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

2. A3 Roadmap for Performance Improvement at Penn Medicine

3. 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!

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

5. 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

6. 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

7. 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)

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

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

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

11. 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.

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

13. 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.