Improving patient flow value stream management

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Improving patient flow value stream management

  1. 1. © 2008 by HealthCare Quality Improvement Solutions, LLC
  2. 2. Value Stream Management  What is a value stream?  All the activities – both value added and non-value added – performed to treat patients from initial hospital arrival through discharge. 2© 2008 by HealthCare Quality Improvement Solutions, LLC
  3. 3. ED Registration ED Triage ED ED Care Transportation Transportation Inpatient Pharmacy Admission Inpatient Care Discharge Home Housekeeping 3© 2008 by HealthCare Quality Improvement Solutions, LLC
  4. 4. Patient Flow Value Streams  Outpatient  Emergency Department  Outpatient Surgery  Outpatient Clinics  Inpatient  Medical  Surgical Cardiothoracic   Orthopedic  Obstetrics  Pediatrics 4© 2008 by HealthCare Quality Improvement Solutions, LLC
  5. 5. Value Stream Management Philosophy  Entails viewing patient flow as a system of processes;  Not as isolated, individual processes.  Involves improving the system;  Not just improving individual components or departments.  Focuses on customer requirements:  Delivering services in a manner that maximizes customer value.  Process improvement is a daily, continuous, responsibility. 5© 2008 by HealthCare Quality Improvement Solutions, LLC
  6. 6. ED Registration ED Triage ED ED Care Transportation Waste Transportation Waste Inpatient Pharmacy Admission Waste Inpatient Care Discharge Home Waste Housekeeping 6© 2008 by HealthCare Quality Improvement Solutions, LLC
  7. 7. Value Added Activity  An activity is value added when:  A physical transformation occurs;  The customer is aware of it and willing to pay for it;  It is performed correctly the first time.  Healthcare value added activity:  The patient receives provider care that favorably transforms their health status;  The provider care is not attributed to treating a preventable adverse event.  The patient is aware of it and willing to pay for it;  It is performed correctly the first time. 7© 2008 by HealthCare Quality Improvement Solutions, LLC
  8. 8. Non-Value Added Activity  Any activity that is not value added  Healthcare non-value added activity:  The patient’s health status is not being transformed favorably ;  The patient is not aware of it and or not willing to pay for it;  Is not performed correctly the first time.  Considered waste 8© 2008 by HealthCare Quality Improvement Solutions, LLC
  9. 9. Waste  There are eight forms of waste: 1. Waiting 2. Motion 3. Transportation 4. Overproduction 5. Defects 6. Overprocessing 7. Underutilized People 8. Inventory 9© 2008 by HealthCare Quality Improvement Solutions, LLC
  10. 10. Value Stream Management Components  Process Steps Select Value Stream  Value Stream Manager Construct Current  Visual Control State Value Stream Map  Real-time Problem Develop Future State Value Stream Map Solving & Process Improvement Develop Value Stream Improvement Plan 10© 2008 by HealthCare Quality Improvement Solutions, LLC
  11. 11. © 2008 by HealthCare Quality Improvement Solutions, LLC
  12. 12. Value Stream Mapping (VSM)  What is a Value Stream Map?  A graphical representation of :  The process steps;  The flow of patients, hospital services and information;  The value added activity provided;  From the beginning to the end of the value stream. 12© 2008 by HealthCare Quality Improvement Solutions, LLC
  13. 13. Current State Value Stream Map 13© 2008 by HealthCare Quality Improvement Solutions, LLC
  14. 14. Value Stream Mapping Purpose  It’s not about developing the map  It’s about understanding the process, service and information flow  AND WHERE WASTE IS IMPEDING PATIENT FLOW 14© 2008 by HealthCare Quality Improvement Solutions, LLC
  15. 15. Current State Value Stream Map  What is Current State?  A value stream map that represents the process steps, flow of patients , services and information as they exist today. 15© 2008 by HealthCare Quality Improvement Solutions, LLC
  16. 16. Current State Value Stream Mapping Steps 1. Select a value stream 2. Map the process flow 3. Determine the process metrics and collect data 4. Map the information flow 5. Add the timeline 16© 2008 by HealthCare Quality Improvement Solutions, LLC
  17. 17. Current State VSM Step 1: Selecting a Value Stream  Identify the value streams from the perspective of the patient:  Determine the process steps they experience  Ascertain the services they receive  A value stream is comprised of similar process steps and services delivered 17© 2008 by HealthCare Quality Improvement Solutions, LLC
  18. 18. Current State VSM Step 1: Selecting a Value Stream ED Surgery Pharmacy Lab Radiology Rehab OT Medical X X X X X X X Surgical X X X X X X X OB X X X 18© 2008 by HealthCare Quality Improvement Solutions, LLC
  19. 19. Current State VSM Step 2: Map The Process Flow  Go observe and follow the process  Draw the process with pad and pencil from left to right  Initially the Current State map is a high level map  Document process categories such as Triage, Waiting Room, Admission, Discharge, etc.  As an initial guide use process categories that represent stages in the process where the patient receives services  The initial goal is to document the overall flow of the process from the beginning to end of the value stream  More detail can be collected later 19© 2008 by HealthCare Quality Improvement Solutions, LLC
  20. 20. Current State VSM Step 2: Map The Process Flow Waiting Waiting  Pay particular attention to where in the process the patient is waiting  This indicates an obstruction to patient flow 20© 2008 by HealthCare Quality Improvement Solutions, LLC
  21. 21. Current State VSM Step 3: Add Process Metrics  Determine the relevant process metrics for each process step and implement data collection  Any metrics that are relevant can be used  Averages and proportions are usually recorded  Collect current data  From a patient flow perspective two measurements should always be collected:  Processing time – the value creating time  The time spent delivering care that favorably transforms the patient’s health status  Cycle time – the total time necessary to execute a task  These times can be recorded as averages 21© 2008 by HealthCare Quality Improvement Solutions, LLC
  22. 22. Current State VSM Step 4: Map Information Flow Manual Information Flow Fax Transmission Telephone Walk Electronic Information Flow 22© 2008 by HealthCare Quality Improvement Solutions, LLC
  23. 23. Current State VSM Step 4: Map Information Flow  Information flow refers to the trigger that signals work to be performed  When mapping information flow it is insightful to ask:  How does each service know what to do for the patient and when to do it?  For example:  How does housekeeping know when to clean a room after a patient has been discharged?  How does the bed control coordinator know when housekeeping has completed preparing the room for the next patient?  How and when does the patient know when to start making arrangements for transportation home? 23© 2008 by HealthCare Quality Improvement Solutions, LLC
  24. 24. Current State VSM Step 5: Add Timeline 24© 2008 by HealthCare Quality Improvement Solutions, LLC
  25. 25. Current State VSM Step 5: Add Timeline Non-Value Added Time Value Added Time Value Added Time 25© 2008 by HealthCare Quality Improvement Solutions, LLC
  26. 26. Current State VSM Step 5: Add Timeline  Add all the Processing Time (value added activity time)  Compute the Lead Time as the average time elapsed from patient arrival to discharge 26© 2008 by HealthCare Quality Improvement Solutions, LLC
  27. 27. Current State Value Stream Map 27© 2008 by HealthCare Quality Improvement Solutions, LLC
  28. 28. © 2008 by HealthCare Quality Improvement Solutions, LLC
  29. 29. Future State Value Stream Map  The purpose of value stream mapping is to identify waste and reduce it by implementation of a Future State value stream that maximizes customer value  Strive to link all processes – from patient arrival to discharge – in a smooth flow without interruptions (waste)  Focuses on meeting customer needs  There is not a single, correct Future State  Is always evolving into a new Future State with less waste 29© 2008 by HealthCare Quality Improvement Solutions, LLC
  30. 30. Future State Value Stream Mapping Steps 1. Identify the customers and their needs 2. Evaluate the Current State Map 3. Establish the time frame to implement improvements 4. Map the Future State a. Establish goals for metrics b. Determine process improvements for implementation 30© 2008 by HealthCare Quality Improvement Solutions, LLC
  31. 31. Future State VSM Step 1: Identify Customers and Their Needs  The patient and their family are the ultimate external customers  Internal customers needs have to met in order to meet patient and family needs  Who receives the output of process steps?  What is required of the output for the customer to execute their processes without waste?  Timing  Format  Frequency 31© 2008 by HealthCare Quality Improvement Solutions, LLC
  32. 32. Future State VSM Step 2: Evaluate Current State Map  The following set of questions can be used as a guide to evaluating the Current State Map:  Where are the largest amounts of waste?  Which process steps create waste?  Why are they being performed?  What knowledge and skills are truly required to perform the process steps  Where can continuous flow processing be implemented?  Where can people and tasks be placed together so that the process flows without delay?  Where are the most troublesome problems occurring? 32© 2008 by HealthCare Quality Improvement Solutions, LLC
  33. 33. Future State VSM Step 2: Evaluate Current State Map  The following set of questions can be used as a guide to evaluating the Current State Map:  How much time elapses from decision to admit to placement of patient in the inpatient bed?  How much time elapses from discharge order to patient vacating inpatient bed?  Are scheduled surgical procedures unevenly distributed throughout the week?  Where is the workload unbalanced?  What process improvements are necessary to achieve the Future State ? 33© 2008 by HealthCare Quality Improvement Solutions, LLC
  34. 34. Future State VSM Step 2: Evaluate Current State Map 13.7% VA© 2008 by HealthCare Quality Improvement Solutions, LLC
  35. 35. Future State VSM Step 3: Establish Time Frame To Improvement  Prior to mapping the Future State establish the time frame to achieve the Future State  This time frame is an important decision:  The longer the time frame, the more improvements that can be undertaken  Consider keeping the first Future State time frame within 6 months  Strive to keep the time frame within 12 months 35© 2008 by HealthCare Quality Improvement Solutions, LLC
  36. 36. Future State VSM Step 4: Map The Future State: Set Goals FS FS 20 30 FS 15/15 36© 2008 by HealthCare Quality Improvement Solutions, LLC
  37. 37. Future State VSM Step 4: Map The Future State: Determine Improvements 16.0% VA 37© 2008 by HealthCare Quality Improvement Solutions, LLC
  38. 38. © 2008 by HealthCare Quality Improvement Solutions, LLC
  39. 39. Future State Implementation  Usually it is not possible to implement the entire Future State Value Stream at once.  When viewed as a process of building a series of inter- connected process flows for a value stream:  The Future State Value Stream can be organized into relatively homogenous segments that represent areas of flow.  These segments can then be the focus of process improvement which are implemented in a systematic manner. 39© 2008 by HealthCare Quality Improvement Solutions, LLC
  40. 40. Future State Implementation Segments Bed Management ED Discharge 40© 2008 by HealthCare Quality Improvement Solutions, LLC
  41. 41. Future State Implementation Segments  In what order should the segments be implemented?  If the discharge process is a segment, implement this segment first  Unimpeded patient flow through the hospital is dependent upon the availability of inpatient beds  A streamlined discharge process facilitates smooth patient flow  Use your judgment on which of the other segments will have the greatest impact on patient flow  If resources permit, multiple segments can be improved simultaneously 41© 2008 by HealthCare Quality Improvement Solutions, LLC
  42. 42. Value Stream Improvement Plan Segment Goal Improvements Jan Feb Mar Apr May Jun Jul •Begin discharge planning within 12 Reduce the discharge hours of patient admission cycle time on day of •Dedicated discharge coordinator Discharge discharge to 15 •Discharge task list minutes •Schedule date and time of discharge at least 24 hours in advance •Implement a Fast Track Reduce the ED ED waiting room time to 20 minutes Reduce the cycle •Implement an automated bed Bed time of bed management system Management assignment to 10 •Dedicated bed management coordinator minutes •Demand prediction 42© 2008 by HealthCare Quality Improvement Solutions, LLC
  43. 43. Value Stream Improvement Review  Conduct at minimum a quarterly review Segment Current Project Progress Identified Proposed Action Taken Performance vs. Problems Solutions Goal Meeting On Schedule At Risk Not Meeting Behind Schedule 43© 2008 by HealthCare Quality Improvement Solutions, LLC
  44. 44. Value Stream Management Components  Value Stream Manager  Visual Control  Real-time Problem Solving & Process Improvement 44© 2008 by HealthCare Quality Improvement Solutions, LLC
  45. 45. Value Stream Management Components  Value Stream Manager  An individual with primary responsibility for understanding, monitoring and continuously improving the value stream  If the value stream is not continuously managed, waste will creep into the stream and obstruct patient flow 45© 2008 by HealthCare Quality Improvement Solutions, LLC
  46. 46. Value Stream Management Components  Visual Control  A graphical report of the status of process performance depicting actual vs. expected performance 60 50 40 30 20 10 0 Bed Assignment Time Inpatient Bed Placement Discharge Planning Unscheduled Discharge Time Actual Expected 46© 2008 by HealthCare Quality Improvement Solutions, LLC
  47. 47. Value Stream Management Components  Visual Control  Should be made visible to everyone involved in the value stream  Updated at least twice daily  Reviewed by the value stream manager at least as frequently as they are updated 47© 2008 by HealthCare Quality Improvement Solutions, LLC
  48. 48. Value Stream Management Components  Real-time Problem Solving & Process Improvement  When actual performance does not meet the expected performance the value stream manager initiates action to:  Determine the root cause(s) of the performance gap;  Identify and implement process improvements to eliminate the root cause(s).  Action is initiated on the same day as the gap in performance is discovered. 48© 2008 by HealthCare Quality Improvement Solutions, LLC
  49. 49. Value Stream Management Advantages  Provides a view from a systems perspective:  Identifies where and how much waste is in the patient flow system  Depicts the interconnection between process steps and information flow  Provides a basis for a process improvement implementation plan from a systems perspective  Avoids suboptimal departmental approaches to improving patient flow  Promotes continuous process improvement 49© 2008 by HealthCare Quality Improvement Solutions, LLC
  50. 50. Value Stream Management Advantages  Ideal method for meeting The Joint Commission’s patient flow standard:  Pertains to identifying and mitigating impediments to efficient patient flow throughout the hospital.  Hospitals are required to identify and correct patient flow issues organization-wide.  They must identify where in the organization problems exist and take action to prevent barriers to patient flow.  New hospital-specific tracer on patient flow:  Beginning in January 2008 surveyors will conduct a new system tracer to identify problems with patient flow. 50© 2008 by HealthCare Quality Improvement Solutions, LLC
  51. 51. © 2008 by HealthCare Quality Improvement Solutions, LLC
  52. 52. Waste  There are eight forms of waste: 1. Waiting: No transformation is taking place. 2. Motion: Activity that does not add value. a. Examples: physical therapy traveling to the patient’s room to find the patient is in X-ray 3. Overproduction: Producing more process output that the downstream process can handle. a. Examples: same day surgery patients schedule for afternoon surgery arriving at 6:00 am 4. Transportation: No transformation is taking place 5. Defects: No favorable transformation is taking place a. Examples: preventable errors, preventable infections, data entry errors, 6. Overprocessing: Activity that , from the customer’s perspective, does not add value a. Examples Producing reports that are not used for decision making or regulatory compliance. 7. Underutilized People: Not harnessing the knowledge and experience of the work force. 8. Inventory: Excess inventory hides process problems. a. Example, a surgical tray that has incorrect instruments is replaced with one of the many in inventory. The surgical procedure continues, but no root cause analysis and process improvement is undertaken to eliminate incorrect instrument trays. 52© 2008 by HealthCare Quality Improvement Solutions, LLC

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