article pointers
Chapter 6.
Flow Processes Improvement:
Reengineering & Lean Management
Chapter 6: Flow Process Improvement
Yasar A. Ozcan
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Outline
Reengineering vs. Other Methods
Lean Management
Work Design in Health Care Organizations
Work Design
Job Design
Work Measurement-Standard Times
Stopwatch Time Studies
Standard and Predetermined Times
Work Measurement Using Work Sampling
Determination of Sample Size
Development of Random Observations Schedule
Training Observers
Work Simplification
Work Distribution Chart
Flow Chart & Flow Process Chart
Value Stream Map
Spaghetti Diagram
Worker Compensation
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Introduction
Organizational Performance is a major concern for health care managers
Performance is usually measured financially by looking at profits, market share, reimbursement, but also can be measured by market share compared to other institutions or healthcare systems.
Performance is usually classified as:
Those who perform adequately with no imminent risk in their finances or market share
Those whose performance is marginally adequate
Those whose performance is less than less than expected
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How do you improve institutional Performance?
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Improve Finances (Restructuring, downsizing/Layoffs, mergers)
What problems are created by restructuring /downsizing?
Will this impact Quality of care?
Pareto Principle “While improving a part of the organization, one should not make other parts of the organization worse off”
Improved Productivity (automation, implement process improvements, cross training staff, etc.)
Improve Quality of Care
Value = Quality/Cost (Increase value by Improving Quality and by reducing cost)
TQM/CQI
To improve both performance and quality one can use TQM (Total Quality Management) and CQI (Continuous Quality Improvement)
This should be a Long-term goal
Make incremental changes (often over 5 to 6 years)
Requires management commitment to quality
Q. Why TQM and CQI end up in failure?
Management’s commitment can become diluted
Responsibility is only assigned to a limited number of people
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Reengineering & Lean Management vs. Other Methods
Healthcare managers have often sought organizational change, restructuring, and downsizing. Although those methods may improve the financial base of the organization or productivity at least temporarily by “cutting the fat,” namely by reducing the staff across the board, yet they create other problems. In particular, reducing staff can lead to major problems in the quality of care.
Two other contemporary and popular methods that aim to improve both performance and the quality are total quality management (TQM) and continuous quality improvement (CQI) which are geared to make incremental changes over time.
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Reengineering and Lean management
What is Reengineering and Lean Management?
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Flow Process Improvement via Reengineering and Lean Management
Reengineering and Lean Management methods are process improvement methodologies intended to overcome the difficulty in realizing TQM/CQI performance over a long duration, as well as the myopic conduct of organizational change, restructuring and downsizing.
To improve the system flow process, healthcare managers must be able to understand work-design, jobs, job measurement, process activities, and reward systems – all well known concepts of industrial engineering. With that knowledge, they can recognize the bottlenecks in the old system, identify unnecessary and repetitive tasks, and eliminate them in the reengineered system of care.
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Chapter 6: Flow Process Improvement
Reengineering
Reengineering in the early 1990 aimed to improve:
Quality
Cost
Service
Speed
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Reengineering
What should Reengineering do?
Eliminate Delays in healthcare delivery
Eliminate duplication in healthcare delivery/Eliminate unnecessary tasks
Implement automation or IT
Retrain employees to provide a comprehensive and undisruptive care
This will help reduce cost and speed up recovery
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Example of Comprehensive and undisruptive care
Example is patient focused or patient centered care. Hospital offering patient-focused cardiac care for a patient recuperating from a heart attack or bypass surgery.
Nurses are trained to perform EKGs and Draw blood, so fewer staff are involved in the patient’s care
Patients are given one on one education about heart disease and cardiac rehab.
Families receive education about their health
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Final Thought: Why reengineering Fails
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One reason such efforts fail is that leaders assume that reengineering is no more than cost reduction. In fact, reengineering must go beyond simple cost reduction and create processes that, by adding value to the product, are attractive to customers.
As one writer has put it, "No company ever shrank to greatness”
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Lean Management
Similar to reengineering in many aspects, Lean Management conceives of business processes as value streams in which value flows through various process steps to the customer.
Lean is a systematic approach intended to identify and eliminate non-value added process steps, or process waste, and reduce lead time in order to create value for the customer using fewer resources.
Lean emphasizes a model of continuous, incremental improvement to the process.
Based on the Toyota Production System, the early applications of lean management focused on manufacturing, but its applications have since expanded into service industries such as health care and software development (Kim et al, 2006).
