Value stream mapping and process mapping

Detailed Process Mapping ResourcesWeb:

Six Steps to a Process Map

Value Stream Mapping ResourcesWeb:

Create a Map using VisioValue Stream Mapping Symbols

Detailed Process Map:- Identifies the major output, and outputs within a process- Identifies and classifies process inputs- Provides a very detailed look at a process- Follow the sequence of events for each input

Source: isixsigma.com

Value Stream Mapping:- Starts with a current state map describing the current service to customers- Continues with a future state map, which shows how the process will look in the future with waste reduction and process improvements- Is “a high-level look at the company’s flow of goods or services from customer to customer”- Contains 7-10 steps- Captures metrics such as cycle times, defect rates, wait times, headcount, inventory levels, changeover times, etc.

Source: isixsigma.com

Value Stream Mapping or Process Mapping?

Use Value Stream Mapping When: - You need to locate the bottleneck in a process- You want to identify opportunities for future improvement efforts- You have a limited time to document a process and find problem areas

Use Detailed Process Mapping When: - You already know the bottleneck in a process- You want to find waste at the micro-level- You have time to take a very in-depth look at a particular process

CLICK HERE

VSM Visio Stencils CLICK

HERE

Journey to a Lean Enterprise: VSM

(courtesy Karen Martin)

CLICK HERE

CLICK HERE

Process Mapping for Health

Service Staff(courtesy Victorian

Quality Council)CLICK HERE

Understanding the Patient Journey –Process Mapping

(courtesy Improvement and Support Team,

Health Delivery Directorate, Scottish

Government)

CLICK HERE

Metrics Based Process Mapping


VSM Charter (courtesy Karen

Martin)CLICK HERE

Future State Implementation Plan


CLICK HERE

MBPM Charter(courtesy Karen

Martin)

CLICK HERE

MBPM 3x8 Template


CLICK HERE

PACE Improvement Prioritization Grid


Metrics Based Process Mapping Resouces

http://office.microsoft.com/en-us/visio/HA101130241033.aspx

http://www.strategosinc.com/value-stream-mapping-3.htm

http://www.strategosinc.com/process_map_example.htm

http://www.isixsigma.com/dictionary/Value_Stream_Mapping-413.htm

http://finance.isixsigma.com/library/content/c060111c.asp

http://www.flowalliance.com/html/downloads.html

Company

LOGO

1

Journey to a Lean Enterprise:Metrics-Based Process Mapping

Society for Health SystemsLean Toolkit 2009

© 2009 Karen Martin & Associates

The Work We Do:Degrees of Granularity

Value Stream

Process Process Process

Step Step Step

Value Stream Map

In the Weeds

(Tactical)

30,000 ft View

(Strategic)

Metrics-Based Process Map


What is a Metrics-Based Process Map?

A visual process analysis tool, which integrates:Functional orientation of traditional swim lane process mapsKey Lean time and quality metrics

Tactical level tool which highlights the disconnects / wastes / delays in a process

Used to “drill down” from a value stream mapHelps see “the waste behind the waste”Reveals the individual steps in a process

Often serves as the analytical and design tool in a Kaizen EventServes as standard work for workforce training and process monitoring

Metrics-Based Process Map (MBPM)


Traditional Mapping Method:Process Flow Chart

Where’s the quality? Where’s the time?


Mapping Prep

Select a skilled, objective facilitator.Create a mapping charter (see slide #8)

Define the scope (see slide #7)“Fence posts” (first and last steps).Specific situation or set of conditions so you can go “narrow and deep.”

Select the cross-functional team.No more than 10 – must currently do the work.Include representatives from all functions within the fence posts.Include external customers and suppliers, when appropriate.When possible, include objective “outside eyes.”If too many people, narrow your scope.Use same exact team for current and future state.

Schedule the activity – best to design the future state immediately after documenting the current state NOTE: If used in a Kaizen Event, the Kaizen Event Charter serves as the Charter (scope, team, etc. already established)


Admissions

Narrowing the Scope: Selected Specific Conditions

Inpatient

Outpatient

Insured

Non-Insured

Insured

Non-Insured

Briefing Schedule

1 Contact Information2 13 24 35 4

51 62 73 84 95 10


1234 Date: Date:

Signature:Date:

Executive Sponsor FacilitatorValue Stream ChampionPotential Obstacles Approvals

NameFunctionProjected Deliverables On-Call Support

Event Goals & Measurable Objectives

FunctionEvent Drivers / Current State Issues Mapping Team

Logiistics Coordinator

Briefing Attendees

Boundaries & Limitations

FS Implementation Timeframe

Metrics-Based Process Mapping CharterEvent Scope Leadership / Coordination Schedule

Start/End Times

Trigger

Specific Conditions

Process

Customer Demand

Last StepFirst Step

Value Stream Champion

Event Date(s)

Team Lead

Facilitator

Meals Provided

Location

Executive Sponsor

Signature: Signature:

Name


Documenting the Current State

Step 1 – Label the map in the upper right hand corner.

Process nameSpecific conditions mappedDateFacilitator and/or team names

Step 1: Label the map

Process Name Included/Excluded Conditions

Current State MBPM Date

Facilitator and/or Team Names

Use 36” wide white paper with 6” swim lanes – hand drawn, chalk lines, or pre-printed (plotter printer template available).



Step 2 – Label the swim lanes with the functions involved.

Include external functions, if appropriate (e.g. customers, suppliers/contractors, etc.)

Step 2: List functions

Process Name Included/Excluded Conditions

Current State MBPM Date

Facilitator and/or Team Names

Function A

Function B

Function C

Function D

Function E

Function F



Step 3 – Document all activities/steps on 3 x 6” post-its.

Use verb/noun format; clear and conciseInclude function.Separate tasks that have different quality outputs or timeframes; combine tasks otherwise.Place post-its in appropriate swim lane, sequentially.

Step1

Step2

Parallel Steps (concurrent activities)

Ticking clock

MBPM Post-it Conventions

Activity (Verb / Noun)

Function that performs the

task



Step 4 – Number the activities.Number the activities sequentially from left to right.For parallel activities, add “A,” “B,” etc.

Example: Step 8A, Step 8B, etc.Don’t number the post-its until the map is “final.”


Step #Activity

(Verb / Noun)Function that performs the

task

Step1

Step2

ParallelSteps:

8A & 8B



Step 5 – Add activity-specific information:Number of staff involved (if relevant)Barriers to flow

BatchesShared resourcesEquipment downtimeEtc.

Key metrics (include units of measure)Process Time (PT)Lead Time (LT)Percent Complete & Accurate (%C&A)


# Staff (if relevant)

Barriers to flow (if relevant)

PT (process time)

LT (Lead time)% Complete & Accurate


Task-Level Metrics: Time

Process time (PT)The time it takes to actually perform the work, if one is able to work on it uninterruptedIncludes task-specific doing, talking, and thinkingaka “touch time,” work time, cycle time

Lead time (LT)The elapsed time from the time work is made available until it’s completed and passed on to the next person or department in the chainaka throughput time, turnaround time, elapsed time


# Staff (if relevant)

Barriers to flow (if relevant)

PT (process time)

LT (Lead time)% Complete & Accurate


Key Lean Metric: Quality

%Complete and Accurate (%C&A)% time downstream customer can perform task without having to “CAC” the incoming work:

Correct information or material that was suppliedAdd information that should have been suppliedClarify information that should or could have been clear

This output metric is determined by the immediate downstream customer and all subsequent downstream customers.

Poor input quality may be the result of output that occurs far upstreamMultiply all downstream customer responses to obtain the cumulative %C&A for the output of a particular step


Metrics Reminders

Typically obtained via interview; questions must be high qualityPT & LT

You can “chunk” these metrics for a series of post-its when necessaryWhen wide variation, do one of three things:

Narrow your scope (pick a specific circumstance)Use the medianIndicate the variation, but use the median for the timeline

%C&ADetermined by immediate downstream customer and all subsequent downstream customersResponse is placed on the post-it for the output step0% at a particular step is not rare



Step 6 – Define the “Timeline Critical Path”Longest LT unless “dead-end” step

If longest LT is a dead end step, then bring the next longest LT to the timeline

Use colored marker

Step 6: Define the “Timeline Critical Path”

For parallel activities: Chose the longest LT unless a “dead-end” activity



Step 7 – Create the timelineBring down the PT & LT from the timeline critical path steps.

Step 7: Create the Timeline



Step 8 – Calculate the summary metricsTimeline PT SumTimeline LT Sum% Activity (also called Activity Ratio)

(PT Sum/Total LT Sum) x 100Rolled First Pass Yield (RFPY)

%C&A x %C&A x %C&A…Include ALL post-its, not just critical timeline path


Total PTSum of all activities, not just timeline

Labor Effort (not a staffing calculation!)

Summary Metrics: Labor Effort

Total PT (in hrs) X # occurrences/year# FTEsAvailable work hrs/year/employee

=

* FTE = Full-time Equivalent (2 half time employees = 1 FTE)

Freed Capacity = CS FTEs - FS FTEs



Step 9 – Identify the value-adding (VA) and necessary non-value-adding (N) activities

Use small colored post-its labeled with “VA” or “N”.All unlabelled post-its represent waste.NOTE – this is the first of two “bridge steps” between current state documentation and future state design.


Step 9: Label the value-adding (VA) andnecessary non-value adding (N) activities



Step 10 – Circle (with a red marker) the step-specific metrics that indicate the greatest opportunity for improvement.

Low step-specific % Activity, low %C&A, etc.This is the second of the two steps that provide the bridge between current state documentation and future state design

Step 10: Circle the data that indicates the greatest need for improvement


Islands of value-adding activitiesAll other time is “waste.”

