value and waste
DESCRIPTION
Value and Waste. Value 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. - PowerPoint PPT PresentationTRANSCRIPT
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 appoint- ment 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 appoint- ment
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
50% of all possible procedures
Runners, Repeaters and Strangers - 100% of all activity
100% of all possible procedures
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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ays
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