Value Stream Mapping

Aims for session

• Introduce the concept of Value Stream Mapping

• Consider identification of value and waste

Patient Flow Process

1. Understand the total process of care delivery – patient pathway

Diagnostic

tests

COMPASS WAITING LIST DIARY - CASE NOTES PULLED 3 WEEKS IN ADVANCE

THEATRE LIST PRINTED L4 HOURS BEFORE - ALLOCATE BEDS

THEATRE LIST SAME DAY FROM JANET. TRY 24 HOURS BEFORE

REPORTS ADMISSION AT FRONT RECEPTION.DETAILS CHECKED

PATIENT ARRIVES RECEPTION DAY SURGERY

TAKE PATIENT TO WARD AND TO BED AREA WITH NOTES. ADVICE TO UNDRESS/GOWN ON. TELL NURSING STAFF.

RECEPTIONIST FINDS OUT IF THEY TO GO TO RADIOLOGY AND WHAT TIME 1 WEEK IN ADVANCE

ADMIT PATIENT VIA CARE PLAN. 5-10 MIN.LOOK AT MOD

CHECK IF TO GO FOR ULTRASOUND - IF TO GO WALK THEM ROUND TO X-RAY WAITING ROOM.

1ST KUB - KID URETER BLADDER X-RAY. PATIENT FULL BLADDER.2ND ULTRASOUND 20-30 MINS IN RADIOLOGY.

PATIENT X-RAY AND ULTRASOUND REPORT BACK - BACK TO BED.

DOCTOR SPEAKS TO PATIENTS - CONSENT SIGNED

THEATRE STAFF ATTEND DAY SURGERY - DATA SHEET GIVEN TO DAY SURGERY STAFF.

THEATRE STAFF TAKE PATIENT STRAIGHT INTO MINOR OP THEATRE.

TEST 10-15 MIN ALLOCATION

DR CANNING 3 1/2 HOUR SESSION

VERBAL REPORT TO PATIENT AND INFORMATION.

TAKEN BACK TO DAY SURGERY

MAKE SURE PATIENT OK - ? DRINK OR EAT. DISCHARGE INSTRUCTIONS

IF DOCTOR NEEDS TO SEE- APPOINTMENT MADE STRAIGHT AWAY - GIVEN TO PATIENT

FOLLOW/REVIEW AT OUTPATIENTS VOL APPOINTMENT NEXT DAY. INDICATED ON CARE PATHWAY

IF RAH DR WILL INDICATE ON TAPE - SECRETARY WILL ARRANGE.

PATIENT ATTENDS RADIOLOGY DEPARTMENT FOR ULTRASOUND

AFTER SCAN PATIENT REPORTS TO RECEPTION DESK IN OUTPATIENTS DEPARTMENT

NURSE ESCORTS PATIENT TO CHANGING ROOM WITHIN THE EXAMINATION

ROOM.PATIENT CHANGES INTO GOWN AND JOINS DOCTOR IN THE EXAM ROOM

DOCTOR EXPLAINS EXAMINATION AND CONSENTS PATIENT.

PROCEDURE CARRIED OUT.

RESULT GIVEN IF APPROPRIATE AND FOLLOW UP INFORMATION GIVEN

PATIENT CHANGES BACK INTO CLOTHES AND LEAVES THE DEPARTMENT.

REPORT TYPED BY UROLOGY SECRETARY AT RAH

Patient attends Health

Care Professional

Clinical assessment

Patient receives radiology

appointmentPatient attends

for radiology appointment

Patient receives clinic

appointment

Patient attends clinic for results Treatment starts

High Level Process Map

The paper chase

Patient attends Health Care Professional

Patient receives radiology

appointment

•Request typed by secretary•Q•Request signed•Q•Request put in post•Request picked up by mail and goes to mail room•Mail sorted•Mail delivered•Request sorted at reception•Request pended•Request issued for Authorisation•Q•Appointment booked within radiology•Q•Appointment letter printed•Appointment to mail out•Appointment picked up by mail and goes to mail room•Appointment goes out in external mail•Appointment delivered

The paper chase

Patient attends for radiology appointment

Patient receives radiology

appointment

•Patient checks date and time of appointment•Rings up radiology to change appointment•Secretary rebooks appointment, sends letters etc….•Appointment filed in pile for date and modality•Day of appointment request pulled •List generated•Request goes to reception to await patient•Receptionist receives patient•Patient booked in•Request to room for radiographer•Patient called to waiting area for room•Radiographer calls patient, checks demographics, explains examination, performs examination•Result reporting explained to patient•(Patient leaves)•Examination confirmed•Request to office

