Value Stream Mapping Basics James McCarthy, Sept 2016 A Value Stream Map (VSM) helps visually display a process from the perspective of the customer. Much like a process flow map, it identifies the steps in a process. Process Map of a patient visit Patient checks in Patient is roomed Physician exam performed Patient discharged with Rx Rx filled at pharmacy Patient picks up Rx Process maps often branch and have decision points. Process Map of a patient visit Patient checks in Family med or peds Patient roomed, red hall Chart placed on MD desk MD arrives and examines Is Rx Needed? Patient discharged with no Rx Family no Peds Yes Patient d/c with Rx Rx filled at pharm Patient picks up Rx Peds MD paged Patient roomed, green hall Chart given to HUC Process flows can become very complex and look like schematic drawings of various pathways within a processes. Others might break out roles into sections, called a swim lane diagram.

While they start out similar, a VSM is different than a process flow map. First, a VSM should be from the viewpoint of the customer or the patient, while a process flow may be from any viewpoint. A VSM is attempting to show what steps are done that add value for the customer, or where are thing happening that contribute to the product or the visit end point.   Second, while process flows can become extremely complex with branches and decisions, a VSM should try to limit, as much as possible, a process to the high level linear steps that are most common in a process. A process flow may break out a clinic visit to include decisions needed to order lab tests or radiology images. A VSM might lump those together as a diagnostic test.   An External Supplier  VSM’s usually contain further data about each step in the process, utilizing symbols. For instance, steps may include some of these symbols: The amount of inventory at this step, or in healthcare often the number of patients at this step 2 Number of operators or staff at this step 1 The patient visit process flow converted to a VSM might look like this: Local Pharmacy Check in Rooming MD Exam Discharge Obtain meds 2 3 5 2 6 2 2 1 8 2 There are 2 staff checking in patients. There are 3 patients at this step. There are 2 nurses rooming patients. There are 5 patients at this step. There are 2 Doctors examining patients. There are 6 patients at this step. There are 2 nurses discharging patients. There are 2 patients at this step. There Is 1 pharmacist filling medications. There are 8 patients at this step.

When measuring time, there are three terms used that are important: The most important difference between a process flow and a VSM is that a VSM measures the times involved in the steps. Local Pharmacy Check in 2 3 Rooming 5 MD Exam 6 Discharge Obtain meds 1 8 3:12 9:35 7:52 0:15 3:58 7:05 4:30 3:10 45:48 Total non Value Added Time 60:33 Total Value Added Time 24:12 Total time 84:45 Value ratio 29% Takt time 4.5 minutes Time is indicated on a line underneath the steps, and in a details box. When measuring time, there are three terms used that are important: Cycle Time Lead Time Takt Time   Cycle time is the time it takes to actually do the work involved in one step. It is the time when something is being done for the customer, the patient, or the product. For example, how long does it actually take to check a patient in, or how long does it take to room a patient. Cycle time does not include waste or wait time. This is considered value added time Lead time is the time between the cycle time steps. It is the time leading up to work actually being done. It includes waste and wait time. This is considered non value added time.

Takt time = 450 minutes/100 patients Takt time is the normal beat of the demand, or incoming work, if it were consistent. This is a calculated number. Takt time = Time Available/Demand. For this VSM, the clinic is open 8:00 am-4:30 pm, but closed 12:00 pm-1:00 pm for lunch. The available time is 7.5 hours, or 450 minutes. The demand is 100 patients on average per day. Takt time = 450 minutes/100 patients Takt time =4.5 minutes per patient Theoretically, a new patient arrives every 4.5 minutes. In reality patient never arrive consistently, but the 4.5 number gives an idea of how quickly the work comes in. It helps estimate at glance that if cycle times are longer then the takt times then multiple staff will be needed. For instance, in the VSM below, the average cycle time for a nurse to room a patient is 9 minutes 35 seconds. That means that if one nurse started rooming a patient, a new patient would arrive just before she was half complete. By the time she finished rooming the first patient, two new patients would be waiting to be roomed. The VSM gives us a good general overview, but we can utilize takt time with other tools to help calculate exactly the correct staff or equipment needed to meet demand. Local Pharmacy Check in 2 3 Rooming 5 MD Exam 6 Discharge Obtain meds 1 8 3:12 9:35 7:52 0:15 3:58 7:05 4:30 3:10 45:48 Total non Value Added Time 60:33 Total Value Added Time 24:12 Total time 84:45 Value ratio 29% Takt time 4.5 minutes Total Lead times Cycle times = value added time Total Cycle times Lead times = non value added time

