Whenever you make the decision to embark on a Lean journey, you need to start thinking about the magnitude of this change, as it is enormous. Many of your current practices will change to become more focused on patient care (the reason why you got into healthcare) and much less on the daily aggravations of searching for all the things you need to deliver that care. You need to have a solid framework to assess the progress of your lean efforts. First, as you think about the changes coming, you must:
• Appeal to the rational mind: Communicate a clear picture of the future state and its benefits for the patients and staff.
• Appeal to the emotional mind: Reason gives you direction, but emotion gives you the energy necessary to make the change. Staff must be emotionally invested in the change, or they will not own it and sustain it.
• Clear the path: Great ideas that are difficult to implement are doomed from the start. Focus on making processes and procedures easy to understand, execute, and document.
This article focuses on a way to appeal to the rational mind by providing a framework to assess the progress of your Lean journey as it pertains to a specific Value Stream.
Let’s start by defining what a hospital value stream is: a Value Stream is a collection of interconnected processes to deliver value to a customer. A value stream example in a hospital describes the care of a patient that arrived to the hospital via the Emergency Department, was admitted to the Telemetry unit, and was discharged home. Another value stream example describes the flow of patients that come to the hospital for outpatient surgeries:
Registration -> Pre-Surgical care -> Procedure -> PACU I ->PACU II -> Discharge
Each process advances the care of the patient. The sum total of these processes delivers value to the patient and is what we call a Value Stream. There are many value streams in a hospital and each of them must mature on its way to perfection, as that is our goal and the goal of any Lean initiative. How do we track the progress of the Lean implementation on a specific value stream? We do that by establishing a five-level framework to measure the progress.
There are several dimensions that we look for when assessing the maturity of an entire Value Stream, that are not seen at the level of the individual processes:
• Linked Processes. Most of the delays in patient care (sometimes over 95%) in a Value Stream occurs between processes, in hand-offs from one person to another, or one department to another. We do not have this visibility if we are only looking within the process.
• Existence of Flow and Pull. Flow and pull go hand-in-hand in a Lean environment, so it is logical to look for formal flow and pull methods. Without formal pull systems, patient care will be delayed in the Value Stream.
• Engagement. By this we mean a high level of involvement by the entire staff. Simply improving is not sufficient in a Lean Value Stream. Without the active involvement by everyone in the task of process improvement, it will be difficult to improve fast enough in today’s competitive environment.
The Value Stream Maturity Scale is used to assess the maturity of a value stream, in the interest of creating or modifying a process improvement plan. A Value Stream that is at Level 0 or Level 1 represents a great opportunity. After all, if you’ve survived this long (apparently) with a low-maturity
Value Stream, imagine what you can do when you cut patient flow times by 50%! Following is a brief description of each maturity level in the Value Stream Maturity Scale.
Level 1: Identify the Value Stream and assign ownership. The first logical step in improving a value stream is to identify and document it. This maturity level involves naming a value stream, assigning a value stream owner to it, and creating both current and future state value stream maps. We will also want to establish performance metrics for the value stream: Discharge performance, Medication Administration performance, productivity, quality, and so on.
Level 2: Patient Flow and Pull. The biggest opportunity when moving from a traditional work environment to a Lean environment is the introduction of flow and pulls methods. Patient wait time in traditional environments can represent up to 70% of the total patient length of stay. In cases where you flow products, like Sterile Processing of Instrument sets, experience has shown that cycle time is related to a long list of related benefits, including improved productivity, better quality, less floor space, improved flexibility, and higher on-time delivery of the Instrument sets back to the OR Suite.
Level 3: Standardization. Once we have harvested the low hanging fruit of flow and pull, we must continue with the task of training the certifying the staff in Standard Work. We need to involve the entire staff in defining the one best way to do work, and to train them to do the work that way. Remember that standard work does not limit creativity or improvement, but it does determine the way the work should be done for the present time.
Level 4: Engagement. The stage of engagement is what separates the Lean pros from the amateurs, when we are assessing value stream maturity. Until we are able to involve the entire workforce in the creative work of continuous improvement, our Lean efforts will continue to be vulnerable to outside competitors simply copying what we have done. Once we are generating hundreds and thousands of small improvement suggestions a year, it will be very difficult for the competition to keep up.
Level 5: Sustained Performance. Until we are able to incorporate flow, pull, standard work and employee engagement into our hospital culture, things will inevitably backslide. We can claim that we are at Level 5 on the value stream maturity scale if we are able to shown that we have maintained continuous improvement for a period of at least 36 months.
The starting point, obviously, is to map your main value streams. While the Value Stream Mapping concept is well-know, in reality few organizations (hospitals or factories) have actually taken that first step. If you’re willing to move forward with the effort, get some expert help from mentoring organizations like Leonardo Group Americas. Getting training and insight from people who have done this before many times is very valuable.
A Value Stream Mapping effort will shine a light on the many improvements that are needed and possible, but before jumping into improvement projects, apply the Value Stream Maturity Scale. If you’re not yet at Level 3, your attention should be spent on achieving flow and standardizing the value stream processes. Otherwise your efforts will be difficult or impossible to sustain.