Advanced Process Mapping

Jennifer Wortham, Dr.PH

© 2010 Healthcare Performance Partners, Inc.

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 Objectives for Today’s Workshop

 At the end of this session you will be able to:

– Describe how process mapping supports Lean
– Describe three types of process mapping and how they are
used:
• Functional process flow using swim lanes
• Value Stream Mapping
• SIPOC’s
© 2010 Healthcare Performance Partners, Inc.

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 Agenda: 1. Create Strategy,
Talk about Budgets & Report
Cards
Step 2.
2. Then a Miracle
Happens
3. Improved Patient
Care Better
Organizational
Results
© 2010 Healthcare Performance Partners, Inc.

“I Think You Should Be More

Explicit Here In Step Two.”
 The 4 “P’s” of Lean

Lean aligns the entire

organization, in the
continuous pursuit of
excellence, through the
development of people to Purpose
solve problems, improve
processes and create
value for the customer. People
© 2010 Healthcare Performance Partners, Inc.

Problem
Process
Solving
 Goal of Lean: Eliminating Waste from Processes

Everything the organization

does needs to be treated as a
 Defects
process that serves the patient/customer.
 Over-Production
Steps that don’t directly provide better care to
the patient/customer  Waiting
must be considered Non-Value added or WASTE!
 Not Clear (Confusion)
 Transporting
RN Time Distribution
 Inventory
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Admin Direct
12% 21%
Indirect
Direct Patient Care  Motion
Indirect Patient Carfe
Waste 18%
Waste
Administrative
 Excess Processing
 How Process Maps are Used in Lean Projects

 They provide a fact-based process

description for understanding current
problems and opportunities.
–They communicate the specific
elements of a process to internal and
external stakeholders.
–They are used to perform value
analysis.
© 2010 Healthcare Performance Partners, Inc.

–They enable teams to quickly see

improvement opportunities within
the process, and to begin defining
critical Xs (underlying causes of
problems).
 Versions of a Process

At least 3 (Usually)

What You Think It Is... What It Actually Is... What You Would Like
It To Be... Future State
© 2010 Healthcare Performance Partners, Inc.

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 Construct for Developing a Care Process
The 4 Rules in Use

 Activities
– Content, Sequence, Timing,
Location and Outcome
 Connections:
– Direct, Paced, Binary
 Pathways (Clear)
– Direct, No forking or looping
© 2010 Healthcare Performance Partners, Inc.

 Improvement:
– Closest to the Work, using
Scientific Method, evidence
based
© 2010 Healthcare Performance Partners, Inc.

Traditional
Process Map
Swim Lane/Functional Process Map – Best Practice
Specialist

Reviews
Checks Complete packing Stocks
Unit

supply request list supplies

stock form against on unit
order
Manager

Review &
Unit

approve
request
Director

Review &
CER
approve > $5,000
No
request

Yes

Review &
VP

Creates delays
approve
request
Purchasing

Review Procure Supplies

request Supplies Delivered

2 hours 5 days 1 day 7 days 1 day

CT – Current State

Only 20% of
Radiologist ED Doc
Place orders are placed
reads film and reviews End
Start order in via order sets.
MD

documents in report and

CPOE Most orders are
EHR completes f/u
5 Mins placed using
10 mins 30 mins
generic orders.

Call ED to Review Transport

Call MD Prep Administer Complete
inform OK pre-exam patient back
to Clarify patient contrast CT
to Send checklist to ED
order 10 mins 5 mins 10 mins
Patient 15 mins 40 mins
25 mins
5 mins
CT- Tech

70% of orders are Patient not ready for CT – avg. Lack of CT-
incomplete – CT busy, delay 10 min. Common cause: Tech
requires call to average wait - Need to call RN to clarify risks available for
MD to clarify. 10 mins - Undress patient transport –
- Remove jewelry avg. delay 40
- Start IV mins

Answers
Unit Secretary

call from
CT Tech &
Contacts
RN to notify
of order
5 Mins

50% of patients did not Reviews Collect

Contact EDT
have Kidney Function order and specimen, and
via Vocera
test ordered determines send to lab,
for Transport
next steps wait for results
5 mins
15 mins 60 mins
RN

RN busy – average
delay in collecting
specimen

Prep
Transport
Patient for
Patient
EDT

Transport
10 mins
10 mins

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5 40 55 115 120 130 140 155 165 170 180 220 230 260
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© 2010 Healthcare Performance Partners, Inc.

Understanding How Processes Perform

© 2010 Healthcare Performance Partners, Inc.

Value Stream Mapping

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 Swim lane/Functional Flowcharts

 Lean best practice process flow chart/map

– Forces the question of who is responsible for a given
activity
– Illustrates the sequence of events
– Provides a timeline
– Indicates the number hand-offs
– Shows opportunities to eliminate/reduce steps
© 2010 Healthcare Performance Partners, Inc.

 Use process map to communicate what is going wrong

(pain points) and identify opportunities for improvement
 Basic Process Flowchart Symbols

Beginning
/ End Data-base In-
Connector process

Direction

Process Decision Document

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Step

15
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Value Stream Mapping

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 Fundamental Concept

Patient and
Customer Focused

Value-Added Non-Value Added

• Diagnosis and • Unnecessary work (click,

Treatment click, click…)
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• Med Rec • Waiting,… for anything

• Surgery • Searching for information
 Information • Redundant Approval
 Coordinating Care Processes
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 Typical Improvement Projects

5 - 15%
85 - 95% NVA
VA
Total Lead Time

 Many organizations focus their efforts on improving the value

added work in a process, but after years of optimization of the
VA steps: How much improvement can you really expect?
 The real opportunity is to reduce the non value-add time in a
© 2010 Healthcare Performance Partners, Inc.

process (waiting, work in queue, transportation, rework, etc.).

