Value Stream Mapping

Value Stream Mapping and

the Journey of the Northern

ACS Patient

Ronnalea Hamman, MSc.

Lean Leader, imPROVE

Provincial Health Services Authority

Barbara Hennessy RN, MN, CCN(C)

Regional Coordinator, Cardiac and Cerebrovascular Services

Northern Health

Julie Dhaliwal, BA CYC (cert)

Manager, Medical Services, University Hospital of Northern BC

Northern Health

© Provincial Health Services Authority

Objectives

1. Understand the process of Value Stream Mapping • Theory

• Tool

• Application in an Agency Setting

2. Review the process of a provincial Value Stream Map • Home to Home Journey of the Northern Health Patient through tertiary

cardiac services.

3. Review initial improvements from a provincial Value

Stream. • Discharge Preparation of the Northern Cardiac Patient


Value Stream Map

A value stream map is a management tool for a cross-

functional team to look at value streams rather than at

discrete operations.


Benefits

• Patient/Family-centric

• Data-driven

• Forces participants to discuss how they see the value stream

• Drives consensus as to how all perspectives are represented along

the value stream

• It is an alignment tool that allows people to understand and improve

processes

• Provides a framework to see, learn and act together


Value Stream Management

Value Stream

Management

Daily Management

Unit Unit Unit Unit Unit

Unit Unit Unit Unit Unit

Unit Unit Unit Unit

Unit Unit

Strategy Deployment

Director Director

Program Program Program Program Program

Exec



How does it differ from process

mapping?

• Flowcharting techniques to understand a process.

• Multiple perspectives define the process boxes (not from

patient POV).

• Does not identify value added components.

Pick up mail

Open & date

stamp

Triage

- Type 1 contact

- Detox

- Children

- Symptomatic

X-ray

Report?

Request abnormal

X-ray report

All documents

received

Yes

No

Hold

unmatched

Enter

Radiology

report

No

Yes

X-ray or CD?

X-ray

Check CD

- name

- report

CD

Onsite or

Offsite

Pull previous

record

Request offsite

record

Enter into iPHIS

Check iPHIS

for previous

record

X-ray or CD?

Radiologist

Review

X-ray

Review by Dr.

Elwood

Yes

No

Yes

Normal /

Abnormal

File X-ray

939 & Normal

report

939

939 & abnormal

X-ray

Normal

Abnormal

CD

Batch CDs, read in

Reading room

Normal /

AbnornalDictation

Check “No

Evidence” Box

Normal

Abnormal

Separate Field

Ops & Vancouver

X-rays

File

copy

return

Normal /

Abnormal

939 & Tape

Transcribe into

iPHIS

Enter “No

Evidence” into

iPHIS

Normal

Abnormal

Dictated 939sSend Referral in

iPHIS

Generate

Validation Sheet

Enter treatment

required into iPHIS

Outbox to

Pharmacy

Enter end date into

iPHIS

Send pick & yellow

copies to Health

Units

Outstanding

referrals iPHIS

Previous Files?

Request

Discharge

Summary

Proof narratives

Discard extra

copies

Create small

envelop &

withdraw card

File 939

Validate

printed

report

Upd?Update

iPHIS

report

Print narratives

Yes

Print upd

report

Separate

- health units

-physicians

Pre-addressed,

pre-stamped

envelop Mail

Withdraw envelop

& mail

CD

Match CD &

939

To VGH for

Radiology

Radiologist

review

Date stamp

upon arrival

Enter

Radiology

report into

iPHIS

To Dr.

Elwood for

review

More

dictations?

File CDFile 939Initial

comments

No

Yes


Current State Value Stream


Future State

Vision of a future state

- Set Value Stream Goals

- Reduction of Time = increased throughput, increased

efficiencies,

- Reduction of Time by elimination or reduction of waste.

- Reduction of Defects


Bridge from Current to Future

• Kaizen Ideas

• Focus: • Value

• Flow

• Work

• Set your improvement agenda

• Manage your improvement agenda and set a clear line

of site from your improvement to your goals.

• Establish and manage an action plan.

• Revisit the value stream (after each improvement and

annually)


Value Streams in Practice

Common Issues

• Team Capacity (3 day exercise)

• Data (current and ongoing monitoring)

• Long process value streams (i.e. mental health)

• Sponsorship (ownership)

• Alignment of VSM goals with department/agency/health

authority/MoH goals


Home to Home Journey of the NH Patient

through Tertiary Cardiac Services


• 95% of these patients travel to Vancouver for diagnosis and

treatment.

• There is a delay in transferring these patients to get access to a

higher level of care.

• There is often a delay in transferring these patients back home.

• Care must be coordinated across three health authorities.

• The improvements in this value stream potentially have a broader

application to all rural remote cardiac patients.

• Support provided by Shared Care & Specialist Services Committees’ Health Authority Redesign Funding

Why this patient group?


Building Current State

Customer:

• Northern health urgent ACS patient.

Customer Requirements:

• Timely access to a higher level of care.

• No delay in transfer.

