starting from scratch - university of waterloo · starting from scratch “every . ... value stream...

Starting from Scratch

“Every block of stone has a statue inside it and it is the task of the sculptor to

discover it.”~ Michelangelo

What is a Value Stream?

Value Stream ◦ all the activities and actions (value added and

non-value added, information and material) that are required to bring a customer through the essential requirements needed

Value Stream (labour, equipment, supplies, support services, facilities)

What is a Value Stream?

Sell Make Purch Design Customers Suppliers

Value Stream

TIME is the Primary Focus

Product and/or Service Flow

Information must flow quickly in all directions

The Value Stream is the set of activities performed to transform the products and services into what the customer requires.

Whenever there is a service or a product for a customer there is a

value stream.

Lean Thinking Principles

Specify Value

Identify the Value Stream

Make It Flow

At the Pull of the Patient

In Pursuit of Perfection

Specify value from the standpoint of the student and the organization

Identify the value stream to teach the student and remove wasted steps

Enable the student and information to flow smoothly and quickly through every step

Match capacity with demand so work is done in line with the pull of the student

While pursuing perfection through continuous improvement of the value stream

Acute & Transitional Care Critical Care & Medical Cardiology, Medical Units, Integrated Stroke Unit / Rehab, Complex Care

Episodic & Outpatient Care Mental Health, Emergency & Urgent Care, Outpatient Clinics

Planned Care Maternal Child & Surgical

Care Support Diagnostic Imaging, Pharmacy, Laboratory, Infection Control & Medical Device Reprocessing

Finance & Supply Support

Accounts Payable/Accounts Receivable & General Finance, Contracts, Home

Oxygen, Purchasing

Stores, Bio-Med, Environmental Services and Nutrition Services

Knowledge & Information Support

Decision Support & Information Technology

Patient Registration & Information, Flow, Health Information Services

Facilities and Maintenance

People Development

Human Resources, Payroll, Volunteers

Occupational Health & Safety, Float Pool, & Scheduling, Organizational

Development

Patient Experience & Quality Outcomes

Patient Experience

Risk, Quality & Accreditation

Strategy Deployment (Continuous Improvement)

Why a Value Stream Approach? Taking a value stream perspective means

working on the big picture, not just the individual processes, and improving the whole, not just the parts (it breaks silos)

Identifying, understanding and improving value stream in our organization – not as isolated tasks but as a flow of interconnected, interdependent activities and processes

Goal Engage staff and students to: ◦ Redesign work to eliminate waste ◦ Create standard layouts ◦ Make the work progress and problems visible ◦ Remove ambiguities, errors and risk

Engage teams to redesign the flow of

work through a value stream ◦ To simplify steps, eliminate delays, level the

workload, reduce errors, save staff time

A3 Thinking

Go See or Gemba “Gemba” means real or actual place Lean practitioners often use this Japanese word to

refer to the workplace, the place in the office or factory where value is created

But, it also means reality or even truth

To look at conditions empirically, you have to leave your office, step away from

your monitor and your data, and observe what is really going on.

Go & See Definition

To observe a situation, problem or improvement opportunity by going to the actual place

Purpose To observe and understand the actual process

Methods Walk along the path of the value stream starting at the end Stand and observe

Objectives To identify the current state Not to fix- Learning only!

At least Three Versions

What You Think It Is... What You Would Like It To Be ...

What It Actually Is...

The Developing Reality…

What is Current State? A pictorial representation of what is

Currently happening in a process

“How can you create the future if you don’t know where you’ve come from ?”

Ways to Identify Current State…

Video all steps

Spaghetti Diagram

Process Map

Before After

Spaghetti Diagram

Circle Diagram (Information Flow)

Source: North York General Hospital. North York, ON.

Information flow for placement to Long Term Care

Process Map

What is a Value Stream Map? Visual representation of the flow of work and

information that links a service or product to a customer

Simple Tool, and Hand Drawn Picture of your process using symbols Shows VA and NVA time Used to identify WASTE normally not seen Highlights for team where to focus CI Goal is to shrink the Value Stream by reducing

time

Why Focus on Time ? Time is the currency of Lean By reducing time, we eliminate waste We gain responsiveness Time is measured in terms of how many

minutes (hopefully), hours or days (realistically) people or information wait

Process Time & Delay Time

Areas of a Value Stream Map

1. The customer 2. The supplier 3. The processes 4. Information Flow 5. Process data or metrics 6. Timeline & Summary

Electronic Information Flow

ABC Department

In Box (queue)

Conversation Information Flow

Iterations or Rework

Worker Data Box

Current State Mapping Icons

XYZ Corporation

Delay

Reminder Notice

Departments or Individuals Providing Information

Outside Sources (customer, supplier)

Technology Used

Work flow

Process

Box

IN

St. Luke’s Emergency Department Treat and Release – Current State

Waiting Room

Radiology

Lab

0-2 hr.

