The Value Stream Maturity Scale – A Framework for Assessing Progress of Your Lean Healthcare Journey

Whenever you make the decision to embark on a Lean journey, you need to start thinking about the magnitude of this change, as it is enormous. Many of your current practices will change to become more focused on patient care (the reason why you got into healthcare) and much less on the daily aggravations of searching for all the things you need to deliver that care. You need to have a solid framework to assess the progress of your lean efforts. First, as you think about the changes coming, you must:

• Appeal to the rational mind: Communicate a clear picture of the future state and its benefits for the patients and staff.
• Appeal to the emotional mind: Reason gives you direction, but emotion gives you the energy necessary to make the change. Staff must be emotionally invested in the change, or they will not own it and sustain it.
• Clear the path: Great ideas that are difficult to implement are doomed from the start. Focus on making processes and procedures easy to understand, execute, and document.

This article focuses on a way to appeal to the rational mind by providing a framework to assess the progress of your Lean journey as it pertains to a specific Value Stream.

Let’s start by defining what a hospital value stream is: a Value Stream is a collection of interconnected processes to deliver value to a customer. A value stream example in a hospital describes the care of a patient that arrived to the hospital via the Emergency Department, was admitted to the Telemetry unit, and was discharged home. Another value stream example describes the flow of patients that come to the hospital for outpatient surgeries:

Registration -> Pre-Surgical care -> Procedure -> PACU I ->PACU II -> Discharge

Each process advances the care of the patient. The sum total of these processes delivers value to the patient and is what we call a Value Stream. There are many value streams in a hospital and each of them must mature on its way to perfection, as that is our goal and the goal of any Lean initiative. How do we track the progress of the Lean implementation on a specific value stream? We do that by establishing a five-level framework to measure the progress.

There are several dimensions that we look for when assessing the maturity of an entire Value Stream, that are not seen at the level of the individual processes:

• Linked Processes. Most of the delays in patient care (sometimes over 95%) in a Value Stream occurs between processes, in hand-offs from one person to another, or one department to another. We do not have this visibility if we are only looking within the process.

• Existence of Flow and Pull. Flow and pull go hand-in-hand in a Lean environment, so it is logical to look for formal flow and pull methods. Without formal pull systems, patient care will be delayed in the Value Stream.

• Engagement. By this we mean a high level of involvement by the entire staff. Simply improving is not sufficient in a Lean Value Stream. Without the active involvement by everyone in the task of process improvement, it will be difficult to improve fast enough in today’s competitive environment.

The Value Stream Maturity Scale is used to assess the maturity of a value stream, in the interest of creating or modifying a process improvement plan. A Value Stream that is at Level 0 or Level 1 represents a great opportunity. After all, if you’ve survived this long (apparently) with a low-maturity
Value Stream, imagine what you can do when you cut patient flow times by 50%! Following is a brief description of each maturity level in the Value Stream Maturity Scale.

Level 1: Identify the Value Stream and assign ownership. The first logical step in improving a value stream is to identify and document it. This maturity level involves naming a value stream, assigning a value stream owner to it, and creating both current and future state value stream maps. We will also want to establish performance metrics for the value stream: Discharge performance, Medication Administration performance, productivity, quality, and so on.

Level 2: Patient Flow and Pull. The biggest opportunity when moving from a traditional work environment to a Lean environment is the introduction of flow and pulls methods. Patient wait time in traditional environments can represent up to 70% of the total patient length of stay. In cases where you flow products, like Sterile Processing of Instrument sets, experience has shown that cycle time is related to a long list of related benefits, including improved productivity, better quality, less floor space, improved flexibility, and higher on-time delivery of the Instrument sets back to the OR Suite.

Level 3: Standardization. Once we have harvested the low hanging fruit of flow and pull, we must continue with the task of training the certifying the staff in Standard Work. We need to involve the entire staff in defining the one best way to do work, and to train them to do the work that way. Remember that standard work does not limit creativity or improvement, but it does determine the way the work should be done for the present time.

