starting from scratch - university of waterloo · starting from scratch “every . ... value stream...
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Starting from Scratch
“Every block of stone has a statue inside it and it is the task of the sculptor to
discover it.”~ Michelangelo
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)
What is a Value Stream?
Sell Make Purch Design Customers Suppliers
Value Stream
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.
Whenever there is a service or a product for a customer there is a
value stream.
Lean Thinking Principles
Specify Value
Identify the Value Stream
Make It Flow
At the Pull of the Patient
In Pursuit of Perfection
Specify value from the standpoint of the student and the organization
Identify the value stream to teach the student and remove wasted steps
Enable the student and information to flow smoothly and quickly through every step
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
Acute & Transitional Care Critical Care & Medical Cardiology, Medical Units, Integrated Stroke Unit / Rehab, Complex Care
Episodic & Outpatient Care Mental Health, Emergency & Urgent Care, Outpatient Clinics
Planned Care Maternal Child & Surgical
Care Support Diagnostic Imaging, Pharmacy, Laboratory, Infection Control & Medical Device Reprocessing
Finance & Supply Support
Accounts Payable/Accounts Receivable & General Finance, Contracts, Home
Oxygen, Purchasing
Stores, Bio-Med, Environmental Services and Nutrition Services
Knowledge & Information Support
Decision Support & Information Technology
Patient Registration & Information, Flow, Health Information Services
Facilities and Maintenance
People Development
Human Resources, Payroll, Volunteers
Occupational Health & Safety, Float Pool, & Scheduling, Organizational
Development
Patient Experience & Quality Outcomes
Patient Experience
Risk, Quality & Accreditation
Strategy Deployment (Continuous Improvement)
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
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
A3 Thinking
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.
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!
At least Three Versions
What You Think It Is... What You Would Like It To Be ...
What It Actually Is...
The Developing Reality…
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 ?”
Ways to Identify Current State…
Video all steps
Spaghetti Diagram
Process Map
Before After
Spaghetti Diagram
Circle Diagram (Information Flow)
Source: North York General Hospital. North York, ON.
Information flow for placement to Long Term Care
Process Map
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
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
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
Electronic Information Flow
ABC Department
In Box (queue)
Conversation Information Flow
Iterations or Rework
Worker Data Box
Current State Mapping Icons
XYZ Corporation
Delay
Reminder Notice
Departments or Individuals Providing Information
Outside Sources (customer, supplier)
Technology Used
Work flow
Process
Box
IN
St. Luke’s Emergency Department Treat and Release – Current State
Waiting Room
Radiology
Lab
0-2 hr.
Primary Complaint
35%
Log In
P/T =1 min. D/T = 0 %C&A =100%
Triage
P/T = 3-5 min. D/T = 5-10 min. %C&A = 99%
Register
P/T = 5 min. D/T = 5-20 min. %C&A = 50%
Examine (RN)
P/T = 5-10 min. D/T = 5-10 min. %C&A = 75%
Examine (MD)
P/T = 5-15 min. D/T = 10-60 min. %C&A = 60%
Enter Orders
P/T = 5-10 min. D/T = 10 min. %C&A = 98%
Treat & Release
P/T = 10-35 min. D/T = 20 min. %C&A = 80%
Patient
Patient
Tx Plan
0-2 hr.
Orders
Results
Status?
EMR LabSys RadSys, EMR EMR, LabSys
LabSys RadSys, EMR
LabSys RadSys
5 min.
35 min. 7.5 min. 12.5 min.
1 min.
60 min.
7.5 min. 7.5 min.
100%
4 min. 10 min.
99% 50% 75% 98%
7.5 min.
P/T
D/T
%C&A
% Complete & Accurate = 17%
Value Stream Summary Metrics
Process Time =57.5 Minutes
Lead Time = 270 Minutes
60%
10 min.
22.5 min.
80%
20 min. 60 min.
Results Orders
University Example
University
OUAC
Degree to Learn
Register OUAC
P/T =. D/T = 0 %C&A =100%
Select School of
choice
P/T = D/T = %C&A = 99%
Register for OSAP
P/T = D/T = %C&A = 5
Register for classes
P/T = D/T = %C&A =
Plan Residence
P/T = D/T = %C&A =
Move In on Moving Day
P/T = D/T = %C&A =
Orientation
P/T = D/T = %C&A = %
Student
Student
Learning Plan
Roommate
100% 99% % % %
P/T
D/T
%C&A
% Complete & Accurate = %
Value Stream Summary Metrics
Process Time = Minutes
Lead Time = Minutes
%
Meal Plan
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
Standardized Work
Flow No Waiting
•Takt Time
•Continuous Flow •Pull System
•Quick Changeover
Engage Everyone
in a
Patient – Focused Philosophy
Quality No Harm
•Andon
•Problem Solving •Root Cause
•Error Proofing
People & Teamwork
Waste Reduction
Continuous Improvement Kaizen
Visual Management 5 S - Work Place Organization
5%
40%55%
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
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 results
CUSTOMERS FOCUS ON WHAT IS OF VALUE TO THEM!
Value Added:
Activities that the customer would be willing to pay for. Teaching, planning, registering
The Three Divisions of Work
Maximize this segment
Minimize
Eliminate
The Eight Wastes
Waiting Overproduction Rework Motion Processing Inventory Transportation Not utilizing the Skills of Employees
St. Luke’s Emergency Department Treat and Release – Current State
Step 1 & 2
Waiting Room
Radiology
Lab
0-2 hr.
