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Six Easy Steps on How to Create a Lean Sigma Value Stream Map for a Multidisciplinary Clinical Operation
Six Easy Steps on How to Create a Lean Sigma Value Stream Map for a Multidisciplinary Clinical Operation Emily Lee, MHAa, Richard Grooms, BSb, Soumya Mamidala, MHSAc, Paul Nagy, PhDd
Value stream mapping (VSM) is a very useful technique to visualize and quantify the complex workflows often seen in clinical environments. VSM brings together multidisciplinary teams to identify parts of processes, collect data, and develop interventional ideas. An example involving pediatric MRI with general anesthesia VSM is outlined. As the process progresses, the map shows a large delay between the fax referral and the date of the scheduled and registered appointment. Ideas for improved efficiency and metrics were identified to measure improvement within a 6-month period, and an intervention package was developed for the department. Key Words: Value stream map, clinical operations, pediatric MRI general anesthesia, practice quality improvement J Am Coll Radiol 2014;11:1144-1149. © 2014 Published by Elsevier Inc. on behalf of American College of Radiology
INTRODUCTION
Value stream mapping (VSM) is a proven technique to build a common team perspective of a workflow process, identify potential “quick-hit” improvements, understand the product/process relationships, and combine product and technical information flows. In the field of radiology, one may work within many different processes, such as patient flow, order flow, and image request flow. VSM was developed as a “lean production management system” technique; however, it is also a useful tool in many quality projects/initiatives. VSM improves upon traditional process map or flow diagrams because this methodology enables the capture of both processes and material flows and in doing so, allows for the clear identification of the value-added steps and nonevalue-added muda, also known as waste. VSM brings together multidisciplinary teams to understand each detail of the process to avoid common project pitfalls, such as the team falsely assuming they are familiar with the process, or failing to see the true current state without observing the process in the gemba, also known as the workplace. This article provides instruction on how to construct a value stream map. Additionally, examples a
Department of Radiology, The Johns Hopkins Hospital, Baltimore, Maryland. Department of Radiology, Medical University of South Carolina, Charleston, South Carolina. b
c
Johns Hopkins Medicine, Baltimore, Maryland.
d
Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins University, Baltimore, Maryland. Corresponding author and reprints: Emily Lee, MHA, Radiology Department of the Johns Hopkins Hospital, Baltimore, 600 Wolfe Street, Baltimore, MD 21287; e-mail: [email protected].
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encompassing VSM techniques are included that are specific to its use in the highly complex workflow of a radiology department tracking pediatric MR cases involving general anesthesia [1]. Before attempting to build a value stream map, it is important to start an improvement project by gaining a clear understanding of your customer’s needs and expectations in relation to the product group to be mapped. VSM has 6 general steps: 1. Create a “suppliers, inputs, processes, outputs, and customers” (SIPOC) chart to place customers and suppliers on the value stream map (end and beginning of process). 2. Go to the gemba (workplace) and observe the process. 3. Map the material (process) flow. The process should capture minimally 4-8 general steps. Be sure to identify queues and/or staging areas in the process. 4. Identify the information systems used, and map the flow. 5. Identify data and time stamps (lag time, number of people, delays, etc.) to be captured and collected. Track time required for each process and the reason it requires that amount of time. When analyzing the map, look for muda (waste) of all forms— information waste, process waste, waste in the physical environmental, and potentially, people waste. 6. Complete and validate the map and baseline data of the current process. Upon completion of the current VSM process, the next step is to begin critiquing the current process to determine the root cause(s) of the problem. Encourage the team to make suggestions for improvement, remove ª 2014 Published by Elsevier Inc. on behalf of American College of Radiology 1546-1440/14/$36.00 http://dx.doi.org/10.1016/j.jacr.2014.08.031
Lee et al/Creating a Lean Sigma Value Stream Map 1145
Fig 1. Example baseline value stream map. Champ ¼ champion, LS ¼ lean sigma.
the waste, and implement necessary interventions accordingly. After identifying changes, map the interventions into the future state of the process. This new map will track the piloting stage of the improvement process. After collecting sufficient data, check to ensure that the benefits expected have been obtained, analyze
the benefits, and if improved, implement the new process. VSM: AN EXAMPLE
A multidisciplinary team was strategically assembled to enhance the pediatric MRI general anesthesia scheduling
Fig 2. Pediatric MRI with general anesthesia scheduling workflow SIPOC. H&P ¼ history and physical; ORMIS ¼ operating room management information system; PACU ¼ pediatric acute-care unit; prep ¼ preparation; rad ¼ radiology; RIS ¼ radiology information system.