Level 4: Engagement. The stage of engagement is what separates the Lean pros from the amateurs, when we are assessing value stream maturity. Until we are able to involve the entire workforce in the creative work of continuous improvement, our Lean efforts will continue to be vulnerable to outside competitors simply copying what we have done. Once we are generating hundreds and thousands of small improvement suggestions a year, it will be very difficult for the competition to keep up.

Level 5: Sustained Performance. Until we are able to incorporate flow, pull, standard work and employee engagement into our hospital culture, things will inevitably backslide. We can claim that we are at Level 5 on the value stream maturity scale if we are able to shown that we have maintained continuous improvement for a period of at least 36 months.

The starting point, obviously, is to map your main value streams. While the Value Stream Mapping concept is well-know, in reality few organizations (hospitals or factories) have actually taken that first step. If you’re willing to move forward with the effort, get some expert help from mentoring organizations like Leonardo Group Americas. Getting training and insight from people who have done this before many times is very valuable.

A Value Stream Mapping effort will shine a light on the many improvements that are needed and possible, but before jumping into improvement projects, apply the Value Stream Maturity Scale. If you’re not yet at Level 3, your attention should be spent on achieving flow and standardizing the value stream processes. Otherwise your efforts will be difficult or impossible to sustain.

Online Professor Positions Are the Future of Teaching

There can no longer be any doubt that deep cuts to public education funds causes many educators to lose their teaching jobs. Of course, not all teachers fall victim to layoffs, but the remaining educators are suffering salary freezes and benefit reductions. The generally accepted wisdom about the direction of a career as a teacher indicates that the traditional classroom is disappearing as a vehicle for professional achieve and personal prosperity and is quickly being replaced by the digital classroom on the Internet. In fact, for academics with earned graduate degrees, a doctorate or master degree, the best way to begin and continue earning a real living form teaching is to learn how to construct a manageable online teaching schedule.

Despite the continual negative news about budgetary stress at colleges, state universities and community colleges the reality is that post-secondary student populations are growing with each semester. This should not be a surprise since new and returning college and university students realize that their best option during this long economic crash is to gain as much knowledge as possible in order to increase their chances at a decent job when the economy eventually turns up. Of course, as more students enroll in college, the physical pressure on the traditional academic landscape increases far beyond the financial capabilities of the available budgetary funds. To put is in simple terms it is much more cost effective to offer online college courses than it is to build new physical classrooms. This means that academic administrators are turning to online college degree programs as a real solution to the need for an affordable way to meet the educational needs of post-secondary students. This ongoing transition off of the physical campus and into a digital academy represents a genuine career opportunity for struggling veteran academics, recent graduates and laid-off corporate employees with a graduate degree and the required computer skills to quickly and efficiently navigate in and out of academic websites and the software platforms the schools’ use to deliver online college courses to their enrolled students.

It is possible for an online professor, an academic with an earned graduate degree teaching for online bachelor degree programs, to survive this economic downturn while peers in physical college and university classrooms are suffering teacher payoffs and salary reductions. Granted, it will be necessary to earn a master degree or doctorate to teach at the post-secondary level of the academy, but the abundance of funding available means it possible for a high school teacher with a bachelor degree to complete the courses required for a master degree and then start applying for online instructor positions with online college degree programs.

As more downward economic pressure is applied to traditional college and university budgets, the more motivated academic administrators are to deploy online degree programs. The reason for this effort on the part of the various college and university administrations is that offering online college courses to new and returning students is simply less expensive than continuing to maintain physical classrooms. The advantage this transition of the actual academic structure offers the prospective online professor is that there will be more opportunities to teach online with each passing semester.

Needless to say, the focus required to move off of the physical college or university campus and into a full time online teaching schedule is severe. It is vital to understand how technology is impacting the delivery of post-secondary academic instruction in order to actually take advantage of it as an online college professor. The quality of instruction on the Internet versus the same instruction in a physical classroom is a hotly debated pedagogical issue, but in no way does this debate slow down the administrators as they field additional online college courses each semester in an effort to cope with diminishing budgets. This means that teaching online for educators qualified to offer instruction at the post-secondary level is actually about the economics of public school teaching as a career choice.