Lean focuses on eliminating non value-added time in a process.

 Typical Process Activities
 Processing (VA) 5% - 15% of lead time
 Work Queue/Waiting (NVA) 70% - 80% of lead time
 Transportation (NVA) 5% - 10% of lead time
 Inspection (RA/NVA) 5% - 10% of lead time
© 2010 Healthcare Performance Partners, Inc.
 Lead Time, Cycle Time and Down Time

 Lead Time (LT): Time from the defined beginning of a process

to delivery to the customer. This includes all travel, waiting,
staging, and storage times between processes and operations
(includes cycle time and down time).
– Cycle Time: Period of time required to complete one
cycle/major step of an operation.
– Down Time: the time between cycles, or non-productive
work within a cycle
© 2010 Healthcare Performance Partners, Inc.

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 Identifying Waste in the Process

 Used to reveal the flow of material and information as a

product/service makes its way through a process.
 Path from the beginning to end from the customers perspective.
 Visual representation of each sub-process in the stream creates
an end-to-end “current state” vision for everyone to follow.
 The value add and non value add (waste) activities are
measured and documented.
 Then, by asking a set of questions about how the work should
© 2010 Healthcare Performance Partners, Inc.

flow, a future state map or proposed plan can be created.

 Lead Time, Cycle Time, Down Time

High Level Value Stream Map

ED Visit

+ +
Check-in + Register + Triage + MSE + Diagnostics Treatment Discharge = LT

5 5 5 5 5 15 5 5 5 45 10 5 30 5 30

Cycle-time Down-time
Down-time
The only time the
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LT = 180 minutes patient really cares

about

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 Detailed Value Stream Map

Clinic Visit

Check-In Prep Exam Check-Out

1. Patient 1. MA: Take vitals 1. MD reviews hx

completes & document in and chief
intake form 2 EMR; 2 complaint; 1 1. Schedule
2. Receptionist 2. Review patient 2. Completes follow-up
reviews forms, intake info in physical exam; appointment
verifies ID, & EHR; 3. Fills out lab req 2. Collect co-pay
verifies benefits 3. Asks & form, and RX
3. Types info into documents 4. MA documents
EMR chief complaint. orders in CPOE

VA 6.5 5 10.2 3.5

NVA 2 12 2 22 3 5

Value Added 36%

VA = 25.2 23

LT= 69.2 Non-Value Added 64%

NVA = 44.0
 Value Stream Map

-Process Name Here-

VA
NVA

Value Added ____%

VA = ____ 24

LT= Non-Value Added ____%

NVA = ____
 © 2010 Healthcare Performance Partners, Inc.

Determining Requirements

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 What’s a SIPOC?

Requirements Requirements

S I P O C
Suppliers Inputs Process Outputs Clients

Input Boundary Output Boundary

© 2010 Healthcare Performance Partners, Inc.

Defines the required inputs and outputs of each step in the process,
and how the process should be performing:
• Outlines the boundary of the process or scope
• Helps identify stakeholders
 SIPOC

Suppliers Inputs Process Outputs Customers

List suppliers List process List 5 to 7 List process List customers

of the inputs inputs high level outputs who receive
process the outputs
List key input steps. List key
requirements output
requirements
© 2010 Healthcare Performance Partners, Inc.

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 SIPOC-R - Example Patient Bed Assignment for ED Admit

Supplier Input Process Step Output Customer Requirement

Physician Patient info Enter orders into Admit Order Bed 5 minutes
Med Rec EHR Notification Coordinator from time of
Labs disposition
decision
Bed Bed Board with Review Bed Board Unit Assignment Unit Charge Within 10
Coordinator bed availability and Enter Unit Notification RN minutes
Assignment into
EHR
Unit Charge Unit Assignment Review Unit Notification of Unit Within 5
RN Log Assignment Log patient Specialist minutes
and Assign assignment
Bed/Nurse
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Unit Bed / Nurse Complete transfer Notification of ED RN Within 5

Specialist Assignment request in Tele- Bed Ready minutes
tracking
ED RN Notice – bed Patient Transported Patient arrival in Assigned Within 10
ready & Patient to Unit unit Nurse minutes
ready

Total Lead Time = 35 minutes

 Completing the SIPOC
Suggested Approach
 Process name
 Process owner
 Determine outputs
 Process start/cue/trigger
 Process end/cue
 Complete supplier, customer, process steps
© 2010 Healthcare Performance Partners, Inc.

 Determine Critical-to-Quality requirements:

– Cycle-time
– Quality, etc.
 Group Exercise

 A patient on one of your medical surgical units has

tested positive for C-Diff. Let’s create a hypothetical
SIPOC.
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 SIPOC
Supplier Input Process Output Customer Requirements
Step
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 Success with SIPOC

 Clearly identify the start and end

 Lean Principle: Gemba: “Go to the Source” and find
out what both internal and external customers truly
need.
 Ensure that assumptions are recorded, discussed, and
validated
 Document definitions of key terms, symbols,
© 2010 Healthcare Performance Partners, Inc.

acronyms, equipment, standards, etc.

 Don’t forget feedback loops and communication
mechanisms
 © 2010 Healthcare Performance Partners, Inc.

Questions and Discussion

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 Overall Thoughts

 The real value of SIPOC is the discussion it creates

 Begin with the end in mind – how will you
use it?
 Determine critical to quality requirements for each step in the
process
 Use only as much detail as needed to communicate well and
understand the process.
© 2010 Healthcare Performance Partners, Inc.
 © 2010 Healthcare Performance Partners, Inc.

The End

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