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Improving Patient Flow
 

Improving Patient Flow

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    Improving Patient Flow Improving Patient Flow Presentation Transcript

    • © 2013 by HealthCare Quality Improvement Solutions, LLC
    • AgendaValue Stream ManagementCurrent State Value Stream MappingBreak-Out SessionLean ConceptsFuture State Value Stream MappingBreak-Out SessionAchieving The Future State2© 2013 by HealthCare Quality Improvement Solutions, LLC
    • © 2013 by HealthCare Quality Improvement Solutions, LLC
    • Value Stream ManagementWhat is a value stream?All the activities – both value added and non-valueadded – currently performed to treat patients frominitial hospital arrival through discharge.4© 2013 by HealthCare Quality Improvement Solutions, LLC
    • ED TriageED RegistrationED CareEDTransportationInpatientAdmissionInpatientCareDischarge HomePharmacyHousekeepingTransportation5© 2013 by HealthCare Quality Improvement Solutions, LLC
    • Patient Flow Value Streams OutpatientEmergency DepartmentOutpatient SurgeryOutpatient Clinics InpatientMedicalSurgicalCardiothoracicOrthopedicObstetricsPediatrics6© 2013 by HealthCare Quality Improvement Solutions, LLC
    • 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 customervalue. Process improvement is a daily, continuous, responsibility.7© 2013 by HealthCare Quality Improvement Solutions, LLC
    • ED TriageED RegistrationED CareEDTransportationInpatientAdmissionInpatientCareDischarge HomePharmacyHousekeepingTransportationWasteWasteWasteWaste8© 2013 by HealthCare Quality Improvement Solutions, LLC
    • 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’s health status is being favorablytransformed;The patient is aware of it and willing to pay for it;It is performed correctly the first time.9© 2013 by HealthCare Quality Improvement Solutions, LLC
    • Non-Value Added ActivityAny activity that is not value addedHealthcare non-value added activity:The patient’s health status is not being transformedfavorably ;The patient is not aware of it and or not willing to payfor it;Is not performed correctly the first time.Considered waste10© 2013 by HealthCare Quality Improvement Solutions, LLC
    • WasteThere are eight forms of waste:1. Waiting2. Motion3. Transportation4. Overproduction5. Defects6. Overprocessing7. Underutilized People8. Inventory11© 2013 by HealthCare Quality Improvement Solutions, LLC
    • Value Stream Management ComponentsProcess Steps Select Value StreamConstruct CurrentState Value Stream MapDevelop Future StateValue Stream MapDevelop Value StreamImprovement PlanValue Stream ManagerVisual ControlReal-time ProblemSolving & ProcessImprovement12© 2013 by HealthCare Quality Improvement Solutions, LLC
    • © 2013 by HealthCare Quality Improvement Solutions, LLC
    • 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.14© 2013 by HealthCare Quality Improvement Solutions, LLC
    • Current State Value Stream Map15© 2013 by HealthCare Quality Improvement Solutions, LLC
    • Value Stream Mapping PurposeIt’s not about developing the mapIt’s about understanding the process, service andinformation flowAND WHERE WASTE IS IMPEDING PATIENT FLOW16© 2013 by HealthCare Quality Improvement Solutions, LLC
    • 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 existtoday.17© 2013 by HealthCare Quality Improvement Solutions, LLC
    • Current State Value Stream Mapping Steps1. Select a value stream2. Map the process flow3. Determine the process metrics and collect data4. Map the information flow5. Add the timeline18© 2013 by HealthCare Quality Improvement Solutions, LLC
    • Current State VSM Step 1:Selecting a Value StreamIdentify the value streams from the perspective of thepatient:Determine the process steps they experienceAscertain the services they receiveA value stream is comprised of similar process stepsand services delivered19© 2013 by HealthCare Quality Improvement Solutions, LLC
    • Current State VSM Step 1:Selecting a Value StreamED Surgery Pharmacy Lab Radiology Rehab OTMedical X X X X X X XSurgical X X X X X X XOB X X X20© 2013 by HealthCare Quality Improvement Solutions, LLC
    • 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, WaitingRoom, Admission, Discharge, etc.As an initial guide use process categories that represent stagesin the process where the patient receives servicesThe initial goal is to document the overall flow of theprocess from the beginning to end of the value streamMore detail can be collected later21© 2013 by HealthCare Quality Improvement Solutions, LLC
    • Current State VSM Step 2:Map The Process FlowPay particular attention to where in the process thepatient is waitingThis indicates an obstruction to patient flowWaitingWaiting22© 2013 by HealthCare Quality Improvement Solutions, LLC
