Value Stream Mapping

Aims for session Introduce the concept of Value Stream Mapping Consider identification of value and waste

Patient Flow Process 1.Understand the total process of care delivery – patient pathway Diagnostic tests

COMPASS WAITING LIST DIARY - CASE NOTES PULLED 3 WEEKS IN ADVANCE THEATRE LIST PRINTED L4 HOURS BEFORE - ALLOCATE BEDS THEATRE LIST SAME DAY FROM JANET. TRY 24 HOURS BEFORE REPORTS ADMISSION AT FRONT RECEPTION. DETAILS CHECKED PATIENT ARRIVES RECEPTION DAY SURGERY TAKE PATIENT TO WARD AND TO BED AREA WITH NOTES. ADVICE TO UNDRESS/GOWN ON. TELL NURSING STAFF. RECEPTIONIST FINDS OUT IF THEY TO GO TO RADIOLOGY AND WHAT TIME 1 WEEK IN ADVANCE ADMIT PATIENT VIA CARE PLAN MIN. LOOK AT MOD CHECK IF TO GO FOR ULTRASOUND - IF TO GO WALK THEM ROUND TO X-RAY WAITING ROOM. 1ST KUB - KID URETER BLADDER X- RAY. PATIENT FULL BLADDER. 2ND ULTRASOUND MINS IN RADIOLOGY. PATIENT X-RAY AND ULTRASOUND REPORT BACK - BACK TO BED. DOCTOR SPEAKS TO PATIENTS - CONSENT SIGNED THEATRE STAFF ATTEND DAY SURGERY - DATA SHEET GIVEN TO DAY SURGERY STAFF. THEATRE STAFF TAKE PATIENT STRAIGHT INTO MINOR OP THEATRE. TEST MIN ALLOCATION DR CANNING 3 1/2 HOUR SESSION VERBAL REPORT TO PATIENT AND INFORMATION. TAKEN BACK TO DAY SURGERY MAKE SURE PATIENT OK - ? DRINK OR EAT. DISCHARGE INSTRUCTIONS IF DOCTOR NEEDS TO SEE- APPOINTMENT MADE STRAIGHT AWAY - GIVEN TO PATIENT FOLLOW/REVIEW AT OUTPATIENTS VOL APPOINTMENT NEXT DAY. INDICATED ON CARE PATHWAY IF RAH DR WILL INDICATE ON TAPE - SECRETARY WILL ARRANGE.

PATIENT ATTENDS RADIOLOGY DEPARTMENT FOR ULTRASOUND AFTER SCAN PATIENT REPORTS TO RECEPTION DESK IN OUTPATIENTS DEPARTMENT NURSE ESCORTS PATIENT TO CHANGING ROOM WITHIN THE EXAMINATION ROOM. PATIENT CHANGES INTO GOWN AND JOINS DOCTOR IN THE EXAM ROOM DOCTOR EXPLAINS EXAMINATION AND CONSENTS PATIENT. PROCEDURE CARRIED OUT. RESULT GIVEN IF APPROPRIATE AND FOLLOW UP INFORMATION GIVEN PATIENT CHANGES BACK INTO CLOTHES AND LEAVES THE DEPARTMENT. REPORT TYPED BY UROLOGY SECRETARY AT RAH

Patient attends Health Care Professional Clinical assessment Patient receives radiology appointment Patient attends for radiology appointment Patient receives clinic appointment Patient attends clinic for results Treatment starts High Level Process Map

The paper chase Patient attends Health Care Professional Patient receives radiology appointment Request typed by secretary Q Request signed Q Request put in post Request picked up by mail and goes to mail room Mail sorted Mail delivered Request sorted at reception Request pended Request issued for Authorisation Q Appointment booked within radiology Q Appointment letter printed Appointment to mail out Appointment picked up by mail and goes to mail room Appointment goes out in external mail Appointment delivered

The paper chase Patient attends for radiology appointment Patient receives radiology appointment Patient checks date and time of appointment Rings up radiology to change appointment Secretary rebooks appointment, sends letters etc…. Appointment filed in pile for date and modality Day of appointment request pulled List generated Request goes to reception to await patient Receptionist receives patient Patient booked in Request to room for radiographer Patient called to waiting area for room Radiographer calls patient, checks demographics, explains examination, performs examination Result reporting explained to patient (Patient leaves) Examination confirmed Request to office

The paper chase Request prioritised for reporting Q Allocated to radiologist Q Request to radiologist desk Q Report generated Request to typist at end of session Q Report typed Report printed (end of day) Report to mail etc etc……

The paper chase Report delivered to referrer Matched with notes Q Read by referrer To secretary for appointment Q OPD Appointment made, letters printed Appointment sent out mail etc etc…. Q Patient receives clinic appointment

The paper chase Patient attends clinic for results Treatment starts Patient arrives at reception Booked into clinic Q Called to see referrer Q Sees referrer Gets diagnosis Needs operation Placed on waiting list Q

The patient journey The paper chase The queues 5 steps in the patient journey 2 steps had clinical impact 35 process steps from referral to diagnosis 13 queues Referral to diagnosis

What is value? The activity is done right first time The activity transforms the patient and moves them towards the next defined outcome The activity is something that the patient cares about

Have a look at the process map Which steps add value for the patient? How many are there? Which steps are necessary but don’t add value? How many are there? How long does the whole process take? How much time adds value for the patient? Activity: Identifying Value

Who to Involve Small team 8-12 people, mixed disciplines Represent people at all the steps you will look at ‘Fresh eyes’ Patients/ carers Nominate a team and clinical lead

What to Measure Agree beforehand improvements in - Journey time for patients - Time spent on non value adding work - Throughput (productivity) - Morale / staff satisfaction

Observe and Gather Data Walk the patient journey - see the actual work place Follow and make notes about each component –What happens to the patient –What staff are doing –What the information / communication flow is Take photos of wastes

Measure the distance patients / staff have to travel

Track both the patient and information flows

Take the cameras on the walkabout, you’ll never convey this verbally!

