The ambitious goal to cut lead-time for a group of patients by as much as 60% is being handled by an improvement team in which all departments of Radiation Oncology are represented: doctors, trainees, administrative workers, technicians, managers, quality consultants, physicists and secretaries.
One of the first activities of the team is mapping the current process. We use a so called Value Stream Map. The whole team literally walks the route of the patient through the various workstations and, from a patient’s perspective, start seeing what is actually happening. They question their colleagues and bring all this information forward on post-its which are then put on a large brown paper. This technique has been described by others in detail.
This post therefore is not as much about the lean technique being used but it’s more about the surprising results which can be achieved using value stream mapping. It provides all participants with insight into the facts rather than opinions, insight into ones’ own work and that of others (from the perspective of value and waste). Through that process of fact finding it has a tremendous positive effect on team dynamics, cooperation and change.
Two years ago, I drew up my first ever value stream map in almost the same process. I walked the patients route through our process on my own, with a notepad. (If the patient was detached from the process I’d follow the patients file). The insights gained and results measured were not very different from the ones we found this time, with our improvement team. The big difference however is the fact that we now collectively understand the activities of colleagues who do their utmost for patients. They all trie and deliver as good and as fast as possible. But given the problems they are constantly faced with it’s almost impossible to do ‘right on time first time’ in almost all of their patients cases. A manager on the team expressed her surprise: "If you look how complicated it is and how many problems there are, it is actually a small miracle that so many things go well"
Fire fighting or prevention?
The participants in the improvement effort were suddenly presented with a totally different angle at which to look at our process: not only from their own contribution to the treatment, but taking a view at the process as a whole. Focussed from patients perspective. It actually shocked participants. This means that personal or departments’ inter
ests suddenly become fully subservient to patients needs. The need to tear down silo’s walls became suddenly obvious.
One of the first activities of the team is mapping the current process. We use a so called Value Stream Map. The whole team literally walks the route of the patient through the various workstations and, from a patient’s perspective, start seeing what is actually happening. They question their colleagues and bring all this information forward on post-its which are then put on a large brown paper. This technique has been described by others in detail.
After lean principles were being adopted by the departments’ management a large, relatively easy-to-handle group of patients was chosen cut lead time. The focus on short lead times is considered to conduct as leverage to improve quality and reduce costs. Because wastes in the process must then be "squeezed out". Less waste frees up space to treat more patients. With virtually the same cost.This project was therefore launched with the objective to cut lead time from application to start of radiation for patients with prostate carcinoma from 25 to 10 days.
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| Brown paper with post-its |
This post therefore is not as much about the lean technique being used but it’s more about the surprising results which can be achieved using value stream mapping. It provides all participants with insight into the facts rather than opinions, insight into ones’ own work and that of others (from the perspective of value and waste). Through that process of fact finding it has a tremendous positive effect on team dynamics, cooperation and change.
Two years ago, I drew up my first ever value stream map in almost the same process. I walked the patients route through our process on my own, with a notepad. (If the patient was detached from the process I’d follow the patients file). The insights gained and results measured were not very different from the ones we found this time, with our improvement team. The big difference however is the fact that we now collectively understand the activities of colleagues who do their utmost for patients. They all trie and deliver as good and as fast as possible. But given the problems they are constantly faced with it’s almost impossible to do ‘right on time first time’ in almost all of their patients cases. A manager on the team expressed her surprise: "If you look how complicated it is and how many problems there are, it is actually a small miracle that so many things go well"
Fire fighting or prevention?
The participants in the improvement effort were suddenly presented with a totally different angle at which to look at our process: not only from their own contribution to the treatment, but taking a view at the process as a whole. Focussed from patients perspective. It actually shocked participants. This means that personal or departments’ inter
ests suddenly become fully subservient to patients needs. The need to tear down silo’s walls became suddenly obvious.
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| Visualization of valuestream |
- 13 different computer systems are being used for patient treatment, logistics and other needs. Many of these systems need hand entered data that is already logged in other systems.
- Appointment planning takes about an hour and a half for each patient. Three different systems are being used and still operators need a calculator and a calendar and partially track the appointments manually. Ultimately many of the planning done is obsolete because patients don’t get into the process or treatment is postponed or changed. In the end planning is being redone for every patient to suit patient needs and treatment team needs.
- The program for CT imaging is almost always fully blocked. But if doctors call the CT staff almost every time a slot can be found. Planners feel superfluous from this experience.
- In one of the departments a full-time employee is needed to process changes. And handling phone calls, "whether the changes have been processed".
One off the admin staff attending the improvement effort exclaimed: "I did not know it was this bad. I do this work every day."
It's not her fault. Or that of any colleague in the department. Over time, as in so many organizations, a system has evolved where every single person tries his or her utmost, but the system itself actually prevents the treatment process to run smoothly. The evolving system is a summation of ever greater innovation in treatment techniques. Ever better but harder to operate equipment. It’s now clear to everyone that the system itself needs to be innovated, to change dramatically, to keep up.
It's not her fault. Or that of any colleague in the department. Over time, as in so many organizations, a system has evolved where every single person tries his or her utmost, but the system itself actually prevents the treatment process to run smoothly. The evolving system is a summation of ever greater innovation in treatment techniques. Ever better but harder to operate equipment. It’s now clear to everyone that the system itself needs to be innovated, to change dramatically, to keep up.
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| Improvement team |
At our second improvement day we were caught by surprise. A clinical study just proved that a new, more accurate technique of irradiation of prostate carcinoma is now suitable to apply to all patients. In this new treatment process markers are placed around the prostate. When irradiated we will now be able to track the actual location of the prostate in a patients body and adjust treatment adaptive. Placing markers actually adds another week of waiting time. Imaging can only be done after one week from placement of markers. Before we started our week the lead-time time for prostate patients would thus have increased up to 33 days. The team's objective has now been set a lead time of 15 days. Five days longer than expected. But including an important clinical innovation
I am proud. Proud to be working in this department. Proud to work in an environment where people are willing to be transparent about what they do, what works well and what does not. Proud that this department chooses to improve the system for patients and workers. And I'm proud to be part of an improvement team that is new to lean, which has a strong ambition and which has learned so much in so little time on value and waste.
The RPIW is conducted in three parts in September and October. In October, I will share the teams improvement results with you
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