There is a difference between the finances of public education and the pedagogy of public education, and while there is enormous merit in the discussion of the quality of instruction in a digital form when compared to that on a traditional university campus the issue of how a teacher makes an actual living must come first because without an actual income that providing a real living the debate over instructional quality falls flat for a lack of input from academics forced to make a living in some other sector of the economy.

The best approach to an online teaching career is to start identifying the academic websites of community colleges, technical schools, four year state universities and colleges and for-profit colleges and learn how to navigate the faculty application sections inside each school’s website. On the first page of the college or university digital presence is a link that will lead to the section of the website that permits the submission of evidence of academic achievement, transcripts of graduate school work, and documentation of classroom experience. While it will take some time to learn how to submit the required information as each college, community college or state university can and often does have their own interface, there will be a point where the application process for possible online adjunct teaching jobs becomes quick and sure.

It should be understood that the prospective online college instructor will have to make several hundreds of applications within these faculty sections in order to secure even six or seven online teaching jobs simply because of the increasing competition resulting from mass teacher layoffs. Additionally, there is competition from graduate degree holders in corporations that have found themselves unemployed as a result of the economic crisis during the last five years. It would not be an exaggeration to say that if you, an academic wanting to teach online for online bachelor degree programs and online master degree programs, want to construct a viable online teaching schedule there are many others that want to do the same.

It is patently obvious that the traditional role of the educator as state employee is a relic of the past. There is no going back now since the cost-effectiveness of online learning programs can no longer be ignored by academic administrators. The number of online degree programs will only grow in the coming decades and the need for technically prepared online adjunct instructors will only increase as the growth of student populations in colleges, universities and for-profit schools continues to swell.

Interestingly, the actual math involved when considering online teaching job openings opens up an entirely new viewpoint for the career educator when compared to the traditional state education position that has been the mainstay for many decades. On average, a given community college, four-year college, state university or for-profit college will pay an online adjunct with a graduate degree about two thousand dollars to teach an online college course. Yes, since each school can decide independently how much to pay online college professors the pay for a single online class can slide up or down by as much as five hundred dollars. The important thing to know is that while the average pay for teaching online is positively impacted by the actual length of the online course.

Many for-profit colleges now offer their enrolled post-secondary students online courses that last from five to eight weeks in duration. Traditional colleges and universities, by contrast, offer their students earning an online bachelor degree or online master degree online classes that last sixteen weeks in duration. Obviously, if an eight week online class pays an average of two thousand dollar and a sixteen week online course pays the same two thousand dollars the advantage of the eight week online college classes is an extra two thousand dollars for the same teaching work during the same sixteen week traditional semester. The alert online adjunct instructor will immediately recognize the economic value of repeated eight-week online teaching positions with for-profit colleges and those traditional academic institutions that are just now beginning to offer online classes that are far shorter than the traditional length.

This sort of calculation is vitally important for prospective online teachers to employ when applying to online college degree programs. Further, the change in viewpoint will alter the perception of how post-secondary education works for the educator. The simple fact is that the schools would prefer to hire many online adjunct instructors at a relatively small amount of pay for each online class than to commit to yearly salaries for tenured professor that will balloon as benefit costs skyrocket and the inevitable increases for state employees are applied across the board. While there may be some initial hesitation on the part of new graduate to accept this new economic model for teachers at college and universities, but there is also the inherent freedom in this model that allows the intellectual with a master degree or doctorate to engage higher education as an academic entrepreneur that can decide when and where to pursue an online teaching career.

