Six Sigma Black Belt Week 1 - Institute of Industrial and ......VS, BP, etc. Pt receives additional lab and radiology testing, as appropriate Pt notified that transfer to OR has been

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Lean Six Sigma Black Belt Week 3

Institute of Industrial Engineers

3577 Parkway Place Suite 200

Norcross, GA 30092

Chapter 3-2: Lean VSM and FLOW

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Value Stream Mapping

3-2-2 © 2014 Institute of Industrial Engineers.

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Value Stream Improvement

Value stream is all steps, value-added and non-value added, that are required to bring a product from raw material to the customer.

Machining Packaging Assembly Inventory Inventory Inventory Inventory

Raw

Material Finished

Product

Customer

Simple Model


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Walk a product’s production path from beginning to end, and draw a visual representation of every transportation, storage, and overall product process in the material and information flows.

Then draw, using the VSM icons, a “future state” map of how value should flow.


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Observe and record the flow of orders, materials, and information for a product family.

Identify non-value added activities

Visualize areas of waste and areas that generate value


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Map the Supply Chain

Product Family

Current State Drawing

Future State Drawing

Plan and Implement

Understanding how

the process

currently operates

Designing a lean flow


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Product/Service Family

A group of products/services that use similar processing steps and/or common equipment.

Healthcare “Value” Examples?

Healthcare “Value Support” Examples?

Healthcare “Supplier” Examples?


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Value Stream Mapping (VSM)

Complete view of all value-added and non-

value added activities.

Can be used for:

Delivery of Healthcare Services to Patients

Designing a Service from concept to operation


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Source: Rother, Mike and Shook, John, Learning to See: Value Stream Mapping to Add Value and Eliminate Muda, The Lean Enterprise Institute, Brookline, MA, 1998.


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Source: Rother, Mike and Shook, John, Learning to See: Value Stream Mapping to Add Value and Eliminate Muda, The Lean Enterprise Institute, Brookline, MA, 1998.


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History of VSM

Toyota Production System method “Material and Information Flow Mapping”

Focus at Toyota is to establish flow, eliminate muda (waste) and add value

Toyota teaches flows of material, information, and people/process


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Value Stream Analysis Steps

Standardize

Draw the

Future

Map

Identify

Standard

Work

Identify

Waste &

Plan

Draw the

Current

State Map

Select a

Product

Family


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Design Approach for VSM

Current State Map -

Clear representation of the situation showing procedural steps, patient flow, material flow and information flow.


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Value Stream Map

© 2014 Institute of Industrial Engineers. 3-2-14

Susquehanna Health, Lycoming County, PA

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East Tennessee Children’s Hospital

3-2-15

*with Waste

© 2014 Institute of Industrial Engineers.

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Mapping the Value Stream

Start with the Patient

Involve the People in the Process

Work your way “Upstream”

Record the Mapping Information/Data

Draft the Map

Verify with the People in the Process

Walk-thru the process from beginning to end

Update/Correct

© 2014 Institute of Industrial Engineers 3-2-16

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Value Stream Mapping Icons

Material Flow Icons

Process

Service Step

Process Shared

Outside Sources

C/T= 25 sec

C/O= 40

2 Shifts

Takt= 1s

Data Box

Inventory Box

Patient

PUSH Arrow

Complete Services

Supermarket

First-In-First-Out Sequence Flow

F I F O

Physical Pull

Document

3-2-17

Bed

© 2014 Institute of Industrial Engineers.

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Information Flow Icons

Manual Info Flow

Electronic Info Flow

Weekly Schedule

Schedule

Load Leveling

Withdrawal Kanban

Production Kanban

Signal Kanban

Kanban Post

Sequenced Pull Ball

Go See Production Scheduling


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General Icons

Kaizen Lightening Burst

Buffer or Safety Stock

Operator

Q

Quality Problem


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© 2014 Institute of Industrial Engineers

Lean Value Stream Guidelines

Know your takt time

How frequently a product must be finished in order to meet customer requirements.

Develop continuous flow

Send the schedule to only one process step

Level the process steps

emandCustomer D

Time Available Takt time

3-2-20

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Future State Map

Purpose is to identify and eliminate sources of waste. Key Questions: How will you level the flow? What is the increment of work that will consistently be

released and taken from the ‘pacemaker’ process? What process improvements will be necessary for the value

stream to flow as your design state specifies? What is the increment of work that will consistently be

released and taken from the pacemaker process?


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• Percent Value Added Time:

– Current State: 42%

– Future State: 49%

• Patient Lead Time:

– Current State: 247 min

– Future State: 67 min

– 115% Reduction



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Value Stream Plan

Current

State Map

Future State

Map

Process

Level Maps

Yearly Value

Stream Plan


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Going to the Gemba

The actual place (gemba)

The actual work center

The actual thing (gembutsu)

The actual facts (gemjitsu)

The actual people

Get out there and see what is going on!!!