Primary Complaint
35%
Log In
P/T =1 min. D/T = 0 %C&A =100%
Triage
P/T = 3-5 min. D/T = 5-10 min. %C&A = 99%
Register
P/T = 5 min. D/T = 5-20 min. %C&A = 50%
Examine (RN)
P/T = 5-10 min. D/T = 5-10 min. %C&A = 75%
Examine (MD)
P/T = 5-15 min. D/T = 10-60 min. %C&A = 60%
Enter Orders
P/T = 5-10 min. D/T = 10 min. %C&A = 98%
Treat & Release
P/T = 10-35 min. D/T = 20 min. %C&A = 80%
Patient
Patient
Tx Plan
0-2 hr.
Results
Status?
EMR LabSys RadSys, EMR EMR, LabSys
LabSys RadSys, EMR
LabSys RadSys
5 min.
35 min. 7.5 min. 12.5 min.
1 min.
60 min.
7.5 min. 7.5 min.
100%
4 min. 10 min.
99% 50% 75% 98%
7.5 min.
P/T
D/T
%C&A
% Complete & Accurate = 17%
Value Stream Summary Metrics
Process Time = 57.5 Minutes
Lead Time = 270 Minutes
60%
10 min.
22.5 min.
80%
20 min. 60 min.
Results Orders
Treat
Requirements: • Patient demographics • Chief complaint • C&A EMR input
Requirements: •C&A Diagnosis •Consult L/T 1 hour max •Adherent to standards of care
Requirements: •LOS = 2 hr. max •Disposition •C&A Dx Summary •C&A Billing •Pt. education •Plan of care
Gather Information
Examine
Orders
St. Luke’s Emergency Department Treat and Release – Current State
Step 3 & 4- Standardized Work and Quality
Waiting Room
Radiology
Lab
0-2 hr.
Primary Complaint
35%
Log In
P/T =1 min. D/T = 0 %C&A =100%
Triage
P/T = 3-5 min. D/T = 5-10 min. %C&A = 99%
Register
P/T = 5 min. D/T = 5-20 min. %C&A = 50%
Examine (RN)
P/T = 5-10 min. D/T = 5-10 min. %C&A = 75%
Examine (MD)
P/T = 5-15 min. D/T = 10-60 min. %C&A = 60%
Enter Orders
P/T = 5-10 min. D/T = 10 min. %C&A = 98%
Treat & Release
P/T = 10-35 min. D/T = 20 min. %C&A = 80%
Patient
Patient
Tx Plan
0-2 hr.
Results
Status?
EMR LabSys RadSys, EMR EMR, LabSys
LabSys RadSys, EMR
LabSys RadSys
5 min.
35 min. 7.5 min. 12.5 min.
1 min.
60 min.
7.5 min. 7.5 min.
100%
4 min. 10 min.
99% 50% 75% 98%
7.5 min.
P/T
D/T
%C&A
% Complete & Accurate = 17%
Value Stream Summary Metrics
Process Time = 57.5 Minutes
Lead Time = 270 Minutes
60%
10 min.
22.5 min.
80%
20 min. 60 min.
Results Orders
Treat
Requirements: • Patient demographics • Chief complaint • C&A EMR input
Requirements: •C&A Diagnosis •Consult L/T 1 hour max •Adherent to standards of care
Requirements: •LOS = 2 hr. max •Disposition •C&A Dx Summary •C&A Billing •Pt. education •Plan of care
Gather Information
Examine
Orders
Combine processes
Triage assesses acuity & mini registration
Develop SLA with Lad and Radiology
Create mini team to sort
Register patients in exam rooms
Develop Standardized registration
Develop standardized discharge porcedure
Examine (RN)
Examine (MD)
LabSys RadSys, EMR EMR, LabSys
Triage & Mini
Register
Register in exam room
Treat & Release
LabSys RadSys, EMR
Enter Orders
LabSys RadSys
Primary Complaint
Patient
Patient
Radiology
Lab
% Complete & Accurate = 44%
Value Stream Summary Metrics
Process Time = 49Minutes
Lead Time = 120 Minutes
St. Luke’s Emergency Department Treat and Release – Future State
Standard Protocols Standard
Protocols
SLA w/ lab & radiology
Standard Discharge protocol
5 min. 4 min 7.5 min. 7.5 min.
100%
10 min.
75% 85% 98%
P/T
D/T
%C&A 75%
15min.
95%
10 min. 60 min. 5 min
Create MD/ RN
protocols to start orders and treatment
Triage nurse assesses acuity
& mini Registers
Standardize registration format to conduct while patient waits
for MD
Develop sort in triage and create
separate team for Treat and Release
Register patients in exam rooms with computers
on wheels
Develop standardized discharge protocols
Develop SLA with Lab
And Radiology
Example from a Surgery
•Run trials, experiment
•Measure results •Create Visual Management •Problem Solve
• Compare performance to goal
• Capture learning
• Brainstorm Ideas
• Future state map
• Goal and action plans
• Socialization
• Standardize what works well
• Identify systemic problems
• Identify barriers • Establish next gap
Act Plan
Do Study G
rasp the
Situation
•Problem Statement •Lean Value proposition •Go & See •Current-state map
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.
4. Check or Study
5. Interpret results, draw conclusions that serve as basis for new hyposthesis.
5. Additional action taken if needed.
5. Act
Issues and Action Log
Ways to Socialize your Progress
•Go & See •Huddles •Visual Story Board
Angela Schrum Brant Community Healthcare System Strategy Deployment 200 Terrace Hill Street Brantford, ON N3R 1G9 Ph: 519.751.5544 ext. 2393
Karla Stonham Brant Community Healthcare System Strategy Deployment 200 Terrace Hill Street Brantford, ON N3R 1G9 Ph: 519.751.5544 ext. 2393
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