Improving Patient Flow

Agenda
Value Stream Management
Current State Value Stream Mapping
Break-Out Session
Lean Concepts
Future State Value Stream Mapping
Break-Out Session
Achieving The Future State
2

Value Stream Management
What is a value stream?
All the activities – both value added and non-value
added – currently performed to treat patients from
initial hospital arrival through discharge.
4

ED Triage
ED Registration
ED Care
ED
Transportation
Inpatient
Admission
Inpatient
Care
Discharge Home
Pharmacy
Housekeeping
Transportation
5

Patient Flow Value Streams
 Outpatient
Emergency Department
Outpatient Surgery
Outpatient Clinics
 Inpatient
Medical
Surgical
Cardiothoracic
Orthopedic
Obstetrics
Pediatrics
6

Value Stream Management Philosophy
 Entails viewing patient flow as a system of processes;
Not as isolated, individual processes.
 Involves improving the system;
Not just improving individual components or departments.
 Focuses on customer requirements:
Delivering services in a manner that maximizes customer
value.
 Process improvement is a daily, continuous, responsibility.
7

ED Triage
ED Registration
ED Care
ED
Transportation
Inpatient
Admission
Inpatient
Care
Discharge Home
Pharmacy
Housekeeping
Transportation
Waste
Waste
Waste
Waste
8

Value Added Activity
An activity is value added when:
A physical transformation occurs;
The customer is aware of it and willing to pay for it;
It is performed correctly the first time.
Healthcare value added activity:
The patient’s health status is being favorably
transformed;
The patient is aware of it and willing to pay for it;
It is performed correctly the first time.
9

Non-Value Added Activity
Any activity that is not value added
Healthcare non-value added activity:
The patient’s health status is not being transformed
favorably ;
The patient is not aware of it and or not willing to pay
for it;
Is not performed correctly the first time.
Considered waste
10

Waste
There are eight forms of waste:
1. Waiting
2. Motion
3. Transportation
4. Overproduction
5. Defects
6. Overprocessing
7. Underutilized People
8. Inventory
11

Value Stream Management Components
Process Steps Select Value Stream
Construct Current
State Value Stream Map
Develop Future State
Value Stream Map
Develop Value Stream
Improvement Plan
Value Stream Manager
Visual Control
Real-time Problem
Solving & Process
Improvement
12

Value Stream Mapping (VSM)
What is a Value Stream Map?
A graphical representation of :
The process steps;
The flow of patients, hospital services and information;
The value added activity provided;
From the beginning to the end of the value stream.
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Current State Value Stream Map
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Value Stream Mapping Purpose
It’s not about developing the map
It’s about understanding the process, service and
information flow
AND WHERE WASTE IS IMPEDING PATIENT FLOW
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What is Current State?
A value stream map that represents the process steps,
flow of patients , services and information as they exist
today.
17

Current State Value Stream Mapping Steps
1. Select a value stream
2. Map the process flow
3. Determine the process metrics and collect data
4. Map the information flow
5. Add the timeline
18

Current State VSM Step 1:
Selecting a Value Stream
Identify the value streams from the perspective of the
patient:
Determine the process steps they experience
Ascertain the services they receive
A value stream is comprised of similar process steps
and services delivered
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Selecting a Value Stream
ED Surgery Pharmacy Lab Radiology Rehab OT
Medical X X X X X X X
Surgical X X X X X X X
OB X X X
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Map The Process Flow
Go observe and follow the process
Draw the process with pad and pencil from left to right
Initially the Current State map is a high level map
Document process categories such as Triage, Waiting
Room, Admission, Discharge, etc.
As an initial guide use process categories that represent stages
in the process where the patient receives services
The initial goal is to document the overall flow of the
process from the beginning to end of the value stream
More detail can be collected later
21

Map The Process Flow
Pay particular attention to where in the process the
patient is waiting
This indicates an obstruction to patient flow
WaitingWaiting
22

Add Process Metrics
 Determine the relevant process metrics for each process step and implement
data collection
 Any metrics that are relevant can be used
 Averages and proportions are usually recorded
 Collect current data
 From a patient flow perspective two measurements should always be collected:
 Processing time – the value creating time
The time spent delivering care that favorably transforms the patient’s
health status
 Cycle time – the total time necessary to execute a task
 These times can be recorded as averages
23

Map Information Flow
Electronic Information Flow
Fax Transmission
Manual Information Flow
Telephone Walk
24

Map Information Flow
 Information flow refers to the trigger that signals work to
be performed
 When mapping information flow it is insightful to ask:
How does each service know what to do for the patient and
when to do it?
For example:
 How does housekeeping know when to clean a room after a
patient has been discharged?
 How does the bed control coordinator know when housekeeping
has completed preparing the room for the next patient?
 How and when does the patient know when to start making
arrangements for transportation home?
25

Add Timeline
26

Add Timeline
Value Added Time
Non-Value Added Time
Value Added Time
27

Add Timeline
Add all the Processing Time (value added activity
time)
Compute the Lead Time as the average time elapsed
from patient arrival to discharge
28

29

Future State Value Stream Map
The purpose of value stream mapping is to identify
waste and reduce it by implementation of a Future
State value stream that maximizes customer value
Strive to link all processes – from patient arrival to
discharge – in a smooth flow without interruptions
(waste)
Focuses on meeting customer needs
There is not a single, correct Future State
Is always evolving into a new Future State with less
waste
31

Future State Value Stream Mapping Steps
1. Identify the customers and their needs
2. Evaluate the Current State Map
3. Establish the time frame to implement
improvements
4. Map the Future State
a. Establish goals for metrics
b. Determine process improvements for implementation
32

