Understanding the Current
Condition
Process Maps (Flow charts)
Making Observations
8 Wastes
A3 Roadmap for Performance Improvement at Penn Medicine
D F
E
F
I
N
E
I
N
D
Problem Statement (from patient’s/customer’s viewpoint): (10 points)




Concise.
Customer- focused.
Addresses the business case. Shows why a change is needed.
Background Provides background for the problem statement (1-3 paragraphs with a minimum of 3
references using APA reference format. Why is this problem important? Who is interested in it (nationally
and/or locally) and why? Is there evidence behind this being a problem in healthcare? If so, provide a
summary of that evidence. [note: this item will be handed in typewritten, attached to your paper A3]
Target Condition: (10 points)



Your target condition will move you towards delivering exactly what the customer wants, closer to IDEAL.
You identify at least one process, outcome, and balancing measure for your proposed project.
You have a clear aim statement, and your process and outcome metrics are expressed as S.M.A.R.T. goals.
P
I
L
A
N
M
P
R
O
V
E
Propose and Test Countermeasures: (10 points)


Each countermeasure is clearly related to a root cause in the previous section.
For each countermeasure, state how you will DO the tests - What, When and by Whom.
A
N
D
D
O
M O
E
A
S
U
R
E
R
G
A
N
I
Z
E
C
Current Condition: (20 points)





There is evidence that you did your “Go and See”.
The section is rich with data. Data is presented graphically – bar charts, run charts, or SPC charts are
preferred.
You have at least one process map (Value-stream, flow chart, spaghetti diagram).
The metric(s) you are trying to move are clearly identified. Baseline/pre-test metrics are presented here.
Must consider at least one potential process, outcome, and balancing metric
You have completed a stakeholder analysis and attached it to your paper A3.
L
A
R
I
F
Y
A U
N
A
L
Y
Z
E
N
D
E
R
S
T
A
N
D
Metrics/Results: (10 points)



Root Cause Analysis: (20 points)
If a test of change has been implemented, the S.M.A.R.T. goals are restated and results presented as data.
Data should be in a run chart or a statistical process control chart (note: this is not required for successful
completion of the project for class; some students may not have this item completed yet; see next bullet)
If a test of change has not been implemented, describe which countermeasure you have chosen to test first
and why.
Reflect on What You Have Done and Learned so Far in Improvement work: (10 points)
Write a 1-3 paragraph reflection on what you learned by going through this process. What was most
challenging and why? What surprised you most and why? What do you think is your biggest challenge going
forward? [note: this will be handed in typewritten attached to your A3]
Make it Standard Work (Implement Successful Countermeasures):
C C
H
E
C
K
or
S
T
U
D
Y
A
C


