A value stream map without pictures?

“Okay, Curmudge, how are you going to do it? No one can teach value stream mapping without pictures.”

“You’re right as usual, Jaded Julie. It would be like trying to teach chemistry without a blackboard, or a whiteboard, or these days without a ‘smart board.’ So I won’t try to teach value stream mapping; I’ll just introduce the concept. Anyone with a bit of imagination should be able to handle that.”

“Oh, I should be able to do that all right. I once imagined that my husband would become a millionaire, but then reality set in.”

“Remember reading about the nurses in Nord 92? They said they didn’t utilize mapping, but I’ll bet they were able to clearly envision their processes. So sit back and try to conceptualize what I describe. But don’t close your eyes or you’ll fall asleep as we senior citizens do.”

“G’night, Curmudge.”

“Up and at ‘em, Julie! Let’s start by imagining a simple flow chart…just a few rectangles connected by lines or arrows. A value stream map (VSM) is a sketch of a process showing procedures in the boxes with intervals between procedures shown by the connecting lines. It differs from a flow chart by showing times for value-added activities (what the customer is willing to pay for) and non-value-added activities (when nothing constructive is happening, from the customer’s view). Think of an appointment with a physician. Your time spent with the nurse and the doctor should be value-added, but any waiting time is non-value-added. Unless you have been on vacation all summer, you should recognize the waiting time as waste or muda.”

“Me! Vacation? Curmudge, you are the one who has been on vacation.”

“How can you tell, Julie? As a retired person, I am on vacation 24/7…or at least that’s what some people think. So back to VSM. A process for study is identified, a team is formed to study the process, and they create the current state value stream map. This reveals the sources of waste in the process. The team then brainstorms ways to improve the process and reduce waste using special symbols for people and activities, storm clouds for problems, and ‘Kaizen bursts’ (stars) for ideas. A future state value stream map depicts the product of their efforts, and it serves as a blueprint for the action plan to upgrade the process.”

“The ‘VSM Game’ sounds like something my kids would like to play. So the team fixes the process and they live happily ever after, right?”

“No, Julie. The future state value stream map becomes the new current state value stream map, and that will help the team discern where even further improvements can be made. Remember, this is Lean, where the people in gemba continually strive to make incremental reductions in process waste.”

“Incremental. That means making little improvements but never reaching perfection.”

“Practically speaking, Julie, that’s true. However, a word that might better fit your definition is ‘asymptotic.’ But don’t worry; that’s a word that you don’t have to remember.”

“Consider it forgotten, Curmudge.”

Affinity’s Kaizen Curmudgeon

P.S.—“Julie, if you want to learn about value stream mapping, go to Lean in the Affinity Learning Center on the Affinity intranet. See also Mike Rother and John Shook’s book Learning to See, published by The Lean Enterprise Institute. The book’s title is very appropriate, because that’s what VSM teaches us. Another excellent resource is the section on Value Stream Mapping in Cindy Jimmerson’s reVIEW, second edition. And most recently, Mark Graban has a chapter that covers VSM in his new book, Lean Hospitals.”

Future State VSM--Triage in the ED

P.P.S.—“Look up, Julie, I’ve got one—a VSM picture. Janice found it for us.”

“That’s not much of a VSM; it doesn’t even show value-added and non-value-added times.”

“Hey, beggars can’t be choosers. Besides, this is a future state VSM. On these, times are only hoped-for estimates.”

“Now you’ll have to revise the title, Curmudge. It’s no longer ‘without pictures.’”

“Not a chance, Julie. We’d need to rewrite the first half page, and I don’t want to delete your dream about your husband becoming a millionaire. Mrs. Curmudgeon once had the same dream about me."

Problem Solving Then and Now

“Curmudge, were you involved in problem solving in your earlier life?”

“Lives, Jaded Julie. I had several of them. I was a chemist, and problem solving was what scientists and engineers did. If we weren’t fairly good at it, the men became mill workers and the women home economics teachers.”

“Tell me how you solved problems back in the last century. It sounds as if it were the exclusive purview (purview; did I say that?) of professionals.”

“Like management in those days, problem solving was essentially a seat-of-the-pants endeavor. For problems requiring research, we followed a sequence sort of like this: Define the problem. Learn what was already known by studying the literature, sometimes in a foreign language. Plan the investigation, and then do it. We didn’t know Plan, Do, Check, Act, although we probably did it intuitively. Dr. Deming may have still been in Japan.”

