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Value Stream Mapping:Value Stream Mapping:A Powerful Tool for ImprovingA Powerful Tool for ImprovingHealthcare ProcessesHealthcare Processes

Society for Health SystemsSan Diego, CA

February 10, 2006



2

Session Objectives

Understand what a value stream is

Learn the benefits of value streammappingLearn how to create current state value

stream mapsLearn how to create future state valuestream mapsLearn how to prioritize improvementopportunities and create an actionableimplementation plan



3

“Where there is a product (or service) for acustomer, there is a value stream.

The challenge lies in seeing it.”

- Jim Womack, Lean Thinking



4

Introduction toValue Streams



6

Defining Value

Value-Add (VA) - any operation or activity thecustomer values (and would be willing to pay for ).

Who are your customers? What do they really want?

Non-Value-Add (NVA) - any operation or activitythat consumes time and/or resources but does notadd value to the service provided or product sold tothe customer.

Necessary – regulatory requirements, etc.Unnecessary – everything else



7

Non-Value-AddedThose activities

between the value-added steps thattypically account for70-95% of steps,

process time andnon-material costs= WASTE

Value-Added



Healthcare Value Stream

!"

Start

End



9

The Lean Journey

Map theValue

Stream

Define valuefrom thecustomer’sperspective

Create Flow;Eliminate theroot causes

of waste

Seekperfection viacontinuous

improvement

Create pullwhere flowis difficultto achieve



10

Value Stream Mapping

Diagnostic toolReveals hidden symptoms of larger problems

Blueprint for change; strategic planning activityHelps prioritize opportunities for improvementResults in an implementation plan

Macro level visual representation of:Information flowPeople & material flowHow macro? Each process block represents ahandoff or a break in the timeline

Contains relevant metrics:Lead time – throughput / turnaround / flow timeCycle time – “touch / process time% Complete & AccurateAdditional “flowstoppers”



11

Benefits ofValue Stream Mapping



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Why Value Stream Mapping?

Helps visualize process steps and WASTE in theprocess

View process flow from “the thing’s” perspective

Helps “see the whole”Helps focus on maximizing overall flow rather thansub-optimizing specific functions/departments

Easy to learn; paper and pencilHave a darn good reason for putting maps intoelectronic form!



13

Why Value Stream Mapping? (continued)

Shows the linkage between information

and material flowMakes the disconnects and obstacles toflow stand outMetrics-based decision making:What you are going to do to affect thenumbers?Provides visibility to product/servicefamilies. Separate maps are drawn foreach product/service family – productgroupings based on shared process

steps



14

Mapping the CurrentState



15

Mapping Team Composition

VSMs are strategic in nature

The resulting implementation plan is thetactical component

Team compositionLeadershipPeople with process knowledgeOutside eyes



16

Product/Service Families

35

10

300

450

500

225

#

$

XXX%&''

XXXX( ')*

XXXXXX( ')&

XXXXXX)++

XXXXXX,++

XXXXXX-./++

-012

“Products” with similar processing requirements are grouped into product families



17

Healthcare Service Families

Primary Value StreamsEmergency ServicesSurgical ServicesImaging ServicesOB ServicesEtc.

Support Value StreamsBillingPayrollMedical RecordsHousekeeping



Product Family

Implementation

Current-StateDrawing

Future-StateDrawing

E v e n t u a l l y

R E P E A T

What are we mapping?

What is the current state -where are the opportunities?

What could flow look likefor this value stream?

