time is of the essence: value stream mapping a national health service (nhs) emergency department in...
TRANSCRIPT
Time is of the Essence: Value Stream Mapping a National Health Service (NHS) Emergency Department in the South West of England
Overview
-Context-The value stream-Issues with the approach-Method-High level map-Detailed level-Operational level map and metrics-Sense-making workshop-Reflections on automation for data extraction and representation
-Software-Digital state in ED-Time point and duration
-Conclusion-Protocolisation-Variation
Context
-National Health Service (NHS) is publically funded (through the taxation system) to provide healthcare that it is free at the point of delivery and that it be based on clinical need, not ability to pay.
-Dealing with patients in EDs within the United Kingdom (UK), in keeping with all components of the urgent care system in the UK's NHS, have been under increasing pressure. Patient numbers are rising, patients are aging and becoming complex whilst there is no real rise in funding and staffing levels.
- NHS's national standard requiring 95% of patients to be admitted, discharged or transferred within four hours of arrival into acute care.
The value stream
A value stream has been described as a sequence of events needed to perform or provide a process or service (Nielson and Leppa, 2007).
- What events need to occur for a patient to be admitted or discharged (leave) ED- What events need to occur for a decision to be made about whether a patient is
admitted or discharged
VSM is the evaluation of the process or service in order to distinguish value-adding steps from wasteful ones (Jimmerson et al, 2005).
In the NHS hospital in the south west of England it was approached an improvement tool
Visualizations used to show where improvements can be made
Issues with the approach
-Value (McClean and Young, 2008)
-Differences between manufacturing and healthcare (Radnor et al, 2012)
-Isolated application (Kaplan et al, 2014)
-Repeatability
+Quantifiable way for assessing patient experience
+Charting ED processes and wait times are hugely important
Method1. Discussing the value stream with an ED doctor
2. Sample mapping occurred and modifications to map
3. Series of ED observations-30 patients-From time of arrival to the time they actually leave the ED bed-Informed consent (excluded children, people in resus and those with impaired cognitive ability)-Un-structured conversations and context of the department were recorded (on paper). -Key information was also recorded (route into hospital, expectation etc)
4. Sense-making workshop
High level Value Stream Map
Individual case example – patient 17
-48 male, queried kidney infection.
-Arrived by ambulance (confusion as to who called the ambulance, himself or GP)
-30 contact points
-19 periods of waiting (range 1min to 25min)
-Fragmented process (e.g. nurse leaves to get medication, equipment etc and is called away to deal with other patients)
-Patients goes to x-ray (admitting decision has been made), no bed to return to in ED, waits in corridor until bed on ward found.
-4 different doctors saw the patient.
-340 minutes (the patient breached)
Workshop
-Medical and non-medical attendees (2 doctors, 1 matron, 2 hospital managers, a receptionist, an I.T manager, 1 improvement managers).
-Wait times clearly identified (although needed to quickly know wait time difference). Discussions ensued as to why this might be case and improvements to this
-Bias of the attendees
-The patient centred viewpoint was challenged
-The VSM was an ideal
-Many, many exceptions and variations
Reflections for data extraction and representation
-Existing VSM software
-The digital ED
-Time points and time duration
-Staged process:Human mappingAutomatic retrieval of medical data to populate mappingSample of staff contact with patientsFilling in the gapsCollaborative discussion process to produce the final map
Conclusion
-Protocolisation and Variation
-Request-Arrival
0 4 8 12 16 20 24
Direct
GP
Other hospital
Other
Unknown
0 4 8 12 16 20 24
Ambulance
Car/Bike
Other
Thank you
The authors would wish to thank that patients and medical staff from the NHS Emergency Department the research is based upon. This work was supported by a grant from the Open Innovation Fund.
Sian Joel-Edgar: [email protected]@kurtesysian