You use a relevant root cause tool. (5 Whys, Fishbone, Pareto). Must use at least one tool, though you may
need more than one for a deep analysis.
Your choice of which root cause(s) to tackle is supported by the data in the Current Condition section – i.e.
the data validates that you have identified the true root cause(s) and have chosen the right one(s) to work
on first.
T
While this step is not required for this class, be aware that failing to execute this step is extremely common in
healthcare. Skipping this step is usually the root cause for failing to sustain improvements after attention has moved
on to the next project. You should think about how you might implement a successful countermeasure and sustain any
improvements.
S
E
L
E
C
T
Executive Sponsor Initial Approval (signature and date):
Executive Sponsor Final Approval (signature and date):
Not required for this class – but never do a real project without this!
Not required for this class – but never do a real project without this!
O
N
T
R
O
L
What Adds Value?
Value Added:
1.
2.
3.
It changes the form, fit or function
It is done right the first time
The customer would pay for it – more of it is better
Non-Value Added (Waste):
1.
Any activity that does not meet the value criteria above:
a) Unavoidable waste- necessary in the process due to regulatory
or supporting value. These activities should be simplified,
reduced, or combined whenever possible.
b) Avoidable waste - activity that is not value or enabling should
be completely eliminated!
The 8 Wastes
D
O
W
N
T
I
M
E
•
•
•
•
•
•
•
•
Defects
Over Production
Waiting
kNowledge wasted - confusion
Transportation
Inventory
Motion
Excess Processing
Eight Wastes: Healthcare Examples
Defects
Example:
•Lab tests are performed
twice because of errors
•An x-ray is read incorrectly
•Wrong site surgery
Overproduction
Example:
•Making more IV bags than are
needed.
•Preparing 4 units of blood “just
in case” for the OR
Unnecessary Transportation
Waiting Time
Example:
•Delayed Cases waiting for
instruments
Wasted Motion
kNowledge
Example:
•A resident’s bright idea is
“lost”, or the resident is
confused about how to do a
task
Extra Processing
Inventory
Example:
•Patient gets wheeled back and forth
between the floor and radiology for
multiple tests instead of taking one trip for
all of them
Example:
•Medicines held over the shelf-life
because of excess ordering
Example:
•Pharmacy tech walks back and forth
looking in multiple places for a particular
med
Example:
•Nurse records respiratory
rate in multiple places in the
chart
•Multiple copies of the same
pathology report – in EPIC,
in Medview, in SCM, on
paper
Process Mapping
• Purpose
– Visually document a process
– Understand the existing process and problems
– Quickly identify improvement opportunities within the
process
– Helps communicate inside and outside the organization
• Key Principles
–
–
–
–
Documentation is not substitute for observation
A flowchart is a means not an end
Your scope defines the boundaries of your map
Involve a cross-representation of those who work in the
process to create the map
– Process maps are meant to be used as working documents
Which Process Map is For You?
Process Map
High Level Process Map
Detailed Process Map
Description
•View from 30,000 Feet
•Depicts major elements and their interactions
•5-8 steps total
•Early in the project to identify boundaries and
scope
•A detailed version of the High Level Process
Map
•Fills in the all the steps within the high level
steps
•To see a detailed process in a simple view
•Helps to identify and follow decision points
Process snapshot that captures information
that is critical to a project
•To come to agreement on project boundaries
and scope
•To verify that process inputs match the outputs
of the process
•Quality issue
•Captures all key flows (of work, information,
materials) in a process and important process
metrics
•Requires a current and future state to be done
•To identify and quantify waste
•Helps visualize the improvement opportunities
•Flow or time issue
Emphasizes the “who” in “who does what”
•To study handoffs between people and/or work
groups in a process
•Especially useful with administrative (service)
processes
Depicts the physical flow of work or material in
a process
•To improve the physical layout of a workspace
(unit, office, floor)
SIPOC
VSM (Value Stream Map)
Swim Lane Flowchart
Spaghetti Map
When to Use
High Level Process Map
•
•
•
View from 30,000 feet
Used early in the project to identify boundaries and scope
5 – 8 steps total
Assess pump/
module need
Order pump/
modules
Pump/module
released
Pump/module
delivery
Pump/module
pick-up
Recycled
Utilization
Tool: Spaghetti Diagramming
• Reveals waste:
 Motion
 Transport
 Over-processing
 kNowledge
Low Fidelity Spaghetti Diagram
Glass
wear
storage
Glass
wear
storage
Lab
Tech’s
Workstat
ion
Lab
Machine
Room
Versions of a Process Map
Any Process Has At Least Three
Versions
What You Think It is . . .
Verify What It Actually is . .
.
What You Would Like it to Be . .
.
The struggle is that this is where
everyone wants to start.
How to Go and See
• NEVER accept opinion
• ALWAYS walk the process
• ALWAYS walk the process multiple times
Guidelines for Observation
•
Agree on a starting point for observation, for example patient enters a
department.
•
Make sure you introduce yourself to the customer and inform them of what it is
you are doing and why.
•
Try to talk to patients and/or staff when they are waiting, to avoid prolonging
the time it takes to complete an operation.
•
You may need to observe staff AND products/patients separately.
– Product/patient observation - stay with the product/patient and record what the
product/patient is going through. If the product/patient waits, you wait.
– Staff observation – stay with your staff member continuously.
•
Not too much detail – just enough.
•
Always do multiple observation sessions.
•
Observers should summarize lessons learned and present them to the whole
team. Discuss the results.