The goal of mapping

Reiterative Process



19

Data Box

Electronic Flow

Finished Goods

Go See Scheduling

Inventory

Manual Info Flow

WorkerProcess Box

Push Arrow

Supplier or

Customer Truck

Basic Mapping Icons

In - box



20

Mapping Details

Order Initiation

Current State MapMay 8, 2003

Be sure to placetitle block inlower right

I n f o r m a t i o n

F l o w

P r o

d u c t

F l o w



21

Mapping Details

Data Box



ScheduleAppt Discharge

Current State Value Stream MapOutpatient Cardiac Lab

Total Lead Time = 27.31 hrsTotal Cycle Time = 1.55 hrs %VA = 5.7% RFPY = 29%

CardiologyGroup

Admission Prep DX/RXProcedure

)' /'&

10 min

24 hrs

12 min 20 min 30 min 15 min 6 min

0.75 hrs .83 hrs 0.5 hrs .13 hrs

CT = 10 minLT = 1 hr%C&A = .90

CT = 12 minLT = 3 days%C&A = .60

CT = 20 minLT = 45 min%C&A = .85

CT = 30 minLT = 50 min%C&A = .75

CT = 15 minLT = 30 min%C&A = .90

CT = 6 minLT = 8 min%C&A = .95

0.1 hrs

Joann Mapper4/23/2005

= 2 = 3= 1= 2 = 2 = 2

1 hr

PrimaryCare MD



23

Mapping Details

Process

ProcessProcess Process

Process

Multiple Flows

Product Flow

Information Flow



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The Value Stream: Micro to Macro

Process LevelFacility Level

Between FacilitiesSuppliers and Customers

(what can you impact?)



25

Creating the Current State VSM

In the conference room:Define which product or service to map (if notpredetermined)Determine start & end fence posts (boundaries)

Order to delivery to revenue receipt

From customer’s perspectiveNarrow focus to a specific type of situationObtain customer demand

Outline the major process blocksChunk of activities that occur before a handoffOR… major stop in time line



26

On “the floor”Walk the process; be “the thing”

Start with the final step and walk upstream (backwards)Viewing a snapshot of today’s process

Take current state photos, if relevantStay focused on “the norm”

Use the “70% rule” to avoid getting bogged down withexceptions

Interview workers to obtain relevant dataCT, LT, %C&A, other barriers to flowAnecdotal metrics are usually fairly accurateUse data sheets or something similar

Create a spaghetti diagram, if relevant

Creating the Current State VSM(continued)



27

Data Box – Barriers to Flow

What else?Changeover timeBatch sizeRun frequencyEquipmentavailabilityWhat else…?

Activity:_____________ ______________

Dept performing: ______________ Cycle (touch) time: ______________ Lead time: ______________ % C&A: ______________ IT systems used: ______________

Current backlog / WIP: ______________ Demand rate: ______________ Longest throughput: ______________ Number of people: ______________ Prioritization rules: ______________ Shared resource?, if

so, % of total load? ______________ _______________: ______________ _______________: ______________ _______________: ______________

Process Data



Spaghetti DiagramCurrent State

BenefitsVerification

PatientHistory

Vitals PhysicianOffice

Imaging

ExamRoom

Laboratory

Billing

Waiting Area

ORDER CASH



29

Current State Mapping Reminders

1. Start with the customer – information flow2. Identify the product or service which is being worked on (“the

thing”)3. Determine your process steps from “cradle to grave”4. Determine the “trigger” that initiates action at each process (it may

be information flow)5. Identify the time it takes to perform the task without delays

(starting or within the process) or interruptions within the process – “cycle time”

6. Identify and quantify the time it takes to perform the taskincluding delays and interruptions – “lead time”(LT = CT + delays)

7. Investigate the causes of the waste between processes - what arethe “barriers to flow”

8. Map what “typically” happens (70% rule)9. Calculate total processing time (cycle time) versus total lead

(throughput/turnaround) time10. Remember: You’re an investigator. Do whatever it takes to

understand all aspects of the current state.



30

Back in the conference roomClassify each step as VA or NVAConsider dividing map into sections:

Pre-productionProductionPost-production

Calculate relevant metrics:CT sum

LT sumCT/LT ratio (CT divided by LT x 100)Rolled first pass yield (product of % C&A’s)

Creating the Current State VSM(continued)



31

Common Current State Findings:Issues

Lots of waitingLots of travelLack of communication (or lots of poorcommunication)

Lack of skills / relevant trainingToo many handoffsToo many approvals / inspections

Too many IT systems / workaroundsDifferent prioritization rules in differentdepartments / areas



32

Common Current State Findings:Metrics

High LT (slow throughput / turnaround)

Low % C&A (poor quality)High WIP (bottlenecks and backlogs)Low CT/LT Ratio (lots of waiting)



S i S h d l d CT S



Current State Value Stream Map

Outpatient Imaging Services

VSM Champion: Paul Scanner

Created: July 18, 2005

Service: Scheduled CT Scans

Demand = 15 per day

Customer Demand:15pieces per Day

(Takt Time 5760seconds)2 shifts

8 hours per shiftReferringPhysician

% C&A = 65 %

Check-inPatient

(Admitting)

Cycle Time = 2 mins.% C&A = 90 %

5

SendReports

(Imaging)


6

Hospital

5 mins.

