Transcript Slide 1

Value and Waste
Value Stream Mapping in a Health
Care Environment
Aims of the session:
• Introduce the concept of Value Stream
Mapping
Process mapping
COMPASS
WAITING LIST
DIARY - CASE
NOTES PULLED 3
WEEKS IN
ADVANCE
THEATRE LIST
PRINTED L4
HOURS BEFORE ALLOCATE BEDS
THEATRE LIST
SAME DAY FROM
JANET. TRY 24
HOURS BEFORE
RECEPTIONIST
FINDS OUT IF
THEY TO GO TO
RADIOLOGY AND
WHAT TIME 1
WEEK IN
ADVANCE
ADMIT PATIENT VIA
CARE PLAN. 5-10
MIN.
LOOK AT MOD
CHECK IF TO GO
FOR ULTRASOUND
- IF TO GO WALK
THEM ROUND TO XRAY WAITING
ROOM.
THEATRE STAFF
ATTEND DAY
SURGERY - DATA
SHEET GIVEN TO
DAY SURGERY
STAFF.
THEATRE STAFF
TAKE PATIENT
STRAIGHT INTO
MINOR OP
THEATRE.
MAKE SURE
PATIENT OK - ?
DRINK OR EAT.
DISCHARGE
INSTRUCTIONS
IF DOCTOR NEEDS TO
SEE- APPOINTMENT
MADE STRAIGHT
AWAY - GIVEN TO
PATIENT
TEST 10-15 MIN
ALLOCATION
FOLLOW/REVIEW AT
OUTPATIENTS VOL
APPOINTMENT NEXT DAY.
INDICATED ON CARE
PATHWAY
REPORTS
ADMISSION AT
FRONT RECEPTION.
DETAILS CHECKED
PATIENT
ARRIVES
RECEPTION DAY
SURGERY
1ST KUB - KID
URETER BLADDER
X-RAY. PATIENT
FULL BLADDER.
2ND ULTRASOUND
20-30 MINS IN
RADIOLOGY.
DR CANNING 3 1/2
HOUR SESSION
IF RAH DR WILL
INDICATE ON TAPE SECRETARY WILL
ARRANGE.
TAKE PATIENT TO
WARD AND TO BED
AREA WITH NOTES.
ADVICE TO
UNDRESS/GOWN
ON. TELL NURSING
STAFF.
PATIENT X-RAY
AND
ULTRASOUND
REPORT BACK BACK TO BED.
DOCTOR SPEAKS
TO PATIENTS CONSENT
SIGNED
VERBAL REPORT
TO PATIENT AND
INFORMATION.
TAKEN BACK
TO DAY
SURGERY
NURSE ESCORTS
PATIENT TO CHANGING
ROOM WITHIN THE
.
PATIENT ATTENDS
RADIOLOGY
DEPARTMENT FOR
ULTRASOUND
AFTER SCAN PATIENT
REPORTS TO RECEPTION
DESK IN OUTPATIENTS
DEPARTMENT
EXAMINATION ROOM
PATIENT CHANGES
INTO GOWN AND
JOINS DOCTOR IN
THE EXAM ROOM
PROCEDURE
CARRIED OUT.
RESULT GIVEN IF
APPROPRIATE AND
FOLLOW UP INFORMATION
GIVEN
PATIENT CHANGES BACK
INTO CLOTHES AND
LEAVES THE DEPARTMENT.
REPORT TYPED BY
UROLOGY SECRETARY
AT RAH
DOCTOR EXPLAINS
EXAMINATION AND
CONSENTS PATIENT.
What is value?
• The activity is done right first time
• The activity transforms the patient and
moves them towards the next defined
outcome
• The activity is something that the patient
cares about
Define value in your service
•
•
•
•
Who are your patients?
What is the ‘value’ your patient wants?
How is the value added?
When you describe value use the patients'
words
Identifying Value - Exercise
•
•
•
•
Have a look at the process map
Which steps add value for the patient?
How many are there?
Which steps are necessary but don’t add
value?
• How many are there?
• How long does the whole process take?
• How much time adds value for the patient?
Current State Map
Runner Group: GP Orthopaedic Out Patient Referrals for Adult Hip X-ray
Responsible for the
process
GP / GP Surgery
Responsible
clinically for the
patient
GP Surgery
GP
Radiology Dept
Radio-logy
reception
GP
Radio-logy
Dept
Radiology Dept
Radiographer
Porters
Radiology Dept
Radio-logy
reception
SCW
Radiology
Dept
GP Surgery GP
Typist
Typist
types draft
report &
Typist collects emails to
tape, films & RadioloXR
gist
Typist
amends
report and
emails to
Radiologist
Typist emails
report to GP
and copies
Reception
Film Store
Porter
Porter collects
old films and
takes to
Radiology
Reception
Film store Film Store
staff pull old Staff ring
films
porter
Film store log
notes, split
and file them
Radiologist
Radiologist
takes XR
form and
films to his
office to
report. Wants
to compare
with previous
films
RadiolGP Surgery GP Surgery Radiology Reception ogy
Radiographer
SCW
Patient
Patient Process
Steps
GP / GP Surgery
Radiographer
takes XRs
Radiol-ogist
agrees report
Radiol-ogist
dictates
report and
takes tape,
films and
XR card to
Reception
Radiol-ogist
reviews
email report
and amends,
sends back
to typist
Reception
send XRs to
Film Store
and file notes.
