Starting from Scratch

Transcription

1 Starting from Scratch

2 Every block of stone has a statue inside it and it is the task of the sculptor to discover it. ~ Michelangelo

3 What is a Value Stream? Value Stream all the activities and actions (value added and non-value added, information and material) that are required to bring a customer through the essential requirements needed Value Stream (labour, equipment, supplies, support services, facilities)

4 What is a Value Stream? Value Stream Suppliers Design Purch Make Sell Customers TIME is the Primary Focus Product and/or Service Flow Information must flow quickly in all directions The Value Stream is the set of activities performed to transform the products and services into what the customer requires.

5 Whenever there is a service or a product for a customer there is a value stream.

6 Lean Thinking Principles Specify Value Specify value from the standpoint of the student and the organization Identify the Value Stream Identify the value stream to teach the student and remove wasted steps Make It Flow Enable the student and information to flow smoothly and quickly through every step At the Pull of the Patient In Pursuit of Perfection Match capacity with demand so work is done in line with the pull of the student While pursuing perfection through continuous improvement of the value stream

7 Care Support Diagnostic Imaging, Pharmacy, Laboratory, Infection Control & Medical Device Reprocessing Acute & Transitional Care Critical Care & Medical Cardiology, Medical Units, Integrated Stroke Unit / Rehab, Complex Care Planned Care Maternal Child & Surgical Episodic & Outpatient Care Mental Health, Emergency & Urgent Care, Outpatient Clinics Finance & Supply Support Knowledge & Information Support People Development Patient Experience & Quality Outcomes Accounts Payable/Accounts Receivable & General Finance, Contracts, Home Oxygen, Purchasing Stores, Bio-Med, Environmental Services and Nutrition Services Decision Support & Information Technology Patient Registration & Information, Flow, Health Information Services Facilities and Maintenance Human Resources, Payroll, Volunteers Occupational Health & Safety, Float Pool, & Scheduling, Organizational Development Patient Experience Risk, Quality & Accreditation Strategy Deployment (Continuous Improvement)

8 Why a Value Stream Approach? Taking a value stream perspective means working on the big picture, not just the individual processes, and improving the whole, not just the parts (it breaks silos) Identifying, understanding and improving value stream in our organization not as isolated tasks but as a flow of interconnected, interdependent activities and processes

9 Goal Engage staff and students to: Redesign work to eliminate waste Create standard layouts Make the work progress and problems visible Remove ambiguities, errors and risk Engage teams to redesign the flow of work through a value stream To simplify steps, eliminate delays, level the workload, reduce errors, save staff time

10 A3 Thinking

11 Go See or Gemba Gemba means real or actual place Lean practitioners often use this Japanese word to refer to the workplace, the place in the office or factory where value is created But, it also means reality or even truth To look at conditions empirically, you have to leave your office, step away from your monitor and your data, and observe what is really going on.

12 Go & See Definition To observe a situation, problem or improvement opportunity by going to the actual place Purpose To observe and understand the actual process Methods Walk along the path of the value stream starting at the end Stand and observe Objectives To identify the current state Not to fix- Learning only!

13 The Developing Reality At least Three Versions What You Think It Is... What It Actually Is... What You Would Like It To Be...

14 What is Current State? A pictorial representation of what is Currently happening in a process How can you create the future if you don t know where you ve come from?

15 Ways to Identify Current State Video all steps Spaghetti Diagram Process Map

16 Spaghetti Diagram Before After

17 Circle Diagram (Information Flow) Information flow for placement to Long Term Care Source: North York General Hospital. North York, ON.

18 Process Map

19 What is a Value Stream Map? Visual representation of the flow of work and information that links a service or product to a customer Simple Tool, and Hand Drawn Picture of your process using symbols Shows VA and NVA time Used to identify WASTE normally not seen Highlights for team where to focus CI Goal is to shrink the Value Stream by reducing time

20 Why Focus on Time? Time is the currency of Lean By reducing time, we eliminate waste We gain responsiveness Time is measured in terms of how many minutes (hopefully), hours or days (realistically) people or information wait Process Time & Delay Time

21 Areas of a Value Stream Map 1. The customer 2. The supplier 3. The processes 4. Information Flow 5. Process data or metrics 6. Timeline & Summary

22 Current State Mapping Icons Process Box Technology Used XYZ Corporation Outside Sources (customer, supplier) Electronic Information Flow Conversation Information Flow ABC Department Work flow Data Box Departments or Individuals Providing Information Worker Reminder Notice IN In Box (queue) Delay Iterations or Rework

