Value and Waste

Value and WasteValue Stream Mapping in a Health

Care Environment

Aims of the session:

• Introduce the concept of Value Stream 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

REPORTS ADMISSION AT FRONT RECEPTION.DETAILS CHECKED

PATIENT ARRIVES RECEPTION DAY SURGERY

TAKE PATIENT TO WARD AND TO BED AREA WITH NOTES. ADVICE TO UNDRESS/GOWN ON. TELL NURSING STAFF.

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 X-RAY WAITING ROOM.

1ST KUB - KID URETER BLADDER X-RAY. PATIENT FULL BLADDER.2ND ULTRASOUND 20-30 MINS IN RADIOLOGY.

PATIENT X-RAY AND ULTRASOUND REPORT BACK - BACK TO BED.

DOCTOR SPEAKS TO PATIENTS - CONSENT SIGNED

THEATRE STAFF ATTEND DAY SURGERY - DATA SHEET GIVEN TO DAY SURGERY STAFF.

THEATRE STAFF TAKE PATIENT STRAIGHT INTO MINOR OP THEATRE.

TEST 10-15 MIN ALLOCATION

DR CANNING 3 1/2 HOUR SESSION

VERBAL REPORT TO PATIENT AND INFORMATION.

TAKEN BACK TO DAY SURGERY

MAKE SURE PATIENT OK - ? DRINK OR EAT. DISCHARGE INSTRUCTIONS

IF DOCTOR NEEDS TO SEE- APPOINTMENT MADE STRAIGHT AWAY - GIVEN TO PATIENT

FOLLOW/REVIEW AT OUTPATIENTS VOL APPOINTMENT NEXT DAY. INDICATED ON CARE PATHWAY

IF RAH DR WILL INDICATE ON TAPE - SECRETARY WILL ARRANGE.

Process mapping

PATIENT ATTENDS RADIOLOGY DEPARTMENT FOR ULTRASOUND

AFTER SCAN PATIENT REPORTS TO RECEPTION DESK IN OUTPATIENTS DEPARTMENT

NURSE ESCORTS PATIENT TO CHANGING ROOM WITHIN THE

EXAMINATION ROOM. PATIENT CHANGES INTO GOWN AND JOINS DOCTOR IN THE EXAM ROOM

DOCTOR EXPLAINS EXAMINATION AND CONSENTS PATIENT.

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

• 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

What is value?

• Who are your patients?• What is the ‘value’ your patient wants?• How is the value added?• When you describe value use the patients'

words

Define value in your service

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

Porters Radiology Dept

Responsible clinically for the patient GP Surgery GP GP

Radio-logy reception

Radio-logy Dept

Radio-grapher SCW

Radio-logy reception GP Surgery GP

Typ

ist Typist collects

tape, films & XR

Typist types draft report & emails to Radiolo-gist

Typist amends report and emails to Radiologist

Typist emails report to GP and copies Reception

Por

ter

Porter collects old films and takes to Radiology Reception

Film

Sto

re

Film store staff pull old films

Film Store Staff ring porter

Film store log notes, split and file them

Rad

iolo

gist

Radiologist takes XR form and films to his office to report. Wants to compare with previous films

Radiol-ogist dictates report and takes tape, films and XR card to Reception

Radiol-ogist reviews email report and amends, sends back to typist

Radiol-ogist agrees report

Rad

iog

raph

er

Radio-grapher takes XRs

Radio-grapher checks XRs

Reception send XRs to Film Store and file notes. Close episode on computer

Rad

iol-

ogy

SC

W

SCW takes XR form to Reception

Rad

iolo

gy R

ecep

tion

Radiology reception staff book appointment on IT system

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

Reception staff request previous films

Radiology Reception staff log old films but can't find latest one

Radiology Reception staff search for films and notes and locate in Radiolo-gist'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

Sur

gery

GP assesses patient

GP gives patient XR form

GP and patient agree referral to Ortho OPD necessary

GP

Sur

gery

Receptionist makes appointment

GP surgery receive report and recall patient

P

atie

nt

Patients wife rings GP Surgery

Patients wife rings XR Dept

Patient Process Steps

Patient has hip pain

Patient assessed by GP

Patient arrives XR Dept

Patient undresses

Patient in Waiting Room

Patient called to XR Room

Radio-grapher positions patient

Patient has XR

Patient dresses

Patient goes home

Patient sees GP. Referred Ortho Out Patients

Value Time

Time Hrs:Mins 0:10 0:05 0:10 0:45 0:05 0:05 0:10 0:05 0:10 0:10 0:05 0:10 0:05 0:15 0:05 5:30 1:00 1:30 0:10 0:15 1:10 0:10 0:15 0:10 0:10 0:05 0:10 0:10 0:10 0:15 0:25

Days Day 1 Day 3 Day 4 Day 8 Day 12 Day 14 Day 17 Day 18 Day 20 Day 22 Day 23 Day 25 Day 30 Day 33 Day 34 Day 36 Day 38 Day 40 Day 44 Day 48 Day 73

Work in progress 5 patients in GP Waiting room

3 people queuing at XR Reception

8 patients in XR Waiting room

102 cards in queue

Radiologist takes 25 cards and x-rays, leaves 77 behind

Stack of 26 other pulled films

Queue of 135 cards& X-rays

Radiol-ogist reports 28 films

Add to queue of 117 films

Collects 25 cards & X-rays, leaves 150 behind

Types 25 reports

Reviews 25 reports, amends 13

Amends 8, leaves 5 in queue

GP receives 19 X-Ray reports from 3 typists

Over 1000 films to be filed

GP

SCWOPD

General Practitioner

Support Care WorkerOut Patient Department

GP / GP Surgery Radiology Dept

VerbalElectronic

Written / Visual

Value Steps

Total Steps (patient)

Radiology Dept Radiology Dept GP / GP Surgery

Communication

Phone / Bleep

ABBREVIATIONS

Notes: Non digital XR system!