Academics Should Recognize the Employment Benefits of Adjunct Jobs Online

The rise of academic layoffs now impacting teachers in traditional public education venues at all levels of the academy means academics should recognize the employment benefits of adjunct jobs online if they wish to continue teaching for a living. The current apprehension felt by teachers will only increase as even more budget cuts are implemented by academic administrators desperately attempting to make smaller amounts of operational funds go further each academic year. The end result is that educators with graduate degrees, a Ph.D. or master degree, or teachers with a bachelor degree willing to return to school as a student and earn a graduate degree can overcome the mounting teacher layoffs on the physical campus by learning to teach online from a personal computer. The presence of accredited online bachelor degree programs and accredited online master’s degree programs represent very positive employment opportunities for adjunct college instructors teaching in physical college classrooms and for any other educators needing to replace or supplement a salary lost to or significantly reduced by budgetary constraints. Interestingly, the for-profit colleges are leading the way for academic employment in a time of falling budgets by proving that new and returning college students actually want to enroll in online college courses in order to earn an accredited online college degree. In the end, the need for more cost-effective ways to satisfy the educational needs of growing post-secondary populations at community colleges, state colleges and four-year universities virtually guarantees that there will be more online adjunct faculty positions in the next academic year that must be filled by academically qualified and computer proficient online adjunct instructors.

In an effort to follow the successful lead of the for-profit academic institutions the traditional post-secondary academic institutions, state colleges, technical school, two-year community colleges and four-year universities are currently in the process of building out their online degree programs in almost every academic discipline as a way to meet the educational needs of their student populations in a cost-efficient manner. This massive effort leads to ever more online college courses that must be taught by teachers with appropriate academic degrees and a willingness to learn how to use a computer to swiftly navigate the Internet and the various online college degree programs located on it. For the academic just starting to build a full time online teaching schedule perhaps the most attractive element of online adjunct faculty employment with these online college degree programs is the level of control the online adjunct instructor gains over the online teaching schedule. It is possible for an online instructor to determine the size of the online teaching schedule according to the amount of online adjunct income desired or needed at any point in the year.

Distance education technology makes it possible for an online college professor to move very quickly from one online degree program to another in search of additional online college courses. While this action requires mastery of a personal computer by a prospective online teacher in order to navigate the faculty application process, it is well worth the effort because there are over five thousand post-secondary schools with online adjunct faculty employment opportunities. Eventually, every state college and state university will have online degree programs, so the need for technically qualified academics will increase sharply over time.

Obviously, it will take some time and effort to acquire enough online adjunct jobs to produce enough online adjunct income to qualify as a full-time salary from college instruction. However, with the daily application of an application strategy to locate schools with online faculty positions and to keep detailed records it is possible to transition entirely out of the physical college classroom and into distance education. Once the transition is made and the search strategy is in place it will be extremely easy for an online adjunct instructor to decline or accept offered online college courses. In this way it is possible for an adjunct instructor to choose a very favorable outcome with online adjunct faculty employment.

The traditional college adjunct faculty member and increasingly large numbers of teachers at the secondary and elementary levels is in a real jam these days on the physical college, university or community college campus. The reason for this is that the amount of money administrators are willing to pay an individual with an earned graduate degree, a master’s degree or doctorate degree, to teach each class of college students is shamefully low. Plus, the only possible way to add more physical classes to the college teaching schedule is to drive to another community college or state university campus and there on it, but that course of action literally requires living in a town or city with enough population to justify multiple post-secondary academic institutions.

Usually, an online professor is limited to three or four college classes during each sixteen week semester and any one of those few classes can be cancelled moments before it starts, so the ability to earn a decent living from college teaching at a physical academic institution is limited at best. At much better way to go about earning a living wage from teaching college students is to acquire, for example, an online adjunct community college job because there are so many community colleges today that already have an array of online college classes that each need qualified online adjunct instructors and there are thousands of community colleges.

The real benefit of online teaching for the college instructor is the personal and professional freedom that results from teaching on an inexpensive laptop computer. For example, since all the online academic work is located on the Internet, the online adjunct instructor can decide independently where to be when interacting with new and returning college students in online class discussion forums.

If an online college professor wants to work an airport lobby, a mobile vehicle in a campground or while sitting in a sidewalk cafe in a major metropolis there isn’t any problem because all that is necessary to access the online adjunct jobs is a wireless signal. Finally, the real reason to examine adjunct jobs online is to enjoy the mobility offered by teaching online as a legitimate career path.

