skills-building webinar series · vsm vs. other process mapping major difference between value...

Skills-building webinar series

Value stream mapping: Finding gaps and opportunities for improvement

Stephen L. Davidow, MBA-HCM, CPHQ, APR

Quality Improvement Program Manager

©2015 PCPI Foundation. All rights reserved.

Speaker

Stephen L. Davidow, MBA-HCM, CPHQ, APR


PCPI

Chicago, IL

312-464-4346 office

[email protected]


Reminders

• Today’s webinar is being recorded

• The slides and a link to the recording will be posted on

the PCPI QI program website

• Please use the chat for the Q&A

– Please submit questions during the presentation

– Questions will be grouped and combined as appropriate


Agenda

• What are value streams and value stream mapping?

• Why is it important?

• Value-added vs. non-value added activity

• How to get started

• Moving from the Current State to the Future State

• Examples

• Takeaways

• Questions


Value stream mapping helps us see what is in plain sight,…


…as well as address workarounds and overcome obstacles.


What is Value? Start with the Customer

Principle Hospitals Must

Value Specify value from standpoint of end customer (patient)

Value

Stream

Identify all value-added steps across department

boundaries (the value stream), eliminating steps that do

not create value

Flow Keep the process flowing smoothly by eliminating causes of

delay, such as batches and quality problems

Pull Avoid pushing work on to the next process or department;

let work and supplies be pulled as needed.

Perfection Pursue perfection through continuous improvement

Adapted from Lean Enterprise Institute, Principles of Lean.


Value added vs. Non-value added: Examples

Department Role VA Activity NVA Activity

Operating Room Surgeon Operating on patient Waiting for delayed

procedure or

performing unnecessary

procedure

Pharmacy Pharmacy technician Creating an intravenous

formulation

Reprocessing

medications that were

returned from patient

units

Inpatient unit Nurse Administering

medications to a patient

Copying information

from one computer

system to another

Radiology Radiology technician Performing magnetic

resonance imaging

procedure

Performing medically

unnecessary procedure

Laboratory Medical technologist Interpreting test result Fixing broken

instrument


Value added vs. Non-value added:Examples

Department “Product” VA Activity NVA Activity

Emergency room Patient Being evaluated or

treated

Waiting to be seen

Clinical laboratory Patient specimen Being centrifuged or

tested

Waiting to be moved as

a batch

Pharmacy Prescription Medication being

formulated or prepared

Being inspected

multiple times

Perioperative services Sterilized instruments Time when instruments

are being sterilized

Instruments being

sterilized repeatedly

without ever being used

from a standard kit

Nutrition services Patient food tray Time when food is

being cooked and tray is

being assembled

Being reworked

because tray was done

incorrectly


What is a value stream?

A value stream involves all the steps, both value added and non-value added, required to complete a product or service from beginning to end.

A value-stream map is:

• Visual representation of a value stream

• Tool to help reveal waste and problems with flow

• Establishes a common language to document processes

• Provides a blueprint for improvement

• Gets front line staff involved in creating the plan for change


VSM vs. other process mapping

Major difference between value stream mapping and flow charting/process mapping is:

• Focus on the end customer (patient)

• Time elements

– How long does each process step take to perform?

– From a patient perspective, value stream mapping reveals most of the time in a system is wasted


Components of a Value Stream Map

• Process flow across the bottom

• Customers outlined on the right

• Suppliers outlined on the left

• Information flow across the top

• Timeline across the bottom

• Symbols that provide insight into flows, process boxes, as well as what happens between the process boxes


Define the problem

• Need a clear understanding of the problem

– What’s not working now?

– What roadblocks are there to fixing the problem?

– Who is affected by the problem?

– What different outcomes are you trying to achieve?

• Spend time detailing these answers before starting a current state map

Most often encapsulated in a problem statement and/or project charter depending on scope of project.