Adding Value

Rework

First Step Last Step

Typical Current State Findings

Future State Design: How can we progress from one “VA” or “N” step to the next and eliminate all waste?

Future State DesignGoals

Reduce overall LT & PTImprove quality (increase RFPY)Increase % activityImprove LT, PT, and %C&A at individual steps

How?Eliminate root causes for non-value-adding activities

May need to use problem trees, fishbone, check sheets, Pareto, etc.Reduce handoffsEliminate reworkReduce batching, WIP & queuingReduce transportation and motion

Mapping stepsClean sheet or modify current state mapSame steps as current stateCalculate projected metrics


Metric Current StateProjected

Future StateProjected %

Improvement

CP PT

CP LT

AR

RFPY

Total PT

Labor effort

Freed capacity

Other?

Document Results

Color-Coded Summary Metrics Sheet

From Metrics-Based Process Mapping: An Excel-Based Solution, Karen Martin & Mike Osterling, Productivity Press, 2008.


Creating an Action Plan

Brainstorm improvementsEliminate those that aren’t possibleCombine those that are similarNumber the tasks sequentiallyPlace tasks accordingly on the PACE Prioritization Grid (slide #41)

PACE Prioritization Matrix

High LowAnticipated Benefit

Ease

of

Imp

lem

en

tati

on

Diff

icul

tEa

sy

20

7

513

4 23

1

2289

2

10

16

11

6

12

1419

15

173

21

18

Value Stream

1 2 3 4 5 6 7 8 9 10 11 12

2 Improve quality of referral KE Sean O'Ryan

3, 4 Reduce lead time beween schedulingand preregistration steps PROJ Dianne

Prichard

5, 6 Eliminate the need for two patient check-ins KE Michael

O'Shea

6 Eliminate bottleneck in waiting area KE Dianne Prichard

9 Eliminate lead time associated with transcription step PROJ Sam Parks

10 Eliminate batched reading KE Sam Parks

7 Reduce inventory costs, regulatory risk and storage needs KE Michael

O'Shea

12 Reduce delay in report delivery PROJ Martha Allen

12 Reduce delay in report delivery KE Martha Allen

Implement voice recognition technology

Reduce setup required

Cross-train and colocate work teams

Implement additional fax ports

Collect copays in Imaging

Balance work / level demand

5S CT supplies area; implement kanban

Value Stream Mapping Facilitator

Increase percentage of physicians receiving electronic delivery (rather than hard copy)

Approvals

Executive Sponsor Value Stream Champion

Signature:

Date: Date: Date:


Block# Goal / Objective Improvement Activity

Implement standard work for referral process

Type Owner Implementation Schedule (weeks) Date Complete

Date Created

11/21/2007Allen WardSally McKinseyDave Parks 12/13/200710/18/2007 1/10/2008

Future State Implementation PlanExecutive Sponsor

Value Stream ChampionValue Stream Mapping Facilitator

Implementation Plan Review Dates11/1/2007

Outpatient Imaging

Create an Action Plan: Who, What, When, Where, and How?


Electronic Documentation?

Archive the team’s workDistribute the maps to remote locationsDocument the new standard work for the process

Training new staff / retraining existing staffMonitoring process performance

Communicate the impact of Kaizen Events and other improvement activities

The Improved State Becomes Standard Work

From Metrics-Based Process Mapping: An Excel-Based Solution, Karen Martin & Mike Osterling, Productivity Press, 2008.


Additional Resources

Metrics-Based Process Mapping: An Excel-Based Solution, Karen Martin & Mike OsterlingThe Kaizen Event Planner, Karen Martin & Mike Osterling

45


Karen Martin, Principal7770 Regents Road #635

San Diego, CA 92122858.677.6799

[email protected]

For Further Questions

Briefing Schedule


51 62 73 84 95 10


1234 Date: Date:

Location

Executive Sponsor


Name

Meals ProvidedTeam Lead

Facilitator

Value Stream Champion

Event Date(s)Process

Customer Demand

Last StepFirst Step

Specific Conditions



Metrics-Based Process Mapping CharterEvent Scope Leadership / Coordination Schedule

Start/End Times

Trigger

Logiistics Coordinator

Briefing Attendees

Event Drivers / Current State Issues Mapping TeamFunction

Event Goals & Measurable Objectives

Projected Deliverables On-Call SupportFunction

Potential Obstacles Approvals

Name

Executive Sponsor FacilitatorValue Stream Champion

Signature:Date:

Metrics-Based Process Mapping Charter SHS 2009 © 2007 Karen Martin Associates. All Rights Reserved.

PACE Improvement Prioritization Grid

High LowAnticipated Benefit

Ease

of

Imp

lem

en

tati

on

Diff

icul

tEa

sy

20

7

5

13

4

23

1

22

8

9

2

10

16

11

6

12

14

19

15

17

3

21

18

24

Company

LOGO

Journey to a Lean Enterprise: Value Stream Mapping

Society for Health SystemsLean Toolkit 2009

Building a Lean Enterprise

The Work We Do:Degrees of Granularity

Value Stream

Process Process Process

Step Step Step

3

In the Weeds

30,000 ft View

TacticalMetrics-Based Process Map

(MBPM)

StrategicValue Stream Map

(VSM)

Value Stream Defined

Value Stream: All of the activities, required to fulfill a customer request from order to delivery.

Customer

4

Value Stream

Process ProcessProcess

CustomerRequest

CustomerReceipt

Current State Value Stream Map Outpatient Imaging Services

VSM Champion: Paul Scanner Created: February 17, 2009

Demand = 15 per day

Customer Demand:15 patients per Day

(Takt Time 1920 seconds)8 hours per day

Referring Physician

% C&A = 65 %

Check-in Patient

(Admitting)

Cycle Time = 2 mins.% C&A = 90 %

5

Send Reports

(Imaging)


6

Hospital

5 mins.

ScheduleAppointment

Cycle Time = 11 mins.Lead Time = 12 mins.% C&A = 98 %

6

Pre-register Patient


5

CT=Cycle Time LT=Lead Time %C&A=% Complete & Accurate

0.0833 hrs.

2 mins.

0.0833 hrs.

1 mins.

0.75 hrs.

10 mins.

0.5 hrs.

15 mins.

0.0833 hrs.

3 mins.

4.13 hrs.

15 mins.

6.08 hrs.

5 mins.

16 hrs.

1 mins.

1.83 hrs.

1 mins.

2 hrs.

3 mins.

LT = 32.5 hrs.

CT = 56 mins.CT/LT Ratio = 2.87%

Lead Time = 12 mins.Lead Time = 990 mins.

PrepPatient(Tech)


2

Check-inPatient

(Imaging)


3

CompleteExam(Tech)


2

TransmitImages(Tech)


2

Read/DictateExam

(Radiologist)


2

TranscribeReport (MDI)


6

ReviewDraft/Sign

(Radiologist)


2

PrintReports

(Imaging)


230 mins. 5 mins. 248 mins. 365 mins. 960 mins. 110 mins. 120 mins.45 mins.

E Pay

Excel

ADS

Symposium

Internet

Waiting RoomManagement

System

Fax OrderSolutions

PACS

5 mins.

Lead Time = 24 days

Meditech

1234

5 6 7 8 9 10 11 12 13 14

Auto Fax 50% Us Mail 25%MD Mailbox 25%

Rework Loop via Fax 25% of the time

Rolled First Pass yield = 29%

Future State Value Stream Map Outpatient Imaging Services

VSM Champion: Paul Scanner Created: February 18, 2009

Demand = 15 per day

Referring Physician

% C&A = 85 %

Send Reports

(Imaging)


6

Hospital

Schedule apptPre-register


6

CT=Cycle Time LT=Lead Time %C&A=% Complete & Accurate

0.0833 hrs.

1 mins.

0.583 hrs.

10 mins.

0.333 hrs.

10 mins.

0.0833 hrs.

2 mins.

2 hrs.

15 mins.

7 hrs.

1 mins.

0.0333 hrs.

1 mins.

0.5 hrs.

3 mins.

LT = 11.3 hrs.

CT = 43 mins.CT/LT Ratio = 6.32%

Lead Time = 45 mins.Lead Time = 15 days

PrepPatient(Tech)


2

Check-inPatient

(Imaging)


3

CompleteExam(Tech)


2

TransmitImages(Tech)


2

Read/DictateExam

(Radiologist)


2

ReviewDraft/Sign

(Radiologist)


2

PrintReports

(Imaging)


220 mins. 5 mins. 120 mins. 420 mins. 2 mins. 30 mins.35 mins.

E Pay

Excel

Symposium

Internet

Waiting RoomManagement

System

Fax OrderSolutions

PACS

5 mins.

Set-upReduction

Remove Check in

and ReduceSystem Access

Work Balancing

StandardWork

Pull System(Supplies Kanban)

VisualWorkplace

Voice Recognition

Batch Reductions

5S

Co-locate

StandardWork

Work Balance

ContinuousFlow

Value StreamAlignment

Auto Fax 80% Us Mail 15%MD Mailbox 5%

Rolled First Pass yield = 40%

Rework Loop via Fax 10% of the time

Customer Demand:15 patients per Day

(Takt Time 1920 seconds)8 hours per day

123

4 5 6 7 8 9 10 11

Risk Reduction

(Joint Commision)

Meditech

Outpatient ImagingProjected Results

7

MetricCurrent

StateProjected

Future State%

ImprovementLead Time 32.5 hrs 11.3 hrs 65%Process Time 56 mins 43 mins 23%% Activity 2.9% 6.3% 117% Rolled First Pass Yield

29% 40% 38%

# Steps 14 11 21%Tech turnover(annual)

100% 25% 75%

Types of Value Streams

Patient Care Value StreamsEmergency ServicesOutpatient ImagingSurgical ServicesObstetrics

Support/ Administrative Value StreamsRecruiting and Hiring ProcessTech SupportAccounts ReceivableAccounts PayablePayrollFacilities ManagementPhysician Credentialing

Value Stream “Loops” or “Segments”

8

Why Value Stream Mapping?

