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Improving Patient Flow
1.
© 2013 by
HealthCare Quality Improvement Solutions, LLC
2.
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 © 2013 by HealthCare Quality Improvement Solutions, LLC
3.
© 2013 by
HealthCare Quality Improvement Solutions, LLC
4.
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 © 2013 by HealthCare Quality Improvement Solutions, LLC
5.
ED Triage ED Registration ED
Care ED Transportation Inpatient Admission Inpatient Care Discharge Home Pharmacy Housekeeping Transportation 5 © 2013 by HealthCare Quality Improvement Solutions, LLC
6.
Patient Flow Value
Streams Outpatient Emergency Department Outpatient Surgery Outpatient Clinics Inpatient Medical Surgical Cardiothoracic Orthopedic Obstetrics Pediatrics 6 © 2013 by HealthCare Quality Improvement Solutions, LLC
7.
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 © 2013 by HealthCare Quality Improvement Solutions, LLC
8.
ED Triage ED Registration ED
Care ED Transportation Inpatient Admission Inpatient Care Discharge Home Pharmacy Housekeeping Transportation Waste Waste Waste Waste 8 © 2013 by HealthCare Quality Improvement Solutions, LLC
9.
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 © 2013 by HealthCare Quality Improvement Solutions, LLC
10.
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 © 2013 by HealthCare Quality Improvement Solutions, LLC
11.
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 © 2013 by HealthCare Quality Improvement Solutions, LLC
12.
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 © 2013 by HealthCare Quality Improvement Solutions, LLC
13.
© 2013 by
HealthCare Quality Improvement Solutions, LLC
14.
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. 14 © 2013 by HealthCare Quality Improvement Solutions, LLC
15.
Current State Value
Stream Map 15 © 2013 by HealthCare Quality Improvement Solutions, LLC
16.
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 16 © 2013 by HealthCare Quality Improvement Solutions, LLC
17.
Current State Value
Stream Map What is Current State? A value stream map that represents the process steps, flow of patients , services and information as they exist today. 17 © 2013 by HealthCare Quality Improvement Solutions, LLC
18.
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 © 2013 by HealthCare Quality Improvement Solutions, LLC
19.
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 19 © 2013 by HealthCare Quality Improvement Solutions, LLC
20.
Current State VSM
Step 1: 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 20 © 2013 by HealthCare Quality Improvement Solutions, LLC
21.
Current State VSM
Step 2: 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 © 2013 by HealthCare Quality Improvement Solutions, LLC
22.
Current State VSM
Step 2: 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 © 2013 by HealthCare Quality Improvement Solutions, LLC
23.
Current State VSM
Step 3: 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 © 2013 by HealthCare Quality Improvement Solutions, LLC
24.
Current State VSM
Step 4: Map Information Flow Electronic Information Flow Fax Transmission Manual Information Flow Telephone Walk 24 © 2013 by HealthCare Quality Improvement Solutions, LLC
25.
Current State VSM
Step 4: 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 © 2013 by HealthCare Quality Improvement Solutions, LLC
26.
Current State VSM
Step 5: Add Timeline 26 © 2013 by HealthCare Quality Improvement Solutions, LLC
27.
Current State VSM
Step 5: Add Timeline Value Added Time Non-Value Added Time Value Added Time 27 © 2013 by HealthCare Quality Improvement Solutions, LLC
28.
Current State VSM
Step 5: 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 © 2013 by HealthCare Quality Improvement Solutions, LLC
29.
Current State Value
Stream Map 29 © 2013 by HealthCare Quality Improvement Solutions, LLC
30.
© 2013 by
HealthCare Quality Improvement Solutions, LLC
31.
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 © 2013 by HealthCare Quality Improvement Solutions, LLC
32.
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 © 2013 by HealthCare Quality Improvement Solutions, LLC
33.
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 © 2013 by HealthCare Quality Improvement Solutions, LLC
34.
Future State VSM
Step 2: 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 © 2013 by HealthCare Quality Improvement Solutions, LLC
35.
Future State VSM
Step 2: Evaluate Current State Map 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 © 2013 by HealthCare Quality Improvement Solutions, LLC
36.
Future State VSM
Step 2: Evaluate Current State Map 13.7% VA © 2013 by HealthCare Quality Improvement Solutions, LLC
37.
Future State VSM
Step 3: 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 © 2013 by HealthCare Quality Improvement Solutions, LLC
38.
Future State VSM
Step 4: Map The Future State: Set Goals FS 20 FS 30 FS 15/15 38 © 2013 by HealthCare Quality Improvement Solutions, LLC
39.
Future State VSM
Step 4: Map The Future State: Determine Improvements 39 © 2013 by HealthCare Quality Improvement Solutions, LLC 16.0% VA
40.
© 2013 by
HealthCare Quality Improvement Solutions, LLC
41.
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 © 2013 by HealthCare Quality Improvement Solutions, LLC
42.
Future State Implementation
Segments DischargeED Bed Management 42 © 2013 by HealthCare Quality Improvement Solutions, LLC
43.
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 © 2013 by HealthCare Quality Improvement Solutions, LLC
44.
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 © 2013 by HealthCare Quality Improvement Solutions, LLC
45.
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 © 2013 by HealthCare Quality Improvement Solutions, LLC Conduct at minimum a quarterly review
46.
Value Stream Management
Components Value Stream Manager Visual Control Real-time Problem Solving & Process Improvement 46 © 2013 by HealthCare Quality Improvement Solutions, LLC
47.
Value Stream Management
Components Value Stream Manager 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 © 2013 by HealthCare Quality Improvement Solutions, LLC
48.
Value Stream Management
Components 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 © 2013 by HealthCare Quality Improvement Solutions, LLC
49.
Value Stream Management
Components 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 © 2013 by HealthCare Quality Improvement Solutions, LLC
50.
Value Stream Management
Components 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 © 2013 by HealthCare Quality Improvement Solutions, LLC
51.
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 © 2013 by HealthCare Quality Improvement Solutions, LLC
52.
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 © 2013 by HealthCare Quality Improvement Solutions, LLC
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HealthCare Quality Improvement Solutions, LLC
54.
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 © 2013 by HealthCare Quality Improvement Solutions, LLC