Lean och arbetsmiljö inom sjukvården: Proaktivt förändringsarbete för hållbara arbetsprocesser inom vården

Det övergripande syftet med projektet (som finansieras av AFA Försäkring) är att skapa bättre förutsättningar för att kombinera effektiva patientflöden och en god arbetsmiljö bland anställda inom sjukvården. Ett delsyfte är att utveckla ett ergonomiskt integrerat komplement till LEAN-verktyget värdeflödesanalys (VFA). Ett annat delsyfte är att studera vilka faktorer som har betydelse i selektionsprocessen av lösningsförslag. Inom Lean är VFA ett etablerat verktyg för att effektivisera flöden. När ett flöde kartläggs så är huvudsyftet att reducera icke värdeskapande aktiviteter, dvs. den tid/aktiviteter som inte tillför varan eller tjänsten något värde. Genom visualisering av olika arbetsuppgifter i flödet (med hjälp av post it-lappar) och dialog tar man sig från ett nuläge till ett önskat framtida läge. Vid VFA finns dock en risk för arbetsintensifiering och därmed en risk för försämrad fysisk och/eller psykosocial arbetsmiljö. Därför är verktyget ERGONOVA (ergonomisk värdeflödesanalys) framtaget som ett integrerat komplement till VFA. Med ERGONOVA beaktas arbetsmiljöaspekter i ett flöde. De arbetsmiljöaspekter som beaktas är fysisk belastning(arbetsställningar, lyft av föremål mm) och arbetsinnehåll (krav, kontroll, kommunikation). Här görs bedömningar på arbetsuppgiftsnivå, flödesnivå och jobbnivå. Utifrån en nulägeskarta för flödet identifieras problem/hinder för arbetets utförande och arbetsmiljöbrister. Analysprocessen resulterar i konkreta lösningsförslag och en preliminär handlingsplan vad gäller ett framtida flöde. Förslagen exponeras sedan på avdelningen, där alla medarbetare ges tillfälle att lämna synpunkter. Slutligen fastställs en handlingsplan med de aktiviteter och åtgärder som krävs för att förändringarna ska kunna genomföras och implementeringen påbörjas. Resultat från tre vårdenheter inom Västra Götalandsregionen visar att de anställda blir delaktiga i förändringsarbetet, där analys av arbetssätt blir i centrum. Fördelen med att använda post it-lappar (olika färger för olika yrkeskategorier) är att de anställda får arbetsuppgifter och flödet ”framför ögonen”. Därmed förskjuts fokus från person till arbetssätt och flöde. De preliminära resultaten visar att den anställde ofta får en bättre förståelse för vad de gör i ett flöde och vad andra yrkeskategorier gör. Ergonomisk värdeflödesanalys genererar en betydande idérikedom vad gäller förslag till förändringar. Resultaten indikerar att de anställda får en tvärfunktionell dialog där man diskuterar och föreslår förändringar som ofta leder till både ökad effektivitet och bättre arbetsmiljö

A Nordic work environment complement to Value Stream Mapping (VSM) for sustainable patient flows at hospitals – A NOVO Multicenter study

The Nordic Council of Ministers (NCM) granted 2007-09 a project with the aim to establish and develop a Nordic Network for scientists regarding research on work environment and efficiency in the health care sector (‘the NOVO network’). The vision is a “Nordic Model for sustainable systems” in health care. A “Sustainable system” is here defined as the joint consideration of competitive performance and working conditions in a long-term perspective (Westgaard & Winkel, 2009, 2011). A preliminary project plan for a Nordic Multicenter project focusing a specific aspect of the vision was developed as part of the above mentioned NCM project. This was entitled: “A Nordic work environment complement to Value Stream Mapping (VSM) for sustainable patient flows at hospitals – A NOVO Multicenter study”. Development of production systems in healthcare is at present to an increasing extent based on Lean Production ideas. In the Lean terminology “value-adding work” (VAW) represents the portion of process time that employees spend on actions that create value as perceived by the customer (Liker 2004). The complementary part is “non-VAW” or “waste” as the general Lean term of non-value-adding activities. In healthcare VSM is a common Lean tool used to identify and minimize waste (Keyte & Locher, 2004). It is a participatory tool, i.e. those affected by this type of rationalization are performing the analyses and subsequently suggesting the interventions. Participation has been shown to be crucial to obtain ownership of the suggested interventions and thereby increase impact. In addition, VSM has been shown to be a powerful rationalization tool. However, the resulting interventions may imply physical work intensification and impaired psychosocial work environment if the proportion of VAW is increased and management issues are not properly considered. In the rationalization process both physical and psychosocial working conditions should therefore be integrated to obtain a competitive performance in a long term perspective. In practice, this is rarely done. Thus, health of the employees and system performance goals often end up on a collision course with short-term performance demands as the winner (e.g. Winkel & Westgaard 1996, Westgaard & Winkel 2011)