23 St. Luke s Emergency Department Treat and Release Current State Lab Radiology Patient Patient Status? Tx Plan Primary Complaint Orders 35% Results Orders Results Log In Triage Register Examine (RN) Examine (MD) Enter Orders Treat & Release P/T =1 min. P/T = 3-5 min. EMR P/T = 5 min. Waiting Room 0-2 hr. LabSys RadSys, EMR P/T = 5-10 min. EMR, LabSys P/T = 5-15 min. LabSys RadSys P/T = 5-10 min. 0-2 hr. LabSys RadSys, EMR P/T = min. D/T = 0 D/T = 5-10 min. D/T = 5-20 min. D/T = 5-10 min. D/T = min. D/T = 10 min. D/T = 20 min. %C&A =100% %C&A = 99% %C&A = 50% %C&A = 75% %C&A = 60% %C&A = 98% %C&A = 80% P/T 1 min. 4 min. 5 min. 7.5 min. 10 min. 7.5 min min. D/T 7.5 min min. 60 min. 7.5 min. 35 min. 10 min. 60 min. 20 min. %C&A 100% 99% 50% 75% 60% 98% 80% Value Stream Summary Metrics Process Time =57.5 Minutes Lead Time = 270 Minutes % Complete & Accurate = 17%

24 University Example OUAC University Student Student Degree to Learn Meal Plan Learning Plan Roommate Register OUAC Select School of choice Register for OSAP Register for classes Plan Residence Move In on Moving Day Orientation P/T =. P/T = P/T = P/T = P/T = P/T = P/T = D/T = 0 D/T = D/T = D/T = D/T = D/T = D/T = %C&A =100% %C&A = 99% %C&A = 5 %C&A = %C&A = %C&A = %C&A = % P/T D/T %C&A 100% 99% % % % % Value Stream Summary Metrics Process Time = Minutes Lead Time = Minutes % Complete & Accurate = %

25 Let s Try Working with your colleagues, create a value stream map for your next big vacation Start with the customer and supplier symbols Then add your process boxes Add the times you think it will take for process and delay

26 Engage Everyone in a Patient Focused Philosophy Flow No Waiting Takt Time Continuous Flow Pull System Quick Changeover People & Teamwork Continuous Improvement Kaizen Waste Reduction Standardized Work Visual Management 5 S - Work Place Organization Quality No Harm Andon Problem Solving Root Cause Error Proofing

27 The Three Divisions of Work CUSTOMERS FOCUS ON WHAT IS OF VALUE TO THEM! Value Added: Maximize this segment Eliminate Non Value Added: Activities that the customer would not want to pay for if they knew they were happening. Searching for equipment supplies, waiting for exam 5% results 55% Activities that the customer would be willing to pay for. Teaching, planning, registering 40% Non Value Added but Necessary: Any work carried out, which is necessary under current conditions but not something the customer would willing pay for. Student statistics, application files Minimize

28 The Eight Wastes Waiting Overproduction Rework Motion Processing Inventory Transportation Not utilizing the Skills of Employees

29 St. Luke s Emergency Department Treat and Release Current State Step 1 & 2 Treat Patient Primary Complaint Gather Information Examine Orders 35% Lab Results Orders Radiology Status? Results Patient Requirements: LOS = 2 hr. max Disposition Tx Plan C&A Dx Summary C&A Billing Pt. education Plan of care Log In Triage Register Examine (RN) Examine (MD) Enter Orders Treat & Release P/T =1 min. P/T = 3-5 min. EMR P/T = 5 min. Waiting Room 0-2 hr. LabSys RadSys, EMR P/T = 5-10 min. EMR, LabSys P/T = 5-15 min. LabSys RadSys P/T = 5-10 min. 0-2 hr. LabSys RadSys, EMR P/T = min. D/T = 0 D/T = 5-10 min. D/T = 5-20 min. D/T = 5-10 min. D/T = min. D/T = 10 min. D/T = 20 min. %C&A =100% %C&A = 99% %C&A = 50% %C&A = 75% %C&A = 60% %C&A = 98% %C&A = 80% P/T 1 min. 4 min. 5 min. 7.5 min. 10 min. 7.5 min min. D/T 7.5 min min. 60 min. 7.5 min. 35 min. 10 min. 60 min. 20 min. %C&A 100% Value Stream Summary Metrics Process Time = 57.5 Minutes Lead Time = 270 Minutes % Complete & Accurate = 17% 99% 50% 75% 60% 98% Requirements: Patient demographics Chief complaint C&A EMR input 80% Requirements: C&A Diagnosis Consult L/T 1 hour max Adherent to standards of care