Value Time

Work in Progress

Total Time

CURRENT STATE MAP SUMMARY

2 hrs

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


Runners, Repeaters and Strangers - 100% of all activity


MRI Team, NHS Tayside

•220 codes for appointments MRI RIE - 63% of MRI throughput from 2.7% of - 63% of MRI throughput from 2.7% of procedure codesprocedure 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 guideLangley et al 1996

What change can we make that will result in an improvement ?

Act

• What changes are to be made?

• Next cycle?

Plan• Objective• Questions and predictions (why)• Plan to carry out the cycle (who, what, where, when)• Plan for data collection

Study• Complete the analysis of the data

•Compare data to predictions

•Summarize what was learned

Do• Carry out the plan• Document problems and unexpected observations• Begin analysis of the data

PDSA Worksheet

MODEL FOR IMPROVEMENT

Objective for this PDSA Cycle

DO: CARRY OUT THE CHANGE OR TEST; COLLECT DATA AND BEGIN ANALYSIS.

DATE:____CYCLE:____

PLAN :QUESTIONS :

PREDICTIONS :

PLAN FOR CHANGE OR TEST: WHO, WHAT, WHEN, WHERE

PLAN FOR COLLECTION OF DATA: WHO, WHAT, WHEN, WHERE

PDS

A

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

PDSAs to inform Patients about new

appointment system

PDSA on ‘Pre-Bookable’ and ‘On

the day’ appointments

PDSA to Introduce Telephone

Consultations

PDSAs PDSAs PDSAs

PDSAs to ensure Phone Appts are provided at most

appropriate time of day

Scottish Primary Care CollaborativeAyrshire GP Practice

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GP 3rd Available Appointment

Diabetes (blood pressure) Improvements with PDSAs

PDSAs to improve shared diabetes information with Secondary Care

PDSA to contact all Patients who have not had a BP check

in the last year

PDSAsPDSAs PDSAs

PDSAs to improve current patient recall system

PDSAs to Validate Diabetes Register

Scottish Primary Care CollaborativeBorders GP Practice

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% of Diabetes Patients with a BP<140/80

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

Sort

Get rid of clutter Set in order

Organise the work area

Shine

Clean the work area

Standardise

Doing the same thingevery time

Sustain

Maintain through empowerment,commitment and discipline

6SSafety

Having a safe working environment

“Having a place for everything, and everything in its place”

Workplace reorganisation

Money is tied up in inventory gathering dust because of Money is tied up in inventory gathering dust because of a supply chain process which is not aligned with the a supply chain process which is not aligned with the patient pathway value streampatient pathway value stream

In amongst this is back up In amongst this is back up emergency equipmentemergency equipment

Clutter- time wasted Clutter- time wasted trying to find thingstrying to find things

Stracathro -theatre store room

3 - Benefits gained from 6S

Tray Room before…Tray Room before… ……and afterand after

6S checklist of the tray roomMonth Week 1 2 3 4 5 1 2 3 4

Date

Initials

2

3

4

5

6

7

8

9

Drawers / cupboards tidy

Floor kept clear of objects

Ensure rotation of trays

Staff on cleaning rota to check stock dates monthly

Wipe down of work surfaces

Tray room June-Oct

Location

6S Check Sheet Area

1 2 3 4 5Just beginning Focus on basics Make it visual Focus on consistency Focus on prevention

SORTSeparate the essential from

the non-essential

Necessary and unnecessary items are mixed throughout

the workplace

Necessary and unnecessary items

are separated

Unnecessary items have been removed from the

workplace.

A dependable, documented method (e.g.

red tagging) has been established to keep the

work area free of unnecessary items

Employees are continually seeking

improvement opportunities

SETA place for everything and

everything in its placeItems 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.

A dependable documented method has

been developed to provide continual evaluation, and a

process is in place to implement

improvements

1 2 3 4 5 Comments

6S Check Sheet Area

1 2 3 4 5Just beginning Focus on basics Make it visual Focus on consistency Focus on prevention

SORTSeparate the essential from

the non-essential

Necessary and unnecessary items are mixed throughout

the workplace

Necessary and unnecessary items

are separated

Unnecessary items have been removed from the

workplace.

A dependable, documented method (e.g.

red tagging) has been established to keep the

work area free of unnecessary items

Employees are continually seeking

improvement opportunities

SETA place for everything and

everything in its placeItems 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.

A dependable documented method has

been developed to provide continual evaluation, and a

process is in place to implement

improvements

SHINEClean everything and check

it is in working order

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

STANDARDISEMake things easy to

maintain

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

SUSTAINMake it a part of everyday

life

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

SAFETYMake a safe working

environment with safe working systems

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

all users

Medical Devices are correctly maintained.

Workplace is free from hazards. Everyone takes ownership to identify and contiually improve ward

safety.

1 2 3 4 5

Theatre Tray Room - 6S Score

0

1

2

3

4

5Sort

Set

Shine

Standardise

Sustain

Safety Score After 6S

Current Score

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 – 2wks RIE Week RIE + 2wks RIE + 4wks

Review Progress

RIE + 6wks RIE + 12wksor byagreement

Remove Blockages

Measure Improvements

Final Presentation(Project Closure)

Share Success

Local Ownership& Sustainability

Team Leader toProduce:• Report• Action Plan

Support

• Run RIE Pre- Meeting

• Run RIE Awareness visits

ManagementCommitment 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

RIEArea

Identified

RapidImprovement

Event

- Ross International

One team’s experience

NHS Tayside Urology RIE

Documents

Value and Waste