Introduction of Lean/Value Stream Mapping at hospital units in three Nordic countries and expected impact on the working environment - A Nordic Multicenter study

Conceptual framework and PurposeA recent review has documented mostly negative effects of rationalization on musculoskeletal and mental health and corresponding risk factors. This goes in particular for the healthcare sector (Westgaard & Winkel, 2011). Lean Practices are increasingly used in healthcare and Value Stream Mapping (VSM) seems to be a commonly used tool to identify and minimize waste (Keyte & Locher, 2004). The health impact of Lean varies considerably between investigations. This may to a large extend be due to differences in the operationalization of Lean (Br\ue4nnmark et al, 2012). VSM is a participatory tool, i.e. those affected by this type of rationalization are performing the analyses and subsequently suggesting the interventions. Participation has been shown to be crucial to obtain ownership of the suggested interventions and thereby increased impact. On this background rationalizations based on VSM may offer a procedure that also includes working environment issues. In addition, workplaces in the Nordic countries seem to offer good opportunities for realizing a true participatory approach considering also working environment issues when rationalizing a value stream (Gu\uf0mundsson, 1993; Westgaard & Winkel, 2011). VSM has been shown to be a powerful rationalization tool in the elimination of non-value-adding tasks (non-VAT). Several studies show that non-VAT generally offer less risky physical and mental exposures (e.g. Kazmierczak et al, 2005; 8stensvik et al, 2008; Palmerud et al, 2012; Jonker et al, 2013). According to this, non-VAT is usually named “the porosity of the working day” (Marx, 1867; Westgaard & Winkel, 2011; Winkel & Westgaard, 2001). Strong political demands to maximize efficiency in healthcare may thus potentially result in an excessive rationalization causing a too large reduction in porosity and thus too risky work intensification.In practice Lean is often perceived as a “threat” by employees at hospitals (H\ue4renstam et al, 2000; many personal communications). In contrast, most Lean consultants generally describe Lean as an opportunity for improvements also in terms of the working environment (numerous personal communications). On this background an ergonomic complement to VSM, the ErgoVSM, has been developed based on existing scientific evidence and in close co-operation with Swedish industry and the healthcare sector (Jarebrant et al, 2013). The ErgoVSM also considers health issues, i.e. risk factors for musculoskeletal and mental health in addition to reduction of waste (Jarebrant et al, 2004; 2009). In this paper we present some preliminary data based on 1st line managers’ assessments of expected impact of action plans based on VSM and ErgoVSM. The presented data are retrieved from a larger NOVO Multicenter Study (Winkel et al, 2012).Design/MethodologyFourteen hospital wards in Denmark, Iceland and Sweden are investigated. Seven of these are using VSM and the remaining the ErgoVSM to improve the efficiency of their patient flows. Current and future states are assessed and action plans presented. 1st line managers are then interviewed and asked to assess expected impact of each suggested intervention in the action plan in terms of efficiency, treatment quality, physical and psychosocial working environment. So far five of the fourteen 1st line managers have been interviewed. Two of the wards have used the VSM tool and 3 the ErgoVSM tool. Results and DiscussionAll together 103 amendments for improved performance have been assessed in the five action plans. Eighty-one of these were assessed also to imply improvements in the working environment. Three suggestions were expected to imply a negative impact and four no impact on the working environment. Fifteen suggestions were not rated as they were decided not to be realized. Using VSM or ErgoVSM did not influence the assessment of expected impact of amendments in the action plan. The dominance of expected positive impact on the working environment of the amendments will be discussed in terms of potential bias and real opportunities. The Multicenter Study includes follow-up investigations of realized impact on the working environment as well as potential national differences between the three investigated countries (cf. Birna & Gunnarsd\uf3ttir, 2012; Edwards & Winkel, 2012; Jarebrant et al, 2012)

