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7/23/2019 VSM Healthcare
1/26
Value Stream Mapping:pp e o ea care sys ems
Krishnan Krishnai er
Dr. F. Frank Chen
Dr. Glenn Kuriger
Center for Advanced Manufacturing & Lean SystemsThe University of Texas at San Antonio , One UTSA Circle , San Antonio, Texas 78249-0670
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Center for Advanced Manufacturing & Lean Systems
Back round
Overview of Value Stream Mapping (VSM)
Methodology Results/Findings
Conclusions
Future Research
The University of Texas at San Antonio 2
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Center for Advanced Manufacturing & Lean Systems
Back round: Wh lean in healthcare?
Budget Projection Expenditure Type
$4.00
$4.50
.
$2.50
$3.00
.
T
rillio
n
s
($)
0.50
$1.00
$1.50
.in
$0.00
.
2010 2011 2012 2013 2014 2015 2016 2017 2018 2019
Foundation, K.F. Trends in Health CareFoster, S.R. and K.S. Heffler. Updated and
The University of Texas at San Antonio
Costs and Spending. Kaiser Family
Foundation 2009.Extended National Health Expenditure Projections,
2010-2019. 2009 06-29-2009
3
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12% of Emergency Department (ED)
patients are admitted to hospital 7 out of 10 are seen in 4 hours
2 % leave without being seen
,
health professionals (74%)
oo e me spen w pa en s Too few nurses (69%)
The University of Texas at San Antonio 4
Study by CDCEller, A., Rapid Assessment and Disposition: Applying LEAN in the Emergency Department. Journal for Healthcare Quality, 2009. 31(3): p. 17-22
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Center for Advanced Manufacturing & Lean Systems
A simple tool to visualize the flow of value
s reams an was e
Identify value-added steps in your processes
Visualize information and material flow
improvements
Get everyone on the same
page with a common visionof the current state and
The University of Texas at San Antonio 5
the future state of operations
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Center for Advanced Manufacturing & Lean Systems
Emphasis on Time-based Performance:
Cycle TimeLead Time
etc
OtherAdd-on Indicators:Cost
Patient safety
Quality
Patient wait times
The University of Texas at San Antonio 6
Customer satisfaction, etc
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Center for Advanced Manufacturing & Lean Systems
Common VSM IconsRother and Shook (2003). Learning to See,
The Lean Enter rise Institute.
C/T=1sec
C/O=1hour
Uptime=85% IStamping4600L
Michigan
Tues.+
Thurs. FIFOmax. 20 piecesMaterial Flow
General
, . .
EPE=2weeks200 T
2400Rtee o.
Process OutsideSources
Data Box Inventory
Truck
Shipment
rs - n- rs - u
Sequence Flow
Operator
PushArrow
Finished Goodsto Customer
Supermarket
PhysicalPull/Withdrawal
SupermarketParts
Weekly
Manual Electronic
Informal Visual
OXOX
Load Leveling
Information Flow
Buffer or
n orma on ow n ormat on ow a e y oc
Changeover
The University of Texas at San Antonio 7
Kanban Kanbangna
KanbanKanbanPost
Sequenced-PullBall
KaizenBurst
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Center for Advanced Manufacturing & Lean Systems
xam ne ow can e success u y
used to:
Visualize waste
Improve quality in the health care
The University of Texas at San Antonio 8
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Center for Advanced Manufacturing & Lean Systems
healthcare and VSM
Classify the articles based on:
the methodology used,
the area of application of VSM, and
The University of Texas at San Antonio 9
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Center for Advanced Manufacturing & Lean Systems
Results/FindingsMethodology Application Metrics ReferenceVSM Hip fracture patients Door-to-theatre (DT) time, admission into trauma
beds, pre- and post-operative medical assessment
Chakrabarti, et al.
(2009)
me m uatory trage es mergency
Department)
me o pat ent arrva to rst sta contact; nurs ng
evaluation; wait times; and arrival until roomplacement time
aa e, et a .