In order to create a VSM it is critical to go to the work area and observe the process as it happens. Before that, there are two questions that the team should discuss and settle before investigation begins. First, who is the customer in this process? This guides the viewpoint. It might be obvious, in this case the customer is the patient, but depending on the reason for investigating it might be another entity, say, perhaps an insurance company, a regulatory agency, etc. Second, in order to gather accurate data on time, the team must determine what the steps are they are going to measure, and which add value. Thus, normally a process flow is started first to determine the detailed steps. The question is, what adds value for the customer and what is waste. This can be a complicated question and it is advisable to seek customer input. As an example, components of rooming a patient, like checking a weight, may be viewed by care providers as value added, but for patients presenting with complaints of congestion may believe this is a waste of their time. A non healthcare example in a restaurant, customers at a fast food joint would consider time spent cooking, preparing, and plating food a waste, while at a fine dining restaurant the extra time transforming raw ingredients into a well presented, perfectly cooked, delicious meal is all added value. (When looking to the future, consider segregating the customer needs and providing multiple options to fit the needs. As with restaurants, hotels, cars, and most products, consumers have multiple choices to fit what they value. Healthcare systems usually have options for some processes, like access to a physician can be through a primary care visit with an appointment, it can be at an urgent care center without an appointment but with less consistency or choice in the staff seen, a phone call without the need to travel, or an executive health program where the physician may actually come to see the patient but with a steep price tag. In other situations, if customers were to be made aware of the reasons for specific waits they may see value in some of them. For instance, time spent waiting for a CT tech to calibrate the CT machine might add value by ensuring the correct images are obtained and that the device wont malfunction or cause injury. Waiting for a culture to grow is value added, waiting for the doctor to call with the results is not. Once the team has agreed on who the customer is, which steps to measure, and which add value and which do not, then the team should go observe the work happening as much as possible. In this case of a clinic visit it would be most advantageous to go to the clinic with a stop watch, witness the flow, count the operators/staff and the patients/inventory at each steps, and time the process.

In some cases it may not be possible to see the work happening, especially for electronic processes, but even in these situations it is usually possible to see parts of the work. If electronic data is available, it is acceptable to use, but be cautious and verify the electronic data accurately reflects reality. A time stamp in an EMR may be accurate, arbitrary, or anywhere in-between. As with a process flow map, we can add call outs with where we observed or perceive issues. In this VSM it was observed that the staff rooming patients did not have thermometers in in the rooms and needed to walk to find them with each visit. The staff discharging patients had to sort too many papers on the printer to find the correct After Visit Summaries, and the lead time to pick up a medication far exceeded the cycle time. Local Pharmacy Check in 2 3 Rooming 5 MD Exam 6 Discharge Obtain meds 1 8 3:12 9:35 7:52 0:15 3:58 7:05 4:30 3:10 45:48 Total non Value Added Time 60:33 Total Value Added Time 24:12 Total time 84:45 Value ratio 29% Takt time 4.5 minutes No thermometers in rooms Many papers to sort Long wait time Remember that lead time is often an indication of other problems. With this VSM more investigation is needed to understand why it takes so long to get a prescription. It could be there is a lot of work from outside the clinic, renewals, mail orders that are not visible on this VSM. Perhaps while the average cycle time to fill a prescription is 3:58, there are some significant outliers that make that a difficult target to meet consistently. In some cases the call outs can become improvement project in and of themselves, especially if they are complex, as in the pharmacy lead time. Others may be simple, easy, quick wins, like when investigation uncovers that there is only one thermometer and the purchase of a second will improve the time. As you plan for the future state, be sure to create a new VSM to show the future after improvements. When possible, test new solutions to determine new timings.