Development of a tool for integrating Value Stream Mapping and ergonomics in healthcare - A Nordic Multicenter study

Aim: To present the most recent draft Nordic version of the ErgoVSM tool for healthcare and some contextual factors influencing the intended impact of the tool. Material and Methods: The ErgoVSM tool is tested at 7 wards on 4 different hospitals in Denmark, Iceland and Sweden. The tests include assessment of tool usability and main factors facilitating or inhibiting the intended impact of the tool. On the basis of these trials a final version of the ErgoVSM is developed. The ErgoVSM tool: According to common VSM procedure the Current State is mapped (visualized) followed by a similar procedure regarding a wanted Future State. The Ergo-module includes assessments of physical exposures (posture, forces, variation, porosity) and psychosocial exposures (demands, control, variation, communication, porosity). It focuses task as well as values stream level. The exposures are assessed by ratings scales with verbally defined end points. The analysis includes discussion of solutions and establishment of an Action Plan needed to realize the wanted Future State. Main contextual factors influencing the intended impact of the tool seem to be previous Lean experience, management style, volume of competing projects and type of value stream analysed

Manifestations and Survival in Coronary Heart Disease

Aim: To investigate how risk factors predict manifestations in coronary heart disease (CHD), and trends in short-term and long-term survival including trends in out-of-hospital mortality. Populations and methods: In the first study 7388 men aged 47 to 55 and free of previous acute myocardial infarction (AMI) or stroke were investigated during 28 years’ follow-up. In the second and third study we created a record linked database from the Swedish hospital discharge and death registries documenting all cases aged 35 to 84 years who had either been hospitalized for a first AMI or who had died from CHD outside hospital without a prior hospitalization for AMI. In the last study data were derived from 143, 457 consecutive patients aged 25 to 105 years from the Swedish Register of Cardiac Intensive Care (RIKS-HIA) with a first episode of either AMI or unstable angina (UAP). Results: Serum cholesterol was a stronger predictor (OR 5.21) for future coronary artery bypass grafting (CABG) than for AMI. Smoking was a weaker risk factor for CABG than for AMI with no discernible increase in risk except in very heavy smokers (OR 2.19). Both short- and long-term case fatality after hospitalization for AMI decreased from 1987 to 1998, more in younger than in older patients. 28-day case fatality was reduced by half in male and female patients <55 years. This reduction was maintained throughout the first five years. The reduction in 28-day case fatality decreased with age to about one third among men and women aged 75 to 84 years. Hospital mortality decreased roughly by half over the period, whereas the reduction in out-of-hospital deaths was about one fourth. The great majority of all fatal first events in CHD occur outside hospital, and this proportion is increasing, particularly in younger CHD victims. Among patients with a first acute coronary syndrome event, male sex, slightly older age, as well as smoking, diabetes, and peripheral arterial disease are major determinants for presenting with AMI, rather than UAP. Differences with respect to smoking, diabetes, and peripheral arterial disease were more pronounced for women than for men. Conclusions: There are decreasing trends in case fatality among patients in all ages with coronary heart disease admitted to hospital. Still, the absolute majority of deaths occur out-of-hospital. Different manifestations of coronary disease have different risk factor patterns, suggesting that secular changes in risk factor pattern could potentially influence the clinical expression of the disease. Keywords: coronary heart disease, acute coronary syndrome, coronary-bypass grafting, mortality, case fatality, survival, manifestation, predictors, risk factors, trends, cholestero

