Improvement Associates Ltd. Using Process Mapping to Identify Improvement Opportunities Presented...

Improvement Associates Ltd.

Using Process Mapping to Identify Using Process Mapping to Identify Improvement OpportunitiesImprovement Opportunities

Presented by:

Rosmin Esmail and Tanis Rollefstad

June 2007 2Improvement Associates Ltd.

PurposePurpose

• By the end of this session, participants will have:– A better understanding of the tool– Experience in using the tool – Ideas on how to apply process mapping to

clinical processes


Systems and processesSystems and processes

“Every system is perfectly designed to get the results it gets.

“If we want better outcomes, we must

change something in the system. To do

this, we need to understand our systems.”

Don Berwick


What is a System?What is a System?

• Collection of parts and processes organised around a purpose

• Health care organisations are – complex - many and varied relationships – adaptive systems - people in the systems can

change in response to new conditions

Source: NHS: www.modern.nhs.uk/improvementguides - Working in Systems Plsek, 2000


What is a process?What is a process?

• A sequence of repeatable steps that lead to a desired end or output

• All work is a process• Many processes are not designed – they evolve• 40- 60% of activity in a large complex process may

be non – value adding

ProcessInputs Outputs

Source: NHS: Improvement Leaders’ Guide to Process mapping, analysis and redesign


What is a process map?What is a process map?

• A “picture” of a process, showing the connections and actual sequence of steps


Source: NHS: www.modern.nhs.uk/improvementguides Managing the Human Dimensions of Change

Feels like an Elephant?Feels like an Elephant?

“The thing that was astounding was the mapping. We all thought we knew how the system worked but none of us had a clue. Many times an hour my mouth was just falling open because I didn’t realize what a mess it was …”

Lead Clinician Cancer Services Collaborative


Why use process maps?Why use process maps?• Communication and understanding

– make work ‘visible’; common understanding– show how work currently gets done – serves as a training aid for new team members– establish performance measures

• Quality Improvement

– identify risks, inefficiencies and improvement opportunities

– standardize work processes, decrease variation• Process Redesign/Development

– show how you want work to be done e.g. planning

Beginning or end of a process

Process Step

Document or file

Decision point

Process interaction- direction of work

Off-page link to sub process

System/ Database

Start End

Common SymbolsCommon Symbols

Boundary between roles

A

Delay or wait stateLooping


Exercise (work on your own)Exercise (work on your own)

• Choose a process you are familiar with e.g. getting to work in the morning

• What are the steps?• Start=you get up• End=you are at work• What is the sequence? • Time (10 mins)• Report out


Types of process mapsTypes of process maps

• Detailed flow chart (micro)

• Cross functional map (deployment)

• Relationship map (macro)

Incr

easi

ng

Det

ail


Relationship Maps (Macro)Relationship Maps (Macro)

• ‘High level’ organizational view of:– functions – what we do– inputs – e.g. where we get clients from– outputs – e.g. where we send clients, services

provided

• Facilitates understanding of the system and how/where one department fits with another


Day Surgery Relationship MapDay Surgery Relationship Map

Admitting

Day surgery

Operating Room

Recovery Room

Client in the Community

Surgeon’s Office

FP Office


Cross-functional mapsCross-functional maps

Illustrate: • How work gets done in an organization

across departments • Departments, functions, or roles that

perform each step- people: process interface

• Inefficiencies e.g. hand-offs

Cross Functional Process MapCross Functional Process Map

Portable / Mobile X-Ray Process

DI G

ener

al

Dut

y T

echn

olog

ist

PC

U C

lerk

PC

U N

urse

Phy

sici

an

No

Yes

Place order

receipt in bin

Page DI for

portable exam

Enter order in order entry

system

Portable Order?

Start

Check in with

pt’s nurse

2

Pick up mobile X-ray equip.

Complete exam

Pick up order

receipt from bin

Phone PCU for

more info

Assist with

exam

Phone PCU to alert of arrival

Change in Patient Condition or Routine Assessment

Assess patient condition, X-ray

required

Use STAT

standard page if STAT

request

If not right after original page


Creating a Cross Functional MapCreating a Cross Functional Map

• Identify start/end points• Draw table on flip chart• Label columns with all departments/roles

involved in process• List process steps on ‘Post-it Notes™’• Place Post-it’s in order in first row of table • For each process step, place check mark in

column of person/department responsible


StartStart – client enters service

Assess client

New Client?

Start new chart or pull chart

Follow-up required? Arrange for f/u

Existing services required?

Provide services

Send Chart to Clerk

Document in chart

Enter into database

EndEnd – File Chart

Send back to program

Client PHN Clerk

X

X

X

X

X

XX

XX

X


Then……..Then……..

• Draw swim lanes on another piece of flip-chart paper

• Label swim lanes with roles/departments• Place each Post-it Note in the appropriate

swim lane• Draw arrows to indicate process flow


Sample Cross Functional MapSample Cross Functional Map

start

end

Client entersservice

Enter into database

New client?