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Lean Management Process
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Define the Value
Map the Process
Identify Process Waste
Identify Improvements
Map the Future State
Implement Improvements
Repeat the Cycle
Define the value
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The first step in lean management is to identify the value that each step in the process provides to the customer.
This may involve engaging the customer and/or stakeholders to understand their perceptions of the value received from the product or service.
8-Process Waste
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Examples
8 Wastes of Lean Management:
Defects: Data entry errors, mislabeled specimens, incomplete documentation
Overproduction: Providing Meals that is not eaten by patients, providing reports that are not utilized by staff
Waiting: Time spent being idle, waiting for exam room or waiting for blood darw
Over-processing: completing unnecessary testing or labs performing surgery instead of minimally invasive procedure
Transportation: transportation of specimens or blood products
Motion: unnecessary walking between departments
Inventory: excess inventory: risk of damage, expiration, becoming obsolete
Under-utilized talent: inappropriate utilization of the talents of the staff
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Map the Process
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Next, a visual map of the process is created using a tool called a value stream map (discussed later).
A value stream map incorporates the results of time observation studies, documenting the amount of time it takes to complete each step of the process.
Ultimately, the value stream map serves as a benchmark of current process performance (Kim et al, 2015).
Once the value stream has been mapped, it can be examined to identify performance issues and process waste.
Identify Improvements
Once process waste is identified, the project team can leverage lean management tools to design improvements that eliminate waste and standardize the process.
5-Why Analysis: drill down to the root cause of a problem by asking “why” a problem is occurring at least five times.
5S: Sort, Straighten, Shine, Standardize, and Sustain. Technique for organizing the workplace.
Mistake-proofing: Involves putting process controls in place that prevent defects from occurring.
Kitting: Items needed to execute a step or steps in the workflow are gathered and packaged as a kit.
Autonomation: Implementation of technology solutions to replace, or automate, specific tasks that may be repetitive or too complicated for staff to complete.
Kanban: Visual signaling system used to ensure a continuous flow of supplies, finished goods, or customers.
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Example of the 5-Why?
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Example of 5 S
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Mistake Proofing
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Kitting
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Map the Future State
Any improvements are then incorporated into a future state process design, which is visualized in a future state value stream map.
The revised value stream map includes a time component that indicates how long each activity will take to complete once the improvements are implemented, providing an estimate of the overall reduction in lead time under the improved process.
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Implement Improvements
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Once the best solutions have been identified and agreed upon by stakeholders, the project team may implement a pilot project to test the improvements on a smaller scale.
The results of the pilot project are then reviewed to ensure the effectiveness of the solution and also collect any lessons learned.
If the pilot project is deemed successful, there is a full scale implementation of the solutions.
Repeat the Cycle
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Lean management does not end once improvements are implemented.
An organization that implements lean management will continue to look for opportunities to improve the process and reduce process waste.
Importance of Lean In HealthCare
Concerns over how process waste has contributed to rising health care costs in the United States have increasingly led health care organizations to implement lean management.
By implementing lean management, health care organizations can:
identify redundant processes,
pinpoint process steps that increase the probability of error, and
categorize processes in terms of importance.
Health care managers can then leverage the numerous lean tools to design and implement process improvements and ultimately improve process efficiency.
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Importance and Purpose Of Human Resources Management
Human resources represents over 40% of healthcare facility budgets
Productivity and satisfaction of staff involves an understanding of the work environment
Work must be designed so that employees are happy, organizational productivity is high, and costs are minimized
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Work Design- A Systems Perspective
Work Design
Work
Measurement
Time Study
Predetermined
Standard
Work Sampling
Job Design
Who?
How?
Where?
Job Simplification
Worker
Compensation
Time Based
Output Based
Incentive Plans
External
Factors
Job Design: Who does what, how, and where?
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Consistent with organizational goals
Write it down!
Understand and communicate it
Involve employees and management
Frederick Winslow Taylor
Developed Scientific Management Approach
Focused on time studies
Conflicts between labor and management occurred because management had no idea how long jobs actually took
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For what types of jobs would this
approach work best? Are there
Healthcare applications?