• Coordinated communication and transfer of information.

• Timely return to home community.



Add high level process steps:



Interviews

Observations HEARTis Data

69 Interviews in 5 health

authorities and BCEHS

Triage Coordinators

Daily Triage Call

Utilization Meetings

Northern Health Processes

• Time to Referral Acceptance

• Time to Transfer

# Cath Referrals/Site

# PCI/Surgery/Site

• Add Data and Metrics:


Bridge to Future State

Limitations and Challenges

• Scoping and Focus not clear enough to fully define

future state and set clear value stream goals.

• Limited authority to make changes within health

authorities.

• Tight timeline: November to March

• Large group with varied experience with value stream

mapping process.


Bridge to Future State

1 2 3 1 2 3 1 2 3

Northern Health Northern Health Cardiac Site BEHS


Improvement Agenda

Change in Value Stream Purpose

1. Standardize the referral form. In order to: •Decrease the time between “time of referral” and “acceptance date”; •Eliminate overproduction by triage coordinators (multiple phone calls); •Decrease the % of incomplete referrals

2. Standardize the patient journey information and education.

In order to: •Decrease the time between “date of intervention” and “time of discharge”; •Decrease the # of patients “unprepared” for discharge.

3. Standardize the referral process with the Patient Transfer Network .

In order to: •Decrease the time between “time of referral” and “time of transfer”; •Reduce rework and overproduction by the triage coordinators;


• Planes, trains and snowmobiles…understanding how our Province can work

better together

• January 2014 a provincial project team was identified

• Team met weekly by teleconference to get to know one another and to

identify the focus of the during the Improvement Workshop - April 29-May 1

Patient Discharge Planning Workshop

April 29 – May 1


Patient Discharge Planning Workshop

April 29 – May 1


Outcomes

Primary Outcome:

Reduce the time between intervention to discharge from 8.5 days

to 6 days.

Process Outcome:

Patients arrive “prepared” at a cardiac site.


Problem Statement 1

Length of stay in cardiac site increases due to amount of

patient preparation required for discharge at the cardiac

site for a safe return home.

Hypothesis: A “prepared” patient upon entering the cardiac

site will have a shorter length of stay.


Solutions

1. Standardized Northern Health Checklist and Patient

Preparation Package.

2. Standardized Northern Health Cardiac Patient Transfer

Plan that involves patient, family and provider to

prepare for transfer to cardiac site.


Pilot Trial – NH Cardiac Patient Transfer

• Standard packages - pilot project from July to September

2014: – Prince George

– Vanderhoof

– Terrace

– Dawson Creek

• All 5 Cardiac Sites participated in pilot project and

collected tracking form when patient arrives. – Patients are prepared when arriving to cardiac site.

• Continuing to monitor primary outcome with CSBC: – Reduction of time between intervention and discharge.


Project Team - What did we learn?

• Given the opportunity – you can improve provincial processes collaboratively.

• Greater understanding of the size, complexity and challenges faced by

Northern Health.

• Greater communication about expectations between health authorities across

patient journey.

• Clarity of how to develop and improve provincial forms (who owns them and

who is accountable?)

• Understanding of the work that was happening in other health authorities on

our shared patient populations.

• Difficulty in finding standard measurements and language across province.


Working better Together

• Listen to understand verses Listen to respond

• What were the ingredients that contributed to our team working successfully

as a high functioning team in such a short period of time…

• The team listened to understand one another and the various barriers and

frustrations that were both unique to each HA and collectively as a larger

health care system

• The individual triage co coordinators shared the lengths they went to get

people home who had arrived in Vancouver with no clothes, shoes, ID or

money


Understanding the Geography

• What contributed to understanding the barriers that each Health Authority

was experiencing was the time we gathered around the NH map

• Stories, experiences and understanding the NH Connections bus routes

provided context to why patients had difficulty in getting home and why we

as a group had to come up with a way to have patients return safely home

with the travelling required in the North…planes, trains and snowmobiles!

• NH is 2/3 of the province we have less population than the lower mainland

but our geography is far reaching with barriers to access in the remote

areas such as Fort Ware and other remote communities.

• Its actually easier to get to Puerto Vallarta than it is to get a patient home

from Vancouver to Terrace


Next Steps

• Pilot project results were presented to the NH Cardiac and Cerebrovascular

Services Working Group in October 2014 o request a next step for working

towards an NH Regional process beyond the Pilot sites.

• Make this package standard for all of Northern Health


Value Stream Mapping as a

Provincial Tool

• The ‘home to home’ patient value stream allows a

system focus to anchor problem solving.

• Creating time for frontline staff to design and trial

processes that cross health authorities is proving

efficient and beneficial to “get the work done.”

• Standardization and collection of data and processes

across health authorities is a challenge.

• Sponsorship at each health authority is crucial for

sustainment of improvements at this level.


References

Making Hospitals Work

Taylor, Maker, Mitchell and Jones

2011

Perfecting Patient Journeys

Worth, Shuker, et al.

2013

Healthcare

Value Stream Mapping