Primary Complaint

35%

Log In

P/T =1 min. D/T = 0 %C&A =100%

Triage

P/T = 3-5 min. D/T = 5-10 min. %C&A = 99%

Register

P/T = 5 min. D/T = 5-20 min. %C&A = 50%

Examine (RN)

P/T = 5-10 min. D/T = 5-10 min. %C&A = 75%

Examine (MD)

P/T = 5-15 min. D/T = 10-60 min. %C&A = 60%

Enter Orders

P/T = 5-10 min. D/T = 10 min. %C&A = 98%

Treat & Release

P/T = 10-35 min. D/T = 20 min. %C&A = 80%

Patient

Patient

Tx Plan

0-2 hr.

Orders

Results

Status?

EMR LabSys RadSys, EMR EMR, LabSys

LabSys RadSys, EMR

LabSys RadSys

5 min.

35 min. 7.5 min. 12.5 min.

1 min.

60 min.

7.5 min. 7.5 min.

100%

4 min. 10 min.

99% 50% 75% 98%

7.5 min.

P/T

D/T

%C&A

% Complete & Accurate = 17%

Value Stream Summary Metrics

Process Time =57.5 Minutes

Lead Time = 270 Minutes

60%

10 min.

22.5 min.

80%

20 min. 60 min.

Results Orders

University Example

University

OUAC

Degree to Learn

Register OUAC

P/T =. D/T = 0 %C&A =100%

Select School of

choice

P/T = D/T = %C&A = 99%

Register for OSAP

P/T = D/T = %C&A = 5

Register for classes

P/T = D/T = %C&A =

Plan Residence

P/T = D/T = %C&A =

Move In on Moving Day

P/T = D/T = %C&A =

Orientation

P/T = D/T = %C&A = %

Student

Student

Learning Plan

Roommate

100% 99% % % %

P/T

D/T

%C&A

% Complete & Accurate = %

Value Stream Summary Metrics

Process Time = Minutes

Lead Time = Minutes

%

Meal Plan

Let’s Try… Working with your colleagues, create a value stream map for your next big vacation • Start with the customer and supplier symbols • Then add your process boxes • Add the times you think it will take for process

and delay

Standardized Work

Flow No Waiting

•Takt Time

•Continuous Flow •Pull System

•Quick Changeover

Engage Everyone

in a

Patient – Focused Philosophy

Quality No Harm

•Andon

•Problem Solving •Root Cause

•Error Proofing

People & Teamwork

Waste Reduction

Continuous Improvement Kaizen

Visual Management 5 S - Work Place Organization

5%

40%55%

Non Value Added but Necessary:

Any work carried out, which is necessary under current conditions but not something the customer would willing pay for. Student statistics, application files

Non Value Added:

Activities that the customer would not want to pay for if they knew they were happening. Searching for equipment supplies, waiting for exam results

CUSTOMERS FOCUS ON WHAT IS OF VALUE TO THEM!

Value Added:

Activities that the customer would be willing to pay for. Teaching, planning, registering

The Three Divisions of Work

Maximize this segment

Minimize

Eliminate

The Eight Wastes

Waiting Overproduction Rework Motion Processing Inventory Transportation Not utilizing the Skills of Employees

St. Luke’s Emergency Department Treat and Release – Current State

Step 1 & 2

Waiting Room

Radiology

Lab

0-2 hr.

Primary Complaint

35%

Log In

P/T =1 min. D/T = 0 %C&A =100%

Triage

P/T = 3-5 min. D/T = 5-10 min. %C&A = 99%

Register

P/T = 5 min. D/T = 5-20 min. %C&A = 50%

Examine (RN)

P/T = 5-10 min. D/T = 5-10 min. %C&A = 75%

Examine (MD)

P/T = 5-15 min. D/T = 10-60 min. %C&A = 60%

Enter Orders

P/T = 5-10 min. D/T = 10 min. %C&A = 98%

Treat & Release

P/T = 10-35 min. D/T = 20 min. %C&A = 80%

Patient

Patient

Tx Plan

0-2 hr.

Results

Status?

EMR LabSys RadSys, EMR EMR, LabSys

LabSys RadSys, EMR

LabSys RadSys

5 min.

35 min. 7.5 min. 12.5 min.

1 min.

60 min.

7.5 min. 7.5 min.

100%

4 min. 10 min.

99% 50% 75% 98%

7.5 min.

P/T

D/T

%C&A

% Complete & Accurate = 17%

Value Stream Summary Metrics

Process Time = 57.5 Minutes

Lead Time = 270 Minutes

60%

10 min.

22.5 min.

80%

20 min. 60 min.