Shows the linkage between information and material flow.Makes the disconnects and obstacles to flow stand out

We begin to better understand our work “ecosystem”

Metrics-based decision making: What are you going to do to affect the numbers?Forces definition of product families.Separate maps are drawn for each product family for goods produced or services provided.

9

One VSM per Product Family

Process Steps & Equipment

Process A Process B Process C Process D Process E Process F

Products

Product ABC X X X X X

Product XYZ X X X X X

Product IBM X X X

Product AWR X X X X

Product ACC X X X

Product SUB X X X

Product IDR X X X X X X

10

Group Product Families (for goods or services) by similar downstream processes, steps or equipment.

Vol.50

73

2

5

15

12

1

Value Stream Mapping

Diagnostic toolReveals hidden symptoms of larger problems

Strategic planning activity; not tacticalBlueprint for change; road map; “north star”Helps prioritize opportunities for improvementResults in an implementation plan

Promotes systems-thinking / seeing the whole

Helps us avoid sub-optimizing

11

Individual vs. System Efficiency

12

Individual Efficiency = Sub-optimization

System Efficiency = Optimal Value Stream

Performance

Value Stream Mapping ProcessDefine

Product Family

Design Future State

Document Current State

Implement!

3 Days

Foundation (the basis) for the future state; 70-80% accurate isacceptable (directionally correct)

Create flow by eliminating waste it is now obvious from yourcurrent state map); typically 3-6months out

Products (good or services) withcommon process steps

Rep

eat

The goal of mapping!

Create Implementation Plan

Include accountability andtimeframes for completion;Implementation strategies includejust-do-its, projects, and KaizenEvents

Words of Caution

A VSM Event is not a Kaizen Event.VSMs should not be created duringKaizen Events.VSMs are a strategic improvement planning tool – done well in advance of actual improvement.

Future state VSM looks out 3-12 monthsIf your map doesn’t contain the essential elements of a VSM (information flow, product flow and timeline), it’s not a VSM.

14

Planning your Value Stream Mapping Event

Create a Value Stream Mapping CharterPlanning tool

Who, what, where, when and why?Scope, team, measurement

Communication toolHere’s what we’re committing toBegins the process of obtaining consensus and buy-in

15


Interim Briefing(s)


51 62 73 84 95 10


1234 Date: Date:

FacilitatorValue Stream Champion

Location

Coordinator

Facilitator


Event Date(s)

Customer DemandTrigger

Name

Team Lead Meals Provided?

Specific Conditions Value Stream Champion

Executive SponsorValue Stream

Last StepFirst Step

Value Stream Mapping CharterEvent Scope Leadership / Coordination Schedule

Start/End Times

Event Drivers Mapping Team

Briefing Attendees



Function

Measureable Objectives

Planned Deliverables On-Call SupportNameFunction

Executive SponsorPotential Obstacles Approvals

Signature:Date:

Setting Objectives

Objectives areMeasurableContain numbersIncludes baseline and desired state

GoalsGeneral statements of intentContain only wordsContain no baseline, nor desired state

Aim for objectives, not goalsGoal: Reduce patient throughput timeObjective: Reduce average patient throughput time from 6 to 2 hours (66.7% improvement)

17

Forming the VSM Team

No more than 10 (6-8 ideally)Primarily those who can authorize the future state

Primarily managers and aboveTo obtain data

Walk the process; interview frontline workforce during the mapping activityObtain data upfront and supply to management

Must have full time representation for all critical operations

18

Interim Briefings:Critical Success Factor

PurposeDay 1 – here’s what we’ve learned

Establishes a mental framework for embracing improvements; “sells” the need for improvement

Day 2 – here’s what we plan to doDoes anyone object? If so, why?

Day 3 – here’s how we’re going to executePriorities, approach, timeframes, accountabilityObtain final buy-in right then and there

AttendanceLeadership who will be affected by the improvement and are not on the teamLeadership who you want to “sell” on the benefits of VSMMandatory vs. courtesy invitation

19

VSM Structure & Icons

20

Typical VSM Components in Manufacturing

Process 1 Process 2 Process 3 Process 4

SUPPLIER CUSTOMER“Production

Control”

Info

rmat

ion

Flow

Prod

uct F

low

Minutes Minutes Minutes Minutes

Hours Hours Hours

Tim

elin

e

1

2

3

I I I

LT

PT

ABC Product Current State Map Demand = XXXX/yr May 8, 2008

Robert Parker

Typical VSM Components in Service/Admin Environments

Process 1 Process 2 Process 3 Process 4

CUSTOMER

Info

rmat

ion

Flow

Prod

uct F

low

Minutes Minutes Minutes Minutes

Hours Hours Hours

Tim

elin

e

1

2

3LT

PT

ABC Process Current State Map Demand = XXXX/yr

May 8, 2008 Robert Parker

I.T. I.T. I.T.

Basic Mapping Icons

Push Arrow

ElectronicInformation

Flow

ManualInformation Flow

Operator / Employee

Material receipts & shipments

Go See Scheduling

External Organization

Process Block

2 ShiftsTakt= 60m

C/O= 40 mPT= 25 m

Data BlockMovementby Truck

In-box

Minutes MinutesMinutesMinutes

Hours HoursHoursLead Time

Process Time

Timeline

Work-in-Process

I

CS VSM Process Block Necessary Information

Key metricsLead timeProcess time%C&A

I.T. Systems “touched”Data entryData access

Number of staff who perform the task

working on different “things”working on the same “thing”

Barriers to flowQueuing / oldest “thing” in processBatchingEquipment downtimeStaff inaccessibility

Excessive multi-taskingShared resourceHeavy travelVacancies

InterruptionsLong setup / changeover time

Work-in-process (WIP)

24

Relevant CS VSM

Data

Key Lean Metrics

26

Minutes Minutes Minutes

Hours Hours HoursLead Time

Process Time

Key Lean Metrics: Time

Process time (PT)The time it takes to actually perform the work, if one is able to work on it uninterruptedIncludes task-specific doing, talking, and thinkingaka “touch time,” work time, cycle time

Lead time (LT)The elapsed time from the time work is made available until it’s completed and passed on to the next person or department in the chainaka throughput time, turnaround time, elapsed time

27

Lead Time vs. Process TimeValue Stream View

28

Lead Time

Customer Request Receipt

Process Time

LT = PT + Waiting / Delays

Lead Time vs. Process TimeProcess Level View

29

Lead Time

Work Received

Work passed to next

step

Process Time

LT = PT + Waiting / Delays

Summary Metrics: Time

% Activity (also called Activity Ratio)The percentage of time work is being done to person or “thing” passing through the process

30

% Act = Timeline Total PT

Timeline Total LTx 100

Key Lean Metrics: Quality

%Complete and Accurate (%C&A)% time downstream customer can perform task without having to “CAC”:

Correct information or material that was suppliedAdd information that should have been suppliedClarify information that could have been clear

Determined by the downstream customer of the work being passed offThe customer’s response is placed on the post-it for the output step.

31

Summary Metrics: Quality

Rolled First Pass Yield (RFPY) = %C&A × %C&A × %C&A × … Out of 100 occurrences, the number of times the data/material/people pass through the entire process with no rework required (expressed as a percentage).

32


33

Current State Mapping Steps

1. Label the map in far upper right cornerValue Stream NameCurrent or Future StateCustomer DemandTakt Time (if relevant)Date map was createdFacilitator and/or mapping team names

2. Place the customer in upper right corner or center3. If relevant, place supplier in upper left corner4. Indicate how “orders” are placed and scheduled5. Add process blocks and I.T. systems

Aim for 5-15 process blocks34

Creating the CS VSM (continued)

6. Add “details”Metrics for each block (PT, LT, %C&A)Barriers to flowStaffingWIP at that momentPush arrows (connecting the process blocks)

7. Draw timeline and calculate summary metricsTotal Timeline Process Time (PT)Total Timeline Lead Time (LT)Activity Ratio (AR)Rolled First Pass Yield (RFPY)Labor Requirements (if relevant)

8. Label the “VA” (value-adding) and “N” (necessary non-value-adding) steps

Unlabelled steps = waste 35

Takt Time: The Key to Continuous Flow

36

Available work timeTakt time =

Customer demand

480 minutes/dayTakt time = = 10.6 mins

45 procedures

OR…Time Available divided by what Kustomer Takes

“Touch down”

Labor Requirements

Total PTSum of all activities, not just timeline

Labor Requirements

37

Total PT (in hrs) X # occurrences/year# FTEsAvailable work hrs/year

=

* FTE = Full-time Equivalent (2 half time employees = 1 FTE)

Freed Capacity = CS FTEs - FS FTEs

Customer-Defined Value

Value-Adding (VA) - any operation or activity your external customers valueand are (or would be) willing to pay for.Non-Value-Adding (NVA) - any operation or activity that consumes time and/or resources but does not add value to the service provided or product sold to the customer.

Necessary – support processes, regulatory requirements, etc.Unnecessary – everything else - WASTE

38© 2007 Karen Martin & Associates

VSM Notes

The process of creating the VSMs is as important as the improvements themselves.

