Mapping the

End-to-End Process
Lean in Healthcare

David Brunt
June 6th 2006

Lean Enterprise Academy www.leanuk.org

 Objectives

„ To give an overview of
Value Stream Mapping

Lean Enterprise Academy www.leanuk.org

 The Essence of Lean
Thinking
“All we are doing is looking at the time line
- from the moment the customer gives us
an order to the point where we collect the
cash. And we are reducing that time line by
removing the non-value-added wastes”
Ohno (1988-ix)

„ Where is the time in your value

stream?
„ The physical patient flow?
„ The information flows – patient lists &
notes?

Lean Enterprise Academy www.leanuk.org

 Value Stream Improvement
& Process Improvement
PROCESS PROCESS PROCESS CUSTOMER

Pre-Op
Out Patients Procedure
Assessment

Raw Finished
Material Product

Value adding Non value adding

5% 60%

Necessary but non value adding

35%

VALUE STREAM: All the steps, VA & NVA, required to bring the
product from raw material to customer

Lean Enterprise Academy www.leanuk.org

 Value Stream Improvement
& Process Improvement
PROCESS PROCESS PROCESS CUSTOMER

Pre-Op
Out Patients Procedure
Assessment

Raw Finished
Material Product
Focus of “traditional”
Value adding
5% efficiency improvements
Non value adding
60%

Necessary but non value adding

35%

VALUE STREAM: All the steps, VA & NVA, required to bring the
product from raw material to customer

Lean Enterprise Academy www.leanuk.org

 Value Stream Improvement
& Process Improvement
PROCESS PROCESS PROCESS CUSTOMER

Pre-Op
Out Patients Procedure
Assessment

Focus of LEAN
Raw improvement Finished
Material Product

Value adding Non value adding

5% 60%

Necessary but non value adding

35%

VALUE STREAM: All the steps, VA & NVA, required to bring the
product from raw material to customer

Lean Enterprise Academy www.leanuk.org

 Helps us see flow

Value Stream Mapping

„ Follow a product’s path from beginning to end

and draw a visual representation of every
process in the material & information flows
„ Then draw (using icons) a “future state” map of
how value should flow

Lean Enterprise Academy www.leanuk.org

 Patient Hernia Current State
GP Practice

National
Choose & Book

Get
“Push”
Letter to GP
Letter to Patient
Letter to GP &
Patient & Letter to GP
Date Consultant

Local Booking
List 2 wks
Consultant Inventory
Follow up
Process
Service
Before
Appointment
Secretary
Come In List
Date

Box List 2 Weeks

Daily List Before
Appointment

Out
Pre Op
Patient Admission
Referral Assess- Procedure Discharge Follow Up
I Appoint-
ment
I ment I (Day Case) I I I

C/T = 7 Min
C/O = 0 min.
Uptime = 100%
2 Shifts
4 Weeks 5 Min 3 Weeks 27,000 sec av. 90 Min 60 Min 6 Weeks
5 Min Data
22 Min 32 Min 7 Min 70 Min 20 Min 12 Min

Box Lead Time

= 65.5 days
Max 13 Months Max 6 Months Process Time
18 Week target = 193 Min
 Using the Value Stream
Mapping Tool
Product Family Deciding what to map

Understanding how the processes

Current State Drawing currently operate

Future State Drawing Designing a lean flow

Work Plan

Lean Enterprise Academy www.leanuk.org

 Deciding What to Map

„ The Glenday Sieve - A tool to help

„ Implement Every Product Every Cycle
„ Identify product families
„ Remove waste

Lean Enterprise Academy www.leanuk.org

 The Glenday Sieve
- first analysis

Cumulative % of Cumulative %
Sales Product Range

50%

95%

99%

Last 1%

Lean Enterprise Academy www.leanuk.org

 The Glenday Sieve
– second analysis

Cumulative % of Cumulative % Colour

Sales Product Range Code

50% Green

95% Yellow

99% Blue

Last 1% Red

Lean Enterprise Academy www.leanuk.org

 The Glenday Sieve &
Value Stream Mapping
„ Map the “greens” because you
want to make these flow
„ Which removes non value added
waste
„ Ask questions about yellow, blue &
red products
„ Can anything be done to include these
in the “green stream?”

