Removing Waste Using Lean Discussion Reply 1

The use of process mapping provides opportunity to identify themes and highlight specific areas of performance improvement (NIH, 2018). Lean refers to an approach that identifies and removes waste in processes and improves efficiency and six sigma is a method used to reduce variation in processes by identifying the root cause of an issue (Murphree, Vath, & Daigle, 2011). In order for a process map to be effective, all individuals that are a part of the process, must partake in the process mapping session. This is essential in order to capture the true essence of the current state (Cookson, Read, Mukherjee, & Cooke, 2011). Both the current state and ideal states are mapped out in order to easily identify barriers and resources in order to achieve the desired process (NHSIII, 2010). The purpose of this discussion is to explain how using a process map can facilitate quality improvement and data collection efforts.

Process Mapping

One of the most effective process mapping tools is the lean model of value stream mapping. Value stream mapping is a visual map of each step within a specific process. For this writer’s course project, the quality improvement issue is lowering the NTSV cesarean section rate. The term NTSV stands for Nulliparous, Term, Singleton, Vertex, which represents first time mothers, at 37 weeks gestation or greater, carrying one baby, in a head down position (TJC, 2019). To begin, a committee was developed, composed of the OB/GYN department director, 5-OB/GYN’s and a quality coordinator.

Patient accounts were pulled onto a special report requested using the hospitals EMR based off of NTSV criteria. Every account was reviewed and discussed by the NTSV committee on a monthly basis for six months. The overall consensus from the committee was that care was appropriate on an overwhelming majority of the cases. It was at this time, the committee decided to take a step back and reflect on the idea of how could the care be appropriate yet the hospital remained an outlier over many other hospitals, both nationally and on a state level. Further analysis, of the six months of data revealed two main trends. Majority of the NTSV patients that underwent cesarean sections was due to either failed inductions or labor management issues.

The committee decided to arrange a value stream mapping session. The results of the value stream mapping session revealed areas of waste such as scheduling practices, patient delays, and variation in the induction process. Additionally, dialogue and pain points identified revealed that the nursing staff were not adequately increasing Pitocin on labor patients due to staffing issues, physicians were not allowing proper time for effective augmentation/inductions and the schedule had very weak parameters for scheduling elective inductions, with little to no standardization. Next steps included revision of the scheduling guidelines and indications for scheduled inductions, and revision of the Pitocin policy. The scheduling practice was standardized for non-medical, elective inductions and patients were counseled that if they were to be late for their induction, they would forfeit their scheduled day/time until the following date.

The manager of Labor and Delivery requested additional staffing on the night shift to ensure proper labor management with Pitocin. In the long-term, the organization decided to implement a Laborist model on L&D which will go-live in the summer of 2020 and are currently developing an outpatient Foley induction protocol. The use of a value stream process map helped to improve quality by exposing key areas in a care delivery process were able to be identified and addressed in order to yield safe, and appropriate care (Abubakker, 2010). Most importantly, the VSM showed an obvious misalignment of practice to high-reliability principles and organizational mission, vision, and values.

Summary

Process mapping is a vital tool to help facilitate leaders and members of the healthcare team towards areas of improvement. It is imperative to involve all key members of the team in order to properly visualize a process in its current state. In addition to revealing areas of concern, this visualization tool also helps to prioritize initiatives and reinforce organizational standards. Frequent reassessment and adaptation to processes is necessary to continuously deliver safe, high-quality care.

References

Cookson, D., Read, C., Mukherjee, P., & Cooke, M. (2011). Improving the quality of emergency department care by removing waste using lean value stream mapping. International Journal of Clinical Leadership. 17(1), 25-30.

Abubakker, H. T. (2010). Practical guide to creating better looking process maps. Retrieved from https://www.isixsigma.com/tools-templates/process-mapping/practical-guide-creating-better-looking-process-maps/

NHS Institute for Innovation and Improvement. (2010). Quality and service improvement tools: Process mapping-an overview. Retrieved from http://www.miltonkeynesccg.nhs.uk/resources/uploads/files/NHS%20III%20Handbook%20serviceimprove.pdf

National Institutes of Health. (2018). Process mapping as a framework for performance improvement in emergency general surgery. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5785284/

Murphree, P., Vath, R. R., & Daigle, L. (2011). Sustaining lean six sigma projects in health care. Physician Executive, 37(1), 38-42.

The Joint Commission (2019). Perinatal care. Retrieved from https://manual.jointcommission.org/releases/TJC2016B1/MIF0167.html