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“I knew six honest serving men

They taught me all I knew

Their names were what and why and when

And where and how and who.”

- Rudyard Kipling


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Analysis

Go to the Gemba. Speak with the data and the processes.

Collect the data

Draw a map

Collect the 6 honest men What Why (*5 Why’s too) When Who Where How


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VSM Exercise


Map the Current State

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VSM Exercise


Identify the Waste

T.I.M. W.O.O.D.

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VSM Exercise


Map the Future State

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© 2014 Institute of Industrial Engineers

Value Stream Plan

DATE SIGNATURES

FACILITY

MANAGER

PLANT

MGR

ENG

VALUE STREAM

MANAGERMONTHLY SCHEDULE UNION MFG

PLANT LEVEL

OBJECTIVE

VS

LOOP

VALUE STREAM

OBJECTIVE

GOAL

MEASURABLE

J

A

N

F

E

B

M

A

R

A

P

R

M

A

Y

J

U

N

J

U

L

A

U

G

S

E

P

O

C

T

N

O

V

D

E

C

RESP TEAM REVIEWER DATE

3-2-31

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Macro Value Stream Mapping

Extends beyond plant level maps

Reasons:

Large portion of costs consist of purchased materials

Costs downstream can negate cost savings internally

Major asset reconfigurations can be identified by showing who does what where


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Macro VSM Process (Cont’d)

Current State:

Select a product or partner that is important to your business.

Decide on practical limits.

Map the facility closest to the customer and work backwards.

Collect data for each step.


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Macro VSM Process (Cont’d)

Future State:

Calculate takt time

Level the demand upstream from the customer

Create a supermarket downstream from each facility

Implement cells in each facility to create a flow


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Levels of a Value Stream

Process Level

Single Facility

Multiple Facilities

Across the

Organization

Begin here

Here is where

we are going

Ultimate goal


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Flow


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Flow


“The absence of delays and waiting in a value stream.”

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Flow: The Many Views

Physical (Floor Layout)

Logical (VSM)

Functional (Process Flowchart)

Varieties

Patient

Personnel

Material

Information


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Components Receiving

Save the Units!


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Save the

Units!


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The “Back Door” Receiving Start Blood Staging Blood Information


Blood Flow

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Records/Information Complete Receiving Info Processing


Blood Flow

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Staging Components Mfg Blood Inventory Components Exit Recv


Blood Flow

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Processing Centrifuge Processing Mix


Blood Flow

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Processing Thawing Handling Storage


Blood Flow

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Centrifuge Processing Storage Handling


Blood Flow

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Processing Out of Storage Centrifuge Handling


Blood Flow

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QC Lab


Blood Flow

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Blood Flow

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Labeling Storage Labeling Area Complete QC


Blood Flow

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Hospitals Shipping


Blood Flow

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Phlebotomy: Collection


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Phlebotomy: Collection

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Flow


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Flow


Copyright 2008 Health Administration Press. All rights reserved.

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Flow


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Flow


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Surgery Patient Flow


ADMISSION CENTER (Current activities conducted in holding and day surgery)

Pt arrives at

day surgery

Pt

escorted

into

‘room’

Pt assessed by nursing,

business office for

completion and accuracy

of previous documentation

Pt assessed by

anesthesiology

or other M.D.s

as appropriate

Pt receives presurgical preparation, begins IV, VS, BP, etc.

Pt receives additional lab and

radiology testing, as appropriate

Pt notified

that

transfer to

OR has

been

indicated

Pt

family

leaves

Pt

transported

to OR room

by

appropriate

means

HOLDING/STAGING

Pt arrives in

holding

Pt assessed by nursing for

completion and accuracy

of previous documentation

Pt assessed by

anesthesiology

or other M.D.s

as appropriate

Pt receives presurgical preparation begins, IV, VS, BP, etc.

Pt receives additional lab and

radiology testing, if appropriate

Pt notified

that

transfer to

OR has

been

indicated

Pt

family

leaves

Pt

transported

to OR room

by

appropriate

means

OR

Pt arrives

in OR

room

Pt moved

to table

Pt

anesthetized

Pt draped,

positioned

and prepped

Incision

made

Procedure

performed

Incision

closed

Pt extubated and

awakened (if

appropriate)

Pt

cleaned

Pt transported to

appropriate

location

Pt receives

appropriate

assessment (VS,

IV, monitoring)

Pt

discharged

to

appropriate

location

Pt moved

to

stretcher

PACU (HOLDING) OR

SICU

DAY SURGERY

INPATIENT UNIT

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CT Scan Flow


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Pre-Certification Flow


Pre-certification Flow Chart

Document pre-cert number on PHS

schedule if obtained

Call office prior to exam for pre-cert

status

Physician office contacts patient to reschedule due to no pre-cert

Make follow-up calls to office in order to

obtain pre-cert

Document pre-cert status on PHS schedule

if not obtained

Physician Office

Notify physician office that no pre-cert is

required

Schedule patient only and document on

schedule NPR

No pre-cert required (NPR)

