Value and Waste

1. Value and Waste Value Stream Mapping in a Health Care Environment

2. Aims of the session: • Introduce the concept of Value Stream Mapping

3. COMPASS WAITING LIST DIARY - CASE NOTES PULLED 3 WEEKS IN ADVANCE THEATRE LIST PRINTED L4 HOURS BEFORE - ALLOCATE BEDS THEATRE LIST SAME DAY FROM JANET. TRY 24 HOURS BEFORE REPORTS ADMISSION AT FRONT RECEPTION. DETAILS CHECKED PATIENT ARRIVES RECEPTION DAY SURGERY TAKE PATIENT TO WARD AND TO BED AREA WITH NOTES. ADVICE TO UNDRESS/GOWN ON. TELL NURSING STAFF. RECEPTIONIST FINDS OUT IF THEY TO GO TO RADIOLOGY AND WHAT TIME 1 WEEK IN ADVANCE ADMIT PATIENT VIA CARE PLAN. 5-10 MIN. LOOK AT MOD CHECK IF TO GO FOR ULTRASOUND - IF TO GO WALK THEM ROUND TO X-RAY WAITING ROOM. 1ST KUB - KID URETER BLADDER X-RAY. PATIENT FULL BLADDER. 2ND ULTRASOUND 20-30 MINS IN RADIOLOGY. PATIENT X-RAY AND ULTRASOUND REPORT BACK - BACK TO BED. DOCTOR SPEAKS TO PATIENTS - CONSENT SIGNED THEATRE STAFF ATTEND DAY SURGERY - DATA SHEET GIVEN TO DAY SURGERY STAFF. THEATRE STAFF TAKE PATIENT STRAIGHT INTO MINOR OP THEATRE. TEST 10-15 MIN ALLOCATION DR CANNING 3 1/2 HOUR SESSION VERBAL REPORT TO PATIENT AND INFORMATION. TAKEN BACK TO DAY SURGERY IF DOCTOR NEEDS TO SEE- APPOINTMENT MADE STRAIGHT AWAY - GIVEN TO PATIENT MAKE SURE PATIENT OK - ? DRINK OR EAT. DISCHARGE INSTRUCTIONS FOLLOW/REVIEW AT OUTPATIENTS VOL APPOINTMENT NEXT DAY. INDICATED ON CARE PATHWAY IF RAH DR WILL INDICATE ON TAPE - SECRETARY WILL ARRANGE. Process mapping

4. NURSE ESCORTS PATIENT TO CHANGING ROOM WITHIN THE EXAMINATION ROOM. PATIENT ATTENDS RADIOLOGY DEPARTMENT FOR ULTRASOUND AFTER SCAN PATIENT REPORTS TO RECEPTION DESK IN OUTPATIENTS DEPARTMENT PATIENT CHANGES INTO GOWN AND JOINS DOCTOR IN THE EXAM ROOM DOCTOR EXPLAINS EXAMINATION AND CONSENTS PATIENT. PROCEDURE CARRIED OUT. RESULT GIVEN IF APPROPRIATE AND FOLLOW UP INFORMATION GIVEN PATIENT CHANGES BACK INTO CLOTHES AND LEAVES THE DEPARTMENT. REPORT TYPED BY UROLOGY SECRETARY AT RAH

5. What is value? • The activity is done right first time • The activity transforms the patient and moves them towards the next defined outcome • The activity is something that the patient cares about

6. Define value in your service • Who are your patients? • What is the ‘value’ your patient wants? • How is the value added? • When you describe value use the patients' words

7. Identifying Value - Exercise • Have a look at the process map • Which steps add value for the patient? • How many are there? • Which steps are necessary but don’t add value? • How many are there? • How long does the whole process take? • How much time adds value for the patient?