Previous experiences of Value Stream Mapping (VSM) at the hospital units included in the Swedish part of the NOVO Multicenter Study

Within the county councils of Sweden (hospitals, elderly care, etc.) two waves of introduction of Lean Production (Lean) have occurred. The first occurred during the 1990s and was unsuccessful mainly due to dramatic and negative impact on the employees (Härenstam et al, 1999). The 2nd wave started after the turn of the millennium. In 2011 about 80% of the county councils were running Lean projects (SKL, 2012). Now more emphasis was put on leadership and teamwork as well as knowledge on methodology. Successful projects creating e.g. more efficient patient flows are supposed to save time. A key issue is, however, that no general agreement seems to occur on how these saved resources should be reprioritized (cf. the “50/50-basis” in Denmark). Due to this, Lean projects are often perceived as “saving projects” where staff will eventually be phased out leading to further “work intensification”. VSM is a main Lean tool used to reduce waste in production flows. Our present case studies show differences between hospitals in Lean and VSM experiences. At one hospital Lean has been developed from "below" in the organization since 2004 through successive education (SkaS-guiden 2008). In our 2 cases from this hospital the initial steps of VSM were guided by internal Lean educated stakeholders. No resistance was met from any employee. However, the writing of action plans and the following actions were integrated in parallel rationalization processes. In contrast, our 2 other cases at another hospital had only been marginally influenced by Lean. The VSM processes were guided by an external Lean educated stakeholder (one of the authors). Especially one of the cases had significant difficulties in achieving consensus on an action plan including work environment issues. The required time for the VSM analyses became considerably prolonged, partly related to lack of Lean and VSM experience. Conclusions: The duration of the VSM process seems to depend on previous Lean experiences. Problems in the assessment of an action plan, an essential part in the VSM procedure, seems partly due to employee uncertainty regarding the consequences for the individual and parallel rationalization processes

Ergonomic Value stream Mapping (ErgoVSM) – potential for integrating work environment issues in a Lean rationalization process at two Swedish Hospitals

Introduction: Lean is used in healthcare as a tool for business development and rationalization. Lean aims at contributing value from a holistic perspective including reduction of waste. Previous research indicates that this often creates work intensification with possible negative implications for the working environment (WE). WE considerations generally take a back seat on the rationalization process and are most often introduced later in a separate process. This paper reports findings from the Swedish part of a Nordic Multicenter Study where WE considerations have been integrated into a rationalization process based on Value Stream Mapping (VSM). ErgoVSM incorporates aspects of the physical and psychosocial WE into the VSM process. The abstract presents pros and cons for using ErgoVSM in relation to VSM at 2 wards at 2 different hospitals based on some of our preliminary data. Material and Methods: The case ward (“Ca”) used the ErgoVSM tool and the control ward (“Co”) the VSM tool. The resulting Action Plans were analyzed regarding number of suggested interventions and expected impact on performance (P) and WE. The expected WE impact was finally categorized according to impact at “Task”, “Work Content” and “Work Situation” (Westlander 1993). Two of the present researchers made these assessments independent of each other followed by a consensus procedure. Results: The Action Plan from Ca comprised 37 and Co 22 interventions. For both wards 65% of the interventions were expected to improve both P and WE. However, for Ca none of the interventions were expected to imply negative or no impact on WE, while this was 23% for Co. For Ca 16% of the interventions concerned Tasks, 46% Work Content and 38% Work Situation. The corresponding results for Co were 55%, 36% and 9% respectively. Conclusions: The Ca ward suggested more interventions, none of these with expected negative impact on WE and the suggestions were more often at a system rather than task level. The present preliminary data suggest that the ErgoVSM tool facilitate development of an Action Plan that may result in higher organizational sustainability compared with VSM

Factors facilitating and inhibiting value stream mapping processes at hospital units in three Nordic countries - a Nordic multicenter study

