“Better health for the back”
Karlskoga Hospital

A. Problem Analysis

 1. What was the problem before the implementation of the initiative?
In the beginning of 1990 we observed that a lot of female employees at Karlskoga Hospital had a lot of sick days (about 400 sick days/year) for work related accidents/diseases during patient transfer. To solve this problem we started a project called “Better health for the back” in order to learn how to move and handle our patient in a careful way. In 1992 seven instructors were educated in moving and handling knowledge and after that we started a five day long mandatory basic training for all nursing staff. As the generality of our employees have got the education we recognized that this moving and handling not only was good for the employees, is also was good for our patients safety. More and more we learned how to link knowledge about the patients unic needs, ways and means, to moving and handling techniques . We also started continual measuring of sick days in 1990 and from 2006 also of pressure ulcers. The results continual are presented to the management and all relevant staff at the hospital.

B. Strategic Approach

 2. What was the solution?
Our director of education (Registrated Nurse) proposed to start the project “Better health for the back” in connection with employees and managers. In 1998 the Hospital Manager decides to create a post as a director of Quality and Development and after that a vision for Karlskoga Hospital was created like this: Karlskoga Hospital will in every moment be a well working hospital! We will also always be regarded as a good workplace where the employees enjoy and feel participation and gladly will recommend Karlskoga Hospital as a workplace! The overriding goals for patient safety and working environment were designed and expressed in the operational plan: Good medical quality: at least as good medical results as mean value for Sweden High patent safety including no pressure ulcer occurs during the stay of any service user Objective patient satisfaction as  90% will recommend friends to choose Karlskoga Hospital if they get sick  95% are satisfied with the way we took care of them  85% are satisfied with the accessibility Working environment - Staff satisfaction  95% will recommend friends to work at Karlskoga Hospital  No harm for our employees due to patient work A strategic plan was created in 1998 but even before we decided to introduce a five day long basic education for all nursing staff in moving and handling knowledge training. Now a day we manage to give this education by our own, and that is our instructor’s responsibility. During the years we have recognized that to have the instructors near in the ward have been a necessity and one of the key point to success. These instructors have a heavy responsibility, both for education of their colleges, for having a sufficient supply of moving aids at the ward, and for collaborative and development work with mattress and technical aid manufacturers. We also have seen that it is necessary to have the moving aids near the patients in all patient room. It is very important to structure the work in a way which has an effect on the emergence of pressure ulcer and strain injuries during patient work and this are parts of the five day long education to all staff. We also have working environment groups in the wards with responsibility to take care of the risks that are identified. Both risk analysis and safety analysis is a part of all our employees’ task, and there is our manager’s responsibility to make sure that we do something about the risks. Through the hospital network for instructors and through meeting with our managers the good examples are spreading all over the hospital.

 3. How did the initiative solve the problem and improve people’s lives?
The new and creative in this is the comprehensive (overall) view to solve the problem, to see the process both in a patient safety and a working environment safety perspective during the hole chain of treatment, long term work (we will never give up), the organization of our instructors (mostly nurses and assistant nurses, at least one in each ward), moving aids in all patient room, collaborative and development work with mattress and technical aid manufactures (the instructors are involved both in the continues attention of all materials and the developing of products) and finally the contents in our five day long compulsory education to all nursing staff and rehearsal training at least once a year.

C. Execution and Implementation

 4. In which ways is the initiative creative and innovative?
We started a project in 1992 with seven instructors who were educated in moving and handling knowledge. The objective at that time was to reduce sick days related to accidents/diseases during patient transfer. The project was completed in 1994, and at that time a majority of the employees have had an education for five days in handling and moving knowledge. After that the method has been developed continuously during the years, an in the middle of the millennium (2005 – 2006) we recognized that this way to handle and moving patient also support the patient safety. It showed up as a successful way to decrease the pressure ulcer! From 2008 the overriding goals, expressed in the operational plan, were: • No pressure ulcer occurs during the stay of any service user and • No harm for our employees due to patient work To achieve the desired goals various efforts have been made, examples: • Continuous ‘moving and handling’ knowledge education for all staff including prevention of pressure ulcers. We learn how to link knowledge about the patients unique need, ways and means, to moving and handling techniques. • Training in the use of different types of mattresses and testing of the same. • Introduction of pressure relieving foam mattresses throughout the organization.

 5. Who implemented the initiative and what is the size of the population affected by this initiative?
As we say above we first started this project as a working environment project. At that time the employees were the primary stakeholders, but of course also the hospital manager and the politician as we hoped to save money and suffering doing this. Now a day our patients are the most important stakeholders!
 6. How was the strategy implemented and what resources were mobilized?
By way of introduction we got about EUR 225 000 from a fund called Working Environment Fund. This money provide capital for the instructors education and also for the deputies during the initial education of our employees. After that Karlskoga Hospital has been financing the costs, both for education and moving aids. Now a day we seldom have any deputies, as we organize the education so the ward can manage to let the employee come without any deputies. But still we are investing in moving aids and mattresses on the basis of need.