8. Current State Map Runner Group: GP Orthopaedic Out Patient Referrals for Adult Hip X-ray Responsible for the GP / GP Surgery Radiology Dept Radiology Dept Porters Radiology Dept GP / GP Surgery Radiology process Dept Responsible clinically for the Radio-logy Radio-logy Radio- Radio-logy patient GP Surgery GP GP reception Dept grapher SCW reception GP Surgery GP Typist types draft Typist report & amends Typist emails Typist collects emails to report and report to GP tape, films & Radiolo- emails to and copies Typist XR gist Radiologist Reception Porter collects old films and takes to Radiology Porter Reception Film store Film Store Film store log Film Store staff pull old Staff ring notes, split films porter and file them Radiologist Radiol-ogist takes XR agrees report form and Radiol-ogist films to his dictates Radiol-ogist office to report and reviews report. Wants takes tape, email report to compare films and and amends, Radiologist with previous XR card to sends back films Reception to typist Reception send XRs to Film Store and file notes. Radiographer Radio- Radio- Close grapher grapher episode on takes XRs checks XRs computer SCW takes Radiol- XR form to SCW ogy Reception Radiology Radiology Radiology Reception Radiology Reception Reception Reception Reception log tape, XR reception staff staff match staff log old staff search staff marry up card & films Radiology register Radiology XR card to films but can't for films and old and new and place in Radiology Reception reception staff patient on IT Reception XR and file in Reception find latest notes and films and XR queue for book appoint- system and staff log new staff request one locate in card and put typing ment on IT give card to patient out on reporting previous Radiolo- back in system SCW IT system queue films gist's Office queue GP and patient agree GP Surgery GP GP gives referral to assesses patient XR Ortho OPD patient form necessary GP surgery GP Surgery Receptionist receive makes appoint- report and ment recall patient Patients wife Patients Patient rings GP wife rings Surgery XR Dept Patient Process Patient has Patient Patient Patient Patient in Patient Radio- Patient Patient Patient Patient grapher Steps hip pain assessed arrives XR undresses Waiting called to has XR dresses goes home sees GP. positions by GP Dept Room XR Room Referred patient Ortho Out Patients Value Time Time Hrs:Mins 0:10 0:05 0:10 0:45 0:05 0:05 0:10 0:05 0:10 0:10 0:05 0:10 0:05 0:15 0:05 5:30 1:00 1:30 0:10 0:15 1:10 0:10 0:15 0:10 0:10 0:05 0:10 0:10 0:10 0:15 0:25 Days Day 1 Day 3 Day 4 Day 8 Day 12 Day 14 Day 17 Day 18 Day 20 Day 22 Day 23 Day 25 Day 30 Day 33 Day 34 Day 36 Day 38 Day 40 Day 44 Day 48 Day 73 2 hrs 5 patients in 3 people 8 patients in 102 cards in Radiologist Stack of 26 Queue of 135 Radiol-ogist Add to queue Collects 25 Types 25 Reviews 25 Amends 8, GP receives Over 1000 Work in progress GP Waiting XR Waiting queue takes 25 other pulled cards& X- reports 28 of 117 films cards & X- reports reports, leaves 5 in 19 X-Ray films to be queuing at room room cards and x- films rays films rays, leaves amends 13 queue reports from 3 filed XR Reception rays, leaves 150 behind typists 77 behind ABBREVIATIONS CURRENT STATE MAP SUMMARY Communication GP General Practitioner Total Steps (patient) Phone / Bleep SCW Support Care Worker Value Steps Electronic OPD Out Patient Department Total Time Verbal Value Time Written / Visual Work in Progress Notes: Non digital XR system!

