ED-PIP Wave 4: Team Lead Training

April 2011
Ontario Ministry of Health and Long Term Care
Introduction to Value Stream Mapping
Session Learning Objectives
1
Session Objectives
By the end of this session, you should be able to
Lead a value stream mapping session
Determine value added steps and waste
Identify and prioritize high level opportunities for improvement
Time
1.25 hours
Module
Introduction to Value Stream
Mapping
Topic Area
Lean Concepts and
Tools
Value Stream Mapping Overview
A value stream map (VSM) is a pictorial representation of how things flow
through the system from beginning to end (e.g., patient flow, information
flow, lab request flow).
It is used to highlight any inefficiencies in the current system (i.e., waste,
flow issues, examples of variability)
A VSM provides a great framework for opportunity identification and
solution development
Allows the team to See the
flow of the value stream and
wastes in the flow
2
11
Working Draft -Last Modified 11/ 07/ 2007 9:18:16 PM
Printed 24/ 06/ 2007 3:18:33 PM
Admi ssi ons process map (1 of 2)
Source: Teamanalysis
Related Activities
Admissions process step
End of Admissions process
Additional
diagnostics
conducted
Additional
diagnostics
conducted
Communication
process re DTAis
inconsistent
There is no flag
that a patient is
being admitted
Communication
process re DTAis
inconsistent
There is no flag
that a patient is
being admitted
Phone on floor may be busy
Unit clerk may be slowto
tell Admitting about an
open bed
Decision is subject to
discharges, priorities,
transfers, and workload
Phone on floor may be busy
Unit clerk may be slowto
tell Admitting about an
open bed
Decision is subject to
discharges, priorities,
transfers, and workload
There is no standard
formfor communicating
requirements
sometimes key info is
missing
Phone in admitting may
be busy
There is no standard
formfor communicating
requirements
sometimes key info is
missing
Phone in admitting may
be busy
Patient
discharged
fromED
Patient
discharged
fromED
0 2+ days
Admission
ordered
Admission
ordered
20 seconds
EDClerk
notified
EDClerk
notified
30 seconds
Admissions
Clerk notified
Admissions
Clerk notified
30 seconds
Inpatient
record created
Inpatient
record created
60 seconds
Unit Clerk
notified
Unit Clerk
notified
15 20 minutes
Bed
assignment
negotiated
Bed
assignment
negotiated
30 seconds
EDCharge
Nurse notified
of assignment
EDCharge
Nurse notified
of assignment
2 3 4 5 6 7 1
Bed Clerk lacks transparency into discharges
Bed Clerk may batch notification to EDCharge
Nurse if multiple upcoming beds
Bed assignment may be re-worked if:
Incomplete/ incorrect info
Change in priorities for Admitting or Unit
Change in patient condition / needs
Unit Clerk may ask Admitting Clerk not to tell ED
of assignment to prevent calls fromEDstaff
Bed Clerk lacks transparency into discharges
Bed Clerk may batch notification to EDCharge
Nurse if multiple upcoming beds
Bed assignment may be re-worked if:
Incomplete/ incorrect info
Change in priorities for Admitting or Unit
Change in patient condition / needs
Unit Clerk may ask Admitting Clerk not to tell ED
of assignment to prevent calls fromEDstaff
May be either
Senior Resident
or Consultant
Senior MDmay
delegate to
junior colleague
without decision-
making authority
MDusually tells
EDNurse to tell
EDClerk
MDmay write
orders in chart
and not tell
anyone
MDmay call
Admitting
directly and
bypass ED
Nurse and ED
Clerk
EDClerk calls
Admissions
Clerk with key
info (e.g.,
precautions,
special care
needs, tests
booked
Admitting Clerk
schedules
patient in
Registration
system
EDClerk creates
admission
package (e.g.
armband,
paperwork)
Admission Clerk
calls with name,
Pin #, and
special
requirements
Unit Clerk notes
patient in Red
Book
Admissions
Clerk and Unit
Clerk negotiate
placement and
transfer time
If bed not ready,
Unit Clerk may
give estimated
time for transfer
Admitting Clerk
calls EDCharge
Nurse (on
dedicated
phone) to share
assignment
n/ a
0 15 min 0 10 min 0 15 min 0 30 min 0 30 min
DRAFT
0 5 min
EDlacks
transparency on
timing of transfer
(e.g., 80%of time
Unit Clerk does not
give estimated time)
EDlacks
transparency on
timing of transfer
(e.g., 80%of time
Unit Clerk does not
give estimated time)
11
Working Draft -Last Modified 11/ 07/ 2007 9:18:16 PM
Printed 24/ 06/ 2007 3:18:33 PM
Use of zeros after
decimals (1.0 mg) in
written orders
Use of zeros after
decimals (1.0 mg) in
written orders
Root cause anal ysi s
Respiratory depression in
elderly EDpatient
Morphine overdose
(10 mg instead of 1 mg)
Order not clarified Order not clarified Lack of independent double check
for narcotic administration
Lack of independent double check
for narcotic administration
Lack of awareness of
dangerous
abbreviations and dose
designations
Lack of awareness of
dangerous
abbreviations and dose
designations
Lack of widespread
implementation of Do
Not Use abbreviation
lists
Lack of widespread
implementation of Do
Not Use abbreviation
lists
Previous experience with
administering 10 mg dose
without incident.
Previous experience with
administering 10 mg dose
without incident.
Environmental
distractions
Environmental
distractions
Organizational
culture
Organizational
culture
Physician
attending to acute
MI patient
Physician
attending to acute
MI patient
EDpreparing for
concurrent arrival of
two CTASI patients.
EDpreparing for
concurrent arrival of
two CTASI patients.
Lack of
experience with
morphine dosing
in elderly patients
Lack of
experience with
morphine dosing
in elderly patients
Newgrad Newgrad Orientation
process
Orientation
process
EXAMPLE
Problem
Why No. 1
Why No. 2
Why No. 3
Why No. 4
Why No. 5
Step 2: IDRoot Cause
Source: McKinsey 9
W
orking Draft -Last Modified 19/02/2008 4:05:55 PM
Printed 22/07/2007 1:55:41 PM
Main ED Opportunities
Opportunity Possible solution
Ease of
implementation
High
Low
Physicians Nurses
Sr
Admin Clerks
Key stakeholders
Improve ED
LOS for CTAS
IV patients

