One of the challenges in implementing Continuous Improvement is developing an effective value stream map for the process being examined. There are many ways to draw a value stream map, but some provide higher quality information than others. Most value stream maps have these components:

1. Use blocks to identify the major process steps.
2. Identify the flow of work with arrows, showing a supplier at the beginning and a customer at the end of the map.
3. Identify process times and delay times between processes.

Within the past four years (from 2010) the work of Karen Martin and Mike Osterling ⁽¹⁾ has added a new dimension to value stream maps by identifying the percent complete and accurate for each process step in the value stream. This overall percent defines the percent that inputs to the process box are both complete and accurate from the previous process box.

Exhibit 1 shows a value stream map for patient flow in a healthcare clinic with the typical supplier, process boxes and customer designations along with process times (P/T) and delay times (D/T). On this process map a new row at the bottom shows "percent complete and accurate (%CA)" for the work coming into the process box from the previous process box.

The %CA indicates that all of inputs to the process box are both complete and accurate. That is, if 90% of inputs (information supplied) are complete and accurate to the customer in following the process block, the %CA designation is 90%. That is, ten percent of the time, the information from the previous step in the process must be corrected, has missing information located or clarification must be obtained. And, as shown in Exhibit 1, the overall %CA for the process is found by multiplying the %CA block together of all of the process blocs [Value Stream Summary: %CA = 69%]

The %CA measure measures both delays and defects in the value stream and gives measure of overall performance of the value stream. One of the next steps in improvement is defining each of the defects and delays and moving the %CA toward 100 percent.

We recommend that when process improvement measures are being defined for a value stream that percent complete and accurate (%CA) measures be included.

Notes:
1. The Kaizen Event Planner - Achieving Rapid Improvement in Office, Service and Technical Environments, by Karen Martin and Mike Osterling, CRC Press, 2010, CRC Press Group

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High Reliability Care is the goal of each healthcare organization and it is a goal that takes constant attention by leaders and managers. Dr. Mark Chassin and Dr. Jerod Loeb published an excellent article in The Milbank Quarterly (Volume 91, No. 3, 2013, pp. 459-490) describing how organizations can reach high-reliability care. This website paper summarizes the major topics addressed by Dr. Chassin and Dr. Loeb.

While health care quality improvement has made great progress in the past twenty years, reaching high-reliability care is a significant challenge for most organizations. This paper describes the challenges that hospitals and other healthcare organizations must address to reach high-reliability care. Here are three major changes that must be addressed:

1. Leaders must commit to the ultimate goal of zero patient harm.
2. Principles of a Safety Culture are implemented throughout the organization.
3. Leaders must adopt/deploy widely the most effective process improvement tools and methods.

And, creating an improvement plan for High-Reliability Care has these three major components:

1. Leaders at each level in the organization must focus on quality improvement.
2. A safety culture must be implemented with trust, accountability, systems and assessment.
3. Performance improvement methods and training must be spread throughout the organization.

The following pages summarize the major concepts in High-Reliability Care and how organizations can begin the journey, as defined by Dr. Chassin and Dr. Loeb.