Efficiency School-- Logical and Systematic
Best for simple, repetitive routine, and separable tasks
Healthcare Examples:
lower level administrative duties
division of labor
standardized forms and paperwork
robots in laboratories
automation of routine tasks
Not good for judgmental/unpredictable tasks
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Advantages and Disadvantages of Specialization
| Management | Employees | |
| Advantages | a. Simplifies training b. Higher productivity c. Low wage costs | a. Low education/skill b. Minimum responsibilities c. Little mental effort needed |
| Disadvantages | Difficult to motivate quality b. Worker dissatisfaction, absenteeism, high turn- over, disruptive tactics, poor attention to quality | a. Monotonous and boring b. Limited opportunities for advancement c. Little control over work d. Little opportunity for self- fulfillment |
Behavioral School Satisfaction of Wants/Needs
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Intrinsic and extrinsic motivators
Specialization leads to monotony and worthlessness
Socio-technical School Approach
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Efficiency School
(Technical Focus)
Behavioral School
(Human Focus)
Socio-Technical School
How can jobs be improved?
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What are examples of each?
1
Job enlargement - give workers a larger portion of the total task (horizontal loading-- additional work at same level of skill and responsibility)
II
Job enrichment - increasing responsibility for planning and coordinating tasks (vertical loading)
III
Job rotation - workers periodically exchange jobs
Work Measurement Using Time Standards
Time standards are important in establishing productivity measures, determining staffing level and schedules, estimating labor costs, budgeting, and designing incentive systems
A time standard represents the amount of time needed for the average worker to do a specific job working under typical conditions
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The First Step. . .
The amount of time it should take a qualified worker to complete a specified task, working at a sustainable rate, using given methods and equipment, raw materials, and workplace arrangements is called a Standard Time.
A Standard Time can be developed through:
Stop-watch studies
Historical times
Predetermined data
Work sampling
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Stopwatch Time Studies
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Take time over a number of trials (cycles)
Workers should be educated regarding the process to avoid suspicion and avoid the Hawthorn Effect
Number of cycles to time (i.e., sample size)
variability in observed times
desired accuracy
desired level of confidence for the estimate
Determining Sample Size
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Desired
Confidence Z-value
90 1.65
95 1.96
98 2.33
99 2.58
Accuracy desired may be explained by the percentage of the mean of the observed time. For instance, the goal may be to achieve an estimate within 10 percent of the actual mean. The sample size is then determined by:
where:
z = number of std. dev.
needed for desired
confidence
s = sample std. dev.
a = desired accuracy
x = sample mean
An Alternative Formula
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Desired accuracy may be expressed as an amount (e.g.,
within one minute of the true mean). The formula for
sample size becomes:
where
e = Accuracy or
maximum error
acceptable
To make an initial estimate of sample size, you should
take a small number of observations and then compute
the mean and std. dev. to use in the formula for n.
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Example 6.1:
A heath care analyst wishes to estimate the time required
to perform a certain job. A preliminary stopwatch study
yielded a mean of 6.4 minutes and a standard deviation of
2.1 min. The desired confidence level is 95 percent. How many
observations will be needed (including those already taken)
if the desired maximum error is:
a) +/- 10 percent?
b) one-half minute?
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a. Using formula (6.1) and z = 1.96, we get:
b. Similarly, using formula (6.2), we get:
Solution:
Time Standard
Once the sample size is determined, observations can be made.
The activity is timed and the standard time is computed.
To compute a time standard, three times must be calculated:
Observed Time
Normal Time
Standard Time
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OT, ST, NT
OT: Observed Time = (∑Xi Observed time for worker i)/n (number of observations for worker i).
The observed time must be adjusted for workers performance to yield the normal time
NT: Normal Time = OT (observed time) x PR (workers performance) (This formula assumes that single performance rating has been made for the entire job); however, Each element or task that composes a job may have a different performance rating
Example testing a clinical sample has many different elements: Transportation, spinning the sample, labeling, testing, resulting, charting etc.