9. Which pathway should we map?

10. Glenday Sieve • Heard of the Pareto (80/20 principle)? • Ladies – think of your wardrobe…..

11. “Few procedures make up for high volume activities” • Orthopaedics – Hips and knees • General Surgery – hernias and lap cholecystectomy • District Nurse – wound care, medication

12. Runners - 50% of all activity 6% of all possible procedures

13. Runners & Repeaters - 95% of all activity 50% of all possible procedures

14. Runners, Repeaters and Strangers - 100% of all activity 100% of all possible procedures

15. MRI Team, NHS Tayside • 220 codes for appointments MRI RIE • - 63% of MRI throughput from 2.7% of • procedure codes(i.e. 6 codes) • Group patients by the process they go through (rather than clinical condition)

16. Urology Team, Clatterbridge • 213 cases over 8 months at Clatterbridge RI event • 52% of theatre throughput from 4.2% of procedures • Group patients by the process they go through (rather than clinical condition) • Focus initially on smart process for the critical few [4.2%]

17. What are your runners?

18. Tea break 15mins

19. PDSA cycle

20. PDSA Cycle The improvement guide Langley et al 1996

21. What change can we make that will result in an improvement ? Act Plan • Objective • Questions and • predictions (why) • Plan to carry out the cycle • (who, what, where, when) • Plan for data collection • What changes • are to be made? • Next cycle? Study Do • Complete the • analysis of the data • Compare data to • predictions • Summarize • what was • learned • Carry out the plan • Document problems • and unexpected • observations • Begin analysis • of the data

22. MODEL FOR IMPROVEMENT CYCLE DATE :____ :____ Objective for this PDSA Cycle A P S D PLAN : : QUESTIONS : PREDICTIONS PLAN FOR CHANGE OR TEST: WHO, WHAT, WHEN, WHERE PLAN FOR COLLECTION OF DATA: WHO, WHAT, WHEN, WHERE DO : CARRY OUT THE CHANGE OR TEST; COLLECT DATA AND BEGIN ANALYSIS. STUDY : COMPLETE ANALYSIS OF DATA; SUMMARIZE WHAT WAS LEARNED. ACT: ARE WE READY TO MAKE A CHANGE? PLAN FOR THE NEXT CYCLE. PDSA Worksheet

23. Scottish Primary Care Collaborative Ayrshire GP Practice GP 3rd Available Appointment 16 14 12 10 Number of Days 8 6 4 2 0 Month 1 Month 2 Month 3 Month 4 Month 5 Month 6 Month 7 Month 8 Month 9 Baseline Month 10 Month 11 Month 12 Month 13 Month 14 Month 15 Month 16 Month 17 Month 18 Month 19 Month 20 Month 21 Month 22 Month 23 Month 24 GP Access – Practice Level Improvements with PDSAs PDSA to Introduce Telephone Consultations PDSAs to inform Patients about new appointment system PDSAs to ensure Phone Appts are provided at most appropriate time of day PDSA on ‘Pre-Bookable’ and ‘On the day’ appointments PDSAs PDSAs PDSAs

24. Scottish Primary Care Collaborative Borders GP Practice % of Diabetes Patients with a BP<140/80 90 80 70 60 50 % of People with Diabetes 40 30 20 10 0 Month 1 Month 2 Month 3 Month 4 Month 5 Month 6 Month 7 Month 8 Month 9 Baseline Month 10 Month 11 Month 12 Month 13 Month 14 Month 15 Month 16 Month 17 Month 18 Month 19 Month 20 Month 21 Month 22 Month 23 Month 24 Diabetes (blood pressure) Improvements with PDSAs PDSAs PDSAs PDSAs PDSAs to improve shared diabetes information with Secondary Care PDSAs to Validate Diabetes Register PDSAs to improve current patient recall system PDSA to contact all Patients who have not had a BP check in the last year

25. PDSA in Primary Care – repeat prescriptions

26. 6S Workplace organisation

27. Safety Set in order Organise the work area Having a safe working environment Sustain Shine Maintain through empowerment,commitment and discipline Clean the work area Standardise Doing the same thingevery time Workplace reorganisation • “Having a place for everything, and everything in its place” Sort Get rid of clutter 6S

28. Stracathro -theatre store room Money is tied up in inventory gathering dust because of a supply chain process which is not aligned with the patient pathway value stream In amongst this is back up emergency equipment Clutter- time wasted trying to find things

