current conditions exercise -...

Current Conditions ExerciseWill iam Huen, MD, MS, MPH

Associate Chief Medical Officer, ZSFGLast Updated: March 21, 2017

• Toolkit Contents: (printed 2 sheets/page)• Overview of Exercise and Setup• Step 1 and Example: Identify Process• Step 2 and Example: Info Gathering and Map• Step 3 and Example: What are our problems? • Data and Example: What data define problem? • Next Steps

5/30/17ZuckerbergSanFranciscoGeneral

HospitalandTraumaCenter

Current Conditions: Where do things stand now?

1. WHAT IS THE CURRENT PROCESS NOW? 2. WHAT DATA DEFINES THE

PROBLEM?

ZuckerbergSanFranciscoGeneralCredit:ExampleadaptedfromChoi,

Lean,UCSFHealth,2017

Measures CurrentPerformance

ExistingBenchmark

Measure X% Y%

Process

steps

RolesorProblems/Wastes

3. WHAT IS YOUR PROBLEM STATEMENT?

Overview of Current Conditions ExercisePurpose: To support individual & team thinking in Current Conditions by thinking about the

current process and the current data, then considering a summary Problem Statement

Materials Needed: 2-3 sheets of flip Chart Paper, Markers, Pink and Yellow Post-Its

Flip Chart Paper Pink Post-Its Yellow Post-Its Markers. Tape

(if transporting)

TitleofProcess:CommonScenario:

SwimlaneSetup

InstructionsStep1

InstructionsSetup

InstructionsStep3

InstructionsStep2

Time=5min1.Place2flipchartpagesside-by-side

2.Label:-Title-Scenario-Drawrows(1post-ittall)-Placeblankpinkpost-itsasstartandend

3.Postinstructions Instructions

NextSteps

SWIMLANEINSTRUCTIONSSTEP1:

q Step 1: Identify the current process related to your problem

q Title: Write the title of your current process across top paper �

qReview who on team has observed process (don’t worry, you

will go back to observe and validate later)

q Common Scenario: Write the “Common Scenario” you will map?

(80:20 rule, e.g. stable adult patients from arrival to medication) �

q Decide First Row Perspective: Decide who customer/client/

patient/recipient of the process is, and write title in yellow post-it in

top row, left column (e.g. “patient”) �

q Start/End Points: Write the start & end points in pink post-its at the

left and right ends of the top row �

ArrivalMedgiven

Time=10min

Patient

TitleofProcess:FromarrivalinEDtoreceiptofanalgesiaCommonScenario:Adultpatientwithstablevitalsignsandlikelylongbonefracture

ArrivalMedgiven

Step1Example��

� �Patient


q Step 2: Information Gathering & Mapping

q Map the process as experienced or performed by the role,

beginning with top row, one row at a time

q Write each major process step on a PINK POST-IT for each

major step of process, beginning-to-end, left-to-right �

q Consider vertical lines to indicate time (e.g. minutes, days) or

high level categories (e.g. arrival->visit->discharge) �

q Add additional roles/rows: Label additional YELLOW POST-ITS

for each role/operator, and PINK POST-ITS for major process steps

from each perspective �

qInitial goal is to finish top row, and identify roles that will need to be observed and validated in detail

q Align steps vertically according to sequence. Note interdependency

or handoffs by connecting steps with lines

ProcessStep

Time=20+min

Triage RN

MD


ArrivalMedgiven

Step2Example

Greeted RoomedSeen by

RNSeen by

MDHas X Ray

TriagePt

AssignsRoom

Pthandoff

AssessPatient

StartsIV

ReceivesOrder

GivesMed

Obtainsmed

PickupPatient

0min 15min 30min 45min 60min 75min

�

�

�

Patient

Triage RN

Room RN

MD

Pharmacist

5/30/17 131


q Step 3: What are our problems in this process?q Invite team to share YELLOW POST-ITS to describe where there

are specific problems or gaps in performance

q Wastes – Add more YELLOW POST-ITS with specific examples of

each of the 8 wastes are in our process? (e.g. Where is there any

Waiting in this process?)

1. Transportation – Unnecessary handling or transportation of

client/customer/product

2. Inventory – Too much, too little, wrong time or wrong place

3. Motion – Excess handling, steps, nonergonomic motion of

staff/materials/equipment

4. Waiting – Time delays, process idle time

5. Overprocessing – Unnecessary processing, steps, elements,

procedures

6. Overproduction – Producing more, sooner or faster than is

required

7. Defects – Errors that travel, rework, failures, quality problems

8. Wasted Talent

Problems/Wastes

Time=10+min

5/30/17 132


ArrivalMedgiven

Step3Example

Greeted RoomedSeen by

RNSeen by

MDHas X Ray

TriagePt

AssignsRoom

Pthandoff

AssessPatient

StartsIV

ReceivesOrder

GivesMed

Obtainsmed

PickupPatient

AssessPatient

WritesOrders

Reviewsxray

0min 15min 30min 45min 60min 75min

Waiting Waiting

Infoisn’tshared

(overprocessing)

MDdoesn’tknowptinfo

MDassignedtomanypatients

Waiting

Patient

Triage RN

Room RN

MD

Pharmacist

Tips for Construction of a Problem Statement: •One, specific summary sentence

•Measurable baseline/performance (How often? How many? May not be known yet)

•Compared to the target, demonstrates a gap

•Clear impact/outcome on the organization or customers (or True North)

•Not a countermeasure in disguise/Proposed “solution”

CURRENT CONDITIONS - DATA INSTRUCTIONS: Purpose: What data defines our problem?

q What are existing or possible measures of our problem?

q What is current performance for each?

q What are known comparisons or benchmarks for this? (Where could we learn them?)

q What is your problem statement and target?

ExistingorPossibleMeasures CurrentPerformance

ComparisonBenchmark/Standards

1.

2.

3.

ProblemStatement:

TargetsandGoals:

Time=10minutes

CurrentConditions:WhatDataDefinesOurProblem?

ProblemStatement:Patientswithlongbonefractureswait89minutesforpainmedications

Targets:Decreasewaitsforpatientswithlongbonefracturesfromarrivaltopainmedicationsto60minutesbyDec2017and45minutesbyDec2019

CurrentConditionsDataExample

MeasureName CurrentPerformance

ComparisonBenchmarkorStandards

1.Arrivaltopainmedication,longbonefractures

89minutes 52minutes

2.

3.

CURRENTCONDITIONSNEXTSTEPS:

q Next Steps: Validate swimlane with stakeholders and dataq Return to the workplace and directly observe roles, process steps

and problems

q Review swimlane with stakeholders

q Collect data or processes, outcomes, and problems, and review

comparison benchmarks

q Incorporate these learnings into your Current Conditions by

summarizing or focusing on smaller pieces

Tips:

• When transporting flipcharts, use tape to secure your post-its

• Remember that root causes (and possible countermeasures are

coming next)

• Photos or vizio can be used to document these current state

process maps/swimlanes

• Future state process maps/swim lanes can be helpful to compare

Time=ReserveforLater

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