NT = ∑Ej (observed time of element j) X PR (Performance rating for element j)
Normal time is the time it takes a worker to perform the job without interruptions, but no one can be asked to work 100% of the time. Therefore the Normal Time is adjusted by an allowance factor to reach the standard time
ST: standard Time = NT X AF (Allowance Factor)
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Determining the Standard Time
Observed Time -- average of observed times
OT = åxi/n
Normal Time -- observed time adjusted for worker performance
NT = OT * PR (where PR = performance standard measured for the entire job)
NT = å(Ej*PRj) (where PR is measured element by element)
PR equals 1 for the average worker; PR< 1 is for a slower worker
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ST = NT * AF
Standard time equals normal time multiplied by an allowance factor
Allowance Factor
Accounts for personal delays, unavoidable delays, and/or rest breaks
AFjob = 1+A, where A= allowance percentage based on job time
AFday = 1/(1-A), where A = allowance percentage based on work day
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Table 6.1 Typical Allowance Percentages for Varying Healthcare Delivery Working Conditions
| Allowance Level | Percent |
| 1. Basic-low (personal, fatigue, standing) | 11 |
| 2. Basic-moderate (basic-low and mental strain) | 12 |
| 3. Basic-high (basic-moderate and slightly uncomfortable heat/cold or humidity | 14 |
| 4. Medium-low (basic high and awkward position) | 16 |
| 5. Medium-moderate (medium-low and lifting requirements up to 20 lbs.) | 19 |
| 6. Medium-high (medium-moderate and loud noise) | 21 |
| 7. Extensive-low (medium-high and tedious nature of work) | 23 |
| 8. Extensive-medium (extensive-low and with complex mental strain) | 26 |
| 9. Extensive-high (extensive-medium and lifting requirement up to 30 lbs.) | 28 |
Source: Adapted from B.W. Niebel, 1988.
The Allowance Factor
Compute the allowance factor if:
The allowance is 20 percent of job time.
The allowance is 20 percent of work day.
A) AF = 1 + A = 1.20, or 120%
B) AF = 1/(1-A) = 1/(1-.2) = 1.25 = 125%
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Example 6.2:
The nursing unit manager at HEALTH FINDER HOSPITAL wants to evaluate the activities in the patient care unit. The manager hired an analyst, who timed all the patient care activities for this job, which has twenty elements. The observed times (OT) and the performance ratings for six samples of a particular employee are recorded in Table 6.2. From those measurements the nursing manager wants to know the standard time for the whole job with its 20 tasks with extensive-medium level allowance. Assume that nursing tasks differ from other clinical and ancillary operations.
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| Nursing Unit Activities | Performance Rating | Observed time in minutes | |||||
| 1 | 2 | 3 | 4 | 5 | 6 | ||
| 1. Patient assessment | 1.08 | 12 | 11 | 12 | 9 | 13 | 12 |
| 2. Care planning | 0.95 | 9 | 7 | 6 | 8 | 7 | 9 |
| 3. Treatments | 1.12 | 8 | 8 | 7 | 9 | 10 | 11 |
| 4. Medication | 1.05 | 4 | 3 | 4 | 5 | 6 | 4 |
| 5. Collecting blood/lab specimens | 1.10 | 8 | 7 | 6 | 9 | 10 | 7 |
| 6. Passing/collecting trays, snacks, feeding patients | 1.20 | 18 | 21 | 18 | 19 | 21 | 20 |
| 7. Shift report | 0.97 | 5 | 6 | 5 | 7 | 8 | 6 |
| 8. Charting/ documentation | 0.98 | 8 | 5 | 6 | 8 | 9 | 10 |
| 9. Responding to patients’ call lights | 1.15 | 4 | 3 | 3 | 5 | 6 | 5 |
| 10. Staff scheduling phone calls | 0.95 | 5 | 4 | 4 | 5 | 6 | 7 |
| 11. Phone calls to/from other departments | 0.96 | 6 | 5 | 5 | 4 | 6 | 7 |
| 12. Transporting patients, specimens etc. | 1.05 | 9 | 11 | 12 | 11 | 9 | 10 |
| 13. Patient acuity classification | 1.11 | 5 | 6 | 5 | 6 | 7 | 4 |
| 14. Attending educational in-services | 1.00 | 75 | 75 | 75 | 75 | 75 | 75 |
| 15. Order transcription and processing | 0.94 | 5 | 6 | 4 | 6 | 7 | 6 |
| 16. Ordering/stocking supplies and lines | 0.98 | 6 | 4 | 5 | 6 | 7 | 4 |
| 17. Equipment maintenance and cleaning | 0.95 | 9 | 11 | 8 | 9 | 11 | 10 |
| 18. General cleaning/room work (garbage, making beds) | 1.15 | 12 | 9 | 12 | 10 | 9 | 11 |
| 19. Assisting with the admission process | 1.06 | 11 | 9 | 10 | 9 | 8 | 9 |
| 20. Breaks/ personal time (not including lunch) | 1.00 | 15 | 15 | 15 | 15 | 15 | 15 |
TABLE 6.2. Observed Times and Performance Rating for Nursing Unit Activities
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Solution:
Table 6.3 displays the calculations summary for all 20 job elements involved in nursing care. Column (4) is the average of the six observations from column (3). Column (5) uses the normalizing formula (6.5):
NT = Sum of [(Avg. time for element j) x (Performance rating for element j)]
To calculate the standard time, an allowance factor should be determined using Table 6.1, in this case 26 percent.
