral improvements in other areas that also needed work. There just didn t seem to be fundamental improvement in the organization s capability to continually improve and adapt. Jack Candoo s dilemma

27 A Case study from real life He concluded that he needed a new and fresh way of leading his organization to improve in all the ways that the future demanded. But he was wary of the management fads that he had seen come and go continuous quality improvement, then total quality management, then reengineering, then Six Sigma, now lean thinking, and who knows what idea will be next. Candoo felt that he needed not a new management craze but a durable and practical approach that (a) fit the special realities of health care, (b) was based on observations of what actually works, and (c) fit the health care system of the future. It was at this point that Candoo started to think more seriously about some conversations he had had with some friends at Dartmouth, a few articles he had read, and an intriguing book by Dartmouth professor James Brian Quinn, titled Intelligent Enterprise. Jack Candoo s dilemma

28 A Case study from real life Candoo started to feel a bit less glum and to think that maybe he could blaze a new path forward toward peak performance that would take his organization where it needed to go in executing strategic imperatives to meet staff needs and to exceed patient expectations. Jack Candoo s dilemma

29 So this was Jack Candoo s dilemma Richard can you give us your thoughts? Is Jack English? Jack Candoo s dilemma

30 The 5 P s of the micro system Mikrosystemets fem P Purpose Patienter Patients People/colleagues Processes Processer/ Patterns/ /syfte medarbetare flöden mönster What value shall we Vilket värde accomplish? ska vi åstadkomma? Vilka Who are är de? they? Hur How väl well känner vi do deras we behov? know their needs? Hur involverar vi dem How mer? do we involve them more? How do we use and Hur nyttjar och take care of the tillvaratar vi competence of our colleagues medarbetarnas in the best way? kompetens på bästa sätt? How do we involve Hur involverar vi them more in the improvement dem mer i work? utvecklingsarbetet? Hur How ökar do we vi increase our colleagues medarbetarnas understanding of our förståelse för sin mission? uppgift? How do we learn Hur lär more vi oss about mer om our våra processes? processer? How do we use Hur the använder result? vi oss av resultatet? How do we improve Hur blir our vi co-operation? bättre på länkning/samv erkan? How do we evaluate Hur the variations utvärderar in vi the variationer clinical i work? det kliniska arbetet? Att kartlägga, reflektera, samtala och försöka systematiskt förbättra To map out, reflect, discuss and try to systematically improve Ref: Godfrey

31 Report s Practice support program for improvement of patientoutcomes, quality of providers life 2 p-groups, support teams for S o QI, Qchampions, teamsharing, collaborative model,

32 NHS Institute for Innovation and Improvement Making the Shift

33 Our values and results gives us the way

34 Amount of 19 year old persons without any kaires at all Andel kariesfria 19-åringar i % åren Riket 23 %

35 Beräknat antal patienter som väntat längre än 90 dagar, per invånare, mars Mottagning, Estimated number of patients that waited longer than 90 days, per specialiserad vård inhabitants, mars Specialist care clinic in hospital Norrb otten Dalarna Sörmland Gävleborg Blekinge Jämtlan d Västerbotten Örebro Uppsala Riket Västra Götaland Gotland Halland Värmland Skåne Stockholm Östergötland Västmanland Kalmar Jönköping Västernorrland Kronoberg Värdet Högst värde Lägst värde Value Highest value Lowest value

36 Kronoberg Estimated Beräknat antal number patienter of som patients väntat längre that än waited 90 dagar, longer per 100 than days, per invånare, inhabitants, mars mars Gävleborg Väs tm anland Jämtlan d D alarna Väs tra Götaland Ö rebro Stockholm Sk åne Gotland Norrb otten R ik et Sörmland Västerbotten Ö stergötland Blekinge H alland U pps ala Värmland Jönköping Västernorrland Kalmar Värdet Högsta värdet Lägsta värdet Value Highest value Lowest value

37 2000 Scatterplot of Diff insekvs Sum index Diff i SEK Sum index

38 Scatterplot of Diff insekvs Sumindex 2000 Stockholm 1500 Gotland 1000 Västmanland Diff i SEK Blekinge Dalarna Västernorrland Norrbotten Örebro Västerbotten Jämtland Uppsala Jönk öping Värmland Kalmar Gävleborg Kronoberg Skåne Halland Östergötland Västra Götaland Sörmland Sum index

39 Antal läkemedel per patient i kommunalt boende 35 patienter (9 män; 26 kvinnor) i Jönköpings kommun jan Antal läkemedel En patient hade 27 mediciner insatta per dag Medeltal läkare/patient 3,5 Medelålder 80 år Vid behov Stående Dosdispenserat

