In blog 4 we covered Hoshin Kanri otherwise known as strategy deployment which is an important senior management tool in the lean methodology of continuous improvement. In addition we defined what an A3 was and how it is used to cascade strategy and create dialogue throughout an entire organization.
In this week's blog I want to describe another critical component of this methodology which again comes under the rubric of Process and that is value stream mapping.Before we can describe a value stream we must first define the word value. The goal of every lean practitioner is to find what is of value to the customer and deliver it reliably, while removing all extraneous acts and materials from the process. In the strictest definition, everything that is not of value is waste.
But how does one identify what is truly of value for the customer? Many healthcare professionals probably think having blood drawn is of value. In fact, most people do not enjoy being stuck with needles and would avoid it if they possibly could. They place a value on being accurately diagnosed, but not on the diagnostic tests, per se. Diagnostic tests fall under the category of “necessary non-value added,” which can be a kind of holding pattern for waste – it is reluctantly accepted as necessary until some innovation comes along in this case, analyzing blood results without actually drawing the blood. This innovation is actually on the horizon now for diabetics who must check their blood sugar regularly. A sensor has been developed that is able to monitor blood sugar through the skin without needles. But for most, the non value added step of using needles to obtain a drop of blood is still the norm.
The most reliable way to determine value is to simply to have the customer answer one question.” Will you pay for this”? We have asked thousand of customers this question over the years and they have all been brutally honest that most of what we do is waste.
Identifying the existing state of a care delivery process is done by identifying each step in the process of delivering that service to the patient. Once completed the caregiver has a map, which we then can ask the “will you pay for it “ question of the customer. For example I was on a team that created this value stream map in obstetrics. We studied the time from when a baby is born to when the baby goes to the doctor for the first visit. This process had 140 steps many of which the customer on the study team said she wouldn’t pay for. For example she was not willing for the nurse to run out to the nurses station to get the baby’s medication but she was willing to pay for the nurse to the deliver the medication to her baby. This led to that team deciding to put all medications in the delivery room so the nurse would not have to perform that non value added step of retrieving medication. At the end of the week long improvement event (I will discuss these events in the next blog) the original 140 steps had been reduced to 70. In other words seventy steps of waste, from the customer’s perspective, had been removed. It is these steps then that make up what Toyota calls a value stream map. These maps originated at Toyota as a tool to help people see the flow of material and information as a product moves through a factory, a value stream map identifies every task required to make a product or deliver a service. In healthcare, these maps document and analyze every move made during a procedure, helping people pinpoint value and waste. They are created in two or three day sessions where front line workers and managers are taken off of their regular jobs to focus on the existing state of the care process,identify waste, and create a new future state value stream that becomes the new standard for delivering care.
A value stream map changes based on the changing understanding of the work.Typically, a new map is developed every few months as the team delivering care becomes more aware of waste and continually removes it. I have heard many staff and physicians say “we can’t believe our initial understanding of the future state was so flawed now that we have had a few months to really see the waste”..
Value stream mapping is one of the key components of the lean methodology of continuous improvement. Next week I will cover Kaizen and it’s role in the methodology.
For more reading on value stream mapping I recommend John Shook's book "Learning to See".
I have also included a value stream map in the link below - Value stream map1
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