    • Current State VSM Step 3:Add Process Metrics Determine the relevant process metrics for each process step and implementdata 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 timeThe time spent delivering care that favorably transforms the patient’shealth status Cycle time – the total time necessary to execute a task These times can be recorded as averages23© 2013 by HealthCare Quality Improvement Solutions, LLC
    • Current State VSM Step 4:Map Information FlowElectronic Information FlowFax TransmissionManual Information FlowTelephone Walk24© 2013 by HealthCare Quality Improvement Solutions, LLC
    • Current State VSM Step 4:Map Information Flow Information flow refers to the trigger that signals work tobe performed When mapping information flow it is insightful to ask:How does each service know what to do for the patient andwhen to do it?For example: How does housekeeping know when to clean a room after apatient has been discharged? How does the bed control coordinator know when housekeepinghas completed preparing the room for the next patient? How and when does the patient know when to start makingarrangements for transportation home?25© 2013 by HealthCare Quality Improvement Solutions, LLC
    • Current State VSM Step 5:Add Timeline26© 2013 by HealthCare Quality Improvement Solutions, LLC
    • Current State VSM Step 5:Add TimelineValue Added TimeNon-Value Added TimeValue Added Time27© 2013 by HealthCare Quality Improvement Solutions, LLC
    • Current State VSM Step 5:Add TimelineAdd all the Processing Time (value added activitytime)Compute the Lead Time as the average time elapsedfrom patient arrival to discharge28© 2013 by HealthCare Quality Improvement Solutions, LLC
    • Current State Value Stream Map29© 2013 by HealthCare Quality Improvement Solutions, LLC
    • © 2013 by HealthCare Quality Improvement Solutions, LLC
    • Future State Value Stream MapThe purpose of value stream mapping is to identifywaste and reduce it by implementation of a FutureState value stream that maximizes customer valueStrive to link all processes – from patient arrival todischarge – 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 lesswaste31© 2013 by HealthCare Quality Improvement Solutions, LLC
    • Future State Value Stream Mapping Steps1. Identify the customers and their needs2. Evaluate the Current State Map3. Establish the time frame to implementimprovements4. Map the Future Statea. Establish goals for metricsb. Determine process improvements for implementation32© 2013 by HealthCare Quality Improvement Solutions, LLC
    • Future State VSM Step 1:Identify Customers and Their NeedsThe patient and their family are the ultimate externalcustomersInternal customers needs have to met in order to meetpatient and family needsWho receives the output of process steps?What is required of the output for the customer toexecute their processes without waste?TimingFormatFrequency33© 2013 by HealthCare Quality Improvement Solutions, LLC
    • Future State VSM Step 2:Evaluate Current State MapThe following set of questions can be used as a guideto 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 theprocess stepsWhere can continuous flow processing beimplemented?Where can people and tasks be placed together so that theprocess flows without delay?Where are the most troublesome problems occurring?34© 2013 by HealthCare Quality Improvement Solutions, LLC
    • Future State VSM Step 2:Evaluate Current State MapThe following set of questions can be used as a guideto evaluating the Current State Map:How much time elapses from decision to admit toplacement of patient in the inpatient bed?How much time elapses from discharge order to patientvacating inpatient bed?Are scheduled surgical procedures unevenly distributedthroughout the week?Where is the workload unbalanced?What process improvements are necessary to achievethe Future State ?35© 2013 by HealthCare Quality Improvement Solutions, LLC
    • Future State VSM Step 2:Evaluate Current State Map13.7% VA© 2013 by HealthCare Quality Improvement Solutions, LLC
    • Future State VSM Step 3:Establish Time Frame To ImprovementPrior to mapping the Future State establish the timeframe to achieve the Future StateThis time frame is an important decision:The longer the time frame, the more improvements thatcan be undertakenConsider keeping the first Future State time framewithin 6 monthsStrive to keep the time frame within 12 months37© 2013 by HealthCare Quality Improvement Solutions, LLC
    • Future State VSM Step 4:Map The Future State: Set GoalsFS20FS30 FS 15/1538© 2013 by HealthCare Quality Improvement Solutions, LLC
    • Future State VSM Step 4:Map The Future State: Determine Improvements39© 2013 by HealthCare Quality Improvement Solutions, LLC16.0% VA
    • © 2013 by HealthCare Quality Improvement Solutions, LLC
    • Future State ImplementationUsually it is not possible to implement the entireFuture 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 intorelatively homogenous segments that represent areas offlow.These segments can then be the focus of processimprovement which are implemented in a systematicmanner.41© 2013 by HealthCare Quality Improvement Solutions, LLC
