advanced process mapping · 2019-12-11 · advanced process mapping jennifer wortham, dr.ph 1 ......

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Advanced Process Mapping

Jennifer Wortham, Dr.PH

1 © 2010 Healthcare Performance Partners, Inc.

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Objectives for Today’s Workshop

At the end of this session you will be able to:

– Describe how process mapping supports Lean

– Describe three types of process mapping and how they are used: • Functional process flow using swim lanes

• Value Stream Mapping

• SIPOC’s

2 © 2010 Healthcare Performance Partners, Inc.

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3

1. Create Strategy, Budgets & Report Cards

2. Then a Miracle Happens

3. Improved Patient Care Better Organizational Results

“I Think You Should Be More

Explicit Here In Step Two.”

Agenda: Talk about Step 2.

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The 4 “P’s” of Lean

Lean aligns the entire organization, in the continuous pursuit of excellence, through the development of people to solve problems, improve processes and create value for the customer.

Purpose

Process

People

Problem Solving

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Goal of Lean: Eliminating Waste from Processes

Everything the organization does needs to be treated as a

process that serves the patient/customer.

Steps that don’t directly provide better care to the patient/customer

must be considered Non-Value added or WASTE!

Defects

Over-Production

Waiting

Not Clear (Confusion)

Transporting

Inventory

Motion

Excess Processing

Direct Patient Care

Indirect Patient Carfe

Waste

Administrative

Waste

Direct 21%

Indirect 18%

Admin 12%

RN Time Distribution

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How Process Maps are Used in Lean Projects

They provide a fact-based process description for understanding current problems and opportunities.

–They communicate the specific elements of a process to internal and external stakeholders.

–They are used to perform value analysis.

–They enable teams to quickly see improvement opportunities within the process, and to begin defining critical Xs (underlying causes of problems).

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Versions of a Process

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At least 3 (Usually)

What You Think It Is... What You Would Like It To Be... Future State

What It Actually Is...

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Construct for Developing a Care Process The 4 Rules in Use

Activities – Content, Sequence, Timing,

Location and Outcome

Connections: – Direct, Paced, Binary

Pathways (Clear) – Direct, No forking or looping

Improvement: – Closest to the Work, using

Scientific Method, evidence based

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Traditional Process Map

Swim Lane/Functional Process Map – Best Practice U

nit

Sp

ec

iali

st

Un

it

Ma

na

ge

r

Dir

ec

tor

VP

Checks

supply

stock

2 hours 5 days 1 day 7 days 1 day

Complete

request

form

Review &

approve

request

Review &

approve

request

Review &

approve

request

Procure

Supplies

Reviews

packing

list

against

order

Stocks

supplies

on unit

Pu

rch

asin

g

CER

> $5,000

Yes

No

Creates delays

Review

request Supplies

Delivered

© 2010 Healthcare Performance Partners, Inc.

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CT – Current StateE

DT

RN

Un

it S

ecre

tary

CT

- T

ech

M

D

Place

order in

CPOE

5 Mins

Review

pre-exam

checklist

15 mins

Answers

call from

CT Tech &

Contacts

RN to notify

of order

5 Mins

Contact EDT

via Vocera

for Transport

5 mins

Prep

Patient for

Transport

10 mins

70% of orders are

incomplete –

requires call to

MD to clarify.

Patient not ready for CT – avg.

delay 10 min. Common cause:

- Need to call RN to clarify risks

- Undress patient

- Remove jewelry

- Start IV

Transport

Patient

10 mins

Lack of CT-

Tech

available for

transport –

avg. delay 40

mins

Call MD

to Clarify

order

25 mins

Complete

CT

10 mins

Transport

patient back

to ED

40 mins

5 5540 115 120 155 180 220

Administer

contrast

5 mins

Call ED to

inform OK

to Send

Patient

5 mins

Start

Reviews

order and

determines

next steps

15 mins

165 170

Only 20% of

orders are placed

via order sets.

Most orders are

placed using

generic orders.

Collect

specimen, and

send to lab,

wait for results

60 mins

50% of patients did not

have Kidney Function

test ordered

RN busy – average

delay in collecting

specimen

230

CT busy,

average wait

10 mins

Prep

patient

10 mins

Radiologist

reads film and

documents in

EHR

10 mins

ED Doc

reviews

report and

completes f/u

30 mins

End

130 140 260

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Understanding How Processes Perform

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Value Stream Mapping

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Swim lane/Functional Flowcharts

Lean best practice process flow chart/map

– Forces the question of who is responsible for a given activity

– Illustrates the sequence of events

– Provides a timeline

– Indicates the number hand-offs

– Shows opportunities to eliminate/reduce steps

Use process map to communicate what is going wrong (pain points) and identify opportunities for improvement

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Process Step

Decision

Beginning / End

Connector

Document

Data-base

Basic Process Flowchart Symbols

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Direction

In-process

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Value Stream Mapping


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Fundamental Concept

• Diagnosis and Treatment • Med Rec

• Surgery

Information

Coordinating Care

• Unnecessary work (click, click, click…)

• Waiting,… for anything

• Searching for information

• Redundant Approval Processes


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Patient and

Customer Focused

Non-Value Added Value-Added

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Typical Improvement Projects

Many organizations focus their efforts on improving the value added work in a process, but after years of optimization of the VA steps: How much improvement can you really expect?