Lean Enterprise Academy www.leanuk.org

 Focus on One Product Family
„ High volume low variety manufacturing
„ Determine product families via similar
downstream “assembly” steps & equipment
„ “Every job is different” processes
„ Sieve & focus on tasks
Process Steps & Equipment

Fixtures
Spot Weld Robot Weld Flash Remove Paint Manual Assy Electronic Test
Assy

LH Steering Bracket X X X X

RH Steering Bracket X X X X
Products

Instrument
Panel Brace X X X X

Seat
Rail X X
Bumper
Brackets X X X

Lean Enterprise Academy www.leanuk.org

 Current State Drawing
Understanding how the shop
floor & offices currently operate
Product Family

„ Material & information flows

Current State Drawing
„ Draw using icons
„ Start with the “door to
door” flow
Future State Drawing „ Have to walk the flow & get
actuals
„ No standard times
Work Plan
„ Draw by hand, in pencil
„ Foundation for the
Future State
Lean Enterprise Academy www.leanuk.org
 “Healthcare” Data Set 1
Acme Healthcare Trust has a number of sites. The case concerns an Elective only site. Analysis of
the Green Stream shows that 5% of procedures account for 50% of demand.

„ Demand (Green Stream)

„ Local Anesthetic Cystoscopy = 15%
„ General Anesthetic Cystoscopy = 11%
„ Hips/Knees Arthroscopy = 9%
„ Hernia & VVS = 7%
„ LA Lumps & Bumps = 4%
„ Lower GI Endoscopy = 3%
„ Carpal Tunnel = 3%

„ Process Steps: Following referral from a GP the patient goes through

the following steps:
„ Out patient appointment
„ Pre-Operation Assessment
„ Admission
„ The Procedure
„ Discharge
„ Follow Up

Lean Enterprise Academy www.leanuk.org

 Patient Hernia Current State
GP Practice

National
Choose & Book
Letter to GP &
Get Letter to GP Letter to Patient Patient & Letter to GP
Date Consultant

List 2 wks
Local Booking Consultant Follow up
Before Come In List
Service Secretary Date
Appointment

List 2 Weeks
Daily List Before
Appointment

Out
Pre Op
Patient Admission
Referral Assess- Procedure Discharge Follow Up
Appoint- (Day Case)
ment
ment

4 Weeks 5 Min 3 Weeks 90 Min 60 Min 6 Weeks

5 Min 22 Min 32 Min 7 Min 70 Min 20 Min 12 Min

Lead Time
= 65.5 days
Max 13 Months Max 6 Months Process Time
18 Week target = 193 Min
Lean Enterprise Academy www.leanuk.org
Analysis Lean Workshop
Workshop Theme: Workshop No. Team Date:
Team Members: Dept:
Process: Slide:
Of:

Lean Enterprise Academy www.leanuk.org

 Future State Questions

„ What is the Takt Time?

„ Will we build to shipping or to a supermarket?
„ Where can we use continuous flow
„ Where do we have to use supermarket pull systems?
„ At what single point in the production chain do we
trigger production?
„ How do we level the production mix at the pacemaker
process?
„ What increment of work will we release and take away
at the pacemaker process? (levelling the volume)

Supporting Improvements
„ What process improvements will be necessary?
(e.g. uptime, changeover & training)
Lean Enterprise Academy www.leanuk.org
 Patient Hernia Current State
GP Practice

?
National
Choose & Book
Letter to GP &
Get Letter to GP Letter to Patient Patient & Letter to GP
Date Consultant

?
List 2 wks
Local Booking Consultant Follow up
Before Come In List
Service Secretary Date
Appointment

?
List 2 Weeks
Daily List Before
Appointment

Referral
? Out
Patient
Pre Op
Assess-
Admission
Procedure Discharge Follow Up
I Appoint-
ment
I ment I (Day Case) I I I

4 Weeks 5 Min 3 Weeks 90 Min 60 Min 6 Weeks

5 Min 22 Min 32 Min 7 Min 70 Min 20 Min 12 Min

Lead Time
= 65.5 days
Max 13 Months Max 6 Months Process Time
18 Week target = 193 Min
 Patient Green Stream Future State
GP Practice

National
Choose & Book
Letter to GP &
Get Patient & Letter to GP
Date Consultant

List 2 wks
Local Booking
Before
Service
Appointment Book n
io
Admiss
Filter
s
Patient
Green Stream
Visual lan Fixed Plan
tP
Upfron
Book
Up
Follow
Out
Patient Admission
Referral FIFO FIFO Procedure FIFO Discharge FIFO Follow Up
Appoint- (Day Case)
ment X Days X Mins X Mins X Days

Reduce
Visits
 A Plan to Get There
Implementation

„ Don’t wait!
„ To “manage the exceptions” you need a plan!
„ Tie it to your business objectives
„ Break your Future State into “loops”
„ Make a VS Plan: What to do by when
„ Now relate the Future State Map to your layout
„ Value Stream manager completes VS Review form in
advance
„ Conduct Value Stream reviews walking the flow

Lean Enterprise Academy www.leanuk.org

 Implementation via Point
Kaizen
Eraser

Future State Map

Process

Point
Kaizen

Lean Enterprise Academy www.leanuk.org

 Mapping the
End-to-End Process
Lean in Healthcare

David Brunt
June 6th 2006

Lean Enterprise Academy www.leanuk.org