1146 Journal of the American College of Radiology/Vol. 11 No. 12PA December 2014
Fig 3. VSM symbols.
process, specifically to move the next available appointment day from 42 days away to <14 days away. This team consisted of individuals from interdependent health care professions: radiologists, anesthesiologists, radiology administrators, nurses, child life specialists, and scheduling and registration staff. The baseline value stream map was specially developed and engineered in multidisciplinary team settings, to ensure that the entire team was able to provide input and understood the objectives of the process (Fig. 1). Create a SIPOC Chart
Identify and document the suppliers, inputs, processes, outputs, and customers for the entire process (Fig. 2). These identified categories will be essential to the construction of the value stream map. The supplier category includes internal and external suppliers that provide
inputs required for the process. Inputs consist of all materials or steps needed to begin the process. The process category includes all steps and activities that must be done to produce the outputs, which consist of the resulting products and any other needs identified after completing the process. Lastly, the customer category includes either the internal or external receiver of the outputs resulting from this process. Walk the Gemba
Walking the gemba (workplace) and observing the process is an important step. Observing the process firsthand allows the opportunity to identify and solve problems within the operations of a process. This step is essential for gaining a fresh perspective, as well as ensuring that the process is in proper alignment with the organization’s goals and values.
Fig 4. VSM: process general steps.
Lee et al/Creating a Lean Sigma Value Stream Map 1147
Fig 5. VSM material and information flow. ACCM ¼ American College of Critical Care Medicine; CPOE ¼ computerized physician order entry; RIS ¼ radiology information system.
Create a Map of the Process Flow
Use Microsoft Visio to map out the process flow. Map the “as-is” process using the symbols shown in Figure 3. Begin mapping at the end of the process with what is
delivered to the customer and work upstream from there. Identify the main activities in the process and place them in sequence on the map (Fig. 4). Next, add the material and information flow to show movement of
Fig 6. Value stream map with data included for outpatient scheduling for pediatric MRI with general anesthesia. ACCM ¼ American College of Critical Care Medicine; CPOE ¼ computerized physician order entry; Ext ¼ external; FTE ¼ full-time equivalent; H&P ¼ history and physical; Int ¼ internal; PCCN ¼ progressive care certified nurse; pts ¼ patients; req ¼ request; RIS ¼ radiology information system; RN ¼ registered nurse; WIP ¼ working in process.
1148 Journal of the American College of Radiology/Vol. 11 No. 12PA December 2014
Fig 7. Data for pediatric MRI with general anesthesia VSM intervention package pilot. ACCM ¼ American College of Critical Care Medicine; CPOE ¼ computerized physician order entry; Ext ¼ external; FTE ¼ full-time equivalent; H&P ¼ history and physical; Int ¼ internal; PCCN ¼ progressive care certified nurse; req ¼ request; RIS ¼ radiology information system; RN ¼ registered nurse.