Improve ED LOS
for CTAS III
patients
Implement Rapid Assessment Zone (RAZ)
Patient
benefit

Improve utilization of existing Fast Track

Other

1
2
3
5

Improve Lab/ DI
processes
tbd
4
DRAFT
Performance Management
Operational improvements Culture and capabilities
communication Overview Solution
design Diagnostic Control and
Roll-out
Pilot and
Implementation Prepare
Performance Management
Operational improvements Culture and capabilities
communication Overview Solution
design Diagnostic Control and
Roll-out
Pilot and
Implementation Prepare
100
Example #2: Patient Discharge
Diagnostic Phase: Guides TEMPLATE
Deliver care
Patient Discharge Patient discharge Patient discharge papers Nurse
Nurse Patient discharge papers Discharge decision /
activities
Discharge decision Ward Clerk
Ward Clerk Discharge Disposition
Decision
Assign bed and admissions
Patient Assessment
Triage / Reception Patient info / symptoms Patient
Customer Output Process Input Supplier
Notes:
For this example, the first 4 process steps were linked together into one step for the high level process
The Customer must be the Supplier for the next row down: Ward Cl erk is the first Customer and the
second Supplier
Generally, the output becomes the input for the next row down: Discharge decision is the first Output and
the second Input
SIPOC
Value Stream
Map
Opportunities
Root Cause
Analysis
What are the highest
impact opportunities
for improving the
process?
What is the root
cause of the
problem?
How does the process
currently work?
How does a Value Stream Map fit into the approach?
3
Waste can occur at any step in a process
4
Value added
(for the
patient)
Activities performed to meet the
customer (or patients) requirements
Steps must be important to the
customer, they must change the thing
going through the process and they
must be done right the first time
Value added
(for the
organization)
Waste
Steps are required due to legal,
fiduciary, fiscal, compliance, etc
reasons
Contributes to running the
organization and is indirectly providing
value to the customer
Steps do not contribute directly to
fulfilling customer needs
Steps in any process can be
Our goal is to
Eliminate waste
Minimize the time
required to do
organization
value-added steps
Example of a Value Stream Map
5
Example: Testing a blood sample
6
STEP 1: Define customer requirements
Who are our customers?
What do they want?
When do they want it?
Customer
Requirements
Lab results need to
be accurate
Urgent need for
results asap

Example: Testing a blood sample
7
STEP 2: Identify key steps in the process
Customer
Requirements
Lab results need to
be accurate
Urgent need for
results asap

Blood sample
taken
Label &
register
sample
Store sample Test sample
Capture
results
Example: Testing a blood sample
8
STEP 3: Gather process data
Customer
Requirements
Lab results need to
be accurate
Urgent need for
results asap

CT = 1 min CT = 2 min CT= 1.5 hr CT = 2 min
CT refers to Cycle Time, the
time to complete the step from
start to finish
CT = 30 min
Blood sample
taken
Label &
register
sample
Store sample Test sample
Capture
results
Example: Testing a blood sample
9
STEP 4: Identify additional information including material/information flows
Customer
Requirements
Lab results need to
be accurate
Urgent need for
results asap