Future State VSM Step 1:
Identify Customers and Their Needs
The patient and their family are the ultimate external
customers
Internal customers needs have to met in order to meet
patient and family needs
Who receives the output of process steps?
What is required of the output for the customer to
execute their processes without waste?
Timing
Format
Frequency
33

Evaluate Current State Map
The following set of questions can be used as a guide
to evaluating the Current State Map:
Where are the largest amounts of waste?
Which process steps create waste?
 Why are they being performed?
What knowledge and skills are truly required to perform the
process steps
Where can continuous flow processing be
implemented?
Where can people and tasks be placed together so that the
process flows without delay?
Where are the most troublesome problems occurring?
34

The following set of questions can be used as a guide
to evaluating the Current State Map:
How much time elapses from decision to admit to
placement of patient in the inpatient bed?
How much time elapses from discharge order to patient
vacating inpatient bed?
Are scheduled surgical procedures unevenly distributed
throughout the week?
Where is the workload unbalanced?
What process improvements are necessary to achieve
the Future State ?
35

13.7% VA

Establish Time Frame To Improvement
Prior to mapping the Future State establish the time
frame to achieve the Future State
This time frame is an important decision:
The longer the time frame, the more improvements that
can be undertaken
Consider keeping the first Future State time frame
within 6 months
Strive to keep the time frame within 12 months
37

Map The Future State: Set Goals
FS
20
FS
30 FS 15/15
38

Map The Future State: Determine Improvements
39
16.0% VA

Future State Implementation
Usually it is not possible to implement the entire
Future State Value Stream at once.
When viewed as a process of building a series of inter-
connected process flows for a value stream:
The Future State Value Stream can be organized into
relatively homogenous segments that represent areas of
flow.
These segments can then be the focus of process
improvement which are implemented in a systematic
manner.
41

Future State Implementation Segments
DischargeED
Bed
Management
42

Future State Implementation Segments
In what order should the segments be implemented?
If the discharge process is a segment, implement this
segment first
Unimpeded patient flow through the hospital is
dependent upon the availability of inpatient beds
A streamlined discharge process facilitates smooth
patient flow
Use your judgment on which of the other segments
will have the greatest impact on patient flow
If resources permit, multiple segments can be
improved simultaneously
43

Value Stream Improvement Plan
Segment Goal Improvements Jan Feb Mar Apr May Jun Jul
Discharge
Reduce the discharge
cycle time on day of
discharge to 15
minutes
•Begin discharge planning within 12
hours of patient admission
•Dedicated discharge coordinator
•Discharge task list
•Schedule date and time of discharge at
least 24 hours in advance
ED
Reduce the ED
waiting room time
to 20 minutes
•Implement a Fast Track
Bed
Management
Reduce the cycle
time of bed
assignment to 10
minutes
•Implement an automated bed
management system
•Dedicated bed management coordinator
•Demand prediction
44

Value Stream Improvement Review
Segment Current
Performance vs.
Goal
Project Progress Identified
Problems
Proposed
Solutions
Action Taken
45
On Schedule
At Risk
Behind
Schedule
Meeting
Not Meeting
Conduct at minimum a quarterly review

Visual Control
Real-time Problem Solving & Process Improvement
46

An individual with primary responsibility for
understanding, monitoring and continuously
improving the value stream
If the value stream is not continuously managed, waste
will creep into the stream and obstruct patient flow
47

Visual Control
A graphical report of the status of process performance
depicting actual vs. expected performance
0
10
20
30
40
50
60
Bed Assignment Time Inpatient Bed Placement
Time
Discharge Planning Unscheduled Discharge
Actual Expected 48

Visual Control
Should be made visible to everyone involved in the value
stream
Updated at least twice daily
Reviewed by the value stream manager at least as
frequently as they are updated
49

Real-time Problem Solving & Process Improvement
When actual performance does not meet the expected
performance the value stream manager initiates action
to:
Determine the root cause(s) of the performance gap;
Identify and implement process improvements to eliminate
the root cause(s).
Action is initiated on the same day as the gap in
performance is discovered.
50

Value Stream Management Advantages
Provides a view from a systems perspective:
Identifies where and how much waste is in the patient
flow system
Depicts the interconnection between process steps and
information flow
Provides a basis for a process improvement
implementation plan from a systems perspective
Avoids suboptimal departmental approaches to
improving patient flow
Promotes continuous process improvement
51

Value Stream Management Advantages
Ideal method for meeting The Joint Commission’s
patient flow standard:
Which pertains to identifying and mitigating
impediments to efficient patient flow throughout the
hospital.
Hospitals are required to identify and correct patient
flow issues organization-wide.
They must identify where in the organization problems
exist and take action to prevent barriers to patient flow.
52

Waste
 There are eight forms of waste:
1. Waiting: No transformation is taking place.
2. Motion: Activity that does not add value.
a. Examples: physical therapy traveling to the patient’s room to find the patient is in X-ray
3. Overproduction: Producing more process output that the downstream process can handle.
a. Examples: same day surgery patients schedule for afternoon surgery arriving at 6:00 am
4. Transportation: No transformation is taking place
5. Defects: No favorable transformation is taking place
a. Examples: preventable errors, preventable infections, data entry errors,
6. Overprocessing: Activity that , from the customer’s perspective, does not add value
a. Examples Producing reports that are not used for decision making or regulatory
compliance.
7. Underutilized People: Not harnessing the knowledge and experience of the work force.
8. Inventory: Excess inventory hides process problems.
a. Example, a surgical tray that has incorrect instruments is replaced with one of the many in
inventory. The surgical procedure continues, but no root cause analysis and process
improvement is undertaken to eliminate incorrect instrument trays.
54

Improving Patient Flow

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