all the material and information systems. Group together material and systems with the same flow, and add suppliers at the beginning of the process (Fig. 5). Finally, collect process data to connect them to the boxes on the chart. This step should be done by walking the process to understand the reality of how it occurs. Data to be gathered include the following 7 metrics: 1. Triggers—what starts each step; 2. Lead time—time to get a product/service from start to finish; 3. Cycle time—time to perform all work elements within a particular process step on a single item; may include value-added as well as nonevalue-added time; 4. Takt rate—rate of customer demand (Takt, defined as the available time for production and/or required units of production); 5. Wait time—downtime between processes; includes time spent standing around waiting for a machine or particular process to complete an action; 6. Working in process—number of people in queue; 7. Total product cycle time—sum of cycle times for all process steps within the value stream. After gathering these data, include them in each respective box on the chart (Fig. 6). It is important to
validate the completed map with the team. Walk through the entire process to ensure that all steps are accounted for and documented correctly [2]. Upon completion of the pediatric MRI with general anesthesia VSM, one can see that the duration from fax referral to patient registration takes 42 days. Based on benchmarking data and onsite visits to best-practice academic health care systems, the multidisciplinary team originally assembled had determined that the standard should be <14 days from fax referral to patient registration. The VSM shows that the cycle time from fax received to scheduled appointment takes 21 days. However, analysis of benchmarking data suggests that this process should take <7 days. Thus, these 2 metrics became the focus of this lean sigma project. The quintessential step in VSM is the one after construction and analysis of the map, and is critical in achieving the overall goal of the project. In this case, the next step consisted of creating interventions, and/or identifying areas of waste to eliminate from the process. The aforementioned scope of this project was to reduce the time from fax referral to patient registration from 42 days to <14 days within 6 months. Interventions were based on the baseline data collected; the team analyzed areas that created excessive delays in the process or had a
Lee et al/Creating a Lean Sigma Value Stream Map 1149
high number of patients waiting. The interventions were brainstormed by the team and then carefully selected for piloting based on priority and impact. If an intervention idea was a high priority and had high impact, it was placed in the intervention package. Interventions that had low priority and low impact were not part of the intervention package. After brainstorming various ways to improve the process, an intervention package was put together in preparation for “go-live” (Fig. 7). CONCLUSIONS
The purpose of VSM is to highlight the current process and indicate the inefficiencies surrounding the current system (ie, waste, flow issues, examples of variability). The current system, also known as baseline, is the foundation for VSM methodology. VSM provides a fundamental framework for opportunity identification, potential solutions, and brainstorming of interventions to launch. More importantly, this lean sigma process allows an entire multidisciplinary team to observe, listen, and ask questions about the process. It may surprise a team to learn about what they did not know was actually occurring [3].
TAKE-HOME POINTS
VSM is a useful technique designed to be used to visualize and quantify the complex workflows often seen in clinical environments. VSM brings together multidisciplinary teams to understand each detail of the process to avoid common project pitfalls, such as the team assuming they know the process well enough or failing to see the real current state. Walking the gemba, also known as the workplace, to observe the process firsthand, is a critical step. Data should be gathered for each process step to help the team brainstorm potential inventions to implement.
REFERENCES 1. Chalice R. Improving healthcare using Toyota lean production methods. Milwaukee, WI: ASQ Quality Press; 2007. 2. Rowlands D, Price M, Maxey J, George ML. The lean Six Sigma pocket tool book. Chicago: The George Group; 2005. 3. Abujudeh HH, Bruno MA. Quality and safety in radiology. New York: Oxford University Press; 2012.
Value stream mapping (VSM) is a very useful technique to visualize and quantify the complex workflows often seen in clinical environments. VSM brings together multidisciplinary teams to identify parts of processes, collect data, and develop interventional ideas. An example involving pediatric MRI with general anesthesia VSM is outlined. As the process progresses, the map shows a large delay between the fax referral and the date of the scheduled and registered appointment. Ideas for improved efficiency and metrics were identified to measure improvement within a 6-month period, and an intervention package was developed for the department. Key Words: Value stream map, clinical operations, pediatric MRI general anesthesia, practice quality improvement J Am Coll Radiol 2014;11:1144-1149. © 2014 Published by Elsevier Inc. on behalf of American College of Radiology
INTRODUCTION
Value stream mapping (VSM) is a proven technique to build a common team perspective of a workflow process, identify potential “quick-hit” improvements, understand the product/process relationships, and combine product and technical information flows. In the field of radiology, one may work within many different processes, such as patient flow, order flow, and image request flow. VSM was developed as a “lean production management system” technique; however, it is also a useful tool in many quality projects/initiatives. VSM improves upon traditional process map or flow diagrams because this methodology enables the capture of both processes and material flows and in doing so, allows for the clear identification of the value-added steps and nonevalue-added muda, also known as waste. VSM brings together multidisciplinary teams to understand each detail of the process to avoid common project pitfalls, such as the team falsely assuming they are familiar with the process, or failing to see the true current state without observing the process in the gemba, also known as the workplace. This article provides instruction on how to construct a value stream map. Additionally, examples a
Department of Radiology, The Johns Hopkins Hospital, Baltimore, Maryland. Department of Radiology, Medical University of South Carolina, Charleston, South Carolina. b
c
Johns Hopkins Medicine, Baltimore, Maryland.
d
Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins University, Baltimore, Maryland. Corresponding author and reprints: Emily Lee, MHA, Radiology Department of the Johns Hopkins Hospital, Baltimore, 600 Wolfe Street, Baltimore, MD 21287; e-mail: [email protected].