1. Conceptual framework and Purpose In healthcare Value Stream Mapping (VSM) is a common Lean tool used to improve the efficiency of patient flows by identifying and minimizing waste (Keyte & Locher, 2004). It is a participatory tool, i.e. those affected by this type of rationalization are performing the analyses and subsequently suggesting appropriate interventions. Participation has been shown to be crucial to obtain ownership of the suggested interventions and thereby increase impact. VSM has been shown to be a powerful rationalization tool. However, the resulting interventions may imply physical work intensification and impaired psychosocial work environment. Due to this, Lean is often perceived as a “threat” by employees at hospitals (Härenstam et al 2000, personal communications). Physical and psychosocial working conditions should therefore be taken into account in the rationalization process to obtain sustainable solutions, i.e. solutions that allow for competitive performance and acceptable work environment in a long term perspective. On this background we have complemented the VSM tool by an ergonomic module assisting the users to consider also physical and psychosocial implications of the suggested interventions. This ErgoVSM tool is now evaluated in a Nordic Multicenter Study including Denmark, Iceland and Sweden (Winkel et al, 2012). The aim of this paper is to present observations that may indicate facilitating and inhibiting factors for the VSM process. 2. Methods Seven wards have used the ErgoVSM and seven the traditional VSM. Information was obtained by screening key hospital documents and interviewing participants in the VSM processes. 3. Results In Sweden one out of three wards using VSM decided not to fulfil the VSM process. On Iceland the only ward using VSM also decided not to fulfil their VSM process. The hospitals of the investigated wards using VSM in Sweden and Iceland had a strong primary focus on financial balance of the business according to key documents. Decisions on when and which value stream to analyse were made by management with little/no dialog with the employees. Work environment issues were not discussed as part of this. In addition, Iceland had a short experience of Lean, mainly based on support from McKinsey, an American global management consulting firm that focuses on solving issues of concern to senior management (http://en.wikipedia.org/wiki/McKinsey_%26_Company). Thus, they had no attention to the wellbeing to the employees and their work environment when introducing Lean. In general, the Icelandic Lean coaches had problems motivating the employees. However, they perceived a facilitated VSM process at the investigated ErgoVSM ward. Due to this, the main Lean coach decided to include work environment aspects in the VSM processes performed at other wards not part of the present Multicenter Study. Positive effects on those VSM processes were reported back to the researchers. In Denmark all three wards using VSM fulfilled their VSM process. This hospital had a long Lean experience. The main Lean coach reported process problems during their 3 initial years when using a top-down approach. Before the present project was initiated they had turned to a bottom-up initiation of the VSM processes. The Lean coach also expressed that work environment issues might be articulated as part of the VSM process. All seven wards using ErgoVSM in the 3 countries fulfilled the process. 4. Conclusion When using the Lean tool “Value Stream Mapping” it seems to be important not only to focus on efficiency but also on issues that are perceived important for the well-being of the individual employee. 5. Financial support The Nordic Council of Ministers and national grants. 6. References Härenstam A, Bejerot E, Johansson K, Leijon O, Schéele P. “Mager och god” eller ”Lean and mean”? Samband mellan organisationsförändringar och arbetsförhållanden. In: Barllöf K (Ed.) Smärtgränsen? En antologi om hälsokonsekvenser I magra organisationer. Rådet för arbetslivsforskning, pp 2000 Keyte, B., Locher, D., 2004. The Complete Lean Enterprise. Value Stream Mapping for Administrative and Office Processes. Productivity Press, New York. Winkel J, Birgisdóttir B D, Dudas K, Edwards K, Gunnarsdóttir S, Jarebrant C, Johansson Hanse J (2012). A Nordic work environment complement to Value Stream Mapping (VSM) for sustainable patient flows at hospitals – A NOVO Multicenter study. 6th NOVO Symposium: Sustainable Health Care: Continuous Improvement of Processes and Systems. Karolinska Institute, Stockholm Sweden. November 15-16, 2012, pp 58-59. ISBN: 978-91-637-2380-