Teaching staff how to “see” and think in new ways.Teaching staff how to simply explain complex processes.

The map should depict a complete loop (customer request to customer receipt).Someone with only a basic understanding of Lean metrics and VSM symbols should be able to interpret your maps.

Waste should be obvious.It should be highly visual.

Defining the process blocksAim for 5-15 blocksEach block represents a break in the timeline

HandoffsSignificant process delays

39

Designing the Future State

40

Future State Design Goal: Eliminate Waste

OverproductionInventoryWaitingOver-ProcessingErrors / Defects

Motion (people)Transportation (material/data)Underutilized people

41

Typical Current State Findings

Islands of value-adding activitiesAll other time is “waste.”

42

Adding Value

Rework

First Step Last Step

Eight Questions for Future State VSM

1. What are the customer requirements? What’s the takt time (if relevant)?

2. With goods, will we produce to order or to finished goods inventory? (With services, you’re almost always producing to order.)

3. Where can continuous flow be put in place?4. Where should pull systems be implemented?5. What is the single point of scheduling?6. How do we level the load and the mix?7. What should the management time frame be?8. What process improvements are necessary to achieve

the future state?43

-- Rother & Shook, Learning to See

Future State Design Considerations

Eliminate steps & handoffsCombine stepsCreate parallel pathsAlter task sequencing and/or timingImplement pullReduce/eliminate batchesImprove qualityCreate an organized, visual workplaceReduce changeover

Create standard workEliminate unnecessary approvals / authorizationsStop performing non-value adding (NVA) tasksCo-locate functions based on flow; create cells (teams of cross-functional staff)Balance work to meet takt time requirements

Future State Icons

Supermarket

ProductionKanban

WithdrawalKanban

SignalKanban

KanbanArriving

in Batches

Withdrawal

OXOXLeveling,

Mix and/orVolume

KanbanPath

KanbanPost

First-InFirst-Out(max WIP defined)

FIFOMax 8 “things”

Kaizen Burst

Buffer Stock

Combined Steps

Eliminated Step


Level I ToolsProcess

Stabilization


Level II ToolsAdvanced

Flow

Future State Mapping Notes

How to depict the future state?May use fresh paper and re-drawOr modify current state mapIf electronic, can create “transitional map” that is the marked up version of the current state map, with a “clean” future state map

Plan for 3-6 months to realize future stateCan create a longer term map to stimulate innovation, if time allows

Kaizen bursts are typically placed on the FS map (rather than CS)Used skilled facilitators to achieve the greatest innovation

48

VSM Future State Implementation Plan

49

Value Stream

1 2 3 4 5 6 7 8 9 10 11 12

2 Improve quality of referral KE Sean O'Ryan

3, 4 Reduce lead time beween schedulingand preregistration steps PROJ Dianne

Prichard

5, 6 Eliminate the need for two patient check-ins KE Michael

O'Shea

6 Eliminate bottleneck in waiting area KE Dianne Prichard

9 Eliminate lead time associated with transcription step PROJ Sam Parks

10 Eliminate batched reading KE Sam Parks

7 Reduce inventory costs, regulatory risk and storage needs KE Michael

O'Shea

12 Reduce delay in report delivery PROJ Martha Allen

12 Reduce delay in report delivery KE Martha Allen

Implement voice recognition technology

Reduce setup required

Cross-train and colocate work teams

Implement additional fax ports

Collect copays in Imaging

Balance work / level demand

5S CT supplies area; implement kanban


Increase percentage of physicians receiving electronic delivery (rather than hard copy)

Approvals


Signature:

Date: Date: Date:


Block# Goal / Objective Improvement Activity

Implement standard work for referral process

Type Owner Implementation Schedule (weeks) Date Complete

Date Created

11/21/2007Allen WardSally McKinseyDave Parks 12/13/200710/18/2007 1/10/2008

Future State Implementation PlanExecutive Sponsor


Implementation Plan Review Dates11/1/2007

Outpatient Imaging

Additional Resources

The Complete Lean Enterprise, Beau Keyte & Drew LocherFlowCharter, iGrafx.com (VSM software)The Kaizen Event Planner, Karen Martin & Mike OsterlingMetrics-Based Process Mapping: An Excel-Based Solution, Karen Martin & Mike Osterling

51

Karen Martin, Principal7770 Regents Road #635

San Diego, CA 92122858.677.6799

[email protected]

52

Additional Questions?

Interim Briefing(s)


51 62 73 84 95 10


1234 Date: Date:

Signature:Date:

Potential Obstacles ApprovalsExecutive Sponsor

NameFunctionPlanned Deliverables On-Call Support

Measureable Objectives

Function

Start/End Times

Event Drivers Mapping Team

Required Attendees



Value Stream Mapping CharterEvent Scope Leadership / Coordination Schedule

Executive SponsorValue Stream

Last StepFirst Step

Name

Team Lead Meals Provided?

Event Date(s)

Customer DemandTrigger

Specific Conditions Value Stream Champion


Location

Coordinator

Facilitator

FacilitatorValue Stream Champion


1 2 3 4 5 6 7 8 9 10 11 12

* Mode = JDI (Just-do-it), KE (Kaizen Event), PROJ (Project), or RPE (Rapid Planning Event)

Approvals


Owner

Signature:

Date: Date: Date:



Block# Goal / Objective Improvement Activity Implementation Schedule (weeks) Date

CompleteMode*

Implementation Plan Review Dates

Date Created

©2009 Karen Martin & Associates

Future State Implementation PlanValue Stream


Executive Sponsor

© 2007 Karen Martin & Associates www.ksmartin.com

Process mapping A guide for health service staff Victorian Quality Council June 2007

Index IntroductionIntroductionIntroductionIntroduction 3333

What is process mapping?What is process mapping?What is process mapping?What is process mapping? 3333

Process mapping as a quality improvement toolProcess mapping as a quality improvement toolProcess mapping as a quality improvement toolProcess mapping as a quality improvement tool 4444

Benefits of process mappingBenefits of process mappingBenefits of process mappingBenefits of process mapping 4444

How to conduct process mappingHow to conduct process mappingHow to conduct process mappingHow to conduct process mapping 5555

Decide on process to be mapped and the project aimDecide on process to be mapped and the project aimDecide on process to be mapped and the project aimDecide on process to be mapped and the project aim 5555

Define the scope of the processDefine the scope of the processDefine the scope of the processDefine the scope of the process 6666

Select the working groupSelect the working groupSelect the working groupSelect the working group 6666

Conduct the mapping meetingsConduct the mapping meetingsConduct the mapping meetingsConduct the mapping meetings 7777

Document the current processDocument the current processDocument the current processDocument the current process 8888

Analyse the existing processAnalyse the existing processAnalyse the existing processAnalyse the existing process 9999

Determine action required and draw the new process mapDetermine action required and draw the new process mapDetermine action required and draw the new process mapDetermine action required and draw the new process map 9999

Implement the new process and complete the quality cycleImplement the new process and complete the quality cycleImplement the new process and complete the quality cycleImplement the new process and complete the quality cycle 10101010

Key messagKey messagKey messagKey messages about process mappinges about process mappinges about process mappinges about process mapping 10101010

AppendicesAppendicesAppendicesAppendices

Appendix 1: Glossary Appendix 1: Glossary Appendix 1: Glossary Appendix 1: Glossary 11111111

Appendix 2: Model for improvementAppendix 2: Model for improvementAppendix 2: Model for improvementAppendix 2: Model for improvement 12121212

Appendix 3: Tips for the process mapping project leaderAppendix 3: Tips for the process mapping project leaderAppendix 3: Tips for the process mapping project leaderAppendix 3: Tips for the process mapping project leader 13131313

Appendix 4: Examples of process mapsAppendix 4: Examples of process mapsAppendix 4: Examples of process mapsAppendix 4: Examples of process maps 15151515

Appendix 5: FlowchartsAppendix 5: FlowchartsAppendix 5: FlowchartsAppendix 5: Flowcharts 17171717

Appendix 6: AdditionalAppendix 6: AdditionalAppendix 6: AdditionalAppendix 6: Additional questions for use in analysis questions for use in analysis questions for use in analysis questions for use in analysis 18181818

ReferencesReferencesReferencesReferences 19191919

3

Introduction The need to constantly improve the quality and safety of services delivered to consumers is well

recognised in health care. However, it is not always easy to know exactly howhowhowhow best to bring about

improvement. Having a variety of methods, or quality improvement tools, to guide activities, can make

the process simpler and more logical for all involved.

Process mapping is one such improvement tool. As the name suggests, it is used to look at processes,

so they can be better understood, simplified and improved. An engineer, Frank Gilbreth, invented the

original process mapping system in the early 1900’s. It is a particularly valuable tool for use in health in

that:

• health care delivery is complex and involves multiple, interlocking processes.

• service processes have had to adapt quickly as practices changed and organisations grew or were

reorganised: in these circumstances, ‘quick-fix’ solutions have often been put in place, rather than

fully planning new processes.

• most processes involve multiple professional or service groups.

• there is rarely one ‘owner’ of a process.

• very few individuals get to see the entirety of a process, although consumers will usually get to see

more than most!

Therefore, any method that helps us to assess ‘process’ is likely to be a useful improvement tool.

This paper is designed to assist anyone who wishes to review processes in their workplace, using a

structured approach. It:

• outlines basic process mapping steps

• provides suggestions on how some commonly experienced problems might be overcome

• provides some simple examples of process maps.

What is process mapping? Process mapping involves developing a simple visual picture, or map, of a process. It is a relatively

simple tool that can help an organisation better understand how parts of the organisation work, and

assist with analysing how it could work better.