1144
encompassing VSM techniques are included that are specific to its use in the highly complex workflow of a radiology department tracking pediatric MR cases involving general anesthesia [1]. Before attempting to build a value stream map, it is important to start an improvement project by gaining a clear understanding of your customer’s needs and expectations in relation to the product group to be mapped. VSM has 6 general steps: 1. Create a “suppliers, inputs, processes, outputs, and customers” (SIPOC) chart to place customers and suppliers on the value stream map (end and beginning of process). 2. Go to the gemba (workplace) and observe the process. 3. Map the material (process) flow. The process should capture minimally 4-8 general steps. Be sure to identify queues and/or staging areas in the process. 4. Identify the information systems used, and map the flow. 5. Identify data and time stamps (lag time, number of people, delays, etc.) to be captured and collected. Track time required for each process and the reason it requires that amount of time. When analyzing the map, look for muda (waste) of all forms— information waste, process waste, waste in the physical environmental, and potentially, people waste. 6. Complete and validate the map and baseline data of the current process. Upon completion of the current VSM process, the next step is to begin critiquing the current process to determine the root cause(s) of the problem. Encourage the team to make suggestions for improvement, remove ª 2014 Published by Elsevier Inc. on behalf of American College of Radiology 1546-1440/14/$36.00 http://dx.doi.org/10.1016/j.jacr.2014.08.031
Lee et al/Creating a Lean Sigma Value Stream Map 1145
Fig 1. Example baseline value stream map. Champ ¼ champion, LS ¼ lean sigma.
the waste, and implement necessary interventions accordingly. After identifying changes, map the interventions into the future state of the process. This new map will track the piloting stage of the improvement process. After collecting sufficient data, check to ensure that the benefits expected have been obtained, analyze
the benefits, and if improved, implement the new process. VSM: AN EXAMPLE
A multidisciplinary team was strategically assembled to enhance the pediatric MRI general anesthesia scheduling
Fig 2. Pediatric MRI with general anesthesia scheduling workflow SIPOC. H&P ¼ history and physical; ORMIS ¼ operating room management information system; PACU ¼ pediatric acute-care unit; prep ¼ preparation; rad ¼ radiology; RIS ¼ radiology information system.
1146 Journal of the American College of Radiology/Vol. 11 No. 12PA December 2014
Fig 3. VSM symbols.
process, specifically to move the next available appointment day from 42 days away to <14 days away. This team consisted of individuals from interdependent health care professions: radiologists, anesthesiologists, radiology administrators, nurses, child life specialists, and scheduling and registration staff. The baseline value stream map was specially developed and engineered in multidisciplinary team settings, to ensure that the entire team was able to provide input and understood the objectives of the process (Fig. 1). Create a SIPOC Chart
Identify and document the suppliers, inputs, processes, outputs, and customers for the entire process (Fig. 2). These identified categories will be essential to the construction of the value stream map. The supplier category includes internal and external suppliers that provide
inputs required for the process. Inputs consist of all materials or steps needed to begin the process. The process category includes all steps and activities that must be done to produce the outputs, which consist of the resulting products and any other needs identified after completing the process. Lastly, the customer category includes either the internal or external receiver of the outputs resulting from this process. Walk the Gemba
Walking the gemba (workplace) and observing the process is an important step. Observing the process firsthand allows the opportunity to identify and solve problems within the operations of a process. This step is essential for gaining a fresh perspective, as well as ensuring that the process is in proper alignment with the organization’s goals and values.
Fig 4. VSM: process general steps.
Lee et al/Creating a Lean Sigma Value Stream Map 1147
Fig 5. VSM material and information flow. ACCM ¼ American College of Critical Care Medicine; CPOE ¼ computerized physician order entry; RIS ¼ radiology information system.
Create a Map of the Process Flow
Use Microsoft Visio to map out the process flow. Map the “as-is” process using the symbols shown in Figure 3. Begin mapping at the end of the process with what is
delivered to the customer and work upstream from there. Identify the main activities in the process and place them in sequence on the map (Fig. 4). Next, add the material and information flow to show movement of
Fig 6. Value stream map with data included for outpatient scheduling for pediatric MRI with general anesthesia. ACCM ¼ American College of Critical Care Medicine; CPOE ¼ computerized physician order entry; Ext ¼ external; FTE ¼ full-time equivalent; H&P ¼ history and physical; Int ¼ internal; PCCN ¼ progressive care certified nurse; pts ¼ patients; req ¼ request; RIS ¼ radiology information system; RN ¼ registered nurse; WIP ¼ working in process.
