CUH 3rd Annual Patient Symposium
Supporting Optimal Patient Flow
Lean Management – Value Stream Mapping
of Orthopaedic Patients
Beth Hackett – Lean Sigma Programme Coordinator CUH
Mr Declan Reidy – Consultant Orthopaedic Surgeon CUH
Value stream mapping is a lean-management method for analysing the current state and designing a future state for the series of events that take a product or service from its beginning through to the customer.
Value stream mapping can help you map, visualize, and understand the flow of patients, materials (e.g., bags of screened blood or plasma), and information.
The “value stream” is all of the actions required to complete a particular
process, and the goal of VSM is to identify improvements that can be made to reduce waste (e.g., patient wait times).
Value stream mapping analyses Value Added versus Non-Value Added time in a process. Studies have shown that we only add value to a product or service for less than 5%, the rest of the time is wasted!
What is Value Stream Mapping?
OLD PATHWAY Patient C: Hemiarthroplasty Right Hip (Patient has Dementia/Asthma/HTN)
OLD PATHWAY Patient C: Hemiarthroplasty Right Hip (Patient has Dementia/Asthma/HTN)
OLD PATHWAY Patient C: Hemiarthroplasty Right Hip (Patient has Dementia/Asthma/HTN)
↓ 21st July Friday ↓ 22nd July Saturday
00:15 00:15 00:15 00:15 00:15 00:15 00:15 00:15 00:15 00:15 00:15
03:30 01:45 05:45 04:15 00:45 06:15 03:45 07:45 08:15 03:45 03:15
22:00 00:00 06:00 10:30 11:30 18:00 22:00 06:00 14:30 18:30 22:00
3B 3B 3B 3B 3B 3B 3B 3B 3B 3B 3B
Nurse
ReviewNurse Review. Nurse Review.
Physio
Review
Nurse
Review.
Nurse
Review.
Nurse
Review.
Nurse
Review. Nurse Review.
Nurse
Review.
Patient
attempts
to get out
of bed.
Seen by ortho.
For Geri
Review.
↓ 21st July Friday ↓ 22nd July Saturday
00:15 00:15 00:15 00:15 00:15 00:15 00:15 00:15 00:15 00:15 00:15
03:30 01:45 05:45 04:15 00:45 06:15 03:45 07:45 08:15 03:45 03:15
22:00 00:00 06:00 10:30 11:30 18:00 22:00 06:00 14:30 18:30 22:00
3B 3B 3B 3B 3B 3B 3B 3B 3B 3B 3B
Nurse
ReviewNurse Review. Nurse Review.
Physio
Review
Nurse
Review.
Nurse
Review.
Nurse
Review.
Nurse
Review. Nurse Review.
Nurse
Review.
Patient
attempts
to get out
of bed.
Seen by ortho.
For Geri
Review.
OLD PATHWAY Patient C: Hemiarthroplasty Right Hip (Patient has Dementia/Asthma/HTN)
OLD PATHWAY Patient C: Hemiarthroplasty Right Hip (Patient has Dementia/Asthma/HTN)
OLD PATHWAY Patient C: Hemiarthroplasty Right Hip (Patient has Dementia/Asthma/HTN)
OLD PATHWAY Patient C: Hemiarthroplasty Right Hip (Patient has Dementia/Asthma/HTN)
OLD PATHWAY Patient C: Hemiarthroplasty Right Hip (Patient has Dementia/Asthma/HTN)
6.4% Value to the Patient
Value Added Time: 50:32
Total Lead Time: 737:35
Total Cycle Time:
788
Hours,
7 Mins
32 Days, 20
Hours, 7 Mins
The “Ideal” Surgical Pathway
Mr. Declan Reidy MCh. FRCS Tr & Ortho, FRCSI
Surgical Pathway
Bone health : Treatment of osteoporosis Falls prevention
NEW PATHWAY CUH Orthopaedic Service Working Group
OVERALL OBJECTIVES: Improve Patient Flow Optimize the use of resources currently allocated to Orthopaedic Service Develop a Quality Improvement (QIP) for the full pathway for patients
presenting to the Orthopaedic Trauma Service from preadmission through ED, within CUH to Discharge.
National Model of Care (MOC) for Trauma and Orthopaedic Surgery 2015. British Orthopaedic Association “Blue Book” Scottish Standards of Care for Hip Fracture Patients 2016 The Scottish Committee for Orthopaedics and Trauma (SCOT) Royal College of Emergency Medicine National Board for Scotland (RCEM) British Geriatric Society (BGS) Orthopaedic Trauma Society (OTS)
KPI: Admitted to an orthopaedic ward within 4 hours: Problem: In Jan- Jun 2017 Average time to ward is 57 hours and the Median is 11 hours. Remedy: Early Review in ED: Fast track Hip fracture patients. Early involvement of Medical and Anaesthetic teams. Pre-operative Orthogeriatrician Care. Standardised admission data set Canterbury/NHS/HSE/Local protocol. Sufficient Bed access. Allocation of specific Hip Fracture Beds Cohorting of all orthopaedic patients on 1 ward. (60+ Vs 25)
KPI: Patients should have surgery within 48 hours. Updated to 36 hours. Problem: Standard 2: CUH Jan-Jun 2017: Average time to surgery is 71 hours and the median is 42 hours. Remedies Discussed at subgroup: New IT scheduling System for the trauma List. Ortho-geriatrician assessment. Increase Parallel processing in Theatre. Spinal/ Nerve Block during preceding case. Increase Surgical Touch time from 50% to 85%. Would require Nursing Staff increase in WTE from 8 to 11. Increase theatre Access during Demand surges.
KPI: Every patient’s recovery should be optimised by a multi-disciplinary team approach such that they are discharged back to their original place of residence within 30 days from the date of admission. Early Identification of Patients suitable for transfer to Trauma rehab. At SIVUH “Live List” updated each am. Permanent Ortho-geriatrician. Early identification of medical issues acute and chronic. Early identification of patients requiring Long term care. Early referral to Local Placement Forum. Transfer of Patient Care to Ortho-geriatrician after completion of surgical phase. Day 2 or Day 3. Community care Involvement. Representatives invited. Ring Fence Ortho Beds in the Community to avoid long waits for discharge.
1. Provision of Pain Relief.
2. Screening for Delirium.
3. Early Warning Score (EWS) system.
respiratory rate, oxygen saturation,
temperature, systolic blood pressure,
heart rate and neurological status
.
4. Full Blood Investigation and Electrocardiogram.
5. Intravenous Fluids Therapy.
6. Pressure Area Care.
BIG SIX PRIORITIES
Demand Exceeds Capacity
Fracture Clinic Waiting Area
Team 3B 101 year old: Day 2 & Day 5 post op
NEW PATHWAY Patient C: Hemiarthroplasty Right Hip (Patient has Dementia/Asthma/HTN)