ScheduleAppointment

Cycle Time = 11 mins.Lead Time = 12 mins.% C&A = 98 %

6

Pre-registerPatient


5

CT=Cycle TimeLT=Lead Time

%C&A=% Complete & Accurate

0.0833 hrs.

2 mins.

0.0833 hrs.

1 mins.

0.75 hrs.

10 mins.

0.5 hrs.

15 mins.

0.0833 hrs.

3 mins.

4.13 hrs.

15 mins.

6.08 hrs.

5 mins.

16 hrs.

1 mins.

1.83 hrs.

1 mins.

2 hrs.

3 mins.

LT = 32.5 hrs.

CT = 56 mins.CT/LT Ratio = 2.87%

Lead Time = 12 mins.Lead Time = 990 mins.

PrepPatient(Tech)


3

Check-inPatient

(Imaging)


3

CompleteExam(Tech)


2

TransmitImages(Tech)


2

Read/DictateExam

(Radiologist)


3

TranscribeReport(MDI)


6

ReviewDraft/Sign

(Radiologist)


2

PrintReports

(Imaging)


230 mins. 5 mins. 248 mins. 365 mins. 960 mins. 110 mins. 120 mins.45 mins.

E Pay

Excel

ADS

Symposium

Internet

Waiting RoomManagement

System

Fax OrderSolutions

PACS

5 mins.

Lead Time = 8 days

Meditech

1234

5 6 7 8 9 10 11 12 13 14

Auto Fax 50%Us Mail 25%MD Mailbox 25%

Rework Loopvia Fax 25% of

the time

Rolled First Passyield = 29%



35

Designing theFuture State



36

Achieving the Future State

Target: 6-9 months outDesign considerations:

Eliminate steps / handoffsMerge stepsCreate parallel pathsImplement pull if flow isn’t possible

Reduce / eliminate batchesImprove qualityCreate standard workCreate an organized, visual workplace

Eliminate unnecessary approvals / authorizationsStop performing nonessential (NVA) tasks from the customer’spoint of viewCo-locate functions based on flow; create teams of cross-functional staffBalance work to meet takt time requirements



37

Lean Objectives

ELIMINATE Unnecessary NVAREDUCE Necessary NVAOPTIMIZE VA

D i i h F S V l



38

Designing the Future State Value

Stream

Target All Waste!



39

Revisiting “Value-Add”

Value Add: Is the customer willing to payan incremental cost for the activity?Non-value Added (NVA)

NecessaryRegulatory requirements and accreditationstandards

Customer requirements due to poorperformance and lack of trust

Unnecessary NVA = WASTE

Challenge the “purpose” of theadministrative processes within yourorganizationChallenge EVERYTHING



40

“Muda” equals “Moola”

=



41

Eight Wastes (NVA)

OverproductionInventory / WIPWaitingUnnecessaryProcessing

Errors / DefectsMotion (people)

Transportation(product)

Underutilized

people



42

Waste Considerations

Waste = The elements of the process flow(or lack thereof) that add no value to theservice providedWaste adds cost and time, but not value

The enterprise objective is to eliminate /minimize non-value added stepsCaution: Remember waste is a symptom –

it is not the root cause of the problem!



43

The Future State Map

1. This is your foundation (andthe basis) for the futurestate

2. 70% accurate is acceptable

1. Design the lean flow by“carving” out the waste (it is

now obvious from yourcurrent state map)2. The challenge is to “create

flow” and minimize the“hand-offs” with your

changes

Product Family

Document CurrentState

Design FutureState

Plan andImplement!

2 Days

d



44

Metrics to Consider

Quality: First Pass Yield / effectivenessDelivery: Lead Time

Customer Service: Your metrics must include somemeasurement of how well you provide service to youinternal and external customers

Cost: Reducing defects, rework, surrogate tasks, hand-off’s, waiting and lead time will result in drasticallyreduced costs

Eight Questions for



45

Eight Questions forFuture State VSM

1. What are the customer requirements?2. Will we produce to order or to finished goods

inventory?3. Where can continuous flow be put in place?4. Where should pull systems be implemented?

