value stream mapping
TRANSCRIPT
Value Stream Mapping and
the Journey of the Northern
ACS Patient
Ronnalea Hamman, MSc.
Lean Leader, imPROVE
Provincial Health Services Authority
Barbara Hennessy RN, MN, CCN(C)
Regional Coordinator, Cardiac and Cerebrovascular Services
Northern Health
Julie Dhaliwal, BA CYC (cert)
Manager, Medical Services, University Hospital of Northern BC
Northern Health
© Provincial Health Services Authority
Objectives
1. Understand the process of Value Stream Mapping • Theory
• Tool
• Application in an Agency Setting
2. Review the process of a provincial Value Stream Map • Home to Home Journey of the Northern Health Patient through tertiary
cardiac services.
3. Review initial improvements from a provincial Value
Stream. • Discharge Preparation of the Northern Cardiac Patient
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Value Stream Map
A value stream map is a management tool for a cross-
functional team to look at value streams rather than at
discrete operations.
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Benefits
• Patient/Family-centric
• Data-driven
• Forces participants to discuss how they see the value stream
• Drives consensus as to how all perspectives are represented along
the value stream
• It is an alignment tool that allows people to understand and improve
processes
• Provides a framework to see, learn and act together
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Value Stream Management
Value Stream
Management
Daily Management
Unit Unit Unit Unit Unit
Unit Unit Unit Unit Unit
Unit Unit Unit Unit
Unit Unit
Strategy Deployment
Director Director
Program Program Program Program Program
Exec
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How does it differ from process
mapping?
• Flowcharting techniques to understand a process.
• Multiple perspectives define the process boxes (not from
patient POV).
• Does not identify value added components.
Pick up mail
Open & date
stamp
Triage
- Type 1 contact
- Detox
- Children
- Symptomatic
X-ray
Report?
Request abnormal
X-ray report
All documents
received
Yes
No
Hold
unmatched
Enter
Radiology
report
No
Yes
X-ray or CD?
X-ray
Check CD
- name
- report
CD
Onsite or
Offsite
Pull previous
record
Request offsite
record
Enter into iPHIS
Check iPHIS
for previous
record
X-ray or CD?
Radiologist
Review
X-ray
Review by Dr.
Elwood
Yes
No
Yes
Normal /
Abnormal
File X-ray
939 & Normal
report
939
939 & abnormal
X-ray
Normal
Abnormal
CD
Batch CDs, read in
Reading room
Normal /
AbnornalDictation
Check “No
Evidence” Box
Normal
Abnormal
Separate Field
Ops & Vancouver
X-rays
File
copy
return
Normal /
Abnormal
939 & Tape
Transcribe into
iPHIS
Enter “No
Evidence” into
iPHIS
Normal
Abnormal
Dictated 939sSend Referral in
iPHIS
Generate
Validation Sheet
Enter treatment
required into iPHIS
Outbox to
Pharmacy
Enter end date into
iPHIS
Send pick & yellow
copies to Health
Units
Outstanding
referrals iPHIS
Previous Files?
Request
Discharge
Summary
Proof narratives
Discard extra
copies
Create small
envelop &
withdraw card
File 939
Validate
printed
report
Upd?Update
iPHIS
report
Print narratives
Yes
Print upd
report
Separate
- health units
-physicians
Pre-addressed,
pre-stamped
envelop Mail
Withdraw envelop
CD
Match CD &
939
To VGH for
Radiology
Radiologist
review
Date stamp
upon arrival
Enter
Radiology
report into
iPHIS
To Dr.
Elwood for
review
More
dictations?
File CDFile 939Initial
comments
No
Yes
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Current State Value Stream
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Future State
Vision of a future state
- Set Value Stream Goals
- Reduction of Time = increased throughput, increased
efficiencies,
- Reduction of Time by elimination or reduction of waste.
- Reduction of Defects
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Bridge from Current to Future
• Kaizen Ideas
• Focus: • Value
• Flow
• Work
• Set your improvement agenda
• Manage your improvement agenda and set a clear line
of site from your improvement to your goals.
• Establish and manage an action plan.
• Revisit the value stream (after each improvement and
annually)
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Value Streams in Practice
Common Issues
• Team Capacity (3 day exercise)
• Data (current and ongoing monitoring)
• Long process value streams (i.e. mental health)
• Sponsorship (ownership)
• Alignment of VSM goals with department/agency/health
authority/MoH goals
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Home to Home Journey of the NH Patient
through Tertiary Cardiac Services
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• 95% of these patients travel to Vancouver for diagnosis and
treatment.
• There is a delay in transferring these patients to get access to a
higher level of care.
• There is often a delay in transferring these patients back home.
• Care must be coordinated across three health authorities.
• The improvements in this value stream potentially have a broader
application to all rural remote cardiac patients.
• Support provided by Shared Care & Specialist Services Committees’ Health Authority Redesign Funding
Why this patient group?
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Building Current State
Customer:
• Northern health urgent ACS patient.
Customer Requirements:
• Timely access to a higher level of care.
• No delay in transfer.
• Coordinated communication and transfer of information.