The paper chase

•Request prioritised for reporting•Q•Allocated to radiologist•Q•Request to radiologist desk•Q•Report generated•Request to typist at end of session•Q•Report typed•Report printed (end of day)•Report to mail etc etc……

The paper chase

•Report delivered to referrer•Matched with notes•Q•Read by referrer•To secretary for appointment•Q•OPD Appointment made, letters printed•Appointment sent out mail etc etc….•Q

Patient receives clinic

appointment

The paper chase

Patient attends clinic for results Treatment starts

•Patient arrives at reception•Booked into clinic•Q•Called to see referrer•Q•Sees referrer•Gets diagnosis•Needs operation•Placed on waiting list•Q•Q•Q

The patient journeyThe paper chase

The queues

5 steps in the patient journey

2 steps had clinical impact

35 process steps from referral to diagnosis

13 queues

•Referral to diagnosis

What is value?

• The activity is done right first time

• The activity transforms the patient and moves them towards the next defined outcome

• The activity is something that the patient cares about

•Have a look at the process map•Which steps add value for the patient?•How many are there?•Which steps are necessary but don’t add value?•How many are there?•How long does the whole process take?•How much time adds value for the patient?

Activity: Identifying Value

Who to Involve

• Small team 8-12 people, mixed disciplines

• Represent people at all the steps you will look at

• ‘Fresh eyes’

• Patients/ carers

• Nominate a team and clinical lead

What to Measure

Agree beforehand improvements in - Journey time for patients - Time spent on non value adding work - Throughput (productivity) - Morale / staff satisfaction

Observe and Gather Data

• Walk the patient journey - see the actual work place

• Follow and make notes about each component – What happens to the patient– What staff are doing– What the information / communication flow is

• Take photos of wastes

Measure the distance patients / staff have to travel

Track both the patient and information flows

Take the cameras on the walkabout, you’ll never convey this verbally!

What do patients actually experience and say about the process?

Ask staff at each step for their views on ‘show stoppers’, frustrations and positives

Take photos

Have plentyof space

Don’t skipprocess steps

Walk theArea

Define the Boundaries of the VSA

Don’t assume

Don’t relyon hearsay

Collect realtime data

Build up the Value Stream Map

Understanding your Current State Map:

• Add value

• Remove waste

Coffee

Lean Tools Overview

• PDSA

• Glenday Sieve

• Workplace Organisation

• Rapid Improvement Events

PDSA Cycle

The improvement guideLangley et al 1996

What change can we make that will result in an improvement ?

Act

• What changes are to be made?

• Next cycle?

Plan• Objective• Questions and predictions (why)• Plan to carry out the cycle (who, what, where, when)• Plan for data collection

Study• Complete the analysis of the data

•Compare data to predictions

•Summarize what was learned

Do• Carry out the plan• Document problems and unexpected observations• Begin analysis of the data

MODEL FOR IMPROVEMENT

Objective for this PDSA Cycle

DO: CARRY OUT THE CHANGE OR TEST; COLLECT DATA AND BEGIN ANALYSIS.

DATE:____CYCLE:____

PLAN:QUESTIONS:

PREDICTIONS:

PLAN FOR CHANGE OR TEST: WHO, WHAT, WHEN, WHERE

PLAN FOR COLLECTION OF DATA: WHO, WHAT, WHEN, WHERE

PDS

A

STUDY: COMPLETE ANALYSIS OF DATA; SUMMARIZE WHAT WAS LEARNED.

ACT: ARE WE READY TO MAKE A CHANGE? PLAN FOR THE NEXT CYCLE.

PDSA Worksheet

Scottish Primary Care CollaborativeAyrshire GP Practice

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GP 3rd Available Appointment

GP Access – Practice Level Improvements with PDSAs

PDSAs to inform Patients about new

appointment system

PDSA on ‘Pre-Bookable’ and ‘On

the day’ appointments

PDSA to Introduce Telephone

Consultations

PDSAs PDSAs PDSAs

PDSAs to ensure Phone Appts are provided at most

appropriate time of day

Scottish Primary Care CollaborativeBorders GP Practice

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% o

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% of Diabetes Patients with a BP<140/80

Diabetes (blood pressure) Improvements with PDSAs

PDSAs to improve shared diabetes information with Secondary Care

PDSA to contact all Patients who have not had a BP check

in the last year

PDSAsPDSAs PDSAs

PDSAs to improve current patient recall system

PDSAs to Validate Diabetes Register

Glenday Sieve

• Heard of the Pareto (80/20 principle)?

• Ladies – think of your wardrobe…..