The allowance factor for this job:
AFjob =1 + A = 1 + 0.26 = 1.26.
Finally, the standard time for the nursing activities:
ST = NT x AF = 243.49 x 1.26 = 306.80 minutes or 5.1 hours.
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| (1) | (2) | (3) | (4) | (5) | ||||||
| Nursing Unit Activities | Performance Rating | Sample Observed Times | Observed | Normal Time | ||||||
| in Minutes | Time | (NT) | ||||||||
| (PR) | 1 | 2 | 3 | 4 | 5 | 6 | (OT) | OT * PR | ||
| 1. Patient assessment | 1.08 | 12 | 11 | 12 | 9 | 13 | 12 | 11.50 | 12.42 | |
| 2. Care planning | 0.95 | 9 | 7 | 6 | 8 | 7 | 9 | 7.67 | 7.28 | |
| 3. Treatments | 1.12 | 8 | 8 | 7 | 9 | 10 | 11 | 8.83 | 9.89 | |
| 4. Medication | 1.05 | 4 | 3 | 4 | 5 | 6 | 4 | 4.33 | 4.55 | |
| 5. Collecting blood/lab specimens | 1.10 | 8 | 7 | 6 | 9 | 10 | 7 | 7.83 | 8.62 | |
| 6. Passing/collecting trays, snacks, feeding patients | 1.20 | 18 | 21 | 18 | 19 | 21 | 20 | 19.50 | 23.40 | |
| 7. Shift report | 0.97 | 5 | 6 | 5 | 7 | 8 | 6 | 6.17 | 5.98 | |
| 8. Charting/documentation | 0.98 | 8 | 5 | 6 | 8 | 9 | 10 | 7.67 | 7.51 | |
| 9. Responding to patients’ call lights | 1.15 | 4 | 3 | 3 | 5 | 6 | 5 | 4.33 | 4.98 | |
| 10. Staff scheduling phone calls | 0.95 | 5 | 4 | 4 | 5 | 6 | 7 | 5.17 | 4.91 | |
| 11. Phone calls to/from other departments | 0.96 | 6 | 5 | 5 | 4 | 6 | 7 | 5.50 | 5.28 | |
| 12. Transporting patients, specimens etc. | 1.05 | 9 | 11 | 12 | 11 | 9 | 10 | 10.33 | 10.85 | |
| 13. Patient acuity classification | 1.11 | 5 | 6 | 5 | 6 | 7 | 4 | 5.50 | 6.11 | |
| 14. Attending educational in-services | 1.00 | 75 | 75 | 75 | 75 | 75 | 75 | 75.00 | 75.00 | |
| 15. Order transcription and processing | 0.94 | 5 | 6 | 4 | 6 | 7 | 6 | 5.67 | 5.33 | |
| 16. Ordering/stocking supplies and lines | 0.98 | 6 | 4 | 5 | 6 | 7 | 4 | 5.33 | 5.23 | |
| 17. Equipment maintenance and cleaning | 0.95 | 9 | 11 | 8 | 9 | 11 | 10 | 9.67 | 9.18 | |
| 18. General cleaning/room work(garbage, making beds etc) | 1.15 | 12 | 9 | 12 | 10 | 9 | 11 | 10.50 | 12.08 | |
| 19. Assisting with the admission process | 1.06 | 11 | 9 | 10 | 9 | 8 | 9 | 9.33 | 9.89 | |
| 20. Breaks/ personal time (not including lunch) | 1.00 | 15 | 15 | 15 | 15 | 15 | 15 | 15.00 | 15.00 | |
| 234.83 | 243.49 | |||||||||
| Job - OT | Job - NT |
TABLE 6.3. Observed and Normal Time Calculations for Nursing Unit Activities
What are the problems with time studies?