Results Orders

Treat

Requirements: • Patient demographics • Chief complaint • C&A EMR input

Requirements: •C&A Diagnosis •Consult L/T 1 hour max •Adherent to standards of care

Requirements: •LOS = 2 hr. max •Disposition •C&A Dx Summary •C&A Billing •Pt. education •Plan of care

Gather Information

Examine

Orders

St. Luke’s Emergency Department Treat and Release – Current State

Step 3 & 4- Standardized Work and Quality

Waiting Room

Radiology

Lab

0-2 hr.

Primary Complaint

35%

Log In

P/T =1 min. D/T = 0 %C&A =100%

Triage

P/T = 3-5 min. D/T = 5-10 min. %C&A = 99%

Register

P/T = 5 min. D/T = 5-20 min. %C&A = 50%

Examine (RN)

P/T = 5-10 min. D/T = 5-10 min. %C&A = 75%

Examine (MD)

P/T = 5-15 min. D/T = 10-60 min. %C&A = 60%

Enter Orders

P/T = 5-10 min. D/T = 10 min. %C&A = 98%

Treat & Release

P/T = 10-35 min. D/T = 20 min. %C&A = 80%

Patient

Patient

Tx Plan

0-2 hr.

Results

Status?

EMR LabSys RadSys, EMR EMR, LabSys

LabSys RadSys, EMR

LabSys RadSys

5 min.

35 min. 7.5 min. 12.5 min.

1 min.

60 min.

7.5 min. 7.5 min.

100%

4 min. 10 min.

99% 50% 75% 98%

7.5 min.

P/T

D/T

%C&A

% Complete & Accurate = 17%

Value Stream Summary Metrics

Process Time = 57.5 Minutes

Lead Time = 270 Minutes

60%

10 min.

22.5 min.

80%

20 min. 60 min.

Results Orders

Treat

Requirements: • Patient demographics • Chief complaint • C&A EMR input

Requirements: •C&A Diagnosis •Consult L/T 1 hour max •Adherent to standards of care

Requirements: •LOS = 2 hr. max •Disposition •C&A Dx Summary •C&A Billing •Pt. education •Plan of care

Gather Information

Examine

Orders

Combine processes

Triage assesses acuity & mini registration

Develop SLA with Lad and Radiology

Create mini team to sort

Register patients in exam rooms

Develop Standardized registration

Develop standardized discharge porcedure

Examine (RN)

Examine (MD)

LabSys RadSys, EMR EMR, LabSys

Triage & Mini

Register

Register in exam room

Treat & Release

LabSys RadSys, EMR

Enter Orders

LabSys RadSys

Primary Complaint

Patient

Patient

Radiology

Lab

% Complete & Accurate = 44%

Value Stream Summary Metrics

Process Time = 49Minutes

Lead Time = 120 Minutes

St. Luke’s Emergency Department Treat and Release – Future State

Standard Protocols Standard

Protocols

SLA w/ lab & radiology

Standard Discharge protocol

5 min. 4 min 7.5 min. 7.5 min.

100%

10 min.

75% 85% 98%

P/T

D/T

%C&A 75%

15min.

95%

10 min. 60 min. 5 min

Create MD/ RN

protocols to start orders and treatment

Triage nurse assesses acuity

& mini Registers

Standardize registration format to conduct while patient waits

for MD

Develop sort in triage and create

separate team for Treat and Release

Register patients in exam rooms with computers

on wheels

Develop standardized discharge protocols

Develop SLA with Lab

And Radiology

Example from a Surgery

•Run trials, experiment

•Measure results •Create Visual Management •Problem Solve

• Compare performance to goal

• Capture learning

• Brainstorm Ideas

• Future state map

• Goal and action plans

• Socialization

• Standardize what works well

• Identify systemic problems

• Identify barriers • Establish next gap

Act Plan

Do Study G

rasp the

Situation

•Problem Statement •Lean Value proposition •Go & See •Current-state map

PDSA Scientific PDSA Clinical PDSA Lean PDSA

1. Define question, gather information and observe.

1. Assessment of patient’s condition, leading to a diagnosis and plan of care.

1. Grasp the situation or problem, investigate cause, select countermeasure.

2. Form hypothesis. 2. Treatment plan. 2. Plan for implementing and testing.

3. Perform experiment and collect results.

3. Treatment is the experiment.

3. Do

4. Analyze results. 4. Follow up with patient to ensure treatment is working or not.

4. Check or Study

5. Interpret results, draw conclusions that serve as basis for new hyposthesis.

5. Additional action taken if needed.

5. Act

Issues and Action Log

Ways to Socialize your Progress

•Go & See •Huddles •Visual Story Board

This Can Be Fun!

Angela Schrum Brant Community Healthcare System Strategy Deployment 200 Terrace Hill Street Brantford, ON N3R 1G9 Ph: 519.751.5544 ext. 2393

Karla Stonham Brant Community Healthcare System Strategy Deployment 200 Terrace Hill Street Brantford, ON N3R 1G9 Ph: 519.751.5544 ext. 2393