Understanding the Current Condition Process Maps (Flow charts) Making Observations 8 Wastes

A3 Roadmap for Performance Improvement at Penn Medicine

What Adds Value? Value Added: It changes the form, fit or function It is done right the first time The customer would pay for it – more of it is better Non-Value Added (Waste): Any activity that does not meet the value criteria above: Unavoidable waste- necessary in the process due to regulatory or supporting value. These activities should be simplified, reduced, or combined whenever possible. Avoidable waste - activity that is not value or enabling should be completely eliminated!

The 8 Wastes D O W N T I M E Defects Over Production Waiting kNowledge wasted - confusion Transportation Inventory Motion Excess Processing

Eight Wastes: Healthcare Examples Defects Overproduction Waiting Time kNowledge Example: Making more IV bags than are needed. Preparing 4 units of blood “just in case” for the OR Example: Lab tests are performed twice because of errors An x-ray is read incorrectly Wrong site surgery Example: Delayed Cases waiting for instruments Example: A resident’s bright idea is “lost”, or the resident is confused about how to do a task Extra Processing Unnecessary Transportation Wasted Motion Inventory Example: Nurse records respiratory rate in multiple places in the chart Multiple copies of the same pathology report – in EPIC, in Medview, in SCM, on paper Example: Patient gets wheeled back and forth between the floor and radiology for multiple tests instead of taking one trip for all of them Example: Medicines held over the shelf-life because of excess ordering Example: Pharmacy tech walks back and forth looking in multiple places for a particular med 5

Process Mapping Purpose Key Principles Visually document a process Understand the existing process and problems Quickly identify improvement opportunities within the process Helps communicate inside and outside the organization Key Principles Documentation is not substitute for observation A flowchart is a means not an end Your scope defines the boundaries of your map Involve a cross-representation of those who work in the process to create the map Process maps are meant to be used as working documents

Which Process Map is For You? Description When to Use High Level Process Map View from 30,000 Feet Depicts major elements and their interactions 5-8 steps total Early in the project to identify boundaries and scope Detailed Process Map A detailed version of the High Level Process Map Fills in the all the steps within the high level steps To see a detailed process in a simple view Helps to identify and follow decision points SIPOC Process snapshot that captures information that is critical to a project To come to agreement on project boundaries and scope To verify that process inputs match the outputs of the process Quality issue VSM (Value Stream Map) Captures all key flows (of work, information, materials) in a process and important process metrics Requires a current and future state to be done To identify and quantify waste Helps visualize the improvement opportunities Flow or time issue Swim Lane Flowchart Emphasizes the “who” in “who does what” To study handoffs between people and/or work groups in a process Especially useful with administrative (service) processes Spaghetti Map Depicts the physical flow of work or material in a process To improve the physical layout of a workspace (unit, office, floor)

High Level Process Map View from 30,000 feet Used early in the project to identify boundaries and scope 5 – 8 steps total

Tool: Spaghetti Diagramming Reveals waste: Motion Transport Over-processing kNowledge

Low Fidelity Spaghetti Diagram Glass wear storage Glass wear storage Lab Tech’s Workstation Lab Machine Room

Versions of a Process Map Any Process Has At Least Three Versions What You Think It is . . . Verify What It Actually is . . . What You Would Like it to Be . . . The struggle is that this is where everyone wants to start.

How to Go and See NEVER accept opinion ALWAYS walk the process ALWAYS walk the process multiple times

Guidelines for Observation Agree on a starting point for observation, for example patient enters a department. Make sure you introduce yourself to the customer and inform them of what it is you are doing and why. Try to talk to patients and/or staff when they are waiting, to avoid prolonging the time it takes to complete an operation. You may need to observe staff AND products/patients separately. Product/patient observation - stay with the product/patient and record what the product/patient is going through. If the product/patient waits, you wait. Staff observation – stay with your staff member continuously. Not too much detail – just enough. Always do multiple observation sessions. Observers should summarize lessons learned and present them to the whole team. Discuss the results. It is essential that time be spent on the floor observing the process and identifying wastes. Here are some guidelines for doing observations.