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7/23/2019 VSM Healthcare

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Value Stream Mapping:pp e o ea care sys ems

Krishnan Krishnai er

Dr. F. Frank Chen

Dr. Glenn Kuriger

Center for Advanced Manufacturing & Lean SystemsThe University of Texas at San Antonio , One UTSA Circle , San Antonio, Texas 78249-0670


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Center for Advanced Manufacturing & Lean Systems

Back round

Overview of Value Stream Mapping (VSM)

Methodology Results/Findings

Conclusions

Future Research

The University of Texas at San Antonio 2


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Back round: Wh lean in healthcare?

Budget Projection Expenditure Type

$4.00

$4.50

.

$2.50

$3.00

.

T

rillio

n

s

($)

0.50

$1.00

$1.50

.in

$0.00

.

2010 2011 2012 2013 2014 2015 2016 2017 2018 2019

Foundation, K.F. Trends in Health CareFoster, S.R. and K.S. Heffler. Updated and

The University of Texas at San Antonio

Costs and Spending. Kaiser Family

Foundation 2009.Extended National Health Expenditure Projections,

2010-2019. 2009 06-29-2009

3


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12% of Emergency Department (ED)

patients are admitted to hospital 7 out of 10 are seen in 4 hours

2 % leave without being seen

,

health professionals (74%)

oo e me spen w pa en s Too few nurses (69%)


Study by CDCEller, A., Rapid Assessment and Disposition: Applying LEAN in the Emergency Department. Journal for Healthcare Quality, 2009. 31(3): p. 17-22


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A simple tool to visualize the flow of value

s reams an was e

Identify value-added steps in your processes

Visualize information and material flow

improvements

Get everyone on the same

page with a common visionof the current state and


the future state of operations


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Emphasis on Time-based Performance:

Cycle TimeLead Time

etc

OtherAdd-on Indicators:Cost

Patient safety

Quality

Patient wait times


Customer satisfaction, etc


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Common VSM IconsRother and Shook (2003). Learning to See,

The Lean Enter rise Institute.

C/T=1sec

C/O=1hour

Uptime=85% IStamping4600L

Michigan

Tues.+

Thurs. FIFOmax. 20 piecesMaterial Flow

General

, . .

EPE=2weeks200 T

2400Rtee o.

Process OutsideSources

Data Box Inventory

Truck

Shipment

rs - n- rs - u

Sequence Flow

Operator

PushArrow

Finished Goodsto Customer

Supermarket

PhysicalPull/Withdrawal

SupermarketParts

Weekly

Manual Electronic

Informal Visual

OXOX

Load Leveling

Information Flow

Buffer or

n orma on ow n ormat on ow a e y oc

Changeover


Kanban Kanbangna

KanbanKanbanPost

Sequenced-PullBall

KaizenBurst


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xam ne ow can e success u y

used to:

Visualize waste

Improve quality in the health care



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healthcare and VSM

Classify the articles based on:

the methodology used,

the area of application of VSM, and



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Results/FindingsMethodology Application Metrics ReferenceVSM Hip fracture patients Door-to-theatre (DT) time, admission into trauma

beds, pre- and post-operative medical assessment

Chakrabarti, et al.

(2009)

me m uatory trage es mergency

Department)

me o pat ent arrva to rst sta contact; nurs ng

evaluation; wait times; and arrival until roomplacement time

aa e, et a .

VSM Emergency Department % of patients ranking the overall care as Very

Dickson, et al. (2009 a,

,

month, average number of patient visits per month

VSM Emergency Department Average Length of Stay, % Patients left without

being seen

Eller, A. (2009)

VSM + Lean Emer enc De artment RuralHealth Avera e Time Searchin for Su lies Avera e Sn der and McDermott

Care Hospital (99 bed)

Time of Discharge Process

(2009)

VSM Physicians Clinic

Obstetrics/Gynecology (OB), Family

Practice, and Internal Medicine

Reduce staff stress level, improve overall

performance

Lummus, et al. (2006)

VSM Medication delivery system errors Cost of human resource ($/yr) Mazur and Chen (2008)VSM Reduce wait times in the Emergency

Department

Overall Patient Satisfaction scores, Accuracy of

triage nurse to predict discharge, time to see

physician, length of stay

Ng, et al. (2010)


VSM Computerized Physician Order Entry

system

Net Present Value Kocakulah and Upson

(2005)

10


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Results/FindingsMethodology Application Metrics ReferenceVSM +Lean

tools

Histology Lab Workflow Turn around time and errors Buesa (2009)

ean

tools

rescr p on renewa an ng y

application

e uc on o process ng me ummer an accare

(2009)VSM Laboratory, Emergency Department,

Surgery department, house keeping

Patient Satisfaction, Cost Savings, Time to

prepare a room

Serrano and Slunecka

(2006)

ean

Tools

mergency epar men n ers

Medical Care Australia

a me, acu e separa ons a were

unplanned readmissions, Length of stay for

medical patients admitted as emergency cases,

Number of notification of serious medicolegal

en- ovm, e a .

.

Process Map +

Six Sigma

(LeanSigma)

Pharmaceutical Industry Cycle times of synthesis, compound analysis and

purification

Andersson, et al. (2009)

Process Map + Imaging Department Mexico Increase patient satisfaction Garcia-Porres, et al.

Kaizen +LeanSigma

(2008), Garca-Porresand Ortiz-Posadas (2009)

VSM + Lean Canadian Health care Provides Wait times, Patient Safety, Culture change and

Quality

Fine, et al. (2009)


VSM + Lean +

5S

Blood Transfusion Establishments -

France

Quality and Safety of Blood Products Bertholey, et al. (2009)

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Key Decision Points of Lean Deployment

Hospital

Who Led

the

Change?