40 What knowledge can healthcare integrate from other high performing industries?

41 Här ska du sedan skriva in din rubrik...

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44 Reflections

45 It s essential to have a basic understanding of how a given system works. If you don t understand the way things work and you try to change them, it won t be sustainable change And to create a high performing organization, you have to have high performing small systems within it» Paul Batalden

46 General Competencies for all employees training programs Patient care Medical knowledge Practice based learning and improvement Professionalism Interpersonal communication Skills System based practice Re-examination is done based on above competencies ACGME

47 The improvement work is based on four cornerstones Understanding the system Psychology Understand variation Vision: For a Good life in an attractive County Edward Deming Knowledge theory

48 To Develop a Changed Culture: You have two jobs: to do your job today and to improve it! Professional knowledge - Professional knowledge - Personal skills - Values, ethics Improvement knowledge -System -Variation - Psychology -Knowledge Improving diagnosis, treatment, care, rehabilitation and follow-up + Improvement in processes and systems in health care Increased Value for the Patients Paul Batalden

49 We need to put different lenses on

50 Where to start? Lawrence J. Henderson Patients and Caregivers (doctors) are part of the same system. NEJM, 1935

51 Customer orientation Engaged leadership Participation from everyone Competence development Sustainability Society responsibility Process orientation Continuous improvements Fast reactions 13 fundamental values Decisions based on facts System view Act preventative Learn from others Co-operation

52 Creating a sustainable situation for the continual improvement of health care Better patient (population) outcome Better professional development Everyone Better system performance Source:Batalden,Henriks

53 catch the spirit! and make it possible for everyone to contribute to the system

54 Ideal vs. Reality Case Study Analysis Solutions Mess Improvement Objective Changes Successes & Failures Academic Answer Solutions Real-world Answer

55 Important concepts Design Processanalyze Primary and secondary drivers PDSA Benchmarking 5p:s Theory of Knowledge Creativity Communication Appreciation of a System Psychology Understanding Variation Source: Deming

56 Ref: Nilsson,Bojestig, Edvinsson,Henriks, Berger

57 Purpose

58 Ref: Nilsson,Bojestig, Edvinsson,Henriks, Berger

59 Amount of 19 year old persons without any kaires at all Andel kariesfria 19-åringar i % åren Riket 23 %

60 Percent Rate of Influensavaccination to inhabitants 65 years of age and older in Jönköping County, Sweden starting to plan the innovation Year 2003 Same activities as the year before Goal=68% Vaccination for free - Vaccination registry - Education in vaccination for 250 nurses and 30 physicians - TV-commercials and advertises in the locale press - Goal=60% Same activities as the two previous years but the TVcommercial is changed a bit. Goal=75% 2005 Same activities as the previous years. This is no longer a project it is a standard Goal=75% 70 Jönköping s newspaper11/9, 2006

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

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63 Juni Augusti Oktober December Hospital Mortality in Jönköping County Council Sjukhusmortalitet Jönköpings läns landsting ,00% 2002 Januari Mars Maj Juli September November 2003 Januari Mars Maj Juli September November 2004 Januari Mars 2,50% 2,00% 1,50% 1,00% 0,50% 0,00% UCL=0, CEN=0, LCL=0, Maj Juli Oktober December Februari April Percentage Procent of av Care vårdtillfällen occasions

64 Early warning system Monthly report of system measures System Measures Adversed Drug Events, ADE Patient Satisfaction Mortality at hospitals, over age 65 Access Cost per inhabitant Cost per care event

65 Ref: Nilsson,Bojestig, Edvinsson,Henriks, Berger

66 A Gap between optimal treatment of cardiac infarction according to guidelines and what is really performed in the clinical activity Big variation between hospitals Big variation within hospitals ACE-inhibitor (%) at discharge after AMI The hospital s treatment Control Chart: traditions Coronary have a angiography tendency to 1999 be stable,8 over time 60 Evidence based methods for quality development is needed,6 50 Activity index in ,4 30,2 20 0, Guidelines Routine care Coronar angiography UCL Center =,29 LCL Sigma level: A ctivity in d e x in