5. What is the single point of scheduling?6. How do we level the load and the mix?7. What should the management time frame be?

8. What process improvements are necessary to achievethe future state?

F S I



46

Future State Icons

supermarket

signalkanban

withdrawalkanban

productionkanban

kanban arrivingin batches

kanbanpath

withdrawal

leveling mixand-or volume

kanban

post

max. 50 pcs.first-infirst-outflow

kaizenlightningburst



47

Create the Future StateValue Stream Mapfor Outpatient Imaging

Exercise

Future State Value Stream MapService: Scheduled CT Scans

Demand = 15 per day



(with out Kaizen Bursts)

Outpatient Imaging Services

VSM Champion: Paul Scanner

Created: July 20, 2005

Demand = 15 per day

ReferringPhysician

% C&A = 85 %

SendReports

(Imaging)


6

Hospital

Schedule apptPre-register


6

CT=Cycle TimeLT=Lead Time

%C&A=% Complete & Accurate

5 mins.

1 mins.

35 mins.

10 mins.

20 mins.

10 mins.

5 mins.

2 mins.

120 mins.

15 mins.

420 mins.

1 mins.

2 mins.

1 mins.

30 mins.

3 mins.

LT = 680 mins.

CT = 43 mins.CT/LT Ratio = 6.32%

Lead Time = 45 mins.Lead Time = 5 days

PrepPatient(Tech)


3

Check-inPatient

(Imaging)


3

CompleteExam(Tech)


2

TransmitImages(Tech)


2

Read/DictateExam

(Radiologist)


3

ReviewDraft/Sign

(Radiologist)


2

PrintReports

(Imaging)


220 mins. 5 mins. 120 mins. 420 mins. 2 mins. 30 mins.35 mins.

E Pay

Excel

Symposium

Internet

Waiting RoomManagement

System

Fax OrderSolutions

PACS

5 mins.

Auto Fax 80%Us Mail 15%MD Mailbox 5%

Rolling First Passyield = 40%

Rework Loopvia Fax 10% ofthe time

Customer Demand:15pieces per Day

(Takt Time 5760seconds)2 shifts

8 hours per shift

123

4 5 6 7 8 9 10 11

Meditech



Quality at theSource (Poka Yoke)

Standard Work Batch Reduction /Continuous Flow Pull Systems

Work Balancing

WorkplaceOrganization / 5S Visual Workplace Layout for Flow

Total ProductiveMaintenance

TeamsMulti-functionalworkers

Value StreamAlignment

Continuous Improvement

via Rapid Improvement Events

ValueStream

Mapping



Implementation Plan



52

Implementation Plan

Value Stream: _____________________ Implementation Plan Owner: _____________________ Date Created: _____________________

Projects

Kaizen Events

Just-Do-Its

Save for later

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

(Months)

(1 to 2 weeks)

(1 or 2 days)



Future Improvements to be Made



56

Future Improvements to be Made

Mistake Proofing

Layout for FlowHeijunka / Level LoadingCross-training

Summary



57

Summary

Identify your product families (based oncommonality of process steps)Select an important product family andmap the value stream (people, product,process and information)Use data from value stream maps toidentify where to drill down analysis to thenext level

Recommended Reading



58

Recommended Reading

Lean Thinking , Jim Womack & Daniel Jones, FreePress, 2003 (2 nd revised edition)

Lean Solutions , Jim Womack & Daniel Jones, FreePress, 2005The Complete Lean Enterprise: Value StreamMapping for Administrative & Office Processes , BeauKeyte & Drew Locher, 2004Value Stream Management for the Lean Office , DonTapping & Tom Shuker, Productivity Press, 2003

Lean Enterprise Institute – www.lean.orgSociety for Health Systems – www.shs.iienet.org

Acronyms



59

Acronyms

CS Current StateCT Cycle TimeFS Future StateLT Lead Time

NVA Non-value-addedRFPY Rolled First Pass YieldVA Value-addedVSM Value Stream MapWIP Work-in-process



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Available work timeTakt time =

Customer demand

540 minutes/dayTakt time = = 36 mins/scan

15 scans/day/scanner

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