C8: Stream Mapping: Making Improvements That Add Value

Transcription

1 C8: Stream Mapping: Making Improvements That Add Value February 16, 2011 Roger Chaufournier This presenter has nothing to disclose.

2 Session Objectives At the end of this session you will be able to: Describe the concept of a value stream to your stakeholders. Analyze a work flow in order to identify waste. Be able to quantify the business case for a value stream in your organization.

3 Agenda Understanding Value Value Exercise Value Stream & Process Maps Identifying Waste Waste Exercise Leading a Value Stream Exercise Back Home

4 Why is this topic so important? The lack of time and resources is a major barrier to sustainability of any improvement work The inability to link improvements to the business case of the organization decreases will and commitment Value stream mapping and application of Lean are leverage points for your business case

5 The Theory and Evidence Base Theories behind these changes relate to lean thinking Lean Principles derive from the Toyota Production System Designed by Taiichi Ohno; made famous by Womack, Jones and Roos The Machine that Ruled the World

6 Principles of Lean Focus on Value-From the Customer s perspective Understand the Value Stream Seek Perfection Optimize Flow Design systems to Pull demand

7 What are your experiences with Lean? For many of you, raise your hand if this is your first introduction to Lean and Value Stream Mapping? For those with experience in Lean, Process Mapping and Value Stream Mapping please share some of your experiences. Word of caution: with all tools and methods there are strong forces driving execution failure; perseverance and mastery of the concepts lead to success!

8 What is value? Value is what is important to the customer Value is viewed through the eyes of the patient

9 Value Exercise As small groups share your experiences on a topic below and identify what the elements of value that were most important to you relative to the: Best hotel stay or meal you ever experienced Best purchase of a product you ever experienced (e.g. car, electronics, etc.) Best experienced with the health care system as a patient for you or a family member

10 What is waste? Everything that does not bring value to the patient

11 7 Forms of Waste and Examples Overproduction---Producing more than needed or producing faster than needed (exam rooms not in use; a provider whose patient is a no-show) Waiting---Time when a person is idle (everywhere!) Transportation---Any movement of material or information not essential for the process (chart handoffs) Processing---Operations that in reality do nothing (the patient providing information to multiple people) Inventory---Anything more than immediate needs (supplies that are brought to an exam room and not used) Motion---Motion of man or machine that is unnecessary (patient walking to the lab for blood draw) Defects---Anything requiring correction, rework or inspection (billing errors; inadequate lab sample)

12 Waste From a Value-Stream Perspective Output Problems Producing the wrong thing Producing defective product Over-producing Producing less than needed Producing too late Variations in output rate & quality Spiky demand External inspection Flow Problems Waiting for material, information, decisions Duplicating effort Rework & correction Over-processing Work interruptions Frequent & uncoordinated handoffs Unbalanced workload Incomplete information Month end push No standard work

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15 VALUE STREAM MAPPING: THE PROCESS MAP

16 Process Mapping A pictorial flow chart of the process Identifies the value stream for the customers Identifies waste in the system Creates a common understanding of work flow on the care team

17 What s a Work Process? A work process is made up of steps, tasks or activities and has a beginning and an end Key concepts: Input the materials, equipment, information, people, money, or environmental conditions needed to carry out the process Output the product or service that is created by the process; that which is handed off to the customer 17

18 Mapping Icons Process Box DB IN Customer Supplier Technology used In Box (Queue) Wait Time P/T W/T FTQ Data Box Conversation Information Flow Weekly Schedule Electronic Information Flow Material (paper) Movement Iterations or rework Step Worker Decision Connector

19 Source: Iowa State

20 Post-it Notes Patient walks in and introduces himself. Staff asks patient to sign log Step # 1 Time: 30 seconds Who: Registration Clerk Jones Value/NVA: NVA

21 Value Analysis using the Brown Paper Mapping approach Shows the Big Picture Describes a process as it works today; an as-is model High touch, low-tech Identifies strengths and opportunities Captures the complexity and disconnects of key operational issues Identifies outside areas involved in the process Use exam table paper or brown wrapping paper

22 How do we get anything done? Process Inspect Wait Administrative Move

23 Instrument Processor Physical Flow (one set assembly) Before After Window Instrument Hanging Racks Window Instrument Hanging Racks Supply Cart Conveyor Belt Instrument Cabinets Conveyor Belt Empty Racks Racks for Incomplete Sets Tool hanging racks Filled Racks - Waiting for assembly 1. conveyer to rack 10ft Filled Racks - Waiting for assembly Work Station Sterilizers Micro-Instruments Station Work Station Sterilizers 2. Rack to work station 52ft Rack waiting for sterilization 7. Cart to sterilizer 33ft Supervisor Station printer Instrument Cabinets Work Station Work Station Work Station Work Station Pegboard Pegboard Work Station 6. WS to cart 25ft Work Station Blue Wrap 3. WS to printer roundtrip 94ft 4. WS to tool cabinet roundtrip - 80ft Blue Wrap Work Station Work Station 5. WS to peg board roundtrip 72ft Peel Pack Station