Any process can be mapped. For example, the process of seeing a new movie involves a number of

steps:

Decide to go to movies

↓

Review movie options and select movie

↓

Drive to cinema

↓

Purchase ticket

↓

4

View movie

↓

Leave cinema

Process mapping as a quality improvement tool Process mapping must be considered within a quality model or framework (refer to Appendix 2 for a

simple model) to actually bring about improvement. This will help ensure the project is worthwhile and

effective and hence ensure valuable use of time and energy. It also means a number of steps beyond

the simple ‘mapping’ of a process are required.

Key aspects of the quality framework as they relate to process mapping are covered in this paper. For

more detailed information, refer to the Victorian Quality Council’s A safety and quality framework for

Victorian health services (2005).

Benefits of process mapping In most settings, health care delivery is complicated and requires input from a range of personnel. This

can lead to a situation where each team member focuses on the steps for which they are responsible.

Process mapping allows us to see the whole picture.

Process mapping can help teams to:

• develop a complete, shared understanding of a ‘process’

• document, as simply as possible, the steps or actions involved in the process (process map)

• determine if the current process is the best it can be

• highlight areas for improvement.

Particular benefits of process mapping include:

• helping to focus on how the end customer (patient/user) views the process; this is particularly

important as it may be the first time the whole team realises how complicated the process is from

the patient's/user’s perspective

• taking a holistic approach, helping explore the inter-relationships of the process and those within it

• helping the team to understand what is actually happening, rather than what individuals thought

was happening

• providing an opportunity for staff, who may not normally have an opportunity, to express their views

• clarifying responsibilities and ownership

• highlighting departments or specialists needed to complete key tasks such as decision-making,

conducting tests or completing forms

• assisting staff to understand how they contribute, which can instil pride and highlight areas for

improvement

• assisting to identify how resources are used

• assisting to identify inefficiencies and how to eliminate them

5

• providing baseline data for measuring how well any changes implemented have worked.

The limitations of process mapping generally relate to project implementation; selecting a process that

is not a priority to most of the team, selecting too large or too small a process, not involving key staff

members, and poor planning or failure to evaluate the impact of process changes. Hints on how to

overcome these issues are dealt with throughout this paper.

How to conduct process mapping There are a number of critical steps in process mapping. As with most processes, if any step is

overlooked, problems are likely to arise.

Decide on the process to be mapped and the project aimDecide on the process to be mapped and the project aimDecide on the process to be mapped and the project aimDecide on the process to be mapped and the project aim

What to map is often one of the most difficult decisions to make. When selecting a process to improve,

it is useful to ask questions commonly used when setting priorities for any other quality improvement

activity.

This initial set of questions is likely to generate a list of processes that could be analysed.

• What do we do a lot (high-volume work)?

• Where and when have things gone wrong for patients or services, adverse events?

• Patient outcomes are less than desired or expected, based on the literature or experience.

• What do patients complain about?

• What creates problems for staff?

• Where do we think resources are wasted?

Once a list of possible processes is generated, further questioning can help decide on the best process

to select. Consider the following for each process.

• To whom is it a priority? Why is it a priority?

• How will we know if the process is improved?

• How much difference will it really make to those involved?

• How committed is the team to the topic and to change, particularly the key stakeholders?

• Will it actually be possible to make any identified necessary changes?

• What will it take to improve in terms of resources, money, time, skills and effort, and do we have

these resources?

Once the process has been decided, the aim of the mapping process needs to be determined. This

could include:

• decreasing same-day cancellations of elective surgery due to ‘patient unfitness for surgery’ by 50

per cent

• decreasing average patient wait time in radiology by 15 minutes

• increasing the speed of diagnosis for those with suspected bowel cancer by one day.

6

All of these aims have specific targets. Not all teams will have enough information to set targets initially.

However, as more information comes to light, it is useful to set specific targets as this helps choose the

most appropriate changes to implement.

Define the scope of the process Define the scope of the process Define the scope of the process Define the scope of the process

It is clear that many processes overlap and intercept. However, to successfully ‘map’ any process,

boundaries must be established, with a clear starting point and a defined endpoint. This is known as

the ‘scope’. The scope will largely be determined by the overall project aim.

Getting the scope right is important. If the boundaries are not clear, the ‘map’ may never be complete

as more and more tasks or steps are examined.

If the process selected is too large:

• the exercise will become too complicated

• it will be difficult to keep on track

• it may prove too difficult to come up with specific areas for improvement

• it will take too long and those involved could lose interest.

If the process selected is too small:

• the exercise may appear trivial

• the team may be tempted to jump to conclusions about required solutions

• it may be difficult to demonstrate any worthwhile improvements.

However, when first starting to do process mapping, it is usually better to choose a smaller, well-defined

process.

Select the working groupSelect the working groupSelect the working groupSelect the working group

As with all improvement activities, it is useful to have a project sponsor or championproject sponsor or championproject sponsor or championproject sponsor or champion. This is usually a

senior person who:

• sanctions the mapping activity, including time and resource allocation, and supports required

changes

• can engage others or encourage active participation

• can facilitate links to others outside the mapping team

• can handle any power issues

• conveys support and allays any fears.

Another key role is project leaderproject leaderproject leaderproject leader. They must have sufficient time and be able to manage and lead the

team. Some suggested specific tasks for the project leader are outlined in Appendix 3.

Selecting the mapping teammapping teammapping teammapping team can now begin. Inclusions will depend upon the selected process, the

scope, and the staff groups involved in the process. There is generally a balance required between

keeping the group size to a manageable number (group sizes of between eight and 12 work best) and

having appropriate representation from all key stakeholders. It is also critical to ensure managers are

7

actively involved in the selection process. The most important thing to understand is that the people people people people

who work in the processwho work in the processwho work in the processwho work in the process should do the mapping.

How consumerconsumerconsumerconsumer input will be gained should also be considered. This could range from including

consumers as a central part of the mapping team from the beginning, to seeking their input at specific

stages such as when the initial map is completed, or when the draft map of a redesigned process has

been developed.

Ensuring all members of the mapping team are clear about their role before they agree to become part

of the team is useful.

Conduct the mapping meetings Conduct the mapping meetings Conduct the mapping meetings Conduct the mapping meetings

Apart from having someone to plan and facilitate these meetings (refer to Appendix 3 for more specific

tips for the project leader), the next major decisions to make are:

• how long should the meetings be?

• how many meetings will be needed?

This depends on:

• the process to be mapped and its scope

• the current knowledge of how things work

• any data or information available

• how much change may be required.

However, a rule of thumb would be that it takes half a day to map a process, then another four hours to

analyse the process, suggest and test changes, remap the changed process, and agree on procedural

changes. This relies on the project leader being able to complete much of the support work outlined in

Appendix 3.

Most of the meetings can be quite short. However, the initial meeting to try to map the process

generally needs to be at least two hours. If there are difficulties getting the team together for this length

of time, consider revisiting:

• the process selected - is it of sufficient importance to invest time and energy?

• the project sponsor - have they made it clear how important this project is, and how valued each

team member’s input is?

• the team selection - have the right people been chosen?

• the planning - have practical issues such as providing enough lead time for meetings, position

back-fill and the timing of meetings been considered?

If, after addressing all of these potential stumbling blocks, time commitment is still an issue, it is

possible that shorter meetings with small numbers of the team may provide enough input. However, it

will generally take more overall meeting time as the map has to be redrawn and adapted after each of

these meetings and then represented to the remainder of the team.

8

Document the Document the Document the Document the current processcurrent processcurrent processcurrent process

Before commencing the more detailed mapping process, it can also be useful for the team to do the

following:

• Draw a high level map (the big picture) - putting the whole process on a single piece of paper gives

the team an idea of the process parameters. This can then be used to determine if the mapping

process is getting off track.

• Draw a picture of the ideal process - if you were starting a new service, with no constraints, how

would this process work? When the process has been remapped, it is interesting to compare it with

this initial ideal process.

There are three critical issues to keep in mind in this stage:

1. Map the process as it actuallyactuallyactuallyactually occurs, not how it is supposedsupposedsupposedsupposed to happen or how the team may want

it to happen. This is when many of the team are surprised by what actually does happen! It is also

important that no fault-finding occurs in this stage. Remember, this is about trying to fix problems,

not add to them.

2. Make sure the map is the simplestsimplestsimplestsimplest possible picture of how the process works. The aim of process

mapping is to make things clear. There is generally no need to use complex symbols and shapes or

computer-generated pictures (these will often distract the team), simple boxes and arrows are all

most processes require.

3. The questquestquestquestionsionsionsions asked when mapping and what happens after mapping are what matter. There is

value in adding any observations or data about times, volumes, or bottlenecks on the map.

As questions get asked, and data gathered, the map will have to be drawn and redrawn a number of

times. Hence, one of the best ways of beginning the more detailed map is to use Post-it notes, arranged

on a wall. For this process:

• get team members to write their own steps or activities.

• only put one step on each Post-it note.

• the notes can also be colour-coded for different functions, professional groups and tasks.

• get the person who wrote the note to place it where they think it comes in the process.

• add to the steps and rearrange as the teams discusses what they know about the process.

Alternatively, teams can work on paper or a white-board. The important thing is to make sure everyone

is involved and the steps are being recorded in a logical sequence.

It is important to recognise when the map is complete, as there is a risk that too much detail will stall

the group. The team will need to agree when they believe the majority of the key steps have been

mapped and that they have a sufficient picture to begin analysing the process.

Examples of some simple process maps are included in Appendices 4 and 5.