• Timely return to home community.
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Building Current State
Add high level process steps:
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Building Current State
Interviews
Observations HEARTis Data
69 Interviews in 5 health
authorities and BCEHS
Triage Coordinators
Daily Triage Call
Utilization Meetings
Northern Health Processes
• Time to Referral Acceptance
• Time to Transfer
# Cath Referrals/Site
# PCI/Surgery/Site
• Add Data and Metrics:
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Bridge to Future State
Limitations and Challenges
• Scoping and Focus not clear enough to fully define
future state and set clear value stream goals.
• Limited authority to make changes within health
authorities.
• Tight timeline: November to March
• Large group with varied experience with value stream
mapping process.
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Bridge to Future State
1 2 3 1 2 3 1 2 3
Northern Health Northern Health Cardiac Site BEHS
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Improvement Agenda
Change in Value Stream Purpose
1. Standardize the referral form. In order to: •Decrease the time between “time of referral” and “acceptance date”; •Eliminate overproduction by triage coordinators (multiple phone calls); •Decrease the % of incomplete referrals
2. Standardize the patient journey information and education.
In order to: •Decrease the time between “date of intervention” and “time of discharge”; •Decrease the # of patients “unprepared” for discharge.
3. Standardize the referral process with the Patient Transfer Network .
In order to: •Decrease the time between “time of referral” and “time of transfer”; •Reduce rework and overproduction by the triage coordinators;
© Provincial Health Services Authority
• Planes, trains and snowmobiles…understanding how our Province can work
better together
• January 2014 a provincial project team was identified
• Team met weekly by teleconference to get to know one another and to
identify the focus of the during the Improvement Workshop - April 29-May 1
Patient Discharge Planning Workshop
April 29 – May 1
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Patient Discharge Planning Workshop
April 29 – May 1
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Outcomes
Primary Outcome:
Reduce the time between intervention to discharge from 8.5 days
to 6 days.
Process Outcome:
Patients arrive “prepared” at a cardiac site.
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Problem Statement 1
Length of stay in cardiac site increases due to amount of
patient preparation required for discharge at the cardiac
site for a safe return home.
Hypothesis: A “prepared” patient upon entering the cardiac
site will have a shorter length of stay.
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Solutions
1. Standardized Northern Health Checklist and Patient
Preparation Package.
2. Standardized Northern Health Cardiac Patient Transfer
Plan that involves patient, family and provider to
prepare for transfer to cardiac site.
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Pilot Trial – NH Cardiac Patient Transfer
• Standard packages - pilot project from July to September
2014: – Prince George
– Vanderhoof
– Terrace
– Dawson Creek
• All 5 Cardiac Sites participated in pilot project and
collected tracking form when patient arrives. – Patients are prepared when arriving to cardiac site.
• Continuing to monitor primary outcome with CSBC: – Reduction of time between intervention and discharge.
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Project Team - What did we learn?
• Given the opportunity – you can improve provincial processes collaboratively.
• Greater understanding of the size, complexity and challenges faced by
Northern Health.
• Greater communication about expectations between health authorities across
patient journey.
• Clarity of how to develop and improve provincial forms (who owns them and
who is accountable?)
• Understanding of the work that was happening in other health authorities on
our shared patient populations.
• Difficulty in finding standard measurements and language across province.
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Working better Together
• Listen to understand verses Listen to respond
• What were the ingredients that contributed to our team working successfully
as a high functioning team in such a short period of time…
• The team listened to understand one another and the various barriers and
frustrations that were both unique to each HA and collectively as a larger
health care system
• The individual triage co coordinators shared the lengths they went to get
people home who had arrived in Vancouver with no clothes, shoes, ID or
money
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Understanding the Geography
• What contributed to understanding the barriers that each Health Authority
was experiencing was the time we gathered around the NH map
• Stories, experiences and understanding the NH Connections bus routes
provided context to why patients had difficulty in getting home and why we
as a group had to come up with a way to have patients return safely home
with the travelling required in the North…planes, trains and snowmobiles!
• NH is 2/3 of the province we have less population than the lower mainland
but our geography is far reaching with barriers to access in the remote
areas such as Fort Ware and other remote communities.
• Its actually easier to get to Puerto Vallarta than it is to get a patient home
from Vancouver to Terrace
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Next Steps
• Pilot project results were presented to the NH Cardiac and Cerebrovascular
Services Working Group in October 2014 o request a next step for working
towards an NH Regional process beyond the Pilot sites.
• Make this package standard for all of Northern Health
© Provincial Health Services Authority
Value Stream Mapping as a
Provincial Tool
• The ‘home to home’ patient value stream allows a
system focus to anchor problem solving.
• Creating time for frontline staff to design and trial
processes that cross health authorities is proving
efficient and beneficial to “get the work done.”
• Standardization and collection of data and processes
across health authorities is a challenge.
• Sponsorship at each health authority is crucial for
sustainment of improvements at this level.
© Provincial Health Services Authority
References
Making Hospitals Work
Taylor, Maker, Mitchell and Jones
2011
Perfecting Patient Journeys
Worth, Shuker, et al.
2013