Close
episode on
computer
Radiographer
checks XRs
SCW takes
XR form to
Reception
Radiology
reception staff
book appointment on IT
system
GP
assesses
patient
Radiology
reception staff
register
patient on IT
system and
give card to
SCW
Radiology
Reception
staff log
patient out on
IT system
Reception
staff match
XR card to
XR and file in
new
reporting
queue
Radiology
Reception
staff log old
films but can't
find latest
one
Reception
staff request
previous
films
Radiology
Reception
staff search
for films and
notes and
locate in
Radiologist's Office
Radiology
Reception
staff marry up
old and new
films and XR
card and put
back in
queue
Reception
log tape, XR
card & films
and place in
queue for
typing
GP and
patient agree
referral to
Ortho OPD
necessary
GP gives
patient XR
form
GP surgery
receive
report and
recall patient
Receptionist
makes appointment
Patients wife
rings GP
Surgery
Patient has
hip pain
Patients
wife rings
XR Dept
Patient
assessed
by GP
Patient
arrives XR
Dept
Patient
undresses
Patient in
Waiting
Room
Patient
Radiocalled to grapher
XR Room positions
patient
Patient
has XR
Patient
dresses
Patient
goes home
Patient
sees GP.
Referred
Ortho Out
Patients
Value Time
Time Hrs:Mins
Days
0:10
Day 1
Day 3
0:05
Day 4
0:10
0:45
0:05
0:05
0:10
0:05
Day 8
0:10
0:10
0:05
0:10
Day 12
0:05
Day 14
0:15
Day 17
0:05
5:30
Day 18
1:00
Day 20
1:30
Day 22
0:10
Day 23
0:15
Day 25
1:10
0:10
0:15
Day 30
0:10
0:10
Day 33
Day 34
Reviews 25
reports,
amends 13
Amends 8,
leaves 5 in
queue
0:05
Day 36
0:10
Day 38
0:10
Day 40
0:10
Day 44
0:15
Day 48
0:25
Day 73
2 hrs
Work in progress
5 patients in
GP Waiting
room
ABBREVIATIONS
GP
General Practitioner
SCW
Support Care Worker
OPD
Out Patient Department
Notes: Non digital XR system!
3 people
queuing at
XR Reception
8 patients in
XR Waiting
room
CURRENT STATE MAP SUMMARY
Total Steps (patient)
Value Steps
Total Time
Value Time
Work in Progress
102 cards in Radiologist
queue
takes 25
cards and xrays, leaves
77 behind
Communication
Phone / Bleep
Electronic
Verbal
Written / Visual
Stack of 26
other pulled
films
Queue of 135 Radiol-ogist Add to queue Collects 25
cards& Xreports 28 of 117 films cards & Xrays
films
rays, leaves
150 behind
Types 25
reports
GP receives
19 X-Ray
reports from 3
typists
Over 1000
films to be
filed
Which pathway should we
map?
Glenday Sieve
• Heard of the Pareto (80/20 principle)?
• Ladies – think of your wardrobe…..
“Few procedures make up
for high volume activities”
• Orthopaedics – Hips and knees
• General Surgery – hernias and lap
cholecystectomy
• District Nurse – wound care, medication
Runners - 50% of all activity
6% of all possible procedures
Runners & Repeaters - 95% of all
activity
50% of all possible procedures
Runners, Repeaters and Strangers 100% of all activity
100% of all possible procedures
MRI Team, NHS Tayside
•220 codes for appointments MRI RIE
- 63% of MRI throughput from 2.7% of
procedure codes (i.e. 6 codes)
•Group patients by the process they go
through (rather than clinical condition)
Urology Team, Clatterbridge
• 213 cases over 8 months at Clatterbridge RI event
– 52% of theatre throughput from 4.2% of
procedures
• Group patients by the process they go through
(rather than clinical condition)
• Focus initially on smart process for the critical few [4.2%]
What are your runners?
Tea break 15mins
PDSA cycle
PDSA Cycle
The improvement guide
Langley et al 1996
What change can we make that will result in an improvement ?
Act
Plan
• Objective
• What changes
• Questions and
are to be made? predictions (why)
• Plan to carry out the cycle
• Next cycle?
