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Topic Title: Multiple Patients on one swim lane diagram
Topic Summary: Applying swim lanes to patient flow
Created On: 04/06/2017 10:46 AM
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04/06/2017 02:44 PM
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Aaron Hunt

Hi all.

We have been working with a specialty physician's office in our organization with the initial objective of understanding staff turnover. What we discovered was a lack of standards and flow which was just causing frustration at every level of the office, and making it difficult to onboard new employees. We were only losing new employees (so far...)

We helped them improve their daily huddles and get more improvement focused than operations focused. We've done a lot of coaching and cheerleading just to buoy the morale as we work to understand this particular office over the last several weeks.

After spending several visits in Gemba and in personal discussion with each team member, we completed our initial VSM, pareto charts of historical performance, baseline financial analysis, and then completed a swim lane of the average patient visit.

One of my PI team members mentioned that the amount of "waiting" time the patient experienced looks like no-one in the opffice is busy on the swim lane, but they're actually seeing other patients. She asked if we could diagram each patient sequentially to see what an entire morning's visits look like instead of just one patient, which would more accurately show what's happening in the office.

I've been working in process improvement circles quite a while, from since I was "green" to now being more and more "gray", but this seemed like a novel approach to me. So we tried it. What we ended up with was a combination swim lane, with a timeline measured in minutes across the tops of the lanes, almost like a standard work chart, which in the end sort of reminds me of whiteboard production scheduling in a machine shop. We built a current state, a "could be" state - which was based on the current schedule and patient arrival because the initial thought was we can;t control when the patients arrive, so how good could the day have been, and then a future state - what would it look like if we challenged the actual clinical steps and scheduling of our flow.

The result resonated with staff, physicians in the practice and executives of our physician's group. We think we can see patients faster and more on time to their appointments, complete charting during business hours, and then possibly scale up the model for growth. In manufacturing, the VSM usually got us to the same place, but in healthcare using VSM hasn't resonated for my teams as strongly. This modified swim lane seems to fit the way the teams think (at least in my organization).

We just used butcher paper and post-it notes, with each patient being a different color post-it.

My question is - has anyone else used a similar technique, and what were your results and outcomes? As followers of the lean philosophy we're always learning, but it's especially exciting when we find a way to adapt methods to make complex processes even more visually clear. In 2 days, we went from trying to accurately describe the problem to a very clear intermediate target of improved performance that everyone seems to really believe in. Like going from hoping there is a way to make things better to knowing what we need to do. Jut like what I used to see and feel in Manufacturing when we did a good VSM.

I look forward to thoughts from others - and maybe learning how to do this a little better.

04/10/2017 11:54 AM
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Willie Carter

Please send me the photos of your process maps with the patient swim lanes. It sounds like a very useful tool.
09/12/2017 10:08 AM
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Richard Tucker

Hello Aaron,
I have done something similar with a swim lane diagram in an Emergency Department.
We used a single lane per patient and used a different color for the different staff members: nurse, nurse practitioner, registrar, phlebotomist for lab draw, etc
We started with a traditional value stream map, but found like you did that it did not really represent that staff were with other patients when a single patient was waiting.
We used the term "multi-tasking delay" to call out the waiting due to staff being with other patients or activities. For example, patient waiting, but provider was charting on prior patient.

We used static cling dry erase sheets (smart-sheets.com) and just rolled out about 15 feet of it on the wall.

Unfortunately, I cannot find any photos of this.
Best regards, Richard
09/20/2017 10:08 AM
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Mark Graban

Is it really "multitasking delay" when a nurse can only really treat one patient at a time?

It sounds like just "delay" to me.
09/20/2017 10:08 AM
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Kathryn Ward

Richard Tucker,

I am very interested to here how you used this technique in the Emergency Department. I am currently in the planning phase of an Emergency Department throughput project using Lean techniques. I would love to see an example of this swim lane.

Thank you,

09/20/2017 10:08 AM
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Kathryn Ward

Hi Richard!
I would love to see an example of the emergency department swim lane that you completed with several patients. I am currently in the planning phase of an emergency department throughput project.
10/12/2017 02:46 PM
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Michael Thelen

Value is from the customer perspective. Even though someone is 'multi-tasking', the patient/process still experiences the waste of waiting. Many hospitals have done work around this. Regretfully, too many haven't engaged both the nurse and the patient in the process to really drive improvement.

While we all understand that 'workers', be they nurses, doctors, billing clerks, or patient admins, can't be everywhere at once, our true measurement of success in this and similar environments is often, simply, patient door-to-door time. That is what matters to the customer. How can you maximize their experience while reducing the stress on the 'staff'? I've seen it done, and helped lead it in hospital/clinic settings, so it can be done.
10/12/2017 02:48 PM
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Azif Amin

Hello Aaron,

Just seen your post. How is your project running?
I do agree, there will be many patient to be observed during Gemba. Do Product Family Matrix. Try to identify your high volume patient, or perharps High Risk patient such as AMI patient, or The most Attended patient. To do this, study your previous cencus for at least 6 months.
Then, for each identify group, try to list all down the core process that should happen when patient presented in ER.
Finally do a matrix- Use the rule of 80-20. Which of the process that is shared about 80% by the identified patient group.
The reason why you need product family is to assist you and to get team agreed that by focusing on a patient that fall within the same will cover many patient group. So no issue if you are observing a patient during your Gemba.

Lean is about process and time.So we need to track the actual time for patient movement from one site to another. E.g Triage-Patient Registration-Vital Sign-Physician Assessment etc.

The following step will be actual steps for my practice here for the VSM.
1. Gemba Walk- Here you need multidisciplinary team involve. Why? because you need them during the mapping process.
2. Do a process flow- Base on what you see. Initially we try to use the post it note, after a while we realize this create more confusion. Why? Because # 3 & 4.
3. Draw your material flow- this how the customer request ( can be your patient) being attended until he/ she receive her treatment in ER.
4. Draw you information flow
5. Enter the timeline
6. Calculate your Value Added Ratio.

VSM has 2 phases -Current and Future. Base on above ( Current), sit down with the team. Can by the table top discussion to identify which process has TIMWOOD. Refer your current VSM and discuss how to eliminate some of the TIMWOOD.

Draw a new map ( Future Map )- Use Kaizen, 5S, Kanban, Just in Time and test it. Please note that there are many lean tool but not all applicable to our healthcare industry e.g SMED.
Calculate the new Value Added ratio. This will tell you if your lean strategy eliminate the waste.

After writing this I realize yours is within the Outpatient Area-So identify what is the most commonly seen patient in the OPD for your Product Family matrix before your further step. Assign a champion as the Lean Manager to observe the process. This can be the Unit Head or Dept Head of that particular process.

Hope this will help your team there.
Feel free to discuss more about your project.

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