Customer
order
Results
Available
80% < 2 hrs
Very variable
(single test
takes 10
min)
Blood sample
taken
Label &
register
sample
Store sample Test sample
Capture
results
CT = 1 min CT = 2 min CT= 1.5 hr CT = 2 min CT = 30 min
Example: Testing a blood sample
10
STEP 5: Determine time between steps
2 hrs
Customer
Requirements
Lab results need to
be accurate
Urgent need for
results asap

Customer
order
Results
Available
80% < 2 hrs
Very variable
(single test
takes 10
min)
CT = 1 min CT = 2 min CT= 1.5 hr CT = 2 min CT = 30 min
Blood sample
taken
Label &
register
sample
Store sample Test sample
Capture
results
10 sec 30 sec
(transport)
30 sec
(walking)
15 min
(waiting)
2 hrs
Example: Testing a blood sample
11
Value-add: ~15 min
Non value add ~ 6 hrs
STEP 6: Identify value add and non-value add times
2 hrs
Customer
Requirements
Lab results need to
be accurate
Urgent need for
results asap

Customer
order
Results
Available
80% < 2 hrs
Very variable
(single test
takes 10
min)
CT = 1 min CT = 2 min CT= 1.5 hr CT = 2 min CT = 30 min
Blood sample
taken
Label &
register
sample
Store sample Test sample
Capture
results
10 sec 30 sec
(transport)
30 sec
(walking)
15 min
(waiting)
2 hrs
VA VA VA
NVA NVA NVA NVA NVA NVA
NVA VA 10 mins
Example: Testing a blood sample
12
Value-add: ~15 min
Non value add ~ 6 hrs
STEP 7: Determine initial areas of opportunity
2 hrs
Customer
Requirements
Lab results need to
be accurate
Urgent need for
results asap

Customer
order
Results
Available
80% < 2 hrs
Very variable
(single test
takes 10
min)
CT = 1 min CT = 2 min CT= 1.5 hr CT = 2 min CT = 30 min
Blood sample
taken
Label &
register
sample
Store sample Test sample
Capture
results
10 sec 30 sec
(transport)
30 sec
(walking)
15 min
(waiting)
2 hrs
VA VA VA 10 mins VA
NVA NVA NVA NVA NVA NVA
NVA
Opportunities
Potential Areas to
focus on
Tips for generating a Value Stream Map (VSM)
13
Map the patients journey, not the providers journey.
Think in terms of the process not departments, professions or individuals.
80/20 - Focus on the main flow and key sub-processes as well as those processes that
have long lead times, high volume or high impact there is no need to map the flow of every
discrete part or input
Collect current state information for how long things take (e.g., wait, travel and service
times), for hours of operation, varying practices, etc - observing a patient and documenting the
experience and times is powerful in building credibility
Include informal information flows (e.g., phone calls, hallway conversations, hand written
notes)
VSMs are non-evaluative focus on the process, not the people doing the work
Map with a cross sectional team, dont paste individual members parts of the process
together
Keep the unit and measurement of time consistent throughout the map (i.e. Map per patient
throughout the map; map in minutes or hours but keep it consistent)
Review: steps for creating a value stream map
14
1. Define customer requirements
2. Identify key steps in the process
3. Gather process data
4. Identify additional information including material/information flows
5. Determine time between steps
6. Identify value add and non-value add times
7. Determine initial areas of opportunity
Materials for a value stream session
15
Process Step
Additional
Information
Cycle Time
1. Brown (Butcher) Paper
2. Post it Notes 5 different colours
Opportunities
Wait Time
between Steps
Assign a facilitator to lead the session they
should be the only one adding post-it notes on
the butcher paper
Assign a scribe from the team for each post-it colour
3. Tape and sharpies
How will it look.
16
Registration
Nurse
Assessment
MD
Assessment
- Nurse
- Triage
Form &
health card
- 24 / 7
- Nurse
- Patient
Chart
- 24 / 7
- MD
- Patient
Chart
- Tracking
Board
- 24 / 7
3 to 5 mins 5 to 10 mins
10 to 15
mins
60 to 90
mins
20 to 180
mins
Reduce Door
to Doc time
Additional information can include who is doing the step, what is the
input to the step, hours of operations, reasons for variability, etc
Roles for Value Stream Mapping session
17
Lead the mapping exercise
Keep the group on task
Ensure the group is focused at the right level of detail
Facilitator
(1)
Scribes
Content
Experts
Outside Eyes
Record key information onto post-it notes
Support the facilitator
Provide your knowledge and experience
Try not to get into the weeds
Make sure you understand the process that is being described
if you dont understand it, the context experts may have missed
something
Think critically, ask questions

Where should you focus your efforts??
18
Value-add: ~15 min
Non value add ~ 6 hrs
STEP 7: Determine initial areas of opportunity
2 hrs
Customer
Requirements
Lab results need to
be accurate
Urgent need for
results asap

Customer
order
Results
Available
80% < 2 hrs
Very variable
(single test
takes 10
min)
CT = 1 min CT = 2 min CT= 1.5 hr CT = 2 min CT = 30 min
Blood sample
taken
Label &
register
sample
Store sample Test sample
Capture
results
10 sec 30 sec
(transport)
30 sec
(walking)
15 min
(waiting)
2 hrs
VA VA VA 10 mins VA
NVA NVA NVA NVA NVA NVA
NVA
Opportunities
Potential Areas to
focus on
At your table agree on what is the
single best opportunity to pursue
with rationale to why.