30 St. Luke s Emergency Department Treat and Release Current State Patient Primary Complaint Triage assesses acuity & mini registration Step 3 & 4- Standardized Work and Quality Gather Information Develop Standardized registration Examine Orders 35% Lab Develop SLA with Lad and Radiology Results Orders Radiology Status? Patient Develop Results standardized discharge porcedure Treat Requirements: LOS = 2 hr. max Disposition Tx Plan C&A Dx Summary C&A Billing Pt. education Plan of care Log In Triage Register Examine (RN) Examine (MD) Enter Orders Treat & Release Combine processes P/T =1 min. P/T = 3-5 min. EMR P/T = 5 min. Waiting Room 0-2 hr. LabSys RadSys, EMR P/T = 5-10 min. EMR, LabSys P/T = 5-15 min. LabSys RadSys P/T = 5-10 min. 0-2 hr. LabSys RadSys, EMR P/T = min. D/T = 0 D/T = 5-10 min. D/T = 5-20 min. D/T = 5-10 min. D/T = min. D/T = 10 min. D/T = 20 min. %C&A =100% P/T D/T 1 min. %C&A = 99% Create mini team to sort %C&A = 50% %C&A = 75% %C&A = 60% %C&A = 98% 4 min. 5 min. 7.5 min. 10 min. 7.5 min. Register patients in exam rooms 7.5 min min. 60 min. 7.5 min. 35 min. 10 min. 60 min. %C&A = 80% 22.5 min. 20 min. %C&A 100% Value Stream Summary Metrics Process Time = 57.5 Minutes Lead Time = 270 Minutes % Complete & Accurate = 17% 99% 50% 75% 60% 98% Requirements: Patient demographics Chief complaint C&A EMR input 80% Requirements: C&A Diagnosis Consult L/T 1 hour max Adherent to standards of care

31 St. Luke s Emergency Department Treat and Release Future State Patient Create MD/ RN protocols to start orders and treatment Lab Radiology SLA w/ lab & radiology Patient Primary Complaint Triage nurse assesses acuity & mini Registers Develop SLA with Lab And Radiology Standard Protocols Standard Protocols Develop standardized discharge protocols Standard Discharge protocol Triage & Mini Register Register in exam room Examine (RN) LabSys RadSys, EMR Examine (MD) EMR, LabSys Enter Orders LabSys RadSys Treat & Release LabSys RadSys, EMR P/T 4 min 5 min. 7.5 min. 10 min. 7.5 min. 15min. D/T 5 min 60 min. 10 min. 100% 75% 85% 75% %C&A 98% 95% Develop sort in triage and create separate team for Treat and Release Value Stream Summary Metrics Process Time = 49Minutes Lead Time = 120 Minutes % Complete & Accurate = 44% Standardize registration format to conduct while patient waits for MD Register patients in exam rooms with computers on wheels

32 Example from a Surgery

33 Standardize what works well Identify systemic problems Identify barriers Establish next gap Act Problem Statement Lean Value proposition Go & See Current-state map Grasp the Situation Plan Brainstorm Ideas Future state map Goal and action plans Socialization Compare performance to goal Capture learning Study Do Run trials, experiment Measure results Create Visual Management Problem Solve

34 PDSA Scientific PDSA Clinical PDSA Lean PDSA 1. Define question, gather information and observe. 1. Assessment of patient s condition, leading to a diagnosis and plan of care. 1. Grasp the situation or problem, investigate cause, select countermeasure. 2. Form hypothesis. 2. Treatment plan. 2. Plan for implementing and testing. 3. Perform experiment and collect results. 3. Treatment is the experiment. 3. Do 4. Analyze results. 4. Follow up with patient to ensure treatment is working or not. 5. Interpret results, draw conclusions that serve as basis for new hyposthesis. 5. Additional action taken if needed. 4. Check or Study 5. Act

35 Issues and Action Log

36 Ways to Socialize your Progress Go & See Huddles Visual Story Board

37 This Can Be Fun!

38 Karla Stonham Brant Community Healthcare System Strategy Deployment 200 Terrace Hill Street Brantford, ON N3R 1G9 Ph: ext Angela Schrum Brant Community Healthcare System Strategy Deployment 200 Terrace Hill Street Brantford, ON N3R 1G9 Ph: ext. 2393