    • Future State Implementation SegmentsDischargeEDBedManagement42© 2013 by HealthCare Quality Improvement Solutions, LLC
    • Future State Implementation SegmentsIn what order should the segments be implemented?If the discharge process is a segment, implement thissegment firstUnimpeded patient flow through the hospital isdependent upon the availability of inpatient bedsA streamlined discharge process facilitates smoothpatient flowUse your judgment on which of the other segmentswill have the greatest impact on patient flowIf resources permit, multiple segments can beimproved simultaneously43© 2013 by HealthCare Quality Improvement Solutions, LLC
    • Value Stream Improvement PlanSegment Goal Improvements Jan Feb Mar Apr May Jun JulDischargeReduce the dischargecycle time on day ofdischarge to 15minutes•Begin discharge planning within 12hours of patient admission•Dedicated discharge coordinator•Discharge task list•Schedule date and time of discharge atleast 24 hours in advanceEDReduce the EDwaiting room timeto 20 minutes•Implement a Fast TrackBedManagementReduce the cycletime of bedassignment to 10minutes•Implement an automated bedmanagement system•Dedicated bed management coordinator•Demand prediction44© 2013 by HealthCare Quality Improvement Solutions, LLC
    • Value Stream Improvement ReviewSegment CurrentPerformance vs.GoalProject Progress IdentifiedProblemsProposedSolutionsAction Taken45On ScheduleAt RiskBehindScheduleMeetingNot Meeting© 2013 by HealthCare Quality Improvement Solutions, LLCConduct at minimum a quarterly review
    • Value Stream Management ComponentsValue Stream ManagerVisual ControlReal-time Problem Solving & Process Improvement46© 2013 by HealthCare Quality Improvement Solutions, LLC
    • Value Stream Management ComponentsValue Stream ManagerAn individual with primary responsibility forunderstanding, monitoring and continuouslyimproving the value streamIf the value stream is not continuously managed, wastewill creep into the stream and obstruct patient flow47© 2013 by HealthCare Quality Improvement Solutions, LLC
    • Value Stream Management ComponentsVisual ControlA graphical report of the status of process performancedepicting actual vs. expected performance0102030405060Bed Assignment Time Inpatient Bed PlacementTimeDischarge Planning Unscheduled DischargeActual Expected 48© 2013 by HealthCare Quality Improvement Solutions, LLC
    • Value Stream Management ComponentsVisual ControlShould be made visible to everyone involved in the valuestreamUpdated at least twice dailyReviewed by the value stream manager at least asfrequently as they are updated49© 2013 by HealthCare Quality Improvement Solutions, LLC
    • Value Stream Management ComponentsReal-time Problem Solving & Process ImprovementWhen actual performance does not meet the expectedperformance the value stream manager initiates actionto:Determine the root cause(s) of the performance gap;Identify and implement process improvements to eliminatethe root cause(s).Action is initiated on the same day as the gap inperformance is discovered.50© 2013 by HealthCare Quality Improvement Solutions, LLC
    • Value Stream Management AdvantagesProvides a view from a systems perspective:Identifies where and how much waste is in the patientflow systemDepicts the interconnection between process steps andinformation flowProvides a basis for a process improvementimplementation plan from a systems perspectiveAvoids suboptimal departmental approaches toimproving patient flowPromotes continuous process improvement51© 2013 by HealthCare Quality Improvement Solutions, LLC
    • Value Stream Management AdvantagesIdeal method for meeting The Joint Commission’spatient flow standard:Which pertains to identifying and mitigatingimpediments to efficient patient flow throughout thehospital.Hospitals are required to identify and correct patientflow issues organization-wide.They must identify where in the organization problemsexist and take action to prevent barriers to patient flow.52© 2013 by HealthCare Quality Improvement Solutions, LLC
    • © 2013 by HealthCare Quality Improvement Solutions, LLC
    • 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-ray3. 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 am4. Transportation: No transformation is taking place5. Defects: No favorable transformation is taking placea. Examples: preventable errors, preventable infections, data entry errors,6. Overprocessing: Activity that , from the customer’s perspective, does not add valuea. Examples Producing reports that are not used for decision making or regulatorycompliance.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 ininventory. The surgical procedure continues, but no root cause analysis and processimprovement is undertaken to eliminate incorrect instrument trays.54© 2013 by HealthCare Quality Improvement Solutions, LLC