67 Ref: Nilsson,Bojestig, Edvinsson,Henriks, Berger

68 Searching for Improvement ideas - Brainstorming - Litterateur searching - Site visits - Learning from other teams

69 Improving the System Learning From Clients Coordinate SWEDAC Audits Design and Redesign Develop Budgets Conduct Planning Attend Professional Society Meetings Conduct Research Handle Complaints Conduct Internal Audit Meeting Research New Techology Coordinate Changes in Work with Our Unions Preparing Measurement Reports Conduct Team Meeiings Conduct Meetingss Conduct Unit Staff Meeting Identify Opportunities to Colloborate Meeting with Referring Clients Clinical l Physiology Mainstay Conduct Tests Referring Professionals Receive Referral Communication Conduct Cardiac Tests Conduct Nuclear Medicine Tests Conduct Nevrsophysiology Tests Prepare Reports Referring Clients University Students Provide Emergency Support Provide Education Provide Consulting Services Scheduling Work with Equipment Suppliers Scheduling Patients Handle Telephone and Fax Communication Maintain Equipment Calibrate Equipment Coordinate IT Support Develop and Update Protocols Scheudling Staff Clinical Physiology Role Statement Healthcare professionals in Jonkoping County Council need access to information and knowledge that enables them to properly diagnosis causes of disease and to ensure that appropriate treatment is given to the patient. The Clinical Physiology department matches this need by providing cardiac, nuclear medicine, neurophysiology tests, consulting and education.

70 A Generic Clinical Microsystem Model Satisfaction of need, monitoring, assessment of outputs Acute care Entry, Assignment Orientation Initial Work-up, Plan for care Chronic care Preventive care Palliative care Ref:Gene Nelson Disenrollment Functional Beneficiary knowledge, including knowledge of life while not in direct contact with the health care system Functional Biological Expectations Biological Satisfaction Costs Costs

71 Ref: Nilsson,Bojestig, Edvinsson,Henriks, Berger

72 Variation. Ryggsäck Efterfrågan Kapacitet Outnyttjad kapacitet kan inte sparas tid Ref: Strindhall, Henriks Murray

73 Knowledge Information Education Delivery System Design Decision Support Clinical Information Systems Problem or improvement area? Meetings Self- Management Support Informed, Activated Patient Prepared, Proactive Practice Team

74 Ref: Nilsson,Bojestig, Edvinsson,Henriks, Berger

75 Planning Strategic Objectives Improvement Efforts Resources

76 Antal Inpatients % Beläggning dagar Watingtime 5,5 5 4,5 4 3,5 3 2,5 2 dagar Lengt of stay antal Number of deths 10 9,5 9 8,5 8 7,5 7 % Patientsatisfaction Antal Contact with coordinator andel 8,00 6,00 4,00 2,00 Percentage of deths % Readmissions within 14 days 0 0, % Staff satisfaction

77 Business Case: Fall prevention Number of Falls reported at Kristinedal nursery home (ward 3 and 4) 20 Changes done: 15 Education for assistant nurses and nurses Risk analysis of falling for all patients in the unit Meetings in the Team planning individual steps for each risk patient Systematic drug survey for all risk patients to prevent falling Information to patients/ relatives around risks for falling Clear of indoors environment Continuous measuring Notice board Purchase of technical facilities n o v. -02 d ec. -02 jan. -03 feb. -03 m ars. -03 ap ril. -03 m aj.-03 One broken hip: Cost for health care: dollars Cost in all for the society: dollars ju n i.-03 ju li.-03 au g.-03 sep t.-03 o kt.-03 n o v.-03 d ec jan

78 Business Case: Pressure Ulcer Now Patient enrolled Pr. ulcer develops? Yes 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 County episodes Council of of Jönköping dollars care/year ALL patients are assessed 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

79 County Council Get every one on the bus Systems View of County Council of Jonkoping Participate in County Council Assembly Participate in Jonkoping Executive Meeting Governance for Spread of Change Design and redesign the system Conduct Business Planning Conduct Council Business Meeting Attending professional meeting Learning how to better serve our Patients Obtain Feedback Primary Care Telephone triage Manage drop in Drop in visits visits Provide nursing Care Neuromus cular Manage Infection controll Ophtalmology Dermatology Support Self Management Conduct Home care visits Provide E-learning Provide care in ER Provide Palliativ care Conduct Surgical care Conduct Ambulance care Conduct evaluation Planning for follow up Conduct Research Customers Patients Speciality Care Access Scheduling appointments Diagnosis, treatment and Decision Support Ear, nose, Women throat diseases Provide Surgical Pediatric diseases care Provide Provide Psychiatric care for care Medical diseases Support IT information systems Delivery system design Provide Provide care for care for In Out patients patients Provide Provide Intensiv Group care visits Define Ongoing Relationship Conduct Social planning Nursing Homes Provide Diagnoses support Information system HR IT Transportation Economy Maintain Buildings & Security Clinical Physiology Provide radiology Provide labratory Public Relations

