Value Stream Mapping

Aims for session Introduce the concept of Value Stream Mapping Consider identification of value and waste Welcome Intro self These are the aims for today Going to start the ball rolling by thinking about how a patient moves through the healthcare

Patient Flow Process 1. Understand the total process of care delivery – patient pathway Diagnostic tests Diagnostic tests are just one part of a patients journey Anyone undertaken process mapping before? (just to check whether people are familiar with this kind of drawing) The object of undertaking any kind of mapping is to identify all the current steps in a patient pathway and to think about whether all of these steps are necessary. Process mapping, along with the Glenday Sieve, are essential building blocks in order to carrying out Value-Stream mapping.

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. 5-10 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 20-30 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 10-15 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. This is an example from a urology service in Scotland who identified that all these steps happen to a patient coming to hospital for investigation of frank haematuria. Basically, patients are admitted to the ward, taken to radiology for a bladder ultrasound, taken back to the ward, consented, taken to a minor ops theatre where they have a cystoscopy. Then the patients is taken back to the ward and discharged. Total of 22 steps.

The flow of patients along the diagnostic pathway has been improved. 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 The team redesigned the pathway so that the number of steps is really reduced. Now a patient goes straight to ultrasound, has their ultrasound investigations then goes straight to outpatients where they have a cystoscopy. The flow of patients along the diagnostic pathway has been improved. So, process mapping identifies the steps in the pathway. Value stream mapping is just a step further in this process.

What is Value? Hairdresser activity Aim with value stream mapping is to identify where the value lies in the patient’s pathway. What is value? Well, lets start off with a quick exercise to get you thinking about the concept. (Now play hairdresser activity Get everyone to write down on a scrap of paper how much they are prepared to pay for a haircut. If you have a big group, get people to work in groups. If you have 10 or less, you can do it as one group. Ask everyone to fold their piece of paper and put it in the middle of the table. Get the groups to unfold the pieces of paper and pick out the highest and lowest amounts. Ask the room what the highest amount was - anyone got more than £30? Etc. Ask if anyone who paid over £30 is willing to explain what is important to them about going to the hairdressers- eg trusting same hairdresser, getting a glass of wine, head massage etc. repeat question with lowest amount paid. Emphasise that outcome is the same i.e. haircut – but that what people value within that process is incredibly varied. ) Value is different for different people. (incidentally, this exercise works best with mixed group – no men present then just ask how much their husbands/boyfriends pay for haircut and why!)

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 What is value in terms of a patient pathway then? Activity that transforms the patient and moves then to the next outcome – ask what do people understand by this statement? Ask for examples of value in their patient pathways, have discussion about value vs non-value. Explain about necessary but non-value added activity eg taking consent. Something that patients care about - An example from Bolton: Discharge planning for patients with fractured neck of femur. As everyone knows, good discharge planning starts at point of admission, so patients arriving in A&E with fnof were always asked about their discharge. But when they began to re-examine the discharge process, they asked patients about the current process and they discovered that for many frail, elderly people coming to A&E with fnof, discharge was the last thing they wanted to talk about. It was in fact quite distressing for them to have to think about going home – some peoples’ circumstances would be completely changed from independence to dependency. So they now talk to relatives and social services about discharge at time of patient’s admission, but not to patient.