The real opportunity is to reduce the non value-add time in a

process (waiting, work in queue, transportation, rework, etc.).

85 - 95% NVA 5 - 15%

VA

Total Lead Time

Lean focuses on eliminating non value-added time in a process.

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Processing (VA) 5% - 15% of lead time

Work Queue/Waiting (NVA) 70% - 80% of lead time

Transportation (NVA) 5% - 10% of lead time

Inspection (RA/NVA) 5% - 10% of lead time

Typical Process Activities

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Lead Time, Cycle Time and Down Time

Lead Time (LT): Time from the defined beginning of a process to delivery to the customer. This includes all travel, waiting, staging, and storage times between processes and operations (includes cycle time and down time). – Cycle Time: Period of time required to complete one

cycle/major step of an operation. – Down Time: the time between cycles, or non-productive

work within a cycle

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Identifying Waste in the Process

Used to reveal the flow of material and information as a product/service makes its way through a process.

Path from the beginning to end from the customers perspective.

Visual representation of each sub-process in the stream creates an end-to-end “current state” vision for everyone to follow.

The value add and non value add (waste) activities are measured and documented.

Then, by asking a set of questions about how the work should flow, a future state map or proposed plan can be created.

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Lead Time, Cycle Time, Down Time

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= LT + + + MSE Diagnostics + Treatment +

Discharge Triage Register Check-in +

5 5 5 15 5 5 5 5 5 5 5 10 30 30

Down-time Cycle-time

45

Down-time

The only time the patient really cares

about

High Level Value Stream Map ED Visit

LT = 180 minutes

23 Value Added 36% Non-Value Added 64%

1. Patient completes intake form

2. Receptionist reviews forms, verifies ID, & verifies benefits

3. Types info into EMR

Check-In Prep Exam Check-Out

1. MA: Take vitals & document in EMR;

2. Review patient intake info in EHR;

3. Asks & documents chief complaint.

1. MD reviews hx and chief complaint;

2. Completes physical exam;

3. Fills out lab req form, and RX

4. MA documents orders in CPOE

1. Schedule follow-up appointment

2. Collect co-pay

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6.5

2

3.5 10.2 5

12 22 3 5 2

2 1

VA

NVA

VA = 25.2

NVA = 44.0 LT= 69.2

Detailed Value Stream Map

Clinic Visit

24 Value Added ____% Non-Value Added ____%

VA

NVA

VA = ____

NVA = ____ LT=

Value Stream Map

-Process Name Here-

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What’s a SIPOC?

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S I P O C

Requirements Requirements

Suppliers Inputs Outputs Clients

Input Boundary Output Boundary

Process

Defines the required inputs and outputs of each step in the process, and how the process should be performing:

• Outlines the boundary of the process or scope • Helps identify stakeholders

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Suppliers Inputs Process Outputs Customers

SIPOC

List process outputs

List key output

requirements

List process inputs

List key input requirements

List 5 to 7 high level process steps.

List customers who receive the outputs

List suppliers of the inputs

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Supplier Input Process Step Output Customer Requirement

Physician Patient info Med Rec

Labs

Enter orders into EHR

Admit Order Notification

Bed Coordinator

5 minutes from time of disposition

decision

Bed Coordinator

Bed Board with bed availability

Review Bed Board and Enter Unit

Assignment into EHR

Unit Assignment Notification

Unit Charge RN

Within 10 minutes

Unit Charge RN

Unit Assignment Log

Review Unit Assignment Log

and Assign Bed/Nurse

Notification of patient

assignment

Unit Specialist

Within 5 minutes

Unit Specialist

Bed / Nurse Assignment

Complete transfer request in Tele-

tracking

Notification of Bed Ready

ED RN Within 5 minutes

ED RN Notice – bed ready & Patient

ready

Patient Transported to Unit

Patient arrival in unit

Assigned Nurse

Within 10 minutes

SIPOC-R - Example Patient Bed Assignment for ED Admit

Total Lead Time = 35 minutes

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Completing the SIPOC Suggested Approach

Process name

Process owner

Determine outputs

Process start/cue/trigger

Process end/cue

Complete supplier, customer, process steps

Determine Critical-to-Quality requirements:

– Cycle-time

– Quality, etc.

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Group Exercise

A patient on one of your medical surgical units has tested positive for C-Diff. Let’s create a hypothetical SIPOC.

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SIPOC

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Supplier Input Process

Step

Output Customer Requirements

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Success with SIPOC

Clearly identify the start and end

Lean Principle: Gemba: “Go to the Source” and find out what both internal and external customers truly need.

Ensure that assumptions are recorded, discussed, and validated

Document definitions of key terms, symbols, acronyms, equipment, standards, etc.

Don’t forget feedback loops and communication mechanisms

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Overall Thoughts

The real value of SIPOC is the discussion it creates Begin with the end in mind – how will you

use it? Determine critical to quality requirements for each step in the

process Use only as much detail as needed to communicate well and

understand the process.

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advanced process mapping · 2019-12-11 · advanced process mapping jennifer wortham, dr.ph 1 ......

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