Define the primary process

Building on your problem statement, answer the following questions:

1. What is the primary process the team will be working on?

– Determine a name for it

– Define the start point (trigger)

– Define the end point

2. Is the primary process a subsection of a larger value stream?

– If yes, determine a name for it


Defining the Primary Purpose: Example

1. Determine a name for it

2. Define the start point (trigger)

3. Define the end point

4. Determine high level stream

1. BSI Detection Process – “Order to Blood Culture Drawn”

2. “Physician writes order for blood culture”

3. “Blood culture drawn and labeled by Phlebotomist”

4. “Patient check-in to blood culture result available”

When defining the start and end points, BE SPECIFIC


Why analyze the current state?

• Determines which steps in the process are currently adding value or waste for our customers

• Identifies or pinpoints the root causes of problems and opportunities to increase efficiency and quality

• Develop a shared recognition of the need and logic for change to a future state

The analysis is the bridge between the Current and Future State value stream maps


Value-added Steps in a Process

“Value-added steps:

• Meet customer needs

• Transform inputs to outputs

• Are correct the first time

Examples:

• Receiving accurate diagnosis

• Getting a timely appointment

• Receiving correct medication when needed

• Getting test result in a timely manner

• Having an actual, necessary procedure or operation


Non-value Added Steps in a Process

“Non-value” added steps:

• Consume time, money and resources

• Do not satisfy customer’s need

Examples:

• Waiting for approval before receiving treatment

• Repeating registration process

• Documentation duplication (e.g., personal and history)

• Redoing tests and procedures


Value Stream Mapping Supplies

• Paper and pencil/pen

• Rolls of craft paper

• Post-its

• Sharpie pens

• Disposable white boards and erasable markers

• Microsoft Power Point software

• Microsoft Visio software

• SmartDraw software

• Lean.org

• Minitab software


Value Stream Mapping Structure

Scoping and / Pre-work

– Define problem

– Customer requirements

– Gemba waste walk

– SIPOC

Current State Map

– Create Map

– Baseline data

– Analysis of Current State

Future State Map

Implementation Planning

Reviews


Value Stream Mapping Template

Most Common VSM Icons


VSM Abbreviations

• C/O – changeover time or setup time to begin new task

• P/T (C/T) – process or cycle time = time to complete a task

– VAT – value-added time or the time needed to complete a required task

– NVA – non-value-added time = PT – VAT

• W/T – wait or queue time for next process step to begin

• L/T – lead time, or the total time from when a task is started within a work center until it leaves work center.

• FTQ or FTT – First time quality or first time through quality yield

Note: Service time units: seconds, minutes, hours, days, months > depends on application


Typical Office Data Attributes

• Process and available time

• Set-up time

• Lead time/turnaround time

• Typical batch size or frequency

• % complete and accurate information (%C&A)

• Rework/revisions (e.g., design changes)

• Number of people involved

• Downtime (e.g., information systems, equipment, etc.)

• Inventory – queues (e.g., for information, supplies, etc.)

• Demand – number of orders, requests for appointments, visits, etc.

• Information technology used


Takt Time = Demand Rate

• Pace of processing to match pace of customer need.

• Rate for completing work based on customer need.

Takt time = Effective working time per shift

Customer requirement per shift

8-hour shift; 30 minute meal; 2, 15-minute breaks

420 minutes/30 patient visits = 14 minutes per patient

• What is the desired “cycle time” or “service time” for each activity?

• What resources will be needed to meet demand?


Current State Mapping Steps

1. Document customer information and need

– Who is it? What do they need? When do they need it?

2. Identify main process steps (in sequential order)

3. Select data attributes

– (process time, wait time, % complete & accurate)

4. Perform value stream walk and fill in data boxes that show the process actually works

– Pretend you are the work/document/item being produced

5. Establish how each process knows what process next (how work is prioritized) and document information flow

6. Calculate process time, wait time, lead time, first time quality, and any other metrics necessary to evaluate your Value Stream

7. Add other icons to illustrate flow/waste

8. Take a step back, look at the map, and answer the question: What is the map telling you?


Lean Metrics

• Process Time: Time to conduct work in the process step

– Can be both value added and non-value added

• Wait Time:

– Within process step (i.e., waiting for a call back from the customer)

– Between process steps (i.e., queue time in an “inbox”)

• Lead time: Total time between process start and customer acknowledgement (completion)

– Lead Time = Process Time + Wait Time

• First Time Quality: The percentage of time that the task is able to be completed accurately the first time it is worked on

• % Vale Added: The Value Added Time divided by the Total Lead Time

– (VAT of 10 minutes/LT of 100 minutes = %VA of 10%

• Other: Depends on project (e.g., number of staff, cost, etc.)