(who, what, where, when)
• Plan for data collection
Study
• Complete the
Do
• Carry out the plan
analysis of the data • Document problems
• Compare data to
and unexpected
predictions
observations
• Summarize
• Begin analysis
what was
of the data
learned
MODEL FOR IMPROVEMENT
CYCLE :____DATE :____
Objective for this PDSA Cycle
A P
S D
PLAN :
QUESTIONS
:
PREDICTIONS
:
PLAN FOR CHANGE OR TEST: WHO, WHAT, WHEN, WHERE
PDSA
Worksheet
PLAN FOR COLLECTION OF DATA: WHO, WHAT, WHEN, WHERE
DO : CARRY OUT THE CHANGE OR TEST; COLLECT DATA AND BEGIN ANALYSIS.
STUDY : COMPLETE ANALYSIS OF DATA; SUMMARIZE WHAT WAS LEARNED.
ACT:
ARE WE READY TO MAKE A CHANGE? PLAN FOR THE NEXT CYCLE.
GP Access – Practice Level
Improvements with PDSAs
Scottish Primary Care Collaborative
Ayrshire GP Practice
GP 3rd Available Appointment
16
14
PDSA to Introduce
Telephone
Consultations
Number of Days
12
PDSAs to inform
Patients about new
appointment system
10
8
PDSAs to ensure Phone
Appts are provided at most
appropriate time of day
6
4
2
0
PDSA on ‘PreBookable’ and ‘On
the day’
appointments
PDSAs
PDSAs
PDSAs
Diabetes (blood pressure)
Improvements with PDSAs
Scottish Primary Care Collaborative
Borders GP Practice
PDSAs
% of Diabetes Patients with a BP<140/80
PDSAs
90
80
% of People with Diabetes
70
60
50
PDSAs to
Validate
Diabetes
Register
PDSAs to improve
shared diabetes
information with
Secondary Care
40
30
20
10
0
PDSAs
PDSA to contact all
Patients who have
not had a BP check
in the last year
PDSAs to improve
current patient
recall system
PDSA in Primary Care – repeat prescriptions
Objective
To identify a more efficient way for patients to hand
in repeat prescription slips
Plan
A box labelled ‘Repeat Prescriptions’ will be placed
on the reception counter for patients to drop in their
prescription. Receptionist will empty box twice daily
and action requests
Do
Start using box on 23rd Feb
Study
Patients were initially reluctant to use box without
checking with reception staff, however uptake has
increased and new system used more and more
Act
As new system is so successful in saving time,
patients are not waiting until receptionist has
finished a call and receptionist is not interrupted.
Box to become a permanent fixture.
6S
Workplace organisation
Workplace reorganisation
“Having a place for everything, and everything in its place”
Sort
Safety
Having a safe
working environment
Sustain
Maintain through empowerment,
commitment and discipline
Get rid of clutter
Set in order
6S
Organise the work area
Shine
Clean the work area
Standardise
Doing the same thing
every time
Stracathro -theatre store room
Money is tied up in inventory gathering dust because of
a supply chain process which is not aligned with the
patient pathway value stream
In amongst this is back up
emergency equipment
Clutter- time wasted
trying to find things
3 - Benefits gained
from 6S
Tray Room before…
…and after
6S checklist of the tray room
Location
Tray room
Month
June-Oct
Week
Date
Initials
Floor kept clear of objects
2
Ensure rotation of trays
3
Staff on cleaning rota to check stock dates
monthly
4
Wipe down of work surfaces
5
Drawers / cupboards tidy
6
7
8
9
1
2
3
4
5
1
2
3
4
6S Check Sheet
1
1
Just beginning
4
4
Focus on consistency
A dependable,
SORT
documented method (e.g.
Necessary and unnecessary
Necessary and
Unnecessary items have
Separate the essential from
red tagging) has been
items are mixed throughout unnecessary items been removed from the
established to keep the
the non-essential
the workplace
are separated
workplace.
work area free of
unnecessary items
SET
A place for everything and
everything in its place
SHINE
Clean everything and check
it is in working order
STANDARDISE
Make things easy to
maintain
SUSTAIN
Make it a part of everyday
life
Items are randomly located
throughout the workplace.
2
2
Focus on basics
Area
A designated
location has been
established
3
3
Make it visual
5
5
Focus on prevention
Employees are
continually seeking
improvement
opportunities
A dependable
A dependable,
documented method has
Designated locations are documented method has
been developed to
marked to make
been established to
provide continual
organisation more
recognise if items are out
evaluation, and a
visible.
of place or exceed
process is in place to
quantity limits.
implement
improvements
Work and break
areas are cleaned
Work and break areas
Area employees have
Workplace areas are dirty,
on a regular
and machinery are
6S agreements are
devised a dependable,
disorganised and key items
scheduled basis. cleaned on a daily basis. understood and practised documented method of
are not marked or identified. Key items to check
Visual controls have
continually
preventive cleaning and
have been
been established.
maintenance
identified.