What do patients actually experience and say about the process?

Ask staff at each step for their views on ‘show stoppers’, frustrations and positives

Take photos Have plenty of space Don’t skip process steps Walk the Area Define the Boundaries of the VSA Don’t assume Don’t rely on hearsay Collect real time data Build up the Value Stream Map

Understanding your Current State Map: Add value Remove waste

Coffee

Lean Tools Overview PDSA Glenday Sieve Workplace Organisation Rapid Improvement Events

PDSA Cycle The improvement guide Langley et al 1996

What change can we make that will result in an improvement ? Act What changes are to be made? Next cycle? Plan Objective Questions and predictions (why) Plan to carry out the cycle (who, what, where, when) Plan for data collection Study Complete the analysis of the data Compare data to predictions Summarize what was learned Do Carry out the plan Document problems and unexpected observations Begin analysis of the data

PDSA Worksheet

GP Access – Practice Level Improvements with PDSAs PDSAs to inform Patients about new appointment system PDSA on ‘Pre- Bookable’ and ‘On the day’ appointments PDSA to Introduce Telephone Consultations PDSAs PDSAs to ensure Phone Appts are provided at most appropriate time of day

Diabetes (blood pressure) Improvements with PDSAs PDSAs to improve shared diabetes information with Secondary Care PDSA to contact all Patients who have not had a BP check in the last year PDSAs PDSAs to improve current patient recall system PDSAs to Validate Diabetes Register

Glenday Sieve Heard of the Pareto (80/20 principle)? Ladies – think of your wardrobe…..

Glenday Seive Actual volume of activity Range of possible activities Green50%6% 6% of possible activities accounts for 50% of actual work done Process Map the “Greens” and make them flow Create time for the difficult cases

Glenday Sieve Orthopaedics – Hips and knees General Surgery – hernias and lap cholecystectomy District Nurse – wound care, medication

MRI Team, NHS Tayside 220 codes for appointments MRI RIE - 63% of MRI throughput from 2.7% of - 63% of MRI throughput from 2.7% of procedure codes procedure codes (i.e. 6 codes) Group patients by the process they go through (rather than clinical condition)

Surgery example 213 cases over 8 months at Clatterbridge. –52% of theatre throughput from 4.2% of procedures Group patients by the process they go through (rather than clinical condition) Focus initially on smart process for the critical few [4.2%]

Workplace organisation

6S – A Technique to Promote workplace organisation Set and ensure adherence to standards Embed the spirit of continuous improvement Improve Quality, Cost Delivery, Safety and Morale

Sort Get rid of clutter Set in order Organise the work area Shine Clean the work area Standardise Doing the same thing every time Sustain Maintain through empowerment, commitment and discipline 6S Safety Having a safe working environment “Having a place for everything, and everything in its place” Workplace reorganisation

Characteristics of a 6S Workplace Only have what is needed Clean enough to “eat off the floor” Everything is organised for the team Obvious to everyone when something is out of order Anything that is required can be retrieved within 30 seconds –No surprise shortages of supplies – visual management of stock levels Responsibilities defined and everyone taking their responsibilities Performance visible to all Improvement ideas being routinely generated and implemented Adapted from Ross International, RIE Training material

6S Vision Taken from Ross International, RIE Training material Adapted from Ross International, RIE Training material

Money is tied up in inventory gathering dust because of a supply chain process which is not aligned with the patient pathway value stream In amongst this is back up emergency equipment Clutter- time wasted trying to find things Stracathro -Theatre Store Room

Benefits gained from 6S Tray Room before… …and after

Rapid Improvement Events (RIEs) – an overview

What are RIEs? Common Lean tool to introduce Lean principles and thinking in organisations RIEs select critical business areas and make real improvements for patients and staff Process-focussed and brings together the team in a highly structured way Results-focussed – establishing the root cause of problems, and achieving measurable improvements Process which is action-orientated and data driven

RIE Programme Timetable RIE - 6wksRIE - 4wksRIE – 2wksRIE WeekRIE + 2wksRIE + 4wks Review Progress RIE + 6wks RIE + 12wks or by agreement Remove Blockages Measure Improvements Final Presentation (Project Closure) Share Success Local Ownership & Sustainability Team Leader to Produce: Report Action Plan Support Run RIE Pre- Meeting Run Getting to know you session Run RIE Awareness visits Management Commitment Meeting Critical success factors Set Scope & Goals Pick Team Leader Pick RIE Team Book Venue Advise Managers about their attendance Gather data on current performance RIE Area Identified Rapid Improvement Event Adapted from Ross International, RIE Training material

The Agenda for an RIE Setting the scene –Training on the Lean principles –Preparing for visits Observing the current process –Map process to see waste & blockages to flow –Identifying the root causes of problems Designing and sharing the new processes –Long day !!!!! Looking for acceptance –Sharing, listening, modifying Reporting what has been done Follow-through planning Day 1 Day 2 Day 3 Day 4 Day 5

One Team’s experience NHS Tayside Urology RIE