Glenday Seive

Actual volume of activity

Range of possible activities

Green 50% 6%

6% of possible activities accounts for 50% of actual work doneProcess Map the “Greens” and make them flowCreate time for the difficult cases

Glenday Sieve

• Orthopaedics – Hips and knees

• General Surgery – hernias and lap cholecystectomy

• District Nurse – wound care, medication

MRI Team, NHS Tayside

•220 codes for appointments MRI RIE - 63% of MRI throughput from 2.7% of - 63% of MRI throughput from 2.7% of procedure codesprocedure codes (i.e. 6 codes)

•Group patients by the process they go through (rather than clinical condition)

Surgery example

• 213 cases over 8 months at Clatterbridge.– 52% of theatre throughput from 4.2% of procedures

• Group patients by the process they go through (rather than clinical condition)

• Focus initially on smart process for the critical few [4.2%]

Workplace organisation

6S – A Technique to

• Promote workplace organisation

• Set and ensure adherence to standards

• Embed the spirit of continuous improvement

• Improve Quality, Cost Delivery, Safety and Morale

Sort

Get rid of clutter Set in order

Organise the work area

Shine

Clean the work area

Standardise

Doing the same thingevery time

Sustain

Maintain through empowerment,commitment and discipline

6SSafety

Having a safe working environment

“Having a place for everything, and everything in its place”

Workplace reorganisation

Characteristics of a 6S Workplace• Only have what is needed• Clean enough to “eat off the floor”• Everything is organised for the team• Obvious to everyone when something is out of order• Anything that is required can be retrieved within 30 seconds

– No surprise shortages of supplies – visual management of stock levels• Responsibilities defined and everyone taking their

responsibilities• Performance visible to all• Improvement ideas being routinely generated and implemented

Adapted from Ross International, RIE Training material

6S VisionTaken from Ross International, RIE Training

material

Adapted from Ross International, RIE Training material

Money is tied up in inventory gathering dust because of Money is tied up in inventory gathering dust because of a supply chain process which is not aligned with the a supply chain process which is not aligned with the patient pathway value streampatient pathway value stream

In amongst this is back up In amongst this is back up emergency equipmentemergency equipment

Clutter- time wasted Clutter- time wasted trying to find thingstrying to find things

Stracathro -Theatre Store Room

Benefits gained from 6S

Tray Room before…Tray Room before… ……and afterand after

6S Check Sheet Area

1 2 3 4 5Just beginning Focus on basics Make it visual Focus on consistency Focus on prevention

SORTSeparate the essential from

the non-essential

Necessary and unnecessary items are mixed throughout

the workplace

Necessary and unnecessary items

are separated

Unnecessary items have been removed from the

workplace.

A dependable, documented method (e.g.

red tagging) has been established to keep the

work area free of unnecessary items

Employees are continually seeking

improvement opportunities

SETA place for everything and

everything in its placeItems are randomly located throughout the workplace.

A designated location has been

established

Designated locations are marked to make

organisation more visible.

A dependable, documented method has

been established to recognise if items are out

of place or exceed quantity limits.

A dependable documented method has

been developed to provide continual evaluation, and a

process is in place to implement

improvements

1 2 3 4 5 Comments

Theatre Tray Room - 6S Score

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1

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5Sort

Set

Shine

Standardise

Sustain

Safety Score After 6S

Current Score

Rapid Improvement Events (RIEs) – an overview

What are RIEs?

•Common Lean tool to introduce Lean principles and thinking in organisations•RIEs select critical business areas and make real improvements for patients and staff•Process-focussed and brings together the team in a highly structured way•Results-focussed – establishing the root cause of problems, and achieving measurable improvements•Process which is action-orientated and data driven

RIE Programme Timetable

RIE - 6wks RIE - 4wks RIE – 2wks RIE Week RIE + 2wks RIE + 4wks

Review Progress

RIE + 6wks RIE + 12wksor byagreement

Remove Blockages

Measure Improvements

Final Presentation(Project Closure)

Share Success

Local Ownership& Sustainability

Team Leader toProduce:• Report• Action Plan

Support

• Run RIE Pre- Meeting•Run Getting to know you session• Run RIE Awareness visits

ManagementCommitment Meeting• Critical success factors

• Set Scope & Goals• Pick Team Leader

• Pick RIE Team• Book Venue

• Advise Managers about their attendance• Gather data on

current performance

RIEArea

Identified

RapidImprovement

Event

Adapted from Ross International, RIE Training material

The Agenda for an RIESetting the scene

– Training on the Lean principles– Preparing for visits

Observing the current process– Map process to see waste & blockages to flow– Identifying the root causes of problems

Designing and sharing the new processes– Long day !!!!!

Looking for acceptance– Sharing, listening, modifying

Reporting what has been done

Follow-through planning

Day 1

Day 2

Day 3

Day 4

Day 5

One Team’s experience

NHS Tayside Urology RIE