Be prepared to share/debrief.
Exercise
19
When identifying opportunities, think about
Where are the biggest pain points for patient? Staff?
Which non-treatment related steps take the most time?
Where do patients spend the most time waiting?
Which steps are prone to errors?
What steps are the most frustrating for the staff?
What are the most complaints from patients?
Where are there frequent handoffs?
Where are there frequently quality issues?

Identifying Opportunities
20
Difficult Easy
High
Low
Ease of implementation
Impact
What additional questions do you need answered to be more
confident in where you placed each opportunity?
Focus initially on
opportunities that are
high impact and easier
to capture
Prioritization Matrix
21
Difficult Easy
High
Low
Ease of implementation
Impact

Example Lean ED Prioritization Matrix
22
Opportunity 1
Opportunity 5
Opportunity 3
Opportunity 4
Opportunity 7
Opportunity 2
Opportunity 6
So what do you do next as the
Team Lead???
Discussion
23
What would you do next??
24
Value-add: ~15 min
Non value add ~ 6 hrs
STEP 7: Determine initial areas of opportunity
2 hrs
Customer
Requirements
Lab results need to
be accurate
Urgent need for
results asap

Customer
order
Results
Available
80% < 2 hrs
Very variable
(single test
takes 10
min)
CT = 1 min CT = 2 min CT= 1.5 hr CT = 2 min CT = 30 min
Blood sample
taken
Label &
register
sample
Store sample Test sample
Capture
results
10 sec 30 sec
(transport)
30 sec
(walking)
15 min
(waiting)
2 hrs
VA VA VA 10 mins VA
NVA NVA NVA NVA NVA NVA
NVA
Opportunities
Potential Areas to
focus on
Opportunity
Description
Expected Impact
(small/med/large)
Ease of
Implementation
(easy/med/difficult)
Important Questions to
Answer
Owner




High impact opportunities
identified from Value Stream Map
Review your VSM to identify any opportunities to improve the patient experience and remove
waste
Estimate the impact of capturing each opportunity and how easy it will be to do so
Highlight what key questions are left to be answered related to the opportunity what do you
still need to know
Identify which team member will own this opportunity
Remember take advantage of the expertise and range of experience around the table!
Confirm that it is really an opportunity
25
Checklist Best Practice
Have representation from all key stakeholder groups
Ensure the room has sufficient wall space to post value stream
mapping paper and flip chart paper
All supplies are available value stream mapping paper (butcher
paper), 5 different post-it note colours, markers and tape
Set session norms at the beginning of a session to set
expectation and guides for interaction
Deliver a short Introduction to Lean presentation covering value
stream mapping and 8 wastes
Have clear roles and responsibilities facilitator and scribes
If you have data available prior to sessionuse it!




Conducting a value stream mapping session
26
Documents the process as experienced by the patient
Builds consensus across the team and with
stakeholders on the current state
Helps visualize waste and the source of waste
Provides a common language to talk about the process
Helps identify and align on key opportunities
Summary of the benefits of a Value Stream Map
27
VSM facilitation: tips and tricks
Consider: are there other ways the work could be flowing?
E.g., loop back, parallel processing
Confirm that everyone understand where the steps under consideration begins and
ends
Put a question mark instead of a process step and move on
If you get
stuck
Use the 80/20 rule to focus the group what happens 80% of the time
Summarize their issue as an opportunity, write a pink sticky and move on
If the group is debating, but theres no evidence, cut the debate off and put a note
about fact finding into the parking lot
Dont be afraid to cut people off, just do it with energy and a smile!

If the group is
going off track
Establish a concise set of group norms that give you the authority to effectively
facilitate
Establish a parking lot where issues that are out of scope can be captured
Set an aggressive time limit for the mapping portion, but plan to go over; groups
are more efficient when theyre running out of time
E.g., book a 3 hour meeting, but schedule 2 hours for the VSM and 1 hour for
project planning
Clearly define the scope of the processes to be mapped
Setting up the
day
Recognize: youll never please everyone, just do the best you can to capture the
collective knowledge of the group
Keep momentum and energy; dont let the group slow down
As the facilitator, you control the language that goes on the map
Dont let the scribes paraphrase
While youre
mapping
28
Questions?
29