Waste Identification Steps

• Simple items to look for:

– Low FTQ

– Long wait times as compared to process times

– Process steps requiring multiple iterations/reviews or rework (chaos)

– Excessive handoffs between people/organizations

• Complex items to look for:

– Multiple systems/computer tools used

– Starting too early

– Look at the “system” level first for opportunities to make bold moves


Problem Definition Tree

Why?

Why?

Why?

Why?

Why?

Why? Why?

5 Why’s, not 5 Who’s • Involvement • Interdisciplinary • Impartial

1. Document potential root causes 2. Ask if any causes are more likely

the root than another 3. Drill down by asking “why” on

most likely root causes


Creating a Future State-Map

1. Define customer requirements

2. Determine scope of change

– Radical vs. incremental

3. Make the work flow

– Optimize value-creating steps

– Apply appropriate lean tools/approaches

4. Improve work quality and reliability

– Control variation

– Standardize

– Make it visual

Continued…


Creating a Future State Map (cont.)

5. Design to manage for improving and learning

– Milestones

– Regular checks and reflection

– Feedback learning

6. Estimate your results

– Quality and process improvements (PT, WT, LT, FTQ, %C&A)

– Resources needed


Wastes and two primary contributing factors

“DOWNTIME”

• Defects

• Overproduction

• Waiting

• Non-utilized/underutilized talent

• Transportation

• Inventory

• Motion

• Excess Processing

Unevenness: A flow of information or product/service processes that are not regular or constant causing many of the other types of waste; the lack of consistency in schedules and info. Unreasonableness: Pushing a machine or people beyond their capabilities or what is considered reasonable; overburden


How does waste affect me?

• Causes physical fatigue

• Causes emotional fatigue

• Increases frustration

• Increases stress

• Causes you to blame others

• Steals your time

All leading to disengagement, lack of ownership, burnout and other manifestations


Typical wastes

• Errors in documents

• Transport of documents

• Doing unnecessary work not requested

• Waiting for the next process step

• Process of getting approvals

• Unnecessary motions

• Backlog in work queues

• Under-utilized employees

• Inappropriate systems

• Wasted utility resources

• Wasted materials


Result: Opportunities for improvement

• Breakdowns

• Workarounds

• Delays (bottlenecks)

• Missed steps

• Too many steps


Current vs. Future State

• To move from the Current State there are Changes that must be made to move to the Future or Improvement State

• The Current State Allows us to grasp the situation

• Allows us to answer: Where are we? vs. Where should we be?

• Helps us to identify root causes and identify the deliverables as they should be

• The specific changes necessary to move from Current to Future State are the deliverables


Defining the current state - SIPOC

Supplier

The group or individual providing the Inputs to the process.

Inputs

What the Supplier adds or provides to the process step to take place. (Resources required by the process)

Process

Individual step(s) listed in sequence to complete the process. (Activity that transforms inputs into outputs)

- 5 to 7

Outputs

The result of the process step being provided to the Customer.

(Delivered products of services)

Customers

Who receives the Output of the process.

(Stake-holders who place the require-

ments on the outputs)


Central line infections – Allegheny Hospital

1. Establish current condition: Chart review of 1,700 MICU and CCU patients for past year

• 5.1 infections per 1,000 line days

• 37 had contracted central line infections, some more than once

• 19 died (51%)

• Goal: ZERO infections

2. Observe the actual work in detail, over time

• 40 hours of observation

• Noted procedures followed by line placements, line maintenance (e.g., dressing changes), and communication during activities

• Noted that femoral lines took longer to dress than subclavian lines

3. Use real-time data and act on it immediately

• Reverted to using data from the lab

• If infection revealed, team went to bedside within six hours to determine the root cause.

Adapted from the Pittsburgh Way to Efficient Healthcare, N. Gruden, 2008.


