improving patient flow value stream management

Value Stream Management

What is a value stream?

All the activities – both value added and non-value added – performed to treat patients from initial hospital arrival through discharge.

2© 2008 by HealthCare Quality Improvement Solutions, LLC

ED Triage

ED Registration

ED Care

ED

Transportation

Inpatient

Admission

Inpatient

Care

Discharge Home

Pharmacy

Housekeeping

Transportation


Patient Flow Value Streams

OutpatientEmergency Department

Outpatient Surgery

Outpatient Clinics

Inpatient

Medical

Surgical

Cardiothoracic

Orthopedic

Obstetrics

Pediatrics


Value Stream Management Philosophy

Entails viewing patient flow as a system of processes;

Not as isolated, individual processes.

Involves improving the system;

Not just improving individual components or departments.

Focuses on customer requirements:

Delivering services in a manner that maximizes customer value.

Process improvement is a daily, continuous, responsibility.


ED Triage

ED Registration

ED Care

ED

Transportation

Inpatient

Admission

Inpatient

Care

Discharge Home

Pharmacy

Housekeeping

Transportation

Waste

Waste

Waste

Waste


Value Added Activity

An activity is value added when:A physical transformation occurs;

The customer is aware of it and willing to pay for it;

It is performed correctly the first time.

Healthcare value added activity:The patient receives provider care that favorably

transforms their health status; The provider care is not attributed to treating a preventable

adverse event.

The patient is aware of it and willing to pay for it;

It is performed correctly the first time.


Non-Value Added Activity

Any activity that is not value added

Healthcare non-value added activity:

The patient’s health status is not being transformed favorably ;

The patient is not aware of it and or not willing to pay for it;

Is not performed correctly the first time.

Considered waste


Waste

There are eight forms of waste:

1. Waiting

2. Motion

3. Transportation

4. Overproduction

5. Defects

6. Overprocessing

7. Underutilized People

8. Inventory


Value Stream Management Components

Process Steps Select Value Stream

Construct Current State Value Stream Map

Develop Future State Value Stream Map

Develop Value Stream Improvement Plan

Value Stream Manager

Visual Control

Real-time Problem Solving & Process Improvement


Value Stream Mapping (VSM)

What is a Value Stream Map?

A graphical representation of :

The process steps;

The flow of patients, hospital services and information;

The value added activity provided;

From the beginning to the end of the value stream.


Current State Value Stream Map


Value Stream Mapping Purpose

It’s not about developing the map

It’s about understanding the process, service and information flow

AND WHERE WASTE IS IMPEDING PATIENT FLOW



What is Current State?

A value stream map that represents the process steps, flow of patients , services and information as they exist today.


Current State Value Stream Mapping Steps

1. Select a value stream

2. Map the process flow

3. Determine the process metrics and collect data

4. Map the information flow

5. Add the timeline


Current State VSM Step 1:

Selecting a Value Stream

Identify the value streams from the perspective of the patient:

Determine the process steps they experience

Ascertain the services they receive

A value stream is comprised of similar process steps and services delivered



Selecting a Value Stream

ED Surgery Pharmacy Lab Radiology Rehab OT

Medical X X X X X X X

Surgical X X X X X X X

OB X X X



Map The Process Flow

Go observe and follow the process

Draw the process with pad and pencil from left to right

Initially the Current State map is a high level map

Document process categories such as Triage, Waiting Room, Admission, Discharge, etc.

As an initial guide use process categories that represent stages in the process where the patient receives services

The initial goal is to document the overall flow of the process from the beginning to end of the value stream

More detail can be collected later 19



Map The Process Flow

Pay particular attention to where in the process the patient is waiting

This indicates an obstruction to patient flow

WaitingWaiting



Add Process Metrics

Determine the relevant process metrics for each process step and implement data collection

Any metrics that are relevant can be used

Averages and proportions are usually recorded

Collect current data

From a patient flow perspective two measurements should always be collected:

Processing time – the value creating time

The time spent delivering care that favorably transforms the patient’s health status

Cycle time – the total time necessary to execute a task

These times can be recorded as averages21



Map Information Flow

Electronic Information FlowFax Transmission

Manual Information Flow

Telephone Walk22



Map Information Flow

Information flow refers to the trigger that signals work to be performed

When mapping information flow it is insightful to ask:

How does each service know what to do for the patient and when to do it?

For example:

How does housekeeping know when to clean a room after a patient has been discharged?

How does the bed control coordinator know when housekeeping has completed preparing the room for the next patient?

How and when does the patient know when to start making arrangements for transportation home?



Add Timeline



Add Timeline

Value Added Time

Non-Value Added Time

Value Added Time



Add Timeline

Add all the Processing Time (value added activity time)

Compute the Lead Time as the average time elapsed from patient arrival to discharge


Future State Value Stream Map

The purpose of value stream mapping is to identify waste and reduce it by implementation of a Future State value stream that maximizes customer value

Strive to link all processes – from patient arrival to discharge – in a smooth flow without interruptions (waste)

Focuses on meeting customer needs

There is not a single, correct Future State

Is always evolving into a new Future State with less waste


Future State Value Stream Mapping Steps

1. Identify the customers and their needs

2. Evaluate the Current State Map

3. Establish the time frame to implement improvements

4. Map the Future State

a. Establish goals for metrics

b. Determine process improvements for implementation


Future State VSM Step 1:

Identify Customers and Their Needs

The patient and their family are the ultimate external customers

Internal customers needs have to met in order to meet patient and family needs

Who receives the output of process steps?