9

Analyse the existing process Analyse the existing process Analyse the existing process Analyse the existing process

At this stage the team has established what is happening in the process as opposed to what they

thought was happening. The team now has to be prepared to ask questions that challenge the status

quo and be prepared to change ( see the VQC’s Successfully Implementing Change, 2006).

The team will need to ask the following questions:

• Could this be simpler, faster, less confusing, or more efficient?

• If a colleague from a similar service or a customer observed the event, would they feel it was

working in the best way?

• Could this be changed to improve outcomes?

• Are there any unnecessary steps?

• Are there any obvious bottlenecks or points where things slow down?

• Are there any steps where errors tend to occur?

• Is the care or service being given at the right time, in the right place and by the right person?

• Are there times when the process works better than others? Why? How?

• How should the process work, what should it look like?

• How can the problems identified above be overcome?

Appendix 6 has a number of additional questions that teams may find useful.

Determine the action required and draw the new process mapDetermine the action required and draw the new process mapDetermine the action required and draw the new process mapDetermine the action required and draw the new process map

Once the team agrees on the answers to the above questions, the process can begin to be redesigned

to meet the project aims. Key questions for the team to discuss and come to consensus include the

following.

• What can we change?

• Are there any risks in changing the process?

• What changes will make the biggest impact?

• Who will the changes impact on most?

• If steps are changed, could there be a positive or negative impact on other processes?

• Will the change be worth it?

When the required changes have been agreed upon, the new process can be mapped and an

implementation plan determined.

Note: It is important to redraw the map, as it will highlight any potential problems in the proposed new

process. It also provides an important tool when discussing proposed changes with the remainder of the

team and when the project is being evaluated.

10

ImplemeImplemeImplemeImplemennnnt the new process / changes and cot the new process / changes and cot the new process / changes and cot the new process / changes and complete the quality cyclemplete the quality cyclemplete the quality cyclemplete the quality cycle

Once the team has agreed on the changes, the remainder of the quality improvement cycle must be completed (keeping in mind change implementation strategies). This includes:

• standardise the new way of working and develop new procedures

• implement the changes

• evaluate the changes

• celebrate what has been achieved

• continue to look for ways to improve the process.

Key messages about process mapping • Process mapping is not difficult!

• Process mapping allows teams to understand the whole process – not just the parts with which they are familiar.

• The most value comes from honestly describing what is happening and then seeking ways of improving it.

• The least value comes if individuals or departments are blamed or criticised.

• Process mapping is just one of the many improvement tools and techniques available.

• Process mapping is fun and it is immensely satisfying when the impact of the improved processes is seen!

11

Appendix 1: Glossary Flowchart a map of a process that uses conventional symbols to represent different

activities (refer to Appendix 5 for an explanation of the symbols used)

Incident* an event or circumstance which could have resulted, or did result, in unintended

or unnecessary harm to a person and/or a complaint, loss or damage

Process a series of connected steps or actions to achieve an outcome or a result

Process map a visual depiction of a process

Process mapping the steps involved in developing an understanding of a process and developing

a process map

Scope the starting and end point of the process to be examined

Stakeholder* those people and organisations who may affect, be affected by, or perceive

themselves to be affected by, a decision or activity

System improvement* the result or outcome of the culture, processes and structures that are directed

towards the prevention of system failure and the improvement in safety and

quality

* Runciman W B, 2006

12

Appendix 2: Model for improvement Planning for ‘how are we going to achieve the change’ should be done at the same time as planning

‘who or what is involved’. During planning, the indicators of success should answer the question: How

will we know it worked? As well as showing the intended and unintended impact of the change, it can

demonstrate if the resources, time and energy invested represent value for money. Ongoing evaluation

can demonstrate the extent to which changes have been sustained. (NHS Managing the human

dimensions of change, 2005)

A commonly used model for improvement is the IHI model, also known as the Nolan model and

modified from quality improvement leaders including Deming and Juran.

13

Appendix 3: Tips for the process mapping project leader

Role of the project leaderRole of the project leaderRole of the project leaderRole of the project leader

The process mapping project leader should be able to:

• lead, support and encourage the team

• project manage the process including developing the plan, organising and leading the mapping

meetings, ensuring deadlines are met and communication maintained.

The process mapping project leader should be able to provide specific support through working with

managers and other key people to:

• decide the process to be mapped and the project aim

• define the scope of the process

• develop a project plan

• gather available data in preparation for any meetings

• identify key people for the mapping team

• conduct the mapping meetings

• document outcomes from the meetings and other activities including drafting reconfigured process

map

• investigate implications of proposed changes and seek agreement from managers and other

affected parties

• draft, re-write procedures

• ensure implementation of agreed changes

• evaluate the project.

Tips forTips forTips forTips for pppprocess mapping team facilitationocess mapping team facilitationocess mapping team facilitationocess mapping team facilitation

Be prepared by:

• making sure everyone who should be in the team has been invited in enough time (at least a month

in advance), has sent an RSVP, has been reminded

• making sure all invitees are clear about what is happening and why, why they are coming and what

will be expected of them

• planning the meetings. It is important to understand that, especially in the early meetings, there will

be a lot of discussion. Hence, set realistic expectations on what can be achieved

• gathering any available data and information eg how long does it take for patients to be given test

results (average, best-case, worst-case). If possible, with one or two other team members, walk

through a process, talking to people who work in the process, seeing what actually happens

• prepare the materials (butchers paper, white-boards, pens, Post-its, refreshments) and the room

14

During the session, ensure you:

• confirm the process to be mapped, including project aim, scope and identify any specific targets to

be met either for that day or for the project

• stay focused on the problem and the scope

• follow the brainstorming rules (below)

• ensure that no train of thought is followed for too long

• encourage people to develop other's ideas or use other ideas to create new ones

• summarise what has been accomplished and what happens next

• stick to the time allocated, start on time and finish on time(people will get used to it).

Follow up by:

• clarifying the next actions, meeting time

• writing brief notes from the meeting, including process mapped to date and homework any

members are to do

• reminding the team of ‘homework’ and next meeting

• sharing the map or findings with the rest of the team once you have a draft.

BBBBrainstormingrainstormingrainstormingrainstorming

Brainstorming is a technique that attempts to create an environment in which team members’ ideas are

able to build and bounce off each other. It uses the experience and creativity of all members. When

individual members reach their limit, another member can take the idea to the next stage.

Brainstorming in a group can be risky for individuals. Some useful rules are:

• ensure participants come from a wide range of disciplines - this brings broad experience and

increases creativity

• ensure that no one criticises or evaluates ideas during the session, encourage an enthusiastic,

uncritical attitude in the group

• try to get everyone to contribute, including the quiet members

• let people have fun

• encourage people to raise as many ideas as possible, from solidly practical to wildly impractical

• build and bounce

• appoint one person to note ideas on a flip chart

• study and evaluate after the initial brainstorming session, not during.

15

Appendix 4: Examples of process maps Example 1: Patient deemed fit for eleExample 1: Patient deemed fit for eleExample 1: Patient deemed fit for eleExample 1: Patient deemed fit for elective orthopaedic surgeryctive orthopaedic surgeryctive orthopaedic surgeryctive orthopaedic surgery It is known in your hospital that there are a frustratingly high number of cases where the patient is deemed unfit for elective orthopaedic surgery only once they have been admitted to the ward. Your team decides to investigate the process as it currently occurs. Note, you have limited the scope to steps related to their fitness for surgery and chosen not to examine all the other aspects of their admission. This helps to focus on how this particular problem could be improved.

Patient assessed in orthopaedic clinic as ‘fit for surgery’

↓ Patient booked for elective admission

↓ Patient told to notify hospital if health changes prior to surgery

↓ Patient arrives at admission office and is admitted

↓ Transferred to ward and nurse conducts nursing assessment

↓ Patient deemed fit by nurse and prepared for surgery

↓ Patient assessed by orthopaedic registrar and deemed fit for surgery

↓ Patient assessed by anaesthetic registrar and deemed fit for surgery

↓ Patient sent to surgery and operated on

At first glance the team may feel the process should be working well. However, as the team discusses the situation, a number of process gap factors may come to light as the different team members tell their ‘stories’. For example:

• patients do not always know what the clinic staff mean when they say ‘changes to health’ as patients are not provided with a set of specific health issues to assess

• patients are worried about delays in having surgery so turn up on the day hoping they will be OK

• the nursing staff think the orthopaedic registrar is doing a complete ‘fitness for surgery’ check but the registrar thinks the nurses complete some details and hence does not include these in their assessment

• the anaesthetists think all patients are contacted the day before surgery and their health status checked at this stage. However, while this was suggested eight months ago at a staff meeting, the procedures were not formally changed, the pre-admission staff ran out of time when another clinic was added and therefore the checks stopped after the first two weeks.

The team agree they can improve this process. They decide to:

• gather some more information on the impact of surgery rescheduling if theatre time was not being wasted by last minute cancellations

• review the fitness-for-surgery checks

• assess the resource implications of making telephone checks before admission day

• meet in one month to consider how the process can be improved. Every health service has different processes and issues. However, by just considering this basic example, you can begin to understand how simple, but powerful process mapping can be to any team.

16

Example 2: Anticoagulant Blood Testing Example 2: Anticoagulant Blood Testing Example 2: Anticoagulant Blood Testing Example 2: Anticoagulant Blood Testing The Improvement Network - East Midlands Health Area

http://www.tin.nhs.uk/index.asp?pgid=1179

Notice that the map is very simple. The only symbols that have been used here are a box and an arrow. Someone has been writing observations about times and volumes on the map. Some good questions have obviously been asked. As more information about the process is gathered this also can be written on the map, making the map more of a working document than a polished finished article. Looking at this map, opportunities for improvement would hopefully be obvious!