80 Ref: Nilsson,Bojestig, Edvinsson,Henriks, Berger

81 Dashboard Dep. of medicine, Värnamo hospital Forest and Garden, Huskvarna AB

82 To make the transformation happen Change Company Culture Change Individual Attitudes Change Behavior Structure & Methods Norman, API

83 Simple rules We protect the patients and ourselves It is the system s result that counts We share the results from our development and improvement work with others Health care emanates from the patient s value, need and whishes Either solve the problem or take responsibility for the handing over to next step Feedback to the step before Work with guidelines Ref: The, 2002 Bojestig, Henriks

84 Make Improvement Mainstream Organisational Structure Parallel organisation Sponsors Engagement Gap Steering committee Programme Management Programme teams

85 The system for care Everybody are involved and improve the processes in the system Lean Consumption User friendly and oriented CARESYSTEM Teamness Change at all levels Ref: The county council of Jönköping, 2005, Bardon, Bojestig, Henriks

86 System Levels Microsystem Example Frontline Nursing Units Mesosystem Nursing Divisions Macrosystem Nursing Services Source: Henriks, Bojestig, Jonkoping CC Sweden

87 Strategic improvement areas Learninng and innovation IT Environm. Access Flow Cooperation Clinical improvements Patient safety Medication Adm Good financies Reliability V a l u e f o r p a t i e n t i n c r e a s e s Ref: The County council of Jönköping 2002, Bojestig, Henriks

88 First Order Change More of, or less of.the same thing Ref: Argyris

89 First Order Change Ref: Argyris More of, or less of.the same thing Tinkering around the edges...vacancy freeze.slow down work.. technical fixes to make bottom line look good.regular performance monitoring and tigher control and scrutiny.the Finance Director authorises all orders even down to stationery...checking all lights are switched off.reactive..quick fixes..dictatorial in approach

90 Second Order Change Reframe. See the big picture See the connections See the wider possibilities Ref: Argyris

91 Second Order Change Where is the waste and variation in the system?...understanding our business and our cost drivers.understanding patient flow what is our comparative performance? what tools, skills and systems do we need?.how do we link the whole system? how do we link cost and quality? Ref: Argyris Source: from Paul Plsek & Helen Bevan s creativity presentation

92 3 steps in building a movement framing mobilising sustaining Helen Bevan, NHS, 2005 Copyright Bate, Robert, Bevan 2002

93 Actors in network for development of courses, research and deployment in practice Landstinget Kronoberg IHH/HJ CIL Ref: Andersson-Gäre, Askenäs, Henriks Vxu Informatik Helix HHJ/HJ Dartmouth College USA HU/LiU Intermountain HS USA JLL Qulturum/ Futurum Liu Pedagogik IDA/EIS Vxu Pedagogik Centrum för ledarskap Landstinget Kalmar FORSS Landstinget Östergötlands

94 Qulturum college Qulturum college Learn from methods and tools Team dev Learn from theory in practice Master Learn from practice to develop theory Ph. D. Develop theory that develops practice Scientist Develop people with knowledge in everyday practice Ref: Andersson-Gäre, Askenäs, Henriks Fascilitation/ Coll.

95 Patient results QI work Figure 6 Expectations towards QI 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.

96 Patient results QI work Figure 7 Literature review. No evidence of patient results through QI 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.

97 Patient results Jönköping QI work Figure 8 Situation of Jönköping County Council 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.

98 Patient results QI work t Figure 9 Hypothesis suggested by this case. A threshold (t) in QI work (zone of noise below which results will not show) 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.

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100 A high performing organization The value of System understanding! The value of Measuring, Holding the Gains and adapt feed back system to the strategy! The value of Shared understanding and the linkages of processes! The value of the Microsystems! The value of shared understanding and Kollegium Qulturum Ref: Pursuing Perfection, The, 2006, Bojestig, Henriks

101 Ref: Nilsson,Bojestig, Edvinsson,Henriks, Berger

102 Based on the presentation of the Microsystem roadmap A couple of the seven questions for example: How do we define our gaps? How do we identify waste and links that do not work? How do we integrate improvement work as an everyday work?

103 Creating a sustainable situation for the continual improvement of health care Better patient (population) outcome Better professional development Everyone Better system performance Source:Batalden,Henriks

104 Reflection and nuggets

105 You find the presentation at