29. 3 - Benefits gained from 6S …and after Tray Room before…

30. Week 1 2 3 4 5 1 2 3 4 Location Month Date Tray room June-Oct Initials Floor kept clear of objects Ensure rotation of trays 2 Staff on cleaning rota to check stock dates 3 monthly Wipe down of work surfaces 4 5 Drawers / cupboards tidy 6 7 8 9 Yes to Question = 6S checklist of the tray room

32. 6S Check Sheet Area 1 2 3 4 5 Comments 1 2 3 4 5 Just beginning Focus on basics Make it visual Focus on consistency Focus on prevention A dependable, SORT documented method (e.g. Employees are Necessary and unnecessary Necessary and Unnecessary items have Separate the essential from red tagging) has been continually seeking items are mixed throughout unnecessary items been removed from the the non-essential established to keep the improvement the workplace are separated workplace. work area free of opportunities unnecessary items A dependable A dependable, documented method has SET Designated locations are documented method has been developed to A designated A place for everything and Items are randomly located marked to make been established to provide continual location has been everything in its place throughout the workplace. organisation more recognise if items are out evaluation, and a established visible. of place or exceed process is in place to quantity limits. implement improvements Work and break areas are cleaned Work and break areas Area employees have SHINE Workplace areas are dirty, on a regular and machinery are 6S agreements are devised a dependable, Clean everything and check disorganised and key items scheduled basis. cleaned on a daily basis. understood and practised documented method of it is in working order are not marked or identified. Key items to check Visual controls have continually preventive cleaning and have been been established. maintenance identified. Working environment Everyone is continually STANDARDISE Methods are being changes are being Workplace methods are not Substantial process seeking the elimination Make things easy to improved but documented. Visual consistently followed and documentation is available of waste with changes maintain changes have not control agreements for are not documented. and followed. documented and been documented labelling and quantity information shared levels established Work area checks are A recognisable There is a general SUSTAIN 6S agreements and randomly performed and effort has been Follow through with 6S appearance of a Make it a part of everyday safety practices have there is no visual made to improve agreements and safety confident understanding life been developed and are measurement of 6S the condition of the practices are evident. of, and adherence to, utilised. performance workplace. the 6S principles Medical Devices are correctly maintained Medical Devices are Recognition exists (storage, charging, clean, correctly maintained. SAFETY Medical Devices and that timely checks Checks & documentation checks, named device Workplace is free from Make a safe working Workplace Safety checks require to be is in place, however manager) hazards. Everyone takes environment with safe are performed randomly with carried out with robust systems required Workplace is free from ownership to identify and poor documented evidence. auidit trail evidence for hazard control. working systems hazards, suitable contiually improve ward mainintained. provisions for welfare of safety. all users

33. Theatre Tray Room - 6S Score Sort 5 4 3 Score After 6S Safety Set 2 1 Current Score 0 Sustain Shine Standardise

34. Rapid Improvement Events (RIEs) – an overview

35. What are RIEs? • Common Lean tool to introduce Lean principles and thinking in organisations • RIEs select critical business areas and make real improvements for patients and staff • Process-focussed and brings together the team in a highly structured way • Results-focussed – establishing the root cause of problems, and achieving measurable improvements • Process which is action-orientated and data driven

36. RIE Programme Timetable RIE - 6wks RIE - 4wks RIE – 2wks RIE Week RIE + 2wks RIE + 4wks RIE + 6wks RIE + 12wks or by agreement Rapid Improvement Event RIE Area Identified Review Progress Final Presentation (Project Closure) Remove Blockages • Management • Commitment Meeting • Critical success factors • Set Scope & Goals • Pick Team Leader • Pick RIE Team • Book Venue • Advise Managers about • their attendance • Gather data on • current performance Measure Improvements Share Success Support • Team Leader to • Produce: • Report • Action Plan • Run RIE Pre- • Meeting • Run RIE • Awareness visits Local Ownership & Sustainability - Ross International

37. One team’s experience NHS Tayside Urology RIE