The maturing of distance education technology is creating many new academic employment opportunities for adjunct college instructor willing to master the efficient use of a personal computer in order to interact with college students enrolled in online college courses. The current situation for individual with doctorate degrees and master degrees teaching in a physical college classroom on traditional post-secondary academic institutions is less than optimal since the chances of actually earning a living wage is no longer possible. The simple reality is that shattered faculty budgets are preventing any upward mobility for academics, and this situation will not correct itself any time soon. The obvious strategy for an adjunct college professor is to acquire an online teaching schedule filled with more than one online faculty position.

An online adjunct instructor can easily teach for a variety of accredited online degree programs by accessing the online college classes with an inexpensive laptop computer with wireless Internet capabilities. Plus, the online professor has no need to actually be on a college or university campus in order to teach the new and returning college students taking online courses in order to earn an online masters degree or bachelor degree online.

In fact, it is this very lack of a required physical presence in the college classroom that creates a sort of silent paycheck from online teaching by making the use of a personal motor vehicle completely unnecessary insofar as arriving in the online degree programs is concerned every day. Thus, the multiple streams of online adjunct income derived from teaching online do not need to be spent on the costs of repairing and maintain a car or truck.

In addition to the cost savings associated using a computer to search for and interact with online adjunct jobs, a college teacher with an online teaching schedule can gain the ability to increase or decrease the numbers of online teaching positions simply by declining offered online college courses or apply to additional online college degree programs with a need for a seasoned academic to teach online courses. It is for these very reasons that traditional college instructors should grab the opportunity of online teaching openings as soon as possible.

While it may be hard for a traditional adjunct faculty member to imagine earning a decent living from teaching college students, it is possible by making the effort to find online adjunct jobs with online bachelor degree programs and online master degree programs. Conceptually, an online adjunct instructor is actually an academic entrepreneur rather than a university or college employee. The difference between the two is that the academic entrepreneur has much more control over the teaching schedule then the adjunct faculty member at a traditional post-secondary academic institution. Currently, there are over five thousand colleges, state universities, community colleges and technical schools that have already implemented some form of online degree program.

There will be even more accredited online college degree programs deployed by post-secondary schools in the near future because it is much more cost efficient to deliver college teaching from a computer that it is from a physical college classroom. The economics of post-secondary education are driving the development of distance education technology to new heights. No one is even surprised anymore by the existence of accredited online bachelor degree programs and accredited online master degree programs because there are so many of them available to college students. The sheer volume of online college courses makes it possible for a college teacher to imagine making a career out of adjunct online teaching positions.

With an inexpensive personal computer and an earned graduate degree, a master degree or doctorate degree, it is possible to acquire an online teaching schedule with enough online college courses in it to generate a decent income. Of course, it is important to treat online teaching like an academic business rather than an academic job. The reason this is important is that colleges and universities are under tremendous pressure to meet the educational demands of new and returning college students with fewer and fewer budgetary dollars. These academic institutions will be changing how college-level information is delivered to student populations dramatically in the future. It will be not at all uncommon for a state college, for example, to offer its students more opportunities to earn a communications degree online, an online project management degree or a library science degree online than it will be to offer them the chance to master these particular academic disciplines in a physical college classroom setting.

Of course, with this increase in the numbers of accredited online college degree programs there will also be a dramatic increase in the need for qualified academics who can step into the role of an online adjunct instructor. Academics now teaching as a traditional adjunct faculty member will be able to find numerous online adjunct faculty positions in education, online adjunct business teaching positions and online adjunct nursing faculty positions by using an inexpensive laptop to both apply for online adjunct jobs and teach the online college courses that result from the application for an online faculty position. In the end, the alert intellectual who either has an earned graduate degree or is willing to make the effort to enroll in an online master degree program in order to earn a degree beyond the bachelor will have ample opportunity to increase the amount of income earned teaching college students. It is primarily a matter of taking the necessary steps to apply every day for online teaching positions and learning how to analyze these online positions in a way that reveals the employment benefits of each one. Ultimately, it is this analytical approach to the employment benefits of adjunct jobs online that will reveal the future of post-secondary instruction as a career path.

