A Value Stream is an end-to-end process that flows horizontally through an organization in order to provide value to a client, patient or customer. Many organizations map processes vertically rather than horizontally focusing on a department over the entity that flows through the entire organization. In a horizontal process design, however, because the entity is what is mapped and not a facility or department, handoffs can be visualized and downstream affects identified.

How Many Value Streams Does Your Organization Have?

Many entities can flow through an organization, but only one entity can flow through a single Value Stream. For instance, a patient would represent the primary entity that flows through a medical practice’s or hospital’s core Value Stream, while a staff member, who also represents an entity flowing through a healthcare organization, flows through an entirely separate Value Stream.

Experience has shown that most organizations have between five and eight Value Streams that either directly or indirectly touch their constituents.

What Makes a Value Stream Map Effective?

For a Value Stream map to be effective, it is critical to determine the beginning and ending points of the end-to-end horizontal process. Identifying the beginning and ending of a Value Stream can easily become an area of great debate.

For example, many may feel that the patient Value Stream begins when a person enters the practice or hospital, whereas others may feel that the Value Stream begins through a healthcare branding campaign. Both are correct, but all must agree on which beginning point to use for the Value Stream. The same goes for the ending point. It is generally best to start the process at the very first point in which the entity is touched and then end at very last point.

Identifying Process Steps

Once the beginning and ending process steps are established, individual process steps must be identified in order of flow. These steps represent a noun and a verb combined to articulate a high level action that is necessary to deliver the entity through the process.

After the high level process steps are determined and aligned into the proper flow, the sub-process steps need to be identified for each high level process step. Again, it is critical that each sub-process step be aligned into its logical flow.  It is recommended that during the mapping exercise, the departmental groups performing each sub-process are named. This allows for a cross-functional visualization for the end-to-end Value Stream.

Defining Core Metrics

After the process is mapped, the core metrics for each Value Stream must be identified and measured. This will facilitate continuous improvement by monitoring and measuring the Value Stream against a patient-stated requirement.

Benefits

Some of the benefits in visualizing the path of an entity as it flows through an organization are:

• Staff members can see how their process directly or indirectly touches a patient.
• The effects upstream processes have on downstream processes become evident.
• When changes are made to an upstream process, it is much easier to model the expected downstream effect.
• When quality and process metrics fail to meet requirements, it is easier to determine the point at which the root cause occurred.
• Hand-offs between processes can be better managed. In many cases, the transition between handoffs is where both defects and delays occur.
• Each process step can be measured in terms of its impact on overall cycle-time.
• It can aid in identifying areas for quick improvement.

Conclusion

Horizontally Value Stream mapping how an entity moves end-to-end though an organization can offer many benefits beyond the traditional vertical way of thinking. This method encourages organizations to take a patient-centered focus in how it manages processes and measures success.

There has been a plethora of discussion in the healthcare industry, concerning the conflicts between Lean and ISO (or other healthcare quality certifications).

While many organizations are initiating Lean as a way to increase process efficiency through waste elimination, others are pursuing ISO certification as a way to ensure their services consistently meet and exceed their patient’s requirements.

Where Lean is embodied through employee empowerment, ISO appears to be embodied through command and control. As Lean seeks to eliminate nonvalue-added activities, ISO seems to add bureaucracy through increased documentation control.

Consequently then, how can a healthcare organization pursue both approaches when the two seem to be in such conflict with each other? As difficult as this may sound, the solution is actually very simple. Apply Lean thinking to the ISO deployment, and ISO thinking for Lean standardization and continual improvement.

Lean Core Concept

The core concept of Lean is to eliminate nonvalue-added activities in the core value streams. Any process step can be tested for value by asking three questions:

1.    Would patients in our community be willing to pay for it

AND

2.    It changes the service or offering

AND

3.    It is completed correctly the first time (quality, access and reliability)

ISO Core Concept

Whereas the core concept of ISO is to ensure the organization consistently delivers a quality service to the patients. Therefore, the two approaches work well together when employees and care teams are empowered to not initiate ISO with process steps that do not meet the Lean criteria, but rather remove them, and only control and continually improve the process steps that result in high patient experience of care.

Combining the Two Approaches

Through this approach, organizations can empower your staff to improve process efficiency while standardizing and controlling the most critical process activities within your value streams.