1148 Journal of the American College of Radiology/Vol. 11 No. 12PA December 2014
Fig 7. Data for pediatric MRI with general anesthesia VSM intervention package pilot. ACCM ¼ American College of Critical Care Medicine; CPOE ¼ computerized physician order entry; Ext ¼ external; FTE ¼ full-time equivalent; H&P ¼ history and physical; Int ¼ internal; PCCN ¼ progressive care certified nurse; req ¼ request; RIS ¼ radiology information system; RN ¼ registered nurse.
all the material and information systems. Group together material and systems with the same flow, and add suppliers at the beginning of the process (Fig. 5). Finally, collect process data to connect them to the boxes on the chart. This step should be done by walking the process to understand the reality of how it occurs. Data to be gathered include the following 7 metrics: 1. Triggers—what starts each step; 2. Lead time—time to get a product/service from start to finish; 3. Cycle time—time to perform all work elements within a particular process step on a single item; may include value-added as well as nonevalue-added time; 4. Takt rate—rate of customer demand (Takt, defined as the available time for production and/or required units of production); 5. Wait time—downtime between processes; includes time spent standing around waiting for a machine or particular process to complete an action; 6. Working in process—number of people in queue; 7. Total product cycle time—sum of cycle times for all process steps within the value stream. After gathering these data, include them in each respective box on the chart (Fig. 6). It is important to
validate the completed map with the team. Walk through the entire process to ensure that all steps are accounted for and documented correctly [2]. Upon completion of the pediatric MRI with general anesthesia VSM, one can see that the duration from fax referral to patient registration takes 42 days. Based on benchmarking data and onsite visits to best-practice academic health care systems, the multidisciplinary team originally assembled had determined that the standard should be <14 days from fax referral to patient registration. The VSM shows that the cycle time from fax received to scheduled appointment takes 21 days. However, analysis of benchmarking data suggests that this process should take <7 days. Thus, these 2 metrics became the focus of this lean sigma project. The quintessential step in VSM is the one after construction and analysis of the map, and is critical in achieving the overall goal of the project. In this case, the next step consisted of creating interventions, and/or identifying areas of waste to eliminate from the process. The aforementioned scope of this project was to reduce the time from fax referral to patient registration from 42 days to <14 days within 6 months. Interventions were based on the baseline data collected; the team analyzed areas that created excessive delays in the process or had a
Lee et al/Creating a Lean Sigma Value Stream Map 1149
high number of patients waiting. The interventions were brainstormed by the team and then carefully selected for piloting based on priority and impact. If an intervention idea was a high priority and had high impact, it was placed in the intervention package. Interventions that had low priority and low impact were not part of the intervention package. After brainstorming various ways to improve the process, an intervention package was put together in preparation for “go-live” (Fig. 7). CONCLUSIONS
The purpose of VSM is to highlight the current process and indicate the inefficiencies surrounding the current system (ie, waste, flow issues, examples of variability). The current system, also known as baseline, is the foundation for VSM methodology. VSM provides a fundamental framework for opportunity identification, potential solutions, and brainstorming of interventions to launch. More importantly, this lean sigma process allows an entire multidisciplinary team to observe, listen, and ask questions about the process. It may surprise a team to learn about what they did not know was actually occurring [3].
TAKE-HOME POINTS
VSM is a useful technique designed to be used to visualize and quantify the complex workflows often seen in clinical environments. VSM brings together multidisciplinary teams to understand each detail of the process to avoid common project pitfalls, such as the team assuming they know the process well enough or failing to see the real current state. Walking the gemba, also known as the workplace, to observe the process firsthand, is a critical step. Data should be gathered for each process step to help the team brainstorm potential inventions to implement.
REFERENCES 1. Chalice R. Improving healthcare using Toyota lean production methods. Milwaukee, WI: ASQ Quality Press; 2007. 2. Rowlands D, Price M, Maxey J, George ML. The lean Six Sigma pocket tool book. Chicago: The George Group; 2005. 3. Abujudeh HH, Bruno MA. Quality and safety in radiology. New York: Oxford University Press; 2012.