Six Measures That Reveal the Secrets to Stream Trout Fishing

Whether you’re fishing familiar local water, or you’re trying your luck at a new stream, trout fishing – there are a few key measures that can help you read the water to reveal where monster size trout are hiding. Admittedly, if you’re sitting bank-side next to waters that you’ve fished time and time again, you’ve probably got a pretty good handle on the stream and where the fish are hiding. Holes, rocks and riffles of familiar streams are undoubtedly great places to look and test your mettle, especially if you’ve pulled trout from those areas of the stream on previous occasions.

But, if you’re fishing new streams or want to look at your local waters under a new light, keep in mind these measures when you approach your next stream, trout fishing. You could reveal monster-sized trout for the taking.

Approach A New Stream and Think Like a Trout

A new stream, trout fishing can present a unique and intimidating set of challenges. Fishing new trout waters can be pretty overwhelming. But, remember to think like a trout and the techniques needed to find trout can become clear. Trout the world over, no matter what stream you’re fishing in require key ingredients to stay alive and thrive. Protection, a plentiful source of food, healthy water flows, cool clear water and plenty of oxygen are the key inputs for a trophy trout to live and grow. Let’s dig into each of these points more deeply.

1. Stream Protection for Trout

Stream trout may be close to the top of the food chain in the waters they inhabit, but there are several outside factors and predators that keep trout that live in streams in constant pursuit of security and cover. Fish eating predators including birds of prey, ducks like mergansers drive stream trout to constantly look for protection. In addition, land-locked predators like bears and humans keep the need for these trout to stay consistently hidden from plain site.

When fishing a new stream, look for overhangs, submerged water features, rocks and other security where trout might hide.

2. Abundant food Sources in Streams for Trout

In the streams you fish for trout, look for seams in water flows where fast moving water meets the slow movement of deeper pools. Typically, this is what’s called a feeding lane for trout in streams. Insects and other food are forced through water flow from the faster moving current into the slower pools naturally. This is where trout hold in streams.

3. Stream Water Flow and Trout Habits

In the U.S., especially out West where I love to fish for trout in streams, water depth, speed, and general flows can change dramatically based on the time of year and the fact that many rivers, their tributaries and streams are regulated by dams.

What this means for you and the stream you’re fishing in can depend on several factors, but a couple of key points to remember are that fish living in these types of streams tend to move from shallower flows to deeper waters when the depth of the stream is reduced dramatically. Conversely, the opposite holds true when water from these dams are released and the depths of rivers and streams are increased dramatically.

4. Water and Oxygen Levels Play a Big Part In the Lives of Big Trout

The main point here is that good fisherman know where well oxygenated water is, and subsequently where big trout are in streams. Trout tend to congregate in cooler water or where water is well oxygenated by churning or exposure to aeration. These types of situations include in deeper pools where trout can lay low in the colder depths or in riffles and other water obstructions where churning waters capture oxygen.

5. Stream Trout Fishing and Obstructions

Trout in streams like to hide behind larger rocks and other obstructions where they have to put forth little to no effort to hang out near food sources. Think about it, why exert yourself if you don’t have to? Trout in streams have the same attitude.

6. Big Trout in Streams Sometimes Buck the Trend

Big trout have the strength and the power to move up and down a stream or river, many times at will, to capture food or get to desired shelter. In many cases it’s wise to cast your rod at the edge of turbulent waters in a feeding channel, or in strong running riffles. That’s where the big trout hang.

In summary, never be intimidated or overwhelmed when fishing new streams or unfamiliar waters for trout just keep in mind that when fish find protection and a steady food source, they are going to lay low in areas where they have to expend the least amount of effort to feed and stay in well oxygenated waters. Keep these points in mind and you can be catching trophy-sized trout in any stream you fish.