Improving patient flow value stream management

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.

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ED Registration

ED Triage
ED

ED Care

Transportation
Transportation

Inpatient Pharmacy
Admission

Inpatient
Care
Discharge Home

Housekeeping

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Patient Flow Value Streams
 Outpatient
 Emergency Department
 Outpatient Surgery
 Outpatient Clinics
 Inpatient
 Medical
 Surgical
Cardiothoracic

 Orthopedic
 Obstetrics
 Pediatrics

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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.

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ED Registration

ED Triage
ED

ED Care

Transportation
Waste
Transportation

Waste

Inpatient Pharmacy
Admission Waste

Inpatient
Care
Discharge Home
Waste

Housekeeping

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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.

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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

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Waste
 There are eight forms of waste:
1. Waiting
2. Motion
3. Transportation
4. Overproduction
5. Defects
6. Overprocessing
7. Underutilized People
8. Inventory

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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

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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.

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Current State Value Stream Map

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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

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 What is Current State?
 A value stream map that represents the process steps,
flow of patients , services and information as they exist
today.

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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

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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

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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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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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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

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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
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Map Information Flow

Manual Information Flow

Fax Transmission Telephone Walk
Electronic Information Flow 22

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?

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Add Timeline

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Add Timeline

Non-Value Added Time

Value Added Time Value Added Time

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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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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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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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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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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?

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 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 ?

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13.7% VA

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

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Map The Future State: Set Goals

FS FS
20 30 FS 15/15
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Map The Future State: Determine Improvements

16.0% VA
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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.

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Future State Implementation Segments
Bed
Management

ED Discharge

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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
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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

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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

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 Value Stream Manager
 Visual Control
 Real-time Problem Solving & Process Improvement

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 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

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 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

 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

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 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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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
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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.

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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.

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Improving patient flow value stream management

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