24 Montefiore Bronx East Center Pediatric Appointment Booking Flow New Patient Calls (1/wk/MD) Switchboard Established Patient Calls (Most) PCP Receptionist (4) # Admin. - Q & A - Page Pedi MA - Assist patient Hold Busy N.A. Answer Appt. req. recept Note: - No triage on phone - Occas. triage walk in + - Book it w/pcp - Overflow MD if walk in when avail min. -- hours or lost Bounce to others when PCP recept. fall Q & A Sick? Not sure Mesg. To MD MD calls patient Q & A Check insur. & confirm on 2 systems new patients longer - Next avail. w/pcp + - Book it - Add on sooner - Occas. Msg to MD or 30" - hrs. Advise Appt. Emerg. - ED Note: Always see pts. 24 Admin. to resolve - non PCP - 1st available

25 Insurance Claim Processing Customer/ Supplier Insurance Co. mail Policy Holder s Family Process Box Process Data Box Inbox Queue Receiving: Open & Array Docs Technology Used Work Priority FIFO Compile FIFO FIFO Calculate FIFO Folder Verify Amount & with Claim Address Docs finan manual Print, Stuff & Mail Check P/T = P/T = P/T = P/T = P/T = L/T = L/T = L/T = L/T = L/T = # inputs = %C&A = % rejects = % rework = Reliability = Reliability = # ops = Reliability = # ops = % errors = System Metric 7 Days 7 Days 7 Days 7 Days 2 Min 5 Min 10 Min 1 Min 1 Min 28 Days 19 Min

26 Suppliers: Physician Offices Central Scheduling 400 procedures/day 250 phone calls 50 faxes 9 operators Current State Map Hospital Procedure Scheduling P/T = min. (average: 50 min.) W/T = 1-43 days (average: 22 D) Percent complete & accurate = 26% Scrap = 20 % Payer Customers Radiology Endoscopy Cardiovascular Physical Med. DM education Hand Rx. Pain mgt. IV Rx Procedure short stay Surgery Cardiac rehab Lab tests Register Activate account Non-Centralized Scheduling 150 procedures/day 43 (part time) operators Central scheduling receive inquiry Enter data: Demographic Procedure Insurance Procedure Clarificatio n 180/day Check procedure availability & resolve schedule conflicts Schedule procedure Payer authorization Documentation, Print & sort audit reports Reschedule, cancel procedure 140/day 9 P/T 4 min W/T 10 min %C&A 80% 5 P/T 2-4 Min W/T 0-3 D % C&A 80% 9 P/T 4-10 Min W/T 1-2 hr %C&A 100% 9 P/T 3-10 Min W/T 0-5 D. %C&A 90% 9 P/T 2 Min W/T 1-2 hr %C&A 80% 9 P/T 1-10 Min W/T 0-5 D. %C&A 80% 12 P/T 10 Min W/T 1-30 D %C&A 80% 9 P/T 4-20 Min W/T 0-6 hr %C&A 90%

27 Value Stream Exercise As small groups use the value stream map case study and identify which steps are value added and which are not Try to quantify how much time and cost you might eliminate from this case study

28 PATIENT VISIT CYCLE TIME SAMPLE DATA COLLECTION SHEET DATE APPT WITH COMMENTS Example DAY STEPS IN VISIT TIME TIME Value ELAPSED Added Step Check in 9 am Non-Value Added Step To waiting room 9: To exam room 9: Physician enters room 9: Physician leaves room 9: To Check out 10: Patient leaves 10:07 Total Cycle Time 67 minutes 37 minutes 30 minutes Tantau & Associates Note: Please modify the steps in the patient visit if necessary to match your actual visit flow

29 What did we identify? What is your impression of this flow? What would you recommend? What is the impact? What are you observations from this exercise?

30 Getting Started Back Home Identify a process Identify and deploy a team of subject matter experts to improve the process Train the team on process mapping tools, expectations and deliverables (including timeline) Have team observe the process Have the team walk through the shoes of the customer

31 Getting Started Have team confirm what is value to the customers Document current process(both process map and Excel Tool documenting business case) Identify waste and proposed changes to the process Test the proposed changes Document impact Institutionalize (train, new policy and procedures, etc.)

32 Dialogue Questions? Additional Resources: "Going Lean in Health Care." Institute for Healthcare Improvement, 2005 "Mistake-Proofing the Design of Health Care Processes." John Grout. Agency for Healthcare Research and Quality, Publication No May 2007.