Value Stream Mapping

Value Stream Mapping and the Journey of the Northern ACS Patient

Ronnalea Hamman, MSc.Lean Leader, imPROVEProvincial Health Services Authority Barbara Hennessy RN, MN, CCN(C)Regional Coordinator, Cardiac and Cerebrovascular ServicesNorthern Health Julie Dhaliwal, BA CYC (cert)Manager, Medical Services, University Hospital of Northern BCNorthern 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 UnitUnitUnitUnit

Unit UnitUnitUnitUnit

Unit UnitUnitUnit

UnitUnit

Strategy Deployment

Director Director

Program ProgramProgramProgramProgram

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-rayReport?

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 iPHISCheck iPHIS for previous

recordX-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 / Abnornal

Dictation

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

iPHISGenerate

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

CDMatch 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


How does it differ from patient journey mapping?• Focus is on patient experience and how care is received.• Visualizes complexity of patient journey.• Identifies touch points in the patient care.


Building the Current State VSM

1. Customer and quantifiable customer requirements

2. Supplier or Inputs

3. Processes

4. Data

5. Communication and Information Flow

6. Timeline and Summary with Value Stream Metrics


Agency Level Value Stream


Building the Current State

1. Who is your customer and what are some quantifiable customer requirements?

The customer is the recipient of the output or the outcome of your value stream.

The customer defines value delivered by the value stream.

Examples: • Total Length of Stay• Delays• % Complete and Accurate• Rework• Sentinel or safety events



Define the Basic Processes

• Start and finish• Altitude



Add Data Boxes

• Cycle time for each process• Amount of time between processes• # of People / Hours• Input Requirements (% Complete and Accurate)• Output Requirements (% Complete and Accurate)



• Add the communication flows to and from the process to external resources and back.

• Add a summary timeline to show the total amount of work time (value added or necessary work) and delay time (non-value added work).




Wastes


Value

Compare the customer requirements to value stream performance:

• Are you meeting requirements?• Length of Stay• Clinic Appointment Time• Value-added service (no delays or waiting)

• Are you meeting quality requirements?• Complete Discharge Plan• Medication Reconciliation• Quality Rounds


Flow

Review unnecessary delays.

• Clear triggers for subsequent steps.• Rework• Excessive handoffs• Interruptions• Requirements for decisions and approvals• Duplication of work


Work

Review how quality and safety are built into each process.

• Standards governing each process (no standards, unclear standards, incorrect standards).

• Passing work on with checkpoints for completeness and accuracy.


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

ObservationsHEARTis Data

69 Interviews in 5 health authorities and BCEHS

Triage CoordinatorsDaily Triage CallUtilization MeetingsNorthern 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 HealthCardiac SiteBEHS


Improvement Agenda

Change in Value Stream Purpose1. 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 WorkshopApril 29 – May 1


Patient Discharge Planning WorkshopApril 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 WorkTaylor, Maker, Mitchell and Jones2011

Perfecting Patient JourneysWorth, Shuker, et al.2013

Value Stream Mapping

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