Document on PHS schedule

if unable to reschedule patient prior to appt

If insurance allows request retro

pre-cert

Document on pre-cert and registration log if

patient had exam without pre-cert

Follow up in Star registration to check if patient had exam without pre-cert

Pre-cert dept or physician office contacts patient to reschedule appointment if pre-cert not obtained

Follow-up with physician office to get

status of pre-cert

Insurance company calls or faxes decision

to physician office

Call insurance company to request pre-cert

Document on pre-cert and registration log if

number was not entered by PAS

Follow-up in Star registration to be sure pre-cert number was

entered by PAS

Document pre-cert number on PHS schedule and log sheet if obtained

Insurance company faxes decision back

to pre-cert dept

Fax in written request for pre-cert

Check pre-cert status on website until decision

is made

Request pre-cert on website

Log in faxed request on log sheet

Pre-cert department

Who is to obtain pre-cert for procedure

if required?

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In Between Visit Activities and Pre Visit

Planning Sub Process Flow


Breakthrough Design Map

© 2004 Leap Technologies, Inc.

In Between Visit Activities and Pre Visit Planning Sub Process

Big Ideas and Enabling Tools:

PROACTIVE

Schedules interaction

via:

-Call

-My Chart

-Kiosk @ mall

- Clinic Kiosk

- Home

Telehealth monitors

- B/P

- CHF

-Blood Sugars

•Automated Triggers

•Automatically order of

needed test as future and &

drive work effort (prioritize)

•Risk Stratification

•Role change of human to

technology

Intervention is:

-Patient Specific

-Measurable

-Adjusted as needed

-Must be

documented via

email, letter or ?

Previsit Planning

- prior to day of,

automatic scrubber

determines needed tests

and orders them

Major Process Steps

Assumptions & Open Questions

Assumption:

Base of

patients

already ID’d

Philosophy:

Human

Touch vs.

Automated

Outside

Labs? Appointment

happensCheck out

should

inititiate the

“in between”

process

Combining

Med vs.

problem list

scrubbing

Coordinate

visit with all

needed

services

Safety Net?

Care

Coordinator

Health Alerts

Developed in Workshop

by:

•Chris

• Mike

• Lisa

• Dennis

• Krister

• Karen

Identified

Patient

Registry

Automated reporting

& Analysis Tools

“Clarity on Steroids”

business

intelligence tools

Patient Education:

•Webcasts

• Podcasts

• Link to Comm. Resources

• Email

• My Chart

Patient

Center, Not

Disease

Patient

REACTIVE

What about

Provider

Autonomy?

Out of Care PT

Patient Kiosk:

• In Clinic

• In retail locations

• Other public sites

Integration System:

Example: vaccination

program

Staff Education and

Development:

- Scripting

Need to

define

Community

Resources!

Policy/Leadership Decisions:

Key: Standardize

protocols and use

them as much as

possible

Create a Problem

List and Med List

Update Policy

Create a policy on

Outside Labs which

supports CCSI

? Hospital or

Assisted Living,

Nursing Home

Pts?

Captures the current reality

Defines value from customer perspective

Forms the basis for an implementation plan

Demonstrates waste, gaps and major constraints in care delivery

Identifies value-added steps needed

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Blood Bank VSM


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Patient Flow Analysis


Patient Pathway/Value Stream Possible Starting Points Possible Ending Points

Emergency Department Phone call made for ambylance ED Discharge

Arrival at door Start of cath lab procedure

Moved into room

Discharge from inpatient care

Outpatient Surgery Arrival at door Start of procedure

First call for scheduling Start of postanesthesia care unit (PACU)

First referral from general practitioner Discharge

Outpatient Cancer Center Arrival at door Start of treatment

Discharge

Scheduled Inpatient Surgery Arrival at door Start of procedure

First call for scheduling procedure Start of PACU

First referral from general practitioner Movement into room

Discharge

Patient Discharge Process MD writing discharge order Patient ready to leave

Patient physically out door

Room physically ready for next patient

Radiology Order for procedure Start of procedure

Arrival at outpatient center End of procedure

Start of procedure Report verified

Possible Start and End Points

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A Healthcare “House Model”


Flow Quality

Goals: Requirements, Safety, Quality, Time, Cost, Morale

Heijunka (Load Leveling)

Kaizen (Continuous Improvement)

Standardized

Work

Developing

People

• Prevent Delays

• Value Stream

Focus

• Pull Systems

• Right Care

Right Place

Right Time

• Identify Root

Causes

• Prevent Errors

at the source

• Involve

Employees

• Avoid Blaming

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Flow Exercise

Process SIPOC

Process Flow Chart

Floor Layout

Value Stream


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Closing thoughts on VSM and Flow?


Documents

Six Sigma Black Belt Week 1 - Institute of Industrial and ......VS, BP, etc. Pt receives additional lab and radiology testing, as appropriate Pt notified that transfer to OR has been