What is required of the output for the customer to execute their processes without waste?

Timing

Format

Frequency



Evaluate Current State Map

The following set of questions can be used as a guide to evaluating the Current State Map:Where are the largest amounts of waste?

Which process steps create waste?

Why are they being performed?

What knowledge and skills are truly required to perform the process steps

Where can continuous flow processing be implemented? Where can people and tasks be placed together so that the

process flows without delay?

Where are the most troublesome problems occurring?




The following set of questions can be used as a guide to evaluating the Current State Map:How much time elapses from decision to admit to

placement of patient in the inpatient bed?

How much time elapses from discharge order to patient vacating inpatient bed?

Are scheduled surgical procedures unevenly distributed throughout the week?

Where is the workload unbalanced?

What process improvements are necessary to achieve the Future State ?



Establish Time Frame To Improvement

Prior to mapping the Future State establish the time frame to achieve the Future State

This time frame is an important decision:

The longer the time frame, the more improvements that can be undertaken

Consider keeping the first Future State time frame within 6 months

Strive to keep the time frame within 12 months



Map The Future State: Set Goals

FS20

FS30 FS 15/15



Map The Future State: Determine Improvements


16.0% VA

Future State Implementation

Usually it is not possible to implement the entire Future State Value Stream at once.

When viewed as a process of building a series of inter-connected process flows for a value stream:

The Future State Value Stream can be organized into relatively homogenous segments that represent areas of flow.

These segments can then be the focus of process improvement which are implemented in a systematic manner.


Future State Implementation Segments

DischargeED

Bed Management


Future State Implementation Segments

In what order should the segments be implemented?

If the discharge process is a segment, implement this segment firstUnimpeded patient flow through the hospital is

dependent upon the availability of inpatient beds

A streamlined discharge process facilitates smooth patient flow

Use your judgment on which of the other segments will have the greatest impact on patient flow

If resources permit, multiple segments can be improved simultaneously


Value Stream Improvement Plan

Segment Goal Improvements Jan Feb Mar Apr May Jun Jul

Discharge

Reduce the discharge cycle time on day of discharge to 15 minutes

•Begin discharge planning within 12 hours of patient admission

•Dedicated discharge coordinator•Discharge task list•Schedule date and time of discharge at least 24 hours in advance

EDReduce the ED waiting room time to 20 minutes

•Implement a Fast Track

Bed Management

Reduce the cycle time of bed assignment to 10 minutes

•Implement an automated bed management system

•Dedicated bed management coordinator•Demand prediction


Value Stream Improvement Review

Segment CurrentPerformance vs.

Goal

Project Progress IdentifiedProblems

ProposedSolutions

Action Taken

43

On Schedule

At Risk

Behind Schedule

Meeting

Not Meeting


Conduct at minimum a quarterly review



Visual Control





An individual with primary responsibility for understanding, monitoring and continuously improving the value stream

If the value stream is not continuously managed, waste will creep into the stream and obstruct patient flow



Visual Control

A graphical report of the status of process performance depicting actual vs. expected performance

0

10

20

30

40

50

60

Bed Assignment Time Inpatient Bed PlacementTime

Discharge Planning Unscheduled Discharge

Actual Expected 46© 2008 by HealthCare Quality Improvement Solutions, LLC


Visual Control

Should be made visible to everyone involved in the value stream

Updated at least twice daily

Reviewed by the value stream manager at least as frequently as they are updated




When actual performance does not meet the expected performance the value stream manager initiates action to:

Determine the root cause(s) of the performance gap;

Identify and implement process improvements to eliminate the root cause(s).

Action is initiated on the same day as the gap in performance is discovered.


Value Stream Management Advantages

Provides a view from a systems perspective:

Identifies where and how much waste is in the patient flow system

Depicts the interconnection between process steps and information flow

Provides a basis for a process improvement implementation plan from a systems perspective

Avoids suboptimal departmental approaches to improving patient flow

Promotes continuous process improvement


Value Stream Management Advantages

Ideal method for meeting The Joint Commission’s patient flow standard:Pertains to identifying and mitigating impediments to

efficient patient flow throughout the hospital.

Hospitals are required to identify and correct patient flow issues organization-wide.

They must identify where in the organization problems exist and take action to prevent barriers to patient flow.

New hospital-specific tracer on patient flow:Beginning in January 2008 surveyors will conduct a new

system tracer to identify problems with patient flow.


Waste There are eight forms of waste:

1. Waiting: No transformation is taking place.

2. Motion: Activity that does not add value.

a. Examples: physical therapy traveling to the patient’s room to find the patient is in X-ray

3. Overproduction: Producing more process output that the downstream process can handle.

a. Examples: same day surgery patients schedule for afternoon surgery arriving at 6:00 am

4. Transportation: No transformation is taking place

5. Defects: No favorable transformation is taking place

a. Examples: preventable errors, preventable infections, data entry errors,

6. Overprocessing: Activity that , from the customer’s perspective, does not add value

a. Examples Producing reports that are not used for decision making or regulatory compliance.

7. Underutilized People: Not harnessing the knowledge and experience of the work force.

8. Inventory: Excess inventory hides process problems.

a. Example, a surgical tray that has incorrect instruments is replaced with one of the many in inventory. The surgical procedure continues, but no root cause analysis and process improvement is undertaken to eliminate incorrect instrument trays.


improving patient flow value stream management

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