VSM Emergency Department % of patients ranking the overall care as Very
Dickson, et al. (2009 a,
,
month, average number of patient visits per month
VSM Emergency Department Average Length of Stay, % Patients left without
being seen
Eller, A. (2009)
VSM + Lean Emer enc De artment RuralHealth Avera e Time Searchin for Su lies Avera e Sn der and McDermott
Care Hospital (99 bed)
Time of Discharge Process
(2009)
VSM Physicians Clinic
Obstetrics/Gynecology (OB), Family
Practice, and Internal Medicine
Reduce staff stress level, improve overall
performance
Lummus, et al. (2006)
VSM Medication delivery system errors Cost of human resource ($/yr) Mazur and Chen (2008)VSM Reduce wait times in the Emergency
Department
Overall Patient Satisfaction scores, Accuracy of
triage nurse to predict discharge, time to see
physician, length of stay
Ng, et al. (2010)
The University of Texas at San Antonio
VSM Computerized Physician Order Entry
system
Net Present Value Kocakulah and Upson
(2005)
10
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Results/FindingsMethodology Application Metrics ReferenceVSM +Lean
tools
Histology Lab Workflow Turn around time and errors Buesa (2009)
ean
tools
rescr p on renewa an ng y
application
e uc on o process ng me ummer an accare
(2009)VSM Laboratory, Emergency Department,
Surgery department, house keeping
Patient Satisfaction, Cost Savings, Time to
prepare a room
Serrano and Slunecka
(2006)
ean
Tools
mergency epar men n ers
Medical Care Australia
a me, acu e separa ons a were
unplanned readmissions, Length of stay for
medical patients admitted as emergency cases,
Number of notification of serious medicolegal
en- ovm, e a .
.
Process Map +
Six Sigma
(LeanSigma)
Pharmaceutical Industry Cycle times of synthesis, compound analysis and
purification
Andersson, et al. (2009)
Process Map + Imaging Department Mexico Increase patient satisfaction Garcia-Porres, et al.
Kaizen +LeanSigma
(2008), Garca-Porresand Ortiz-Posadas (2009)
VSM + Lean Canadian Health care Provides Wait times, Patient Safety, Culture change and
Quality
Fine, et al. (2009)
The University of Texas at San Antonio
VSM + Lean +
5S
Blood Transfusion Establishments -
France
Quality and Safety of Blood Products Bertholey, et al. (2009)
11
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Key Decision Points of Lean Deployment
Hospital
Who Led
the
Change?
Who Drove
Work?
How Was
Knowledge
or Expertise
Acquired?
Crisis of
Lever
First Value
Stream
Mapping First Win Objective
HDGH EVP LEA(R)N
coordinator
Training,
consultant
ED in
newspaper
Portering ED Reduce ED
wait timesUHN PMO senior
manager
PMO Hire consultant CEO's
transformation
agenda
Bullet rounds
(GIM)
ED-GIM Reduce ED
wait times
everage o
introduce lean
St.
Joseph's
Former VP,
now CEO
Manager of
access services
Consultant VP challenge ED admit and
discharge
processes
ED-GIM Improve
patient
safety
,
government
brought CEO
to see Lean at
VMMC
culture
NYGH VP Lean de lo ment Hire consultant SARS ED-GIM ED-GIM Move
leader chairedFlow Steering
Committee
outbreak andsubsequent
leadership
transformation
patientsafety and
quality
agenda
CEO = chief executive officer ED = emer enc de artment EVP = executive vice- resident FHHR = Five Hills Health Re ion GIM = eneral internal medicine
The University of Texas at San Antonio 12
HDGH = Hotel-Dieu Grace Hospital; NYGH = North York General Hospital; PMO = project management office; SARS = severe acute respiratory syndrome; QI =
quality improvement; UHN = University Health Network; VMMC = Virginia Mason Medical Center; VP = vice-president
Fine, B. A., B. Golden, et al. (2009). "Leading Lean: A Canadian Healthcare Leader's Guide." Healthcare Quarterly 12(3): 32-41.
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VSM Visualize WasteExample of VSM in Emergency Room
The University of Texas at San Antonio 13
Dickson, E. W., S. Singh, et al. (2009). "Application of Lean Manufacturing Techniques in the Emergency Department." The Journal of
Emergency Medicine 37(2): 177-182.