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Appendix 5: Flowcharts Flow-charting is a specific approach to process mapping. Rather than just using arrows and boxes, it

uses conventional symbols to represent different activities or tasks. These symbols can convey more

meaning and assist with analysis. For example:

• who is making decisions and about what

• how many pieces of paper are generated in different places for one process

• where unexpected delays are occurring.

The most commonly used symbols are:

SymbolSymbolSymbolSymbol DescriptorDescriptorDescriptorDescriptor

Arrow Connects all the symbols and shows the direction of flow of

the process

Rectangle

Indicates a task or a step in the process such as admission

details recorded. Usually only one arrow should come out of a

task rectangle. If there is more than one arrow, a diamond or

question symbol may be needed instead

Oval

Indicates the beginning and end of the process such as the

patient walks into emergency

Diamond

Indicates a yes/no question must be asked or a decision has

to be made such as triage category 4 or 5?

Semi-oval

Indicates a delay in process such as the patient waits for

result

Rectangle with wavy base

Document is produced, such as a referral form

There are many ways of drawing a flowchart but to make analysis easier, it is recommended that you try

to construct the flowchart so that the ‘preferred’ process goes down the left side of the page. Hence,

when a decision has to be made, you are trying to elicit a ‘yes’ answer such as: Are notes available? Is

the patient is in good enough health to have the planned operation? Have risk factors been assessed?

When the answer is ‘no’ the team can see the number of steps required to get the process back on

track and therefore what needs to be improved.

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Appendix 6: Additional questions for use in analysis

Ten good questions to ask when mapping a processTen good questions to ask when mapping a processTen good questions to ask when mapping a processTen good questions to ask when mapping a process

1. Are there any wasteful handovers in the process?

2. Could one person instead of several people carry out some tasks?

3. Are tasks carried out for our benefit or the patient's?

4. Should some tasks that are performed in another process be performed here?

5. Is the process measured according to activity or purpose?

6. Are the people who work in the process allowed to make decisions?

7. Which tasks help to achieve the purpose and which ones create waste?

8. Is there any duplication of work?

9. Are there any bottlenecks?

10. How much error correction (rework) is being carried out?

Extracted from: NHS The Improvement Network - East Midlands website, UK Department of Health, available at http://www.tin.nhs.uk/index.asp?pgid=1179

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References Gilbreth, F 1916, ‘The effect of motion study upon the workers’, Annals of the American Academy of Political and Social Science, Vol. 65, Personnel and Employment Problems in Industrial Management (May), pp. 272-276. Madison, D 2005, Process Mapping, Process Improvement and Process Management: A Practical Guide to Enhancing Work and Information Flow, Paton Press, Chico Runciman W B 2006 ‘Shared meanings: preferred terms and definitions for safety and quality concepts’, The Medical Journal of Australia, 184: S41-S43. Outline of definitions devised by the former Australian Council for Safety and Quality in Health Care, available at Australian Commission on Safety and Quality in Healthcare website: http://www.safetyandquality.org/internet/safety/publishing.nsf/Content/former-pubs-archive-definitions National Health Service (NHS) The Improvement Network East Midlands, Process mapping, UK Department of Health, available at http://www.tin.nhs.uk/index.asp?pgid=1179 National Health Service (NHS) Modernisation Agency 2005, Improving Flow: Process and systems thinking, UK Department of Health, available at http://www.wise.nhs.uk/sites/toolandtechniques/ILG/Building%20on%20the%20Basic%20Tools%20and%20Techniques/1/2.3IF.pdf

Victorian Quality Council 2005 Better Quality, Better Health Care: A Safety and Quality

Improvement Framework for Victorian Health Services, Department of Human Services,

Melbourne.

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Understanding the Patient Journey - Process Mapping Why Process Map? It is important to understand how patients proceed through the care delivery system. The best way to achieve this is through process mapping. Process maps are an effective way to identify constraints and bottlenecks, rework (activity required to correct situations that could have been avoided) and unnecessary process steps (duplication, waste and error). It is unlikely that any one member of staff will fully understand the whole service until the process has been mapped. Process mapping is the single most useful diagnostic tool for determining where problems lie. Understanding the process from the patient perspective is essential if patient focussed service improvements are to be made. The process map must always depict the total number of steps taken, as well as the total number of people involved, the total time taken to perform the process step, and all documents used. What are the Stages? There are two stages to process mapping. First, understand what happens to the patient, where it happens and who is involved. Secondly, examine the process map to determine where there are problems - such as multiple hand-offs, parts of the process that are unnecessary or do not add value. These include waste, error and duplication or parts of the process which would flow better if undertaken in a different order. How to Process Map The first step is to get the staff together and map the process at a high level. Choose clearly defined start and end points; for example for minors patients in A&E, when the patient enters the A&E until they are discharged. When mapping the patient journey, it is important to identify and concentrate on the high volume runner groups – please see appendix 1. At this stage a quick mapping exercise by a few staff may be useful to determine who will be involved in a more detailed mapping exercise. It is essential to have representatives of all staffing groups involved in the process at the main mapping exercise, and a quick high level map will help ensure no staff group is forgotten. Do not forget to involve patients in the mapping process.

Top Tip Remember to map the process as it usually happens, not the ideal

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You might find it useful to use “post-it” notes to capture the information, this way they can be rearranged as the exercise progresses and the patient journey emerges. They need to capture information at the level of one person, one place and one time. Arrange the post-its to ensure they capture the journey as the patient experiences it, including hand-offs, multiple staff, changes in location, loops and parallel processes.

Patient Arrives in A&EDiagnostics

High level

TEST ORDERED TEST COMPLETED REPORT RECEIVED REPORT SEEN

Initial Assessment

Detailed Level

Top Tip Walk the process with a patient to check that all events are included

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Demonstrate complexity visually(chest x ray- 62 tasks, 12 hand offs)

start

finish

centraloffice

secs office

X-ray room

filmstorage

radiologist office

Analysing the Process Map Once the patient journey is mapped and you have agreed the process, get the team to analyse it by considering the following:

• how many times is the patient passed from one person to another (hand-off)? • where are delays, queues and waiting built into the process? • where are the bottlenecks? • What are the longest delays? • what is the approximate time taken for each step (task time)? • what is the approximate time between each step (wait time)? • what is the approximate time between the first and last step? • how many steps are there for the patient ? • how many steps add no value for the patient? • Are there things that are done more than once? • look for “re-work loops” where activities are taken to correct situations that could

be avoided • is work being batched? • where are the problems for the patients? • at each step is the action being undertaken by the most appropriate staff

member? • where are the problems for staff?

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Ask yourselves if the patient getting the most efficient care at the most appropriate time in the right place?

Consider the steps which cause the most delays. These steps can then be mapped in more detail. This can be done several times, each time getting a greater level of detail. Key causes of delays: Handoffs This is where patient care or information is handed from one individual to another. For example:

Doctor Triage Nurse

X-Ray

Patient enters A&E reception

Nurse

Plaster Technician

Discharged Home

Top Tip Also consider what patients complain about.

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Bottlenecks and Constraints A bottleneck is any part of the system where patient flow is obstructed causing waits and delays. It interrupts the natural flow and hinders movement along the care pathway. However there is usually something that is the actual cause of the bottleneck and is the constraint. This is usually a skill or piece of equipment. There are two different types of bottlenecks; process bottlenecks and functional bottlenecks. Process bottlenecks are that stage in a process that takes the longest time to complete. Process bottlenecks are often referred to as the ‘rate limiting step or task’ in a process.

1 2 3 4 Functional bottlenecks are caused by services that have to cope with demand from several sources. Radiology, pathology, radiotherapy, and physiotherapy are often functional bottlenecks in healthcare processes. Functional bottlenecks cause waits and delays for patients because:

• one process, such as ENT surgery, might share a function, such as imaging with other processes, e.g. orthopaedic surgery, and medicine • a surgeon may be called to theatre when he is also needed in A&E • a GP has to go out on an emergency call when they have patients waiting to be seen in surgery • a social worker may be torn between representing an existing client in court or doing an assessment of a patient to allow them to be discharged

In the example to the left, activity 3, is the process bottleneck as it takes the longest time. It could be the time to taken to get an x-ray.

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This type of bottleneck causes a disruption to the flow of all patient processes. Functional bottlenecks act like a set of traffic lights, stopping the flow of patients in one process while allowing the patients to flow in another.

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Look for batching

Dr sees patients

individually

Requests sent in batches

Results return in batches

Batching is where ‘tasks’ are queued before processing. Parallel Processes Parallel processes are important and are the cause of delays for patients and frustration for staff. Mapping, analysing and improving parallel processes will often deliver great benefits. Parallel processes include:

• processes involved in generating a referral letter and notifying the patient about referral arrangements

• processes involved in dealing with pathology specimens - from the time the specimen is taken to the point when the requesting clinician receives the test results

• processes involved in the imaging reporting system – from the image and the report being received by the referring clinician

• processes involved in medical records – from getting the notes to returning them to ‘file’

Tracking

Process mapping is basic and simple — the best way to learn it is to do it!

Process mapping is a repetitive process, maps should never be thrown away but reviewed

and updated.

Display the maps so all staff can see them and contribute to ongoing improvements.