Subjective performance ratings and allowances
Only observable jobs can be studied
Highly costly -- best for repetitive tasks
Disrupts worker routine
May cause worker resentment
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Other Methods
Historical/Standard Elemental Times
Firms collect data on standard job elements
Put these data together to determine job times
Less costly and disruptive
Limited applications in healthcare
Predetermined Standards
Obtained from trade publications
Need no performance of allowance factor
Operations are not interrupted
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Technique for estimating the proportion of time that a worker or machine spends on various activities
Observers make brief observations of a worker or a machine at random intervals over a period of time and simply note the nature of the activity
Purpose:
To estimate percentage of unproductive or idle time for repetitive jobs
To estimate the percentage of time spent on various tasks for non-repetitive jobs
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Work Measurement Using Work Sampling
Work Sampling Steps
1) Determine the sample size
2) Train the observers
3) Develop random sample schedule
4) Take observations, and re-compute the desired sample size several times if initial estimates are not reliable
5) Determine the estimated proportion of time spent on specified activity
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Step 1: Sample Size
CI = confidence interval,
e = error,
z = number of standard deviations needed to achieve desired confidence,
sample proportion (number of occurrences divided by sample size),
n = sample size.
The goal of work sampling is to obtain an estimate that provides a specified confidence not differing from the true value by more than a specified error
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Sample Size, cont.
Example 6.3: A hospital administrator wants an estimate of X-ray idle time that has a 95.5 percent confidence of being within 4 percent of the actual percentage. What sample size should be used?
e = 0.04 z = 2.00
Desired
Confidence Z-value
90 1.65
95 1.96
95.5 2.00
98 2.33
99 2.58
n = (z/e)2p(1-p)
When p is unknown, a
preliminary estimate of
sample size can be obtained
using p = 0.5. Then after 20
observations, a new estimate
can be obtained.
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Solution:
Given: e = 0.04; z = 2.00 (see Appendix A);
= 0.5 (preliminary).
If for 20 observations, it is observed that the x-ray machine was idle only once, the revised estimate is then
= 1/20 = 0.05.
= 0.05, n = (2.00/0.04)2 x .05 x (1-..05) = 118.75 or 119 observations.
The revised estimate of sample size is:
= 0.5: n = (2.00/0.04)2 * .50 * (1-.50) = 625 observations.
Step 2: Train Observers
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A comprehensive training program of three steps should be standardized for all data collectors. Data collectors should be first educated as to the study’s goals, protocol, collection procedures, and data submission procedures, and the guidelines for their behavior. Then, the observers should be trained in data collection. Training may include sessions using videotaped activities for practice in identifying and recording actual nursing services. In the third phase, observers participate with a project member, in explaining the nature of the project to those who will be observed, in the observation setting.
Step 3: Random Observation Schedule
Need random number for day, hour, and minute, with the number of digits needed for each number equaling the number of days in the study, hours per day, and minutes per hour.
Excel has a dynamic random generation method
Formula = RAND() * (End Date ‑ Begin Date) + Begin Date
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EXAMPLE 6.4:
The manager of Transesophageal Echocardiogram laboratory would like to improve efficiency of the processes in this department. To observe the proportion of time spent in various processes, a pilot work sampling study with an initial 20 observations will be taken during March 2017. Laboratory is open 8:00 a.m. to 5:00 p.m. during the week days only. Determine the random observation schedule using Excel.
SOLUTION:
Using the steps described earlier, beginning date and time of the observation schedule is placed in column A as a date function “=DATE(2017,3,1)+TIME(8,0,0).” First parenthesis indicates year, month and day to begin observations, and the second parenthesis show 8:00 a.m. as the start time. Similarly, column B includes the last permissible observation date/time using “=DATE(2017,3,31)+TIME(17,0,0).” Finally, the formula (6.12) is entered in column C as “=RAND()*(B3-A3)+A3.” The next step would be copying these three columns to the following rows. Figure 6.3 displays the resulting random selections.