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VSM Visualize WasteExample of VSM in Emergency Room
The University of Texas at San Antonio
Dickson, E. W., S. Singh, et al. (2009). "Application of Lean Manufacturing Techniques in the Emergency Department." The Journal of
Emergency Medicine 37(2): 177-182.14
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VSM Reduce Costurren a e
Example of VSM in Computerized Physician Order Entry
The University of Texas at San Antonio
Kocakulah, M.C. and J. Upson, Cost analysis of computerized physician order entry using value stream analysis: a case study.
Research in Healthcare Financial Management, 2005. 10(1): p. 13(13)
15
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VSM Reduce Costu ure a e
Example of VSM in Computerized Physician Order Entry
The University of Texas at San Antonio
Kocakulah, M.C. and J. Upson, Cost analysis of computerized physician order entry using value stream analysis: a case study.
Research in Healthcare Financial Management, 2005. 10(1): p. 13(13)16
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VSM Reduce CostExample of VSM in Computerized Physician Order Entry
The University of Texas at San Antonio
Kocakulah, M.C. and J. Upson, Cost analysis of computerized physician order entry using value stream analysis: a case study.
Research in Healthcare Financial Management, 2005. 10(1): p. 13(13)17
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VSM Improve Quality Current SateExample of VSM in Emergency Room Houston Texas (32,000 annual visit)
The University of Texas at San AntonioEller, A., Rapid Assessment and Disposition: Applying LEAN in the Emergency Department. Journal for Healthcare Quality, 2009. 31(3): p. 17-22
18
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VSM Improve QualityExample of VSM in Emergency Room Houston Texas (32,000 annual visit)
The University of Texas at San Antonio
Eller, A., Rapid Assessment and Disposition: Applying LEAN in the Emergency Department. Journal for Healthcare Quality, 2009. 31(3): p. 17-22
19
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VSM Improve QualityExample of VSM in Emergency Room Houston Texas (32,000 annual visit)
3,500
Patient Total Volume
80%
Total Diversion
1,000
1,500
2,000
2,500
,
30%
40%
50%
60%
70%
-
500
Baseline
Aug
-07
Sep
-07
Oct-07
Nov
-07
Dec
-07
Jan-08
Feb-08
Mar-08
Apr-08
May
-08
Jun-08
Jul-08
Aug
-08
Sep
-08
Oct-08
Nov
-08
Dec
-08
Jan-09
Target, 8.00%
0%
10%
ase
line
Aug
-07
Sep
-07
Oct-07
Nov
-07
Dec
-07
Jan
-08
Feb
-08
Mar-08
Apr-08
May
-08
Jun
-08
Ju
l-08
Aug
-08
Sep
-08
Oct-08
Nov
-08
Dec
-08
Jan
-09
Target, 120300
400
500
Length of Stay (Minutes)
7%8%9%
Left Without Being Seen
0
100
200
eline
g-0
7
p-0
7
t-07
v-0
7
c-0
7
n-0
8
b-0
8
r-08
r-08
y-0
8
n-0
8
l-08
g-0
8
p-0
8
t-08
v-0
8
c-0
8
n-0
9
Target,1.90%
0%1%2%3%4%5%
ine
-07
-07
-07
-07
-07
-08
-08
-08
-08
-08
-08
-08
-08
-08
-08
-08
-08
-09
The University of Texas at San Antonio
Eller, A., Rapid Assessment and Disposition: Applying LEAN in the Emergency Department. Journal for Healthcare Quality, 2009. 31(3): p. 17-22
Bas
Au
Se
O No
De
Ja
Fe
M A Ma
Ju J
Au
Se
O No
De
Ja
Basel
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
20
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Gap in Literature
Current Silo focus areas
nterna ustomer xterna ustomer
Employee Hiring Patient Flow
BillingCapital Expenses
Hospital Services Emergency careLab
Needed Holistic end to end Hospital Management VSM
The University of Texas at San Antonio 21
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ar ous examp es were s own o
demonstrate that VSM can be used to
success u y n ea care o
Visualize wasteReduce cost
Improve quality
The University of Texas at San Antonio 22
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Center for Advanced Manufacturing & Lean Systems
Complete internal operations of hospital
VSM (employee hiring to retention) Com lete atient care and billin VSM
Establish an end-to-end VSM
management:
Internal hirin
Purchasing,
Patient care, and
The University of Texas at San Antonio
Patient billing
23
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The University of Texas at San Antonio 26