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Exercise Undertake a patient tracking exercise again concentrating on high volume runner groups. The best thing to use is a blank sheet of paper with just the patient’s name or identifier. You will need to track each key event/stage with the time it occurs and the person carrying out the intervention. This will allow you to track the complexity of the patient journey. Track at least 25 patients. You may need to consider doing this on different days of the week or times of the day Analysis of the patient tracking forms will allow you to either validate the process mapping or challenge any assumptions made. What Next? Test and make the changes Start to use the model (Plan, Do, Study Act) to implement changes:

• Identify the improvement areas from your process mapping; simplify them into manageable tasks (Plan)

• Initiate system redesign and carry out the test or change (Do) • Study the data before and after the change (Study) • Plan the next change cycle or plan implementation (Act)

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Flow Analysis What is Flow Analysis? The Flow Analysis Tool (FAT) builds on the concept of process mapping. It has been adapted from a tool widely used in manufacturing and allows sites to ‘deconstruct’ elements of the process so that it is possible to see in detail what is happening at each stage of the patient process. Understanding patient flow is vital in complex systems to fully identify repetition, queues and delays. The FAT builds upon the detailed process mapping to create the current state flow analysis map. The FAT will allow you to:

• analyse patient flow across more complex processes • identify whether the systems are managed and in control • see what adds value and where waste occurs • understand roles and responsibilities related to managing patient flows

The value of showing several sets of information related to the flow together on the same map is that patient, communication and information flows can be clearly seen, and the value of each step analysed in terms of the time taken and the value of that step in the journey. Identifying clearly who ‘owns’ (or is responsible for) each stage of the process is important, and will see where there are gaps where no-one appears to own what is happening. The first stage is to identify the main high volume runner groups, as with process mapping you can use Pareto analysis (80/20 rule) to focus efforts on the problems offering the greatest potential for improvement without being side-tracked by events that rarely happen. See appendix 1. Flow Analysis and Process Mapping- Differences Process mapping looks at the care process and understands how patients flow through the system. Flow analysis builds on the work of process mapping and looks at the care process from a unit/department perspective bringing a number of patient process maps together to look at work flow.

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Building the Current State Flow Define the main emergency runner group to be analysed and define the start and end points of the flow map. The start maybe the arrival in the A&E. The end point is when the patient is discharged from hospital acute care. Step 1: Identify the high level patient process steps through process mapping Step 2: Simultaneously identify and map the communication and information steps around the patient process. It is useful to note who communicates with who and how they communicate, i.e. fax, bleep, IT system…. The information and communication steps will be complex and cross many departmental and organisational boundaries, it will be difficult to address problems without understanding the true complexity. Step 3: Identify who is who is clinically responsible for the patient. This could be the person performing direct clinical care for the patient. This will change as the patient moves from department to department, and maybe within each clinical area. There may be periods of time when no-one appears to be managing the care. Step 4: Identify who is responsible for the overall process at each point. This might be departments, divisional or corporate level. There may be periods of time when no-one appears to be responsible for the process. The figure below shows the emergency flows in its 4 parts.

Flow Analysis Tool:Responsible for making each part of the process happen

A&E Major receptionist checks patient is expected

A&E Major receptionist logs patient onto A&E IT system

BB bleep SHO

BB create paper record

BB fax A&E & MAU

BB request patients notes

BB log patient onto BB IT system

GP rings BBGP rings BB again

GP rings for ambulance

Patients wife rings GPPatient Collapses

Patient assessed by GP

Patient & his wife arrive A&E

Patient triaged on Majors

0:152:30 2:00

GP Bed Bureau

GP Bed Bureau

A&E Receptionist

A&E Receptionist

Triage Nurse

GP Ambulance Triage Nurse

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Step 1 – patient process steps (pink) Step 2 – communication/information steps (white) Step 3 –clinical responsibility (blue) Step 4 – process responsibility (yellow) Work out the time the whole process takes by identifying how long each stage in the process takes with a line across the bottom of the map. Use a common unit to record time, i.e. hours or minutes. Look at what adds value to the patient process from the patients’ point of view and what is clinically necessary. Analyse the current state map:

• Identify hand-offs, bottlenecks and batching

• Define and collect any data that will help understand the flow, and see where waste occurs, and the relationship between different factors

• Use the waste spotters guide, clearly indicating where waste occurs,

• Identify which are the value steps for the patient and the value clinical steps

Waste Analysis Identifying waste as a part of the analysis of the current state map is important to help you assess which steps add value to the patient process, and where waste occurs. On the current state map identify where waste occurs, what type of waste it is and consider waste related to the longest stages of the process. There are several types of waste that exist in patient journeys. See the waste spotters guide in appendix 2 Value and Non Value Added Activity By identifying those activities that do not add value to the patient or have no clinical value, and by seeking to reduce or eliminate them from the patient journey, it is possible to provide a service that is more responsive to the patient and reduces waits and delays. Value adding activities are those activities that in the eyes of the patient make the service they are receiving valuable. e.g. the taking of an x-ray to enable diagnosis, closure of a wound in A&E. Consider value adding ideas as those you would consider paying for. Waste is anything that does not add value for the patient. What Next?

• Use the flow analysis tool for each flow to map the main emergency runner group • Analyse it using the waste spotters guide, clearly indicating where waste occurs,

which are the value steps for the patient and the value clinical steps • Define and collect any data that will help understand the flow, and see where waste

occurs, and the relationship between different factors

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Improving your Value Flow Establishing the logical flow of patients through a hospital is key to reducing the length of the patient journey. The value steps must be in the right order and can be re-ordered if necessary. Re-ordering is important as it is inappropriate to do more work on a flow that has value steps in the wrong order, or has too many steps. The are four key principles to making the flow more effective: Small batch sizes

– patients move in groups of as near to one as possible Linked processes

– Each stage of the process linked to the previous one Setting the pace

– each part of the process able to deal with the same level of demand – patients move from one part of the process to the next at the same rate

Overall co-ordination

– Whole process co-ordinated by one individual – High level of visibility of how the flow is working

Linked Processes Linked processes means that each stage of the process is linked to the previous one and no part of the process functions in isolation. The importance of linking one step to the next is that they always have the capacity to deal with what they are receiving and know what to expect in advance. For example, if the Medical Assessment Unit know who is arriving in A&E they can manage their own work taking this into consideration

Patient and Information Flow

Clinical assessment Investigations Clinical

decision Admission Treatment Discharge

Patient and Information Flow

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Setting the Pace This means that each part of the process must be able to deal with the same level of demand at the same time, so patients can move from one part of the flow to the next at the same rate.

Setting the Pace

Clinical assessment

Investigations Clinical decision Admission Treatment Discharge

If 5 patients arrive an hour, 5 patients need to move between each step each hour

If 10 patients arrive an hour, 10 patients need to move between each step each hour

Overall Coordination Flows should have a single person, team, or area responsible for the whole flow. This will work best if they are responsible for the flow from start to finish. If there is no overall co-ordination, several departments are responsible, this will result in more communication ‘hand-offs’ and there is the potential for poor overall co-ordination. What Next? Further material will be introduced as part of the bed management improvement programme in Autumn 2005.

Example The pace of your emergency flow should be determined by the arrival rate of patients who require admission. This can be done by analysing historical data by hour of the day and setting the pace over the 24 hours.

Remember use PDSAs to test and implement change

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Appendix 1 Pareto Analysis Pareto analysis is a simple tool that helps to focus efforts on the problems offering the greatest potential for improvement. Pareto Law is also known as the ‘80/20 rule’: ‘80% of the benefits will be found in the simplest 20% of the system, and the final 20% of

the benefits will come from the most complex 80% of the system’.

Applying the 80/20 rule will help you focus on high volume runner groups (the most common presenting conditions) and avoid you being side-tracked by events that rarely happen. The characteristics of runners, specials and strangers the 3 groups of patients based on principles outlined below:

Runners

•high volume

• share common characteristics

• “standardised” patient routes

•up to 90% pre-scheduled

•fast throughput

Specials

•customized

•lower volume

•predictable

• share some steps but require extra steps

•standardised patient routes

•can be pre-scheduled Strangers

•low volume, unique requirements

•unpredictable demand patterns

•route unpredictable and complex

•throughput time tends to be longer

Runners

Specials

Strangers

Group of patients

No.

in e

ach

cate

gory

wit

hin

the

grou

p

Appendix 2 - Waste Spotters Guide Waste Symptom Example

Waiting

• Information stored on a computer awaiting action.

• Imbalance between capacity and demand.

• Large Waiting Rooms.

• Long length of hospital stay.

• Surgeon awaiting arrival of patient in the operating theatre.

• Patient queuing for diagnostic test.

• Medically fit patient waiting to go home.

Mistakes • Clinical Incident.

• Complaints.

• Multiple Checking Systems.

• Patient with more than one PAS number.

• Post operative wound infection.

• Drug error.

• Equipment failure.

• Patient outlying on the ‘wrong’ ward.

Uncoordinated activity

• Tests undertaken before they are needed and when they are not necessary. • Bed requested ‘just in case’.

Stock • Poor ability to respond to problems.

• Increased need for storage space. • High volume stock in wards and departments.

Transportation • Movement of documents, materials and patients.

• Ambulance conveys patient within minor injury to A&E Department.

• Patient outlying in ‘wrong’ ward.

• Specimens transported to centralised laboratory for processing

Unnecessary motion Excessive walking. • Poor layout of working environment

Inappropriate processing

• High variation.

• Duplication.

• Batching.

• Patients seen by many healthcare professionals when one would do.

• Multiple data entry on information systems which do not communicate.

• Patient details recorded on A&E ‘white board’ in addition to A&E card and information system.

• ‘Bed State’ updated twice daily.

• Twice weekly consultant ward rounds.

Value stream mapping and process mapping

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