“That sounds difficult, Curmudge, especially the foreign language part. It’s pretty evident why the Toyota Production System had to be developed if they wanted everyone to become a problem solver. On January 25 and 31 we talked about some general aspects of the TPS; perhaps it’s time to tackle the specifics.”

“I agree, Julie. To sum up the two approaches to problem solving, let’s call the old way ‘seat-of-the-pants for scientists and engineers’ and the new way ‘organized common sense, i.e., Lean tools, for the people in gemba.’ The beauty of Lean tools is that everyone can use them.”

“My brain is in gear. When do we start?”

“We already did. On January 18 we used The Five Why’s to identify the root cause of a problem. More recently, on July 10, we introduced 5S, and on August 14 we talked about The Eight Wastes of Health Care. Although the Eight Wastes is not really a tool, it helps guide our thinking. Recall once again, however, that in a blog we can only introduce a concept. Taking a workshop, studying a dedicated text, or working with an experienced person will be necessary before one can rigorously apply a Lean tool.”

“Curmudge, I believe you once said that one of the principles of a Lean transformation is continuous improvement of processes. If we are going to solve problems in processes, we’d better understand the difference between a process and a procedure.”

“Okay, here it is, courtesy of an international standard (ISO 9000) and a seminar at SEH by Lucia Berte on 10/12/06. A process is a sequence of activities involving more than one person (usually) across a span of time. A process description defines who does what in the proper sequence (when). Typically, a process involves several procedures. Thus, the process description, outline, or flow chart is the tie that binds the procedures into a coordinated effort to achieve the desired outcome. A procedure tells how to do something. It is a set of instructions that describe the stepwise actions taken to complete an activity identified in a process. It usually involves just one person. Here is a simple example: Getting up and going to work is a process; brushing one’s teeth is a procedure.”

“The definitions sound reasonable to me, Curmudge. I think the term, ‘procedure,’ is overworked. It is too often used to refer to processes as well as procedures, and we throw in surgical procedures for good measure. Is it really important for us to differentiate between processes and procedures?”

“If people become too absorbed in performing their own procedures, they are apt to acquire a ‘silo’ mentality. In a Lean transformation we need to remove the boundaries between silos and think about how we are going to move patients through processes efficiently.”

“Curmudge, for an old chemist, you’ve covered a lot of ground in two pages. I noticed that you mentioned using a flow chart to describe a process. Does that mean that we’ll talk about value stream mapping sometime soon?”

“Of course, Julie. You can depend on me to be here. After 40 years of getting up and going to work, I’ve hardwired the process.”

Affinity’s Kaizen Curmudgeon

The Eight Wastes of Health Care

“Jaded Julie, I’ve forgotten something.”

“Of course you have, Curmudge. You’ve spent the past 40 years forgetting most everything you learned in the preceding 20.”

“You are probably right, Julie, but more to the point, we haven’t said much about Lean tools. Several months ago we decided to focus on the Lean culture, and that’s what we have done. Things like the Toyota Way pyramid, leadership, The Flywheel.”

“I recall learning about The Eight Wastes of Health Care. That’s not a tool, but it’s a Lean fundamental that everyone must know. When did we discuss that?”

“It was back in the winter of ’07, Julie. Before my transformation into the Kaizen Curmudgeon. The list was published on the Affinity intranet but not in a blog. Why don’t I name a type of waste, and you can provide some health care examples? Then the blog readers won’t feel neglected.”

“Okay, let’s do it.”

“Waiting:”
“To be seen in the ED
To be admitted to the hospital from the ED
For testing, treatment, or discharge
For laboratory test results”

“Motion:”
“Searching for meds, charts, supplies, patients
Handling paperwork”

“Transportation:”
“Moving patients for testing or treatment
Moving specimens”

“Defects:”
“Wrong patient or procedure
Medication error or omission
Missing information”

“Processing:”
“Unnecessary testing (defensive medicine)
Excessive paperwork”

“Inventory:”
“Pharmacy stock and lab supplies
Paperwork in process”

“Overproduction:”
“Any testing or treatments done at the convenience of the institution rather than the patient”

“Underutilization of Human Resources:”
“Lack of involvement and participation of all members of the workforce”

“Good job, Julie. Did I ever tell you that the Japanese word for waste is muda?”

“You just did, and I am forever in your debt. How did I ever live this past year without knowing that? I must admit that as Japanese words go, muda isn’t too tough. At least it’s easier than genchi genbutsu. By the way, Curmudge, what does genchi genbutsu mean?”

“You know me, Julie; I forgot. We’d better look it up in Liker’s The Toyota Way.”

Affinity’s Kaizen Curmudgeon