Services provided

Start new chart

Pull chart

Existing services required?

Follow-up req’d?

Arrange for f/u

Document in chart

Send chart to clerk

Clerk

Client

PHN/Outreach worker

Pro

gra

m X

Syst

em

Com

munit

y

XYZ databaseSystem

no

no

no

yes

yes

yes

Assess client

Send back to program

File chart


Flow ChartFlow Chart

• Document sequence of events e.g. investigating sentinel event

• Most detailed map – shows process detail

• Useful for process steps of single individual

Flowchart of Process of Obtaining Antibiotics Flowchart of Process of Obtaining Antibiotics from Pharmacy at FMC- May 28 2004from Pharmacy at FMC- May 28 2004

Flow Chart of Process for Obtaining Antibiotics from Pharmacy at FMC-May 28, 2004

Order Acyclovir (Antibiotic)on TDS in the ICU

START

Order is printed inpharmacy and oncomputer in ICU

immediately

Order printed onprinter in ICU and

pharmacy.Pharmacy

technician checksprinter every 2 to

10 minutes

NO

YES

Pharmacist sticksa red flag for STATon order and puts

in grey box atentering pharmacytechnician’s desk

Entering pharmacytechnician entersorder in pharmacy

system BDM

Fillingpharmacy

technician picks upthe order if it’s

STATDELAY in picking

up order

DELAY in pickingup order bypharmacytechnician

*Order statesdrug, dose, howto administer, itis a STAT, any

allergies*STAT is

highlighted onthe bottom of

page

Need to phonedoctor?

Pharmacist triesto find entering

pharmacytechnician to do

this right away forSTAT

Need to makedrug?

NO

Pharmacistchecks drug and

signs order.Order filed in

pharmacy

STAT red flagremoved and

pharmacyassistant takes

drug to ICU rightaway

Filling pharmacytechnician bringsdrug to front tableand signs order

*The hospital isdivided up into 2

sides (ICU isside #2).

Pharmacist checksthe order on TDSto make sure it isright i.e profile,check allergies,

not interacting withanything, look up

microbiology ifresistant

Pharmacist signsthe order

Pharmacist callsthe doctor and

clarifies-this cantake up to 20

minutes to 1 hourDELAY

Order is taken topharmacist to

review and checkPharmacist may

not be thereDELAY

DELAY if enteringpharmacy

technician notthere

*Patient islooked up,

patient bed, ID#,doctors name,drug selected,

dose, labels areprinted.

Enteringpharmacy

technician signsorder and puts it

on the desk

Filling pharmacytechnician checks

cupboard forAcyclovir

*Pharmacy assistantis paged bypharmacy

technician. Arriveswithin 15 minutes

END

Mixing pharmacytechnician writes

up order at table atback

Mixing pharmacytechnician entersinformation in thecomputer in Wordfor labels, order

filled in

Mixing Pharmacytechnician makes

drugs in hood

Mixing pharmacytechnician making

2 to 3 drugsDELAY

Mixing pharmacytechnician takes to

filling pharmacytechnician at front

table

Filling pharmacytechnician labelsdrug and signs

order

Filling pharmacytechnician picks up

the labels

*Wash up = 10mins

*Clean hood=10mins

*Takes 5 to 10minutes to make

drug

Mixing pharmacytechnician checksorder, order filed

YES

Notes:1. Process for a STAT drug if it does not need to be made= ½ hour.2. Process for a STAT drug if it does needs to be made=1 to 1½ hour.3. Process for ASAP drug-deliveries made on the ½ hour every hour exceptmornings (730, 8, 830, 9, 930).3. Night cupboard-code phoned in, porter gets print out, porter gets drug fromcupboard (approximately 12 to 14 orders on average a night), and delivers drugto unit. Pharmacist on call (called in once per week).4. Days-five pharmacists until 11am, 4 pharmacists until 330, 3 pharmacistsuntil 1030pm. Weekends-5 pharmacists until 11am, 4 pharmacists until 330, 2pharmacists unitl 1030pm.5. Six pharmacy techs during day (2 entering, 2 filling and 2 mixing techs, 6pharmacy assistants). All can be different for each drug order. Number of techsvaries at night and on weekends.6. Most antibiotics in fridge or desk A, B in ICU.7. Dispensary extremely noisy, chaotic, lots of people, inadequate room to fill,store, too many distractions, located in basement.

Pharmacyassistant puts

STAT drug in bluebox at desk A and

tells unit clerk

DELAY in unitclerk telling

nurse or take tobedside and no

nurse there

Nurse administers drug topatient

*Labels for IVand pills areprinted onseparateprinters.


