MMHA 6700 Week 7 Discharge Value Stream Map Example

Ready at Ten, Gone at Four: A Value Stream Map of One Discharge Day With Its Wastes Named by Type

Student Name

Walden University

MMHA 6700: Healthcare Operations

Instructor Name

Month Day, Year

Ready at Ten, Gone at Four: A Value Stream Map of One Discharge Day With Its Wastes Named by Type

Scope

This value stream map follows a single discharge day for medical patients on 5 West at Linden Ford Medical Center, the community hospital invented for this term's assignments. It begins when the patient is medically ready to leave, meaning the physician would discharge the patient if every task were done, and ends when environmental services marks the bed clean and available. Medical readiness was recorded prospectively by the unit's charge nurse during morning huddle for 40 discharges over four weeks. The figures are illustrative.

In the Week 1 profile, orders were signed at a median of 13:40, patients were out the door around 15:50, and housekeeping needed roughly another 70 minutes to turn the room. This map asks what happens between readiness, which the charge nurse recorded at a median of 10:00, and that clean bed at around 17:00.

The Value Stream

A value stream map shows each step in a process, separates time that adds value for the patient from time that does not, and names the types of waste that fill the gap (Mazzocato et al., 2010). Lean practice usually names several waste types: waiting, transport, motion, overprocessing, inventory, defects and unused talent. This map uses the types that appear.

Table 1

Discharge Day Value Stream, Medians for 40 Discharges (Illustrative)

Seven hours separate readiness from a clean bed. Ninety minutes of that is work that adds value; the rest is waiting between steps.

Wastes by Type

Waiting dominates, but the map also shows other waste types hidden inside the steps.

Motion and transport waste appear in the pharmacy step. Bedside prescription delivery requires a pharmacy technician to walk each filled prescription to the unit; when several are ready at once, they wait for a single trip. Nurses also walk to the pharmacy window when a patient is anxious to leave.

Overprocessing appears in discharge paperwork. The nurse completes a discharge checklist in the record and a separate paper checklist that duplicates most of it, a holdover from before the record was installed.

Defects appear in medication reconciliation. In 6 of the 40 discharges, the pharmacist called the physician to correct the discharge medication list, adding a median of 35 minutes to those discharges. This is rework, the same kind of loop the Week 2 admission map found for level of care.

Unused talent appears in case management. The unit's case manager identifies most patients likely to need a ride or home services a day ahead, but that information does not reach the physician's rounding list, so rides are arranged on the day of discharge.

Where the Largest Gaps Are

The largest single wait, 130 minutes, is for the physician to reach the patient. Hospitalists round in the order of their patient list, often grouped by room number, so a patient ready to leave may be seen at noon. Studies of efforts to discharge patients earlier in the day have found that changing rounding to see likely discharges first is one of the most effective steps (Wertheimer et al., 2014). The next largest wait, 60 minutes for a nurse to see the order, reflects a nurse caring for five patients who learns of the order only by checking the record. The pharmacy and ride waits are each around an hour.

Each of these waits is short alone. Together, they push the clean bed past 17:00, after the emergency department's boarding peak has begun, which links this map back to the bottleneck located in Week 4.

Future State

The future state would move the median clean bed from about 17:00 to about 13:00, freeing beds before the afternoon admission peak. Reviews of lean in health care caution that such gains depend on changes being owned by front-line staff rather than imposed (D'Andreamatteo et al., 2015), so the next assignment examines why the physician wait exists before redesigning it.

Table 2

Future State Targets (Illustrative)

The future state does not speed any value-adding step. It removes waiting between them.

Limits

Forty discharges from one unit may not represent the hospital. Readiness was judged by charge nurses and may vary between them. Some waits overlap in practice, such as ride arrangements during pharmacy filling, so adding them overstates the total slightly. The map does not include patients discharged to nursing facilities, whose delays follow a different path.

Conclusion

A medical patient on 5 West who is ready to leave at 10:00 leaves a clean bed at about 17:00. Only ninety minutes of those seven hours add value. The rest is waiting between steps, with smaller wastes of motion, overprocessing, defects and unused information. The largest wait is for the physician to reach the patient, which makes the order of morning rounds the place to look next.

References

D'Andreamatteo, A., Ianni, L., Lega, F., & Sargiacomo, M. (2015). Lean in healthcare: A comprehensive review. Health Policy, 119(9), 1197-1209. https://doi.org/10.1016/j.healthpol.2015.02.002

Mazzocato, P., Savage, C., Brommels, M., Aronsson, H., & Thor, J. (2010). Lean thinking in healthcare: A realist review of the literature. Quality and Safety in Health Care, 19(5), 376-382. https://doi.org/10.1136/qshc.2009.037986

Wertheimer, B., Jacobs, R. E., Bailey, M., Holstein, S., Chatfield, S., Ohta, B., Horrocks, A., & Hochman, K. (2014). Discharge before noon: An achievable hospital goal. Journal of Hospital Medicine, 9(4), 210-214. https://doi.org/10.1002/jhm.2154