SIPOC – Central line infection – Current state

Supplier

• Catheter manufacturer

• Medical Products distributer

• Hospital Materials Management Dept.

• House physician

• Nurse

Inputs

• Catheter

• Tape

• Gauze

• Wipes

• Antiseptic

• Other

Process

• Assess patient

• Insert femoral line

• Respond to infection

• Remove femoral line

• Insert subclavian line

• Administer antibiotics

Outputs

• Infection

• Sick patient gets sicker

• Well patient (eventually)

• Death

• Adrenaline

• Anxiety

• Frustration

Customers

• Patient

• Family

• Physician

• Health care team members


Value stream map: Current state

Patient

Family

Physician

Health Care

team

ED:

House

officer

Assess

patient

Insert

femoral line

Infection

develops

Bedside

team

assesses

patient

Remove

femoral line;

insert

subclavian

Administer

antibiotics

6 hours

Supplier

Customers

4 days

after line

insertion Patient

recovers

from infection

Current state

Central line insertion

Allegheny Hospital


Central line infections – Allegheny Hospital

Root-cause analysis: Lines inserted into the femoral, or groin, area are more likely to become infected despite campaign to use subclavian or jugular area.

1. Why did the patient have a femoral line?

– The line was inserted emergently at night

2. Why would a physician choose to insert a femoral line at night?

– At a teaching hospital, fellows usually end their shift at 6 pm. House officers must call a fellow in from home or insert themselves.

3. Why would house officers choose a femoral line?

– Because many house officers had not been trained yet to insert the subclavian lines, and femoral lines were safer and easier to insert until they were trained.

4. Why would a femoral line be left in for four days?

– Because the risk of infection had been understated, there was no sense of urgency to remove and insert a new line in a preferred place.

Adapted from the Pittsburgh Way to Efficient Healthcare, N. Gruden, 2008.


Value stream map: Future state

Patient

Family

House

Officer

Medical

Team

ED:

House

officer

Assess

Patient

Insert

femoral line

Remove

femoral line;

insert

preferred

line

Maintain site

12 hours

Supplier Customer

CHANGES:

• Automatic time limit on femoral

line – replaced after 12 hours

• Implemented training

RESULTS:

• ↓Wait Time - 4 days +

recovery time

• Prevents infection; ↓ sick

patients

• ↓ need to administer antibiotics

• Standardized process

OUTPUTS

• Better Care – no harm

• Healthy patient

• Happier medical/health care staff

Future state

Central line insertion

Allegheny Hospital

1,898 lines inserted, 3 infections, ZERO deaths.

>95% reduction in central-line infections in the MICU and CCU

Example


The real and imperfect world – Current state


The real and imperfect world – Future state


ED to Floor Hand Off: Current State


ED to Floor Hand Off: Future State


Registration Process: Current State


Takeaways

• Value stream mapping is scalable to small or large processes

• Value stream mapping can be used in daily work to:

– Understand current process (Create common definitions and understanding among team members)

– “Learn to see” the current process as it is, with the value (VA) and waste (NVA) in the current process

– Create improved future state process based on the current state

• A good problem definition and scope are essential before value stream mapping

• Serves as basis for determining root causes and generating improvements for an improved Future State

• Use current and future state mapping questions to guide mapping

• Goal of mapping is to develop the implementation plan


Additional resources

• Learning to See: Value Stream Mapping to Add Value and Eliminate MUDA, Mike Rother and John Shook

• Value Stream Mapping for Healthcare Made EasySep 8, 2009, Cindy Jimmerson

• The Complete Lean Enterprise: Value Stream Mapping for Office and Services, Second Edition, Beau Keyte and Drew A. Locher

• The Lean Six Sigma Pocket Toolbook: A Quick Reference Guide to 100 Tools for Improving Quality and Speed, Michael L. George and John Maxey

• Value Stream Mapping: How to Visualize Work and Align Leadership for Organizational Transformation, Karen Martin and Mike Osterling

• www.Lean.org

• www.ASQ.org

http://www.lean.org/

http://www.asq.org/


Thank you! Stephen L. Davidow, MBA-HCM, CPHQ, APR


312-464-4346 office

[email protected]

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