Working environment
Everyone is continually
Methods are being
changes are being
Workplace methods are not
Substantial process
seeking the elimination
improved but
documented. Visual
consistently followed and
documentation is available of waste with changes
changes have not
control agreements for
are not documented.
and followed.
documented and
been documented
labelling and quantity
information shared
levels established
Work area checks are
randomly performed and
there is no visual
measurement of 6S
performance
A recognisable
6S agreements and
effort has been
safety practices have
made to improve
been developed and are
the condition of the
utilised.
workplace.
Follow through with 6S
agreements and safety
practices are evident.
Medical Devices are
There is a general
appearance of a
confident understanding
of, and adherence to,
the 6S principles
6S Check Sheet
11
Just beginning
SORT
Separate the essential from
the non-essential
SET
A place for everything and
everything in its place
SHINE
Clean everything and check
it is in working order
STANDARDISE
Make things easy to
maintain
SUSTAIN
Make it a part of everyday
life
SAFETY
Make a safe working
environment with safe
working systems
Necessary and unnecessary
items are mixed throughout
the workplace
Area
22
Focus on basics
33
Make it visual
Necessary and
unnecessary items
are separated
Unnecessary items have
been removed from the
workplace.
44
Focus on consistency
A dependable,
documented method (e.g.
red tagging) has been
established to keep the
work area free of
unnecessary items
55
Focus on prevention
Employees are
continually seeking
improvement
opportunities
A dependable
documented method has
been developed to
provide continual
evaluation, and a
process is in place to
implement
improvements
Items are randomly located
throughout the workplace.
A designated
location has been
established
Designated locations are
marked to make
organisation more
visible.
A dependable,
documented method has
been established to
recognise if items are out
of place or exceed
quantity limits.
Workplace areas are dirty,
disorganised and key items
are not marked or identified.
Work and break
areas are cleaned
on a regular
scheduled basis.
Key items to check
have been
identified.
Work and break areas
and machinery are
cleaned on a daily basis.
Visual controls have
been established.
6S agreements are
understood and practised
continually
Area employees have
devised a dependable,
documented method of
preventive cleaning and
maintenance
Workplace methods are not
consistently followed and
are not documented.
Methods are being
improved but
changes have not
been documented
Working environment
changes are being
documented. Visual
control agreements for
labelling and quantity
levels established
Substantial process
documentation is available
and followed.
Everyone is continually
seeking the elimination
of waste with changes
documented and
information shared
Work area checks are
randomly performed and
there is no visual
measurement of 6S
performance
A recognisable
effort has been
made to improve
the condition of the
workplace.
6S agreements and
safety practices have
been developed and are
utilised.
Follow through with 6S
agreements and safety
practices are evident.
There is a general
appearance of a
confident understanding
of, and adherence to,
the 6S principles
Medical Devices and
Workplace Safety checks
are performed randomly with
poor documented evidence.
Recognition exists
that timely checks
require to be
carried out with
auidit trail evidence
mainintained.
Checks & documentation
is in place, however
robust systems required
for hazard control.
Medical Devices are
correctly maintained
(storage, charging, clean,
checks, named device
manager)
Workplace is free from
hazards, suitable
provisions for welfare of
Medical Devices are
correctly maintained.
Workplace is free from
hazards. Everyone takes
ownership to identify and
contiually improve ward
safety.
Theatre Tray Room - 6S Score
Safety
Sort
5
4
3
2
1
0
Sustain
Set
Current Score
Shine
Standardise
Score After 6S
Rapid Improvement Events (RIEs)
– an overview
What are RIEs?
•Common Lean tool to introduce Lean principles and
thinking in organisations
•RIEs select critical business areas and make real
improvements for patients and staff
•Process-focussed and brings together the team in a
highly structured way
•Results-focussed – establishing the root cause of
problems, and achieving measurable improvements
•Process which is action-orientated and data driven
RIE Programme Timetable
RIE - 6wks
RIE - 4wks
RIE
Area
Identified
RIE – 2wks
RIE Week
Rapid
Improvement
Event
RIE + 4wks
RIE + 6wks
RIE + 12wks
or by
agreement
Review Progress
Final Presentation
(Project Closure)
Remove Blockages
Management
Commitment Meeting
• Critical success factors
• Set Scope & Goals
• Pick Team Leader
• Pick RIE Team
• Book Venue
• Advise Managers about
their attendance
• Gather data on
current performance
RIE + 2wks
Measure Improvements
Share Success
Support
• Run RIE PreMeeting
• Run RIE
Awareness visits
Team Leader to
Produce:
• Report
• Action Plan
Local Ownership
& Sustainability
- Ross International
One team’s experience
NHS Tayside Urology RIE