Who Drove

Work?

How Was

Knowledge

or Expertise

Acquired?

Crisis of

Lever

First Value

Stream

Mapping First Win Objective

HDGH EVP LEA(R)N

coordinator

Training,

consultant

ED in

newspaper

Portering ED Reduce ED

wait timesUHN PMO senior

manager

PMO Hire consultant CEO's

transformation

agenda

Bullet rounds

(GIM)

ED-GIM Reduce ED

wait times

everage o

introduce lean

St.

Joseph's

Former VP,

now CEO

Manager of

access services

Consultant VP challenge ED admit and

discharge

processes

ED-GIM Improve

patient

safety

,

government

brought CEO

to see Lean at

VMMC

culture

NYGH VP Lean de lo ment Hire consultant SARS ED-GIM ED-GIM Move

leader chairedFlow Steering

Committee

outbreak andsubsequent

leadership

transformation

patientsafety and

quality

agenda

CEO = chief executive officer ED = emer enc de artment EVP = executive vice- resident FHHR = Five Hills Health Re ion GIM = eneral internal medicine


HDGH = Hotel-Dieu Grace Hospital; NYGH = North York General Hospital; PMO = project management office; SARS = severe acute respiratory syndrome; QI =

quality improvement; UHN = University Health Network; VMMC = Virginia Mason Medical Center; VP = vice-president

Fine, B. A., B. Golden, et al. (2009). "Leading Lean: A Canadian Healthcare Leader's Guide." Healthcare Quarterly 12(3): 32-41.


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VSM Visualize WasteExample of VSM in Emergency Room


Dickson, E. W., S. Singh, et al. (2009). "Application of Lean Manufacturing Techniques in the Emergency Department." The Journal of

Emergency Medicine 37(2): 177-182.


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VSM Visualize WasteExample of VSM in Emergency Room


Dickson, E. W., S. Singh, et al. (2009). "Application of Lean Manufacturing Techniques in the Emergency Department." The Journal of

Emergency Medicine 37(2): 177-182.14


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VSM Reduce Costurren a e

Example of VSM in Computerized Physician Order Entry


Kocakulah, M.C. and J. Upson, Cost analysis of computerized physician order entry using value stream analysis: a case study.

Research in Healthcare Financial Management, 2005. 10(1): p. 13(13)

15


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VSM Reduce Costu ure a e

Example of VSM in Computerized Physician Order Entry



Research in Healthcare Financial Management, 2005. 10(1): p. 13(13)16


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VSM Reduce CostExample of VSM in Computerized Physician Order Entry



Research in Healthcare Financial Management, 2005. 10(1): p. 13(13)17


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VSM Improve Quality Current SateExample of VSM in Emergency Room Houston Texas (32,000 annual visit)

The University of Texas at San AntonioEller, A., Rapid Assessment and Disposition: Applying LEAN in the Emergency Department. Journal for Healthcare Quality, 2009. 31(3): p. 17-22

18


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VSM Improve QualityExample of VSM in Emergency Room Houston Texas (32,000 annual visit)


Eller, A., Rapid Assessment and Disposition: Applying LEAN in the Emergency Department. Journal for Healthcare Quality, 2009. 31(3): p. 17-22

19


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VSM Improve QualityExample of VSM in Emergency Room Houston Texas (32,000 annual visit)

3,500

Patient Total Volume

80%

Total Diversion

1,000

1,500

2,000

2,500

,

30%

40%

50%

60%

70%

-

500

Baseline

Aug

-07

Sep

-07

Oct-07

Nov

-07

Dec

-07

Jan-08

Feb-08

Mar-08

Apr-08

May

-08

Jun-08

Jul-08

Aug

-08

Sep

-08

Oct-08

Nov

-08

Dec

-08

Jan-09

Target, 8.00%

0%

10%

ase

line

Aug

-07

Sep

-07

Oct-07

Nov

-07

Dec

-07

Jan

-08

Feb

-08

Mar-08

Apr-08

May

-08

Jun

-08

Ju

l-08

Aug

-08

Sep

-08

Oct-08

Nov

-08

Dec

-08

Jan

-09

Target, 120300

400

500

Length of Stay (Minutes)

7%8%9%

Left Without Being Seen

0

100

200

eline

g-0

7

p-0

7

t-07

v-0

7

c-0

7

n-0

8

b-0

8

r-08

r-08

y-0

8

n-0

8

l-08

g-0

8

p-0

8

t-08

v-0

8

c-0

8

n-0

9

Target,1.90%

0%1%2%3%4%5%

ine

-07

-07

-07

-07

-07

-08

-08

-08

-08

-08

-08

-08

-08

-08

-08

-08

-08

-09


Eller, A., Rapid Assessment and Disposition: Applying LEAN in the Emergency Department. Journal for Healthcare Quality, 2009. 31(3): p. 17-22

Bas

Au

Se

O No

De

Ja

Fe

M A Ma

Ju J

Au

Se

O No

De

Ja

Basel

Aug

Sep

Oct

Nov

Dec

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec

Jan

20


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Gap in Literature

Current Silo focus areas

nterna ustomer xterna ustomer

Employee Hiring Patient Flow

BillingCapital Expenses

Hospital Services Emergency careLab

Needed Holistic end to end Hospital Management VSM



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ar ous examp es were s own o

demonstrate that VSM can be used to

success u y n ea care o

Visualize wasteReduce cost

Improve quality



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Complete internal operations of hospital

VSM (employee hiring to retention) Com lete atient care and billin VSM

Establish an end-to-end VSM

management:

Internal hirin

Purchasing,

Patient care, and


Patient billing

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