 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
We can show that at safe environment for our employees also leads to a safe patient care, which save money and suffering. The incidence of pressure ulcer has been reduced from 9% in 2008 to about 1% in 2014. This value is to compare with the mean value in Sweden in 2014 at 15% of which about 7% started during the hospital visit, the other half started before the patient came to the hospital. In Sweden we can save about EUR 165 million a year if all the hospitals have the same frequency as Karlskoga Hospital. Numbers of sick days have been reduced from about 400 days/year in the period of 1990-1999 to about 10 days/year in the period of 2000 – 2010 and about 3.5 days/year for the last 4 years. We have only had 14 sick days in total related to accidents/diseases during patient transfer for the period 2010 – 2013. The cost reduction for this increasing of sick days is about EUR 83 000/year for Karlskoga Hospital for the last 14 years. Other successful outputs are increased participation, both from our patients and our employees which had result in more satisfied patients and employees. Our overall quality objective is to be a well working hospital. About 92% of our patients agree to this. About 95% of the employees say that they can recommend a friend to work at Karlskoga Hospital. About 92% of our patients agree to this and 98% of our patients say they can recommend Karlskoga Hospital.

 8. What were the most successful outputs and why was the initiative effective?
Continual improvement is one of our keystones to be a well working hospital. We always want to improve our processes based on objective measurement. Here you can see some of our procedurers:  the authority and responsibility is defined for the processes and for each employee  risk analysis and safety analysis is a part of our task  measurable objectives  follow up and analyze results (all results are in our intranet)  Compare with other hospitals result from national register and open comparing systems In this development project the measurable objectives are no pressure ulcer during the hospital visit and no sick days for our employees due to patient work. The first objective is measured two times a year as a PPM and the second objective is measured continuous and presented once a year. The overridden objectives concerning patient satisfaction and employee satisfaction are measured in a period of two years and as a complement we have focus groups interviews every year.

 9. What were the main obstacles encountered and how were they overcome?
The main obstacles were that the education took too long time, that it was hard to get deputies and that the moving aids and deputies cost a lot of money. To overcome that opposition we involved all our managers early during the project, and we choose the instructors from the wards and the employees who show most interest. Still, we offer the employee who shows a genuine interest the commission to be an instructor. The first years it was hard to see the result in economic terms, but early we thought that this was a successful way to work to decrease the harm for our employees.

D. Impact and Sustainability

 10. What were the key benefits resulting from this initiative?
The key benefits were : Higher patient safety, very low frequency of pressure ulcer occurring during the hospital visit More healthy employees, a very low frequency of sick days due to patient work More satisfied patient and employees Shorter time needed for hospital care And all this bring lower costs for defective quality.

 11. Did the initiative improve integrity and/or accountability in public service? (If applicable)
At Karlskoga Hospital the knowledge of moving aids, chairs, mattresses and beds including test of moving aids are a connecting thread during the systematic work. This way of taking care of patients and employees are sustainable and transferable to all health care, both in hospitals and in municipality care. During the last years we have had a lot of educational visits from a lot of public healthcare as well as from some municipality. We also have had some educational visits from other countries such as Japan, The United Arab Emirates and the Republic of Korea. We also have been taking part in a lot of conferences and networks, in Sweden as well as international, both for people working in healthcare sector and in other sectors such as industry sector. Finally we also have education commission to some University in Sweden.

 12. Were special measures put in place to ensure that the initiative benefits women and girls and improves the situation of the poorest and most vulnerable? (If applicable)
The impact is a safer patient care and a safer working environment and we can show that Good Work Environment and Good Performance Go Hand in Hand! The results have proven that, through intensive work with Moving and handling’ knowledge including focus on employees´ environment and on pressure ulcer reduction activities, the incidence can be reduced, as well as the number of sick days for work related accidents/diseases during patient transfer. An absolute condition is however to have a strategy for the work and to have the management participation. Our success factors have been: • Customer partnership • Management participation (involvement from all managers of staff) • Continual improvement and decisions on the basis of facts • Everyone´s participation and development And to never give up!

Contact Information

Institution Name:   Karlskoga Hospital
Institution Type:   Public Agency  
Contact Person:   Ing-Marie Larsson
Title:   Quality and Development Manager  
Telephone/ Fax:   +46586 - 66327
Institution's / Project's Website:  
E-mail:   ing-marie.larsson@orebroll.se  
Address:   Lasarettsvägen 1
Postal Code:   69181
City:   Karlskoga
State/Province:   County council of Örebro

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