Jerry Green is Director of Quality Management at Phytel.

It’s an enticing notion: focus resources on the sickest patients if you want to drive savings in health care, the 20% of the patients that drive 80% of the costs (or the 5% that drive 43% of Medicare‘s costs).

As I write, smart people are getting caught in the appeal of the notion. We can solve a big chunk of our health care crisis if we just take advantage of the 80-20 rule! There are health system administrators busy instructing data analysts to mine their data for high-cost patients. Those same analysts will be instructed to pass the information along to case managers who will then be told to bring order to the spiraling costs. When the administrators review their efforts, it may even look like they worked: the patients who were “case managed” showed lower costs in the period after they started getting managed. The problem is that there really wasn’t any other outcome possible.

I’ve been involved in health care analytics in one form or another for the past 15 years. The most common analytic error by far involves concluding that the inevitable was instead caused by intervention. One example is showing savings on a disease management program for heart failure patients in which the patients were enrolled right after they’ve had a hospital stay for a heart attack. The statistical problem with such an analysis is called “regression to the mean.” In practical terms, it means that most patients don’t stay acutely ill all the time. If you measure future outcomes versus the time a population was sickest, odds are that at least some of the population will improve and the outcomes will look better.

Back when I ran the analytics department at a disease management company, we did research in which we found that even for the rare diseases we worked with (diseases such as multiple sclerosis, cystic fibrosis and systemic lupus) the highest cost patients in one year were not always the highest cost patients the next. Generally, there was more than a 50% turnover of the top 10% of patients from year to year. That means that if you took the 1,000 highest costs patients in 2009, 500 or less would still be high cost patients in 2010. Usually, it was because they had some kind of an acute crisis from which they recovered. Whether we did nothing or provided intensive case management to the costliest patients, about 50% were going to get better and their costs were going down (which is why we didn’t just focus on the sickest of the sick).

One of the standard quality metrics followed by groups that track health care quality is the percentage of diabetic patients with an HbA1c value of greater than 9%. (The Wisconsin Collaborative for Health Care Quality does a good job of creating visibility around this metric.) Programs are currently being designed to target the 9%ers, to bring their scores back in line. The challenge with focusing only on the 9%ers is the same as with the high cost patients. Here at Phytel, we’ve done research on the turnover rate of the 9% patients. We’re finding that like any other outlier, they change from year to year – at a rate of over 60%. That is, for every 1,000 patients with an HbA1c score of 9% or more in 2008, only 400 of them continued to have a score of over 9% in 2009. Despite the turnover of the 9%ers, the overall percentage of patients with 9%+ HbA1c scores has remained relatively stable from year to year (at least in the data we’ve analyzed). In other words, as soon as one 9%er drops to a lower level, another is waiting to take his or her place.

I grew up in the North East where we had frozen ponds most of the winter. That meant a lot of pond hockey. The best players were always the ones that skated to where the puck was going to be rather than to where it was at any point in time. The same approach is critical when it comes to affecting the small pool of patients that drive the bulk of health care costs. You need to find them early, before they’re a high cost patient.

Why is this issue important? I wrote in the second paragraph that some health system administrators are busy creating case management programs designed to target their sickest patients. One of the reasons is to prepare their organization to take on global payments, with the goal of becoming an accountable care organization. The reasoning is that if they can just remove unnecessary costs for the sickest patients, they’ll save enough money to make those global payments profitable. But their efforts are akin to Sisyphus rolling his rock up the hill only to have it fall once he gets to the top. No sooner will a high cost patient start improving in this scenario than another will be waiting to take his or her place. If the “manage sickest 5, 10 or 20%” approach is employed on a grand scale, we won’t move any closer to bending the health care cost trend curve.

The trick is finding sick patients before a crisis event, before they’re really sick. The availability of lab results data from electronic medical records is critical in that regard. And once you find them, affecting those patients requires a skill set that our health system (which includes more than only the providers themselves) is just beginning to develop – that of reaching out to patients and motivating them to actually modify their behavior. One just has to reference the massive efforts (both public and private) that have gone into reducing the number of smokers to understand how significant this challenge truly is.

Ted Courtemanche is the Vice President of Analytics and Outcomes at Phytel.