How to start mapping…How to start mapping…

• Determine intended use of process map– e.g. measurement, quality improvement, process

re-design

• Decide how to collect information– e.g. self generate,1 on 1 interviews, team

interview

• Select an appropriate team • Decide the level of map • Identify boundaries – start & end points


StepsSteps

• Agree to start & end points, customers, and measures

• Agree to appropriate levels of detail.• Brainstorm process participants (if using

cross-functional flowchart)• Brainstorm all possible activities, inputs,

outputs and decisions using appropriate symbols

• Sequence the steps


StepsSteps

• Use “swim lanes” to distinguish departments (if using a cross-functional flowchart)

• Add arrows and symbols• Test for completeness by

– comparing it with what is actually happening– asking content experts

• Finalize the chart


Using Process Maps Using Process Maps

• Bottlenecks• Delay• Errors and work-arounds• Rework loops – to fix errors• Role ambiguity - don’t know who…• Cycle time – too long, variation• Duplication - of data entry, work steps• Unnecessary steps – non-value added for staff or client• Inappropriate decision steps – too many steps or too many

people making similar decisions

Smith, M.L. BOLO (Be On Look Out) List for Analyzing Process Mapping. No date www.isixsigma.com/library/content/c040301a.asp

Remember our Quality definition:right service for the right patient at the right time by theright provider with a minimum of waste and rework


Analysis of Flowchart / Process Analysis of Flowchart / Process RedesignRedesign

• Can it be standardized?

• Does every step or activity add value?

• Is there duplication of work?

• Are there invalid assumptions?

• Is it possible to simplify?

June 2007 27Source: The Improvement Guide. Langley et al. 1996

Example of improvement – blood donationDonor arrives

Donor is interviewed and fills out

form

Donor’s veins are checked in waiting room

Doctorevaluation

occurs

Donor goes to donor room

Veins OK ?

Yes

No

RejectedHealthOK ?

Rejected

Yes

No

Phlebotomist checks veins

Veins OK ?

Rejected

No

Yes

Plasma drawn

Redesigned

Donor arrives


form

Doctorevaluation occurs and phlebotomist

checks veins


Plasma drawn

Healthand veins

OK ?No

Yes

Rejected

June 2007 28Source: The Improvement Guide. Langley et al. 1996

Example of improvement – blood donationDonor arrives


form

Donor’s veins are checked in waiting room

Doctorevaluation

occurs


Veins OK ?

Yes

No

RejectedHealthOK ?

Rejected

Yes

No

Phlebotomist checks veins

Veins OK ?

Rejected

No

Yes

Plasma drawn

Redesigned

Donor arrives


form

Doctorevaluation occurs and phlebotomist

checks veins


Plasma drawn

Healthand veins

OK ?No

Yes

Rejected

June 2007 29

Example of improvement – ovarian cancer clinic


Clinic Clinic ClinicHospital for ultrasound

Hospital for blood test

Hospital to see physician

Hospital for chest x ray

Simplication

Hospital for blood test, ultrasound, chest x - ray

ClinicHospital to see

physician

June 2007 30

Example of improvement – ovarian cancer clinic


Clinic Clinic ClinicHospital for ultrasound

Hospital for blood test

Hospital to see physician

Hospital for chest x ray

Simplification

Hospital for blood test, ultrasound, chest x - ray

ClinicHospital to see

physician


TipsTips• Use a group knowledgeable about the process and interested in

improvement

• Use a facilitator

• Don’t focus on solutions - keep a ‘parking lot’ for issues, solutions

• Adopt ‘rough draft’ principle – get it down, then get it good

• To clarify steps: go to the program and observe the process, consult with clients/staff


TipsTips• Use post-it notes for ease of mobility

• Keep the flowchart simple using basic symbols

• Be consistent with levels of detail

• Ensure flowchart represents process as it really is, not how it ought to be

• Use “verb noun” structure for activities


Software Software

• Low Tech Stickies

• Visio


Some Examples Some Examples


Example: Dodek P et al. Translating family

satisfaction data into quality improvement ((Critical Care Med 2004 Vol. 32, No. 9)

Figure 1. Key processes in patient/family/clinician interactions in the intensive care unit (ICU). This flowchart illustrates the general trajectory and possible outcomes for patients and families of patients in an ICU.

Outreach Documentation

Pt. Assessment Interventions by Outreach Team Documentation Recommendations Distribution of documents

Out

reac

h R

RT

Out

reac

h R

RT

Out

reac

h M

DO

utre

ach

MD

Uni

t RN

Uni

t RN

Atte

ndin

g M

D

Atte

ndin

g M

DO

utre

ach

RN

Out

reac

h R

N

Assess patient

Provide pt. history

Work collaboratively with Outreach

Team

1. Enter STAT orders into

SCM*

2. Administer medications as

ordered.

Enter STAT orders into

SCM*

1. Document Code 66 call on the Tablet, including vital signs & fluids

2. Print out SBAiR form to leave on patient’s chart.

3. Document Meds administered on e-MAR in SCM

4. Document on Code Blue form as per Code Blue definition ♦

1. Enter recommendations into Outreach document.

2. Print out a copy of the SBAiR (recommendations are treated like a consult).

3. Place a copy of the recommendations (SBAiR) printout in MDPR section

1. Review recommendations

2. If decision is to proceed with recommendations enter orders into SCM

Document fld intake & output on flow

sheet in SCM. (Any v/s completed by unit