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Improving Patient Flow
- 1. © 2013 by HealthCare Quality Improvement Solutions, LLC
- 2. 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 State
2
© 2013 by HealthCare Quality Improvement Solutions, LLC
- 3. © 2013 by HealthCare Quality Improvement Solutions, LLC
- 4. Value Stream Management
What is a value stream?
All the activities – both value added and non-value
added – currently performed to treat patients from
initial hospital arrival through discharge.
4
© 2013 by HealthCare Quality Improvement Solutions, LLC
- 5. ED Triage
ED Registration
ED Care
ED
Transportation
Inpatient
Admission
Inpatient
Care
Discharge Home
Pharmacy
Housekeeping
Transportation
5
© 2013 by HealthCare Quality Improvement Solutions, LLC
- 6. Patient Flow Value Streams
Outpatient
Emergency Department
Outpatient Surgery
Outpatient Clinics
Inpatient
Medical
Surgical
Cardiothoracic
Orthopedic
Obstetrics
Pediatrics
6
© 2013 by HealthCare Quality Improvement Solutions, LLC
- 7. 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.
7
© 2013 by HealthCare Quality Improvement Solutions, LLC
- 8. ED Triage
ED Registration
ED Care
ED
Transportation
Inpatient
Admission
Inpatient
Care
Discharge Home
Pharmacy
Housekeeping
Transportation
Waste
Waste
Waste
Waste
8
© 2013 by HealthCare Quality Improvement Solutions, LLC
- 9. 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 favorably
transformed;
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
- 10. 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
10
© 2013 by HealthCare Quality Improvement Solutions, LLC
- 11. Waste
There are eight forms of waste:
1. Waiting
2. Motion
3. Transportation
4. Overproduction
5. Defects
6. Overprocessing
7. Underutilized People
8. Inventory
11
© 2013 by HealthCare Quality Improvement Solutions, LLC
- 12. Value Stream Management Components
Process Steps Select Value Stream
Construct Current
State Value Stream Map
Develop Future State
Value Stream Map
Develop Value Stream
Improvement Plan
Value Stream Manager
Visual Control
Real-time Problem
Solving & Process
Improvement
12
© 2013 by HealthCare Quality Improvement Solutions, LLC
- 13. © 2013 by HealthCare Quality Improvement Solutions, LLC
- 14. 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
- 16. 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
16
© 2013 by HealthCare Quality Improvement Solutions, LLC
- 17. 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.
17
© 2013 by HealthCare Quality Improvement Solutions, LLC
- 18. 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
18
© 2013 by HealthCare Quality Improvement Solutions, LLC
- 19. 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
19
© 2013 by HealthCare Quality Improvement Solutions, LLC
- 20. 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
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© 2013 by HealthCare Quality Improvement Solutions, LLC
- 21. 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
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© 2013 by HealthCare Quality Improvement Solutions, LLC
- 22. Current State VSM Step 2:
Map The Process Flow
Pay particular attention to where in the process the
patient is waiting
This indicates an obstruction to patient flow
WaitingWaiting
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© 2013 by HealthCare Quality Improvement Solutions, LLC
- 23. 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
23
© 2013 by HealthCare Quality Improvement Solutions, LLC
- 24. Current State VSM Step 4:
Map Information Flow
Electronic Information Flow
Fax Transmission
Manual Information Flow
Telephone Walk
24
© 2013 by HealthCare Quality Improvement Solutions, LLC
- 25. 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?
25
© 2013 by HealthCare Quality Improvement Solutions, LLC
- 26. Current State VSM Step 5:
Add Timeline
26
© 2013 by HealthCare Quality Improvement Solutions, LLC
- 27. Current State VSM Step 5:
Add Timeline
Value Added Time
Non-Value Added Time
Value Added Time
27
© 2013 by HealthCare Quality Improvement Solutions, LLC
- 28. 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
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© 2013 by HealthCare Quality Improvement Solutions, LLC
- 30. © 2013 by HealthCare Quality Improvement Solutions, LLC
- 31. 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
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© 2013 by HealthCare Quality Improvement Solutions, LLC
- 32. 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
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© 2013 by HealthCare Quality Improvement Solutions, LLC
- 33. 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
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© 2013 by HealthCare Quality Improvement Solutions, LLC
- 34. 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?
34
© 2013 by HealthCare Quality Improvement Solutions, LLC
- 35. 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 ?
35
© 2013 by HealthCare Quality Improvement Solutions, LLC
- 36. Future State VSM Step 2:
Evaluate Current State Map
13.7% VA
© 2013 by HealthCare Quality Improvement Solutions, LLC
- 37. 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
37
© 2013 by HealthCare Quality Improvement Solutions, LLC
- 38. Future State VSM Step 4:
Map The Future State: Set Goals
FS
20
FS
30 FS 15/15
38
© 2013 by HealthCare Quality Improvement Solutions, LLC
- 39. Future State VSM Step 4:
Map The Future State: Determine Improvements
39
© 2013 by HealthCare Quality Improvement Solutions, LLC
16.0% VA
- 40. © 2013 by HealthCare Quality Improvement Solutions, LLC
- 41. 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.
41
© 2013 by HealthCare Quality Improvement Solutions, LLC
- 43. 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
43
© 2013 by HealthCare Quality Improvement Solutions, LLC
- 44. Value Stream Improvement Plan
Segment Goal Improvements Jan Feb Mar Apr May Jun Jul
Discharge
Reduce the discharge
cycle time on day of
discharge to 15
minutes
•Begin discharge planning within 12
hours of patient admission
•Dedicated discharge coordinator
•Discharge task list
•Schedule date and time of discharge at
least 24 hours in advance
ED
Reduce the ED
waiting room time
to 20 minutes
•Implement a Fast Track
Bed
Management
Reduce the cycle
time of bed
assignment to 10
minutes
•Implement an automated bed
management system
•Dedicated bed management coordinator
•Demand prediction
44
© 2013 by HealthCare Quality Improvement Solutions, LLC
- 45. Value Stream Improvement Review
Segment Current
Performance vs.
Goal
Project Progress Identified
Problems
Proposed
Solutions
Action Taken
45
On Schedule
At Risk
Behind
Schedule
Meeting
Not Meeting
© 2013 by HealthCare Quality Improvement Solutions, LLC
Conduct at minimum a quarterly review
- 46. Value Stream Management Components
Value Stream Manager
Visual Control
Real-time Problem Solving & Process Improvement
46
© 2013 by HealthCare Quality Improvement Solutions, LLC
- 47. 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
47
© 2013 by HealthCare Quality Improvement Solutions, LLC
- 48. Value Stream Management Components
Visual Control
A graphical report of the status of process performance
depicting actual vs. expected performance
0
10
20
30
40
50
60
Bed Assignment Time Inpatient Bed Placement
Time
Discharge Planning Unscheduled Discharge
Actual Expected 48
© 2013 by HealthCare Quality Improvement Solutions, LLC
- 49. 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
49
© 2013 by HealthCare Quality Improvement Solutions, LLC
- 50. 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.
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© 2013 by HealthCare Quality Improvement Solutions, LLC
- 51. 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
51
© 2013 by HealthCare Quality Improvement Solutions, LLC
- 52. Value Stream Management Advantages
Ideal method for meeting The Joint Commission’s
patient flow standard:
Which 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.
52
© 2013 by HealthCare Quality Improvement Solutions, LLC
- 53. © 2013 by HealthCare Quality Improvement Solutions, LLC
- 54. 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.
54
© 2013 by HealthCare Quality Improvement Solutions, LLC