Define Value in Your Service Who are your patients? What is the ‘value’ your patient wants? How is the value added? When you describe value use the customers' words What about your service? Think about it all from the patient’s perspective, what is value for the patient? When you describe value, use the customers words. Get group to think about value for their patients, discuss examples and language to describe the examples. ACTIVITY Lets look at a mock up patient journey for a patient coming to hospital for an upper endoscopy. This is a made up journey with some times added in for each step and some time added in for waiting between each step. (drawn out by hand to emphasise no need for fancy computer skills to do this kind of exercise). Can you get into groups of 2 – 3 In group, please answer the questions on the map How many steps do you think add value to the patient’s journey? Which ones are they? Work out how long the whole journey takes Add up the time for each value adding step – how much time adds value to the patient? You’ve got 15 mins to do this. Any questions? (After exercise, go round groups and get answers.) Discuss the differences in the identification of value amongst the groups – refer back to value being an activity that transforms the patient and moves them along to the next outcome. Point out the huge amount of time in the journey in comparison to the short time of the actual clinical procedure. Would streamlining the actual clinical procedure add much value to the journey? (answer is no compared to all the other time you can save – demonstrates to people that this isn’t about questioning clinical practice). Has anyone asked the patient what they perceive as adding value? Critical thing to do. What about steps that don’t add value? Fall into 2 categories – those that don’t directly add value to the patient journey but are necessary eg checking patient details prior to a procedure Those that add no value and are a waste – these can be removed.

Stage 2: Waste Leads us to next question – what activities are waste?

Opportunities to Remove Waste: Waiting – delays for things to happen Mistakes – things going wrong Uncoordinated activity – things out of sequence Stock – too much or too little Transportation – moving info / things Motion – unnecessary human movement Inappropriate processing – unnecessary work Quick run through this slide – each one is detailed after this.

Activity: Watch the video, identify and discuss the different sorts of waste shown Now going to watch a short DVD which illustrates all these types of waste. Don’t get hung up on what type of waste you see – the categories just help you to get thinking. See if you can identify all the waste in the DVD. (handout sheet with gaps for people to write down what they see) I will play it again afterwards with the wastes identified so you will get another chance as it goes quite fast. Play DVD Discuss what comes up Hand out sheets with waste identified on them then play second version of DVD which has numbers on it corresponding to wastes id’d on sheet.

Value Stream Mapping the patient journey Define start and end points Supporting Organisational Structure: Sponsor Team Lead and Clinical Lead, Team Members So, summary for practical application. If you’re going to do VSM – decided which patient journey, define start and end points of the journey. You will need support from your organisation to take this forward – this should be there for diagnostics and planned care.

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 Get a member of staff from each part of the patient journey Make sure you still consult all those who don’t get involved Get patient/carer views – can be gathered beforehand, some can be gathered during the mapping Have a clinical lead and someone responsible for leading the mapping exercise.

What to Measure Agree beforehand improvements in - Journey time for patients - Time spent on non value adding work - Throughput (productivity) - Morale / staff satisfaction Think about what you are going to measure so you can demonstrate improvement when you make changes.

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 Go and walk the journey – really important! Take notes as you go – make sure staff know what you are doing, it’s about systems and processes, not people. Photos are powerful story tellers.

Measure the distance patients / staff have to travel Some photos from Bolton of staff doing this kind of thing.

Track both the patient and information flows

Take the cameras on the walkabout, you’ll never convey this verbally! Tea room or records room?

What do patients actually experience and say about the process? Speak to patients as you go round – how have they found it?

Ask staff at each step for their views on ‘show stoppers’, frustrations and positives Same for staff – what drives them potty?

Build up the Value Stream Map Walk the Area Collect real time data Have plenty of space Don’t rely on hearsay Take photos Don’t skip process steps Don’t assume This is impressive! Don’t all end up like this but isn’t it a powerful picture? Define the Boundaries of the VSA

Understanding your Current State Map: Add value Remove waste Make sure you really understand what is going on before you make chances to processes, this is sometimes called your current state map.

Quantifying Value Added Activity and Time: Value Adding Add in those times – they help clarify where the big problems are Non Value Adding

Highlight opportunities to reduce waste on the map Waiting Mistakes Uncoordinated activity Stock Transportation Motion Inappropriate processing Use the map to highlight where the waste is

Ideal State What process would the team design to align the value adding steps in the right sequence, complete the process as fast as possible, right first time, and reduce or eliminate waste? What would the patient, staff and information steps look like? Only then move on to thinking about what would be the ideal pathway? Get the whole team to design the new way