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FIGURE 6.3 RANDOM OBSERVATION SCHEDULE
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FIGURE 6.4 STABILIZED DATES AND TIMES
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FIGURE 6.5 VALID DATES AND TIMES
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FIGURE 6.6 FINAL OBSERVATION SCHEDULE
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Table 6.4 Abridged Patient Care Tasks in a Nursing Unit
| Patient Care Tasks | Professional | Non-Professional | Direct | Indirect |
| 1. Ace bandage application | * | * | ||
| 2. Admit – patient orientation | * | * | ||
| 3. Assist to/from bed, chair | * | * | ||
| 4. Bed bath | * | |||
| 5. Bed change – empty | * | * | ||
| 6. Bed change - occupied | * | * | ||
| 7. Bed pan | * | * | ||
| 8. Blood pressure | * | * | ||
| 9. Catheterization of bladder | * | * | ||
| 10. Census count | * | * |
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Table 6.5 Work Sampling Data Collection Form for Nursing Unit
| Unit: 4 West | Observer: CL | Date: 11/02/17 | Shift: AM | Time: 10:04 | ||||||
| Observed Staff Name& Title | Prof. Direct | Non-Prof. Direct | Prof. Indirect | Non-Prof. Indirect | In Communication with | On Break | ||||
| Patient | Staff | Physician | ||||||||
| G. Smith, RN | ||||||||||
| V. Black, RN | ||||||||||
| E. Mason, RN | ||||||||||
| Z. Sander, RN | ||||||||||
| P. Bills, RN | ||||||||||
Work Sampling Steps
4) Take observations, and re-compute the desired sample size several times if initial estimates are not reliable
5) Determine the estimated proportion of time spent on specified activity
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Advantages of Work Sampling
Observations less susceptible to short term fluctuations
Little or no work disruption
Workers are less resentful
Less costly and time-consuming
Many studies can be conducted simultaneously
Useful for non-repetitive tasks
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Disadvantages of Work Sampling
Less detail on elements/tasks of a job
Workers may alter patterns
Often no record of method used by worker
Observers may fail to adhere to random observation schedule
Not useful for short, repetitive tasks
Much time required to move from observation area to observation area to ensure randomness
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Nobody likes to do things the hard way! Work Simplification
Work Simplification -- process of changing work methods:
Eliminate unnecessary parts of work
Combine and rearrange parts of work
Simplify work when possible
Work Simplification Tools
Work Distribution Chart
Flow Process Chart
Flow Chart
Value Stream Map
Spaghetti Diagram
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The Work Distribution Chart
Shows what a department does to identify each of its major activities and to pinpoint the contribution of each employee to those activities
Must be specific!
Spotting Trouble
Which activities consume the most time?
Are tasks evenly distributed?
Is there under-specialization?
Are employees assigned too many unrelated tasks?
Are talents utilized efficiently?
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Table 6.6 Partial Work Distribution Chart for Nursing Unit
| Activity | Hours | Nurse Manager | Hours | Nurse I | Hours | Nurse II | Hours |
| Patient admissions | 12 | Coordination with Admissions Dept. | 8 | 2 | 2 | ||
| Communications | 16 | Physicians and patient family | 8 | Patient family | 4 | Patient family | 4 |
| Direct patient care | 48 | 8 | Medication administration | 20 | 20 | ||
| Indirect patient care | 16 | Monitor charts | 4 | Meals | 6 | Update Charts | 6 |
| Discharge planning | 14 | 2 | 6 | 6 | |||
| Scheduling & Adm. | 4 | 4 | |||||
| Miscellaneous | 10 | Supervisory meeting Sessions with trainees | 42 | Emergency coverage | 2 | 2 | |
| TOTAL | 120 | 40 | 40 | 40 |
Flow Process Chart
Records a procedure in a graphic form, using a sort of shorthand to simplify and unify the record
Ensures every significant detail of the work process in its proper sequence is recorded
Highlights inconsistencies and redundancies
Can eliminate, combine, change (sequence, place, person), or improve activities
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Operation
Move
Inspect
Delay
Store
OPERATION
MOVE
INSPECT
DELAY
Flow Process Chart for Emergency Room Specimen Processing
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Process
Decision
Start/Terminate
Preparation
Document
Manual
Operation
Commonly Used Flow Chart Symbols
Off page connector
On page connector
Patient
entry
Flow Chart for Emergency Room Specimen Processing
Triage:
need blood?
Nurse draws
blood
MD orders
lab
IS order
entry
Label &
package
Verification
Lab
Accession &
analysis
IS double
entry
MD
terminates
lab order
(End)
Patient
entry
Triage:
need blood?
Nurse draws
blood
MD orders
lab
IS entry
label & package
Lab
Accession &
analysis
Results
arrive in ER
(End)
Initial Process
After Improvement
Yes
End
No
End
No
Value Stream Map
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Value Stream Maps are the primary tool in Lean, providing a more detailed view of the current state workflow and its corresponding time components.
Process steps are typically depicted using a process box symbol, while wait time or delays are depicted as a triangle.
A lead time ladder is displayed below the process flow, documenting the time it takes to complete each process step.
Any wait or delay is recorded as non-value added time, while time completing tasks is recorded as value-added time
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Value Stream Map
Adding the total non-value added time and the total value-added time gives the total Lead Time, or Cycle Time, for a product or person to make it through the entire workflow.
Value Stream Maps can be expanded to include information flows, inventory information, daily demand and other related factors to provide a more comprehensive view of the workflow.
Value Stream Maps are frequently used to highlight lag time and bottlenecks in a workflow.
Once such process waste has been identified, health care managers can identify opportunities for improvement, and then create a future state Value Stream map that incorporates these process improvements.
Using the future state Value Stream Map, health care managers can then assess what the expected reduction in lead time will be once an improvement is implemented.
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Value Stream Map for Prescribing and Dispensing Medication
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Spaghetti Diagram
A Spaghetti Diagram captures the actual physical flow of a product or person through a process.
A continuous flow line is used to trace the path and distance traveled on a floor plan layout, such as a hospital floor or unit. The name “Spaghetti Diagram” comes from the resulting flow line, which typically looks like cooked spaghetti (and not a straight line).
The Spaghetti Diagram is used to locate unnecessary travel, redundancies, and areas of congestion in the process.
This information can then be leveraged to design a more efficient process layout that shortens travel distance and reduces process lead time.
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Front Desk Check-In Spaghetti Diagram
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EXAMPLE 6.5:
After the results of a patient satisfaction survey indicated that patients felt wait times were unacceptable, the director of a primary care resident clinic put together a lean management project team to identify inefficiencies and opportunities for improvement of patient flow.
Solution:
The team followed the lean management systematic approach for identifying process waste and opportunities for improvement, beginning with defining the value.
1. Define the Value – The value this process provides to the patient is direct care in the form of primary care services. Accordingly, the goal of this project was to minimize any time not spent providing direct patient care.
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2. Map the Process – In order to map the process, the project team first conducted time motion observations to understand the patient’s course through the clinic as well as estimate the length of each process step. The average of the observed times for each activity was calculated, and then multiplied by the appropriate performance and allowance factors to calculate the standard time for each activity in the patient’s workflow, as shown in Table 6.7. The team also determined whether each process step was value added or non-value added. From this information, the team was able to construct a value stream map of the patient’s flow through the clinic, shown in Figure 6.12.
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| Activity | Value/ Non-Value | Standard Time (mins) |
| Waiting to Sign-In | Non-Value | 3.5 |
| Signing-In | Value | 0.58 |
| Waiting to Check-In | Non-Value | 4.77 |
| Checking In - Height & Weight | Value | 0.78 |
| Checking In – Vitals | Value | 5.25 |
| Checking In - History & Chief Complaint | Value | 7.95 |
| Waiting in Waiting Room after Check-In | Non-Value | 21.97 |
| LPN Preps Patient in Exam Room | VA | 1.25 |
| Waiting in Exam Room | Non-Value | 11.38 |
| Time with Physician in Exam Room | VA | 14.67 |
| Wait for Procedures/Testing | Non-Value | 15 |
| Procedures | VA | 1.95 |
| Testing | VA | 5.75 |
| Waiting to Check-Out | Non-Value | 8.03 |
| Check-Out | VA | 8.82 |
TABLE 6.7. Time Study Results
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Figure 6.12. Value Stream Map – Patient Flow
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The team also constructed a Spaghetti Diagram to illustrate patient travel through the clinic. Each observed patient’s travel path was layered on top of the clinic floor plan, as shown in Figure 6.13.
Figure 6.13. Spaghetti Diagram
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3. Identify Process Waste – Analysis of the Value Stream Map and Spaghetti Diagram revealed several bottlenecks in the clinic.
A patient spends 58% of their time, or 65 minutes, in the clinic waiting. There are three key process steps serving as bottlenecks to patient flow:
waiting for an exam room,
waiting for the physician to conduct the exam, and
waiting for a clinician to complete any procedures or testing.
Observation revealed that these bottlenecks result from an inefficient resident reporting process.
This reporting process produces process waste in the form of waiting, motion, as well as overprocessing.
Eight resident physicians report to two attending physicians, and each resident sees up to eight patients each. This means that 2 attendings are responsible for the care of up to sixty-four patients per day. This inefficiency is ultimately passed along to the patient, creating increased wait-time in the exam room and further backing up patient flow through the clinic.
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Figure 6.14. Bottlenecks – Value Stream Map
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Figure 6.15. Bottlenecks - Spaghetti Diagram
Identify Process Waste
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Review of the Spaghetti Diagram revealed congestion near the registration area, where sign-in, check-in, and check-out occur.
When examined in conjunction with the Value Stream Map, it was apparent that this congestion may be contributing to wait times.
Additionally, some patients mistakenly come to the resident clinic instead of the faculty