VSM AND FLOW IMPROVEMENT AT THE                                                                  MEDICAL ONCOLOGY UNIT    ...
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Value Stream Mapping at HRVP case report

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Case Report of VSM at HRVP/IOV regarding Chemotherapy order processing in a public hospital in Brazil. Published in 2010.

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Value Stream Mapping at HRVP case report

  1. 1. VSM AND FLOW IMPROVEMENT AT THE MEDICAL ONCOLOGY UNIT HOSPITAL REGIONALhttp://www.hospitalregional.org.br VALE DO PARAIBA (HRVP/IOV) Authors: Marcelo Taborda MD, Evelin Marotta MD, Camila Santos Pharm., Sheila Reis RN, Fernanda Paim, Stela Maris Coelho, Carlos F Pinto MD.HRVP Oncology Unit Backgrounds. The Value Stream Mapping (VSM) involved doctors, nurses, pharmacists, and attendants working atInstituto de Oncologia do Vale’s Medical Oncology Unit inside HRVP (State Regional Hospital) and was part of our Lean ImplementationProject. The process involved the chemotherapy prescription, authorization, filling and billing processes that usually required two days to becompleted (from prescribing to billing). 110 prescriptions are filled daily and consume a lot of movement and energy. Clients (internal andexternal) frequently complain about long queues, billing errors, reprocessing and delays. The complete VSM (planning and executingphases) took place in early 2009, motivated by our poor performance at the 2008’s Internal Customer Satisfaction Survey.Initial problem analysis clearly Assessment of problem and rootstated that patient prescription and causes: We used the VSM (aspatient chart flows are different. proposed by Rother and Shook inThe information needed to fill and “Learning to See”: current state, futurebill prescriptions (chemo treatment) state and value stream plan) to access,is not available to all involved. This identify root causes, quantify and solveproblem imposes nurses, problems. While designing the currentpharmacists and attendants to state, several broken processes werefrequently request patient chart to identified, and possible solutions werecheck information like ICD, disease Figure 1: Spaghetti Diagram: Current and Future States pointed and listed below as Table 1.stage, billing code, etc.Table 1: “Problem, Root Causes, Lean Tools Applied, Proposed Solution”: Problem Analysis: Root Causes Lean Tools Proposed Solutions Applied Oral drug dispensed without nurse approval Poor integration of New patient flow to nurse consultation process Spaghetti diagram Multiple visits to reception before treatment Poor patient Flow Kanban Levelling by a new flow Drug dose (increased patient risk) and bill Wrecked Error proof Poka yoke: prescription pre-filled with code check information flow Layout billing code, dose range and signalling Multiple chart movement to treatment, Poor work flow improvement Chart flow along patient flow, then reception and billing areas Supermarket moved to billing and archive Nurse and doctor call frequently for treatment Poor information Continuous flow Patient chart supermarket created at or chart information flow treatment area, not only prescriptionStrategy for change: All personnel received basic lean tools improvements can be seen throughout the report and into acceptabletraining. Proposed solutions were treated as Kaizen events range (not achieved in 2008).(point and small events) and executed as 5W1H spreadsheets Figure 2: Columnswith a detailed time frame. All changes were agreed with office, green (2008) and rednurses, doctors and admittance teams. (2009): (1) Right billing code; (2) Completeness ofMeasurement of improvement: The improvements achieved docs and timelywere measured calculating the lead, cycle and opportunity times delivery; (3) (4) Rightof the process (see Table 2 below). admittance process; (5) Adequacy ofTable 2: Improvement Measurements Printed Forms; (6) Current Future % reduction Overall Customer State State Satisfaction. Lessons Learned and Message for others: Lead Time 611 min 104 min - 84% The VSM is a powerful tool to improve process flow, safety and Cycle Time 133 min 85 min - 36% Opport. Time 511 min 19 min - 96% reduce waste in healthcare. We experienced impressive results in Process Steps 31 9 - 71% flow improvement and waste reduction as seen on Spaghetti Diagram (Figure 1) and on the reduction of steps involved in the process, fromThese data are consistent with the reduction of steps needed in 31 to 9 steps. Customer satisfaction (Figure 2) - the most reliablethe process: from 31 to 9 process steps, an impressive reduction improvement measurement - and team morale improved as well.in movement and other associated wastes. Values Stream Map and lean tools are feasible and easy tools to use; but require highly committed teams, well planned events andEffects of changes: The VSM improved the billing process time adequate lean training to succeed.from two days (or 10 work hours) to less than two hours, it Corresponding Author:also improved patient safety by creating pre-filled prescriptions Carlos F. Pinto MD MBAfor the pre-coded billing. These benefits are acknowledged by the Hospital Regional do Vale do Paraíba - Instituto de Oncologia do Vale2009’s Internal Customer Satisfaction Survey comparison to Av. Tiradentes 280, Taubaté – SP – Brazil2008’s data. The comparison in Figure 2 clearly exhibits our Email: carlosfpinto@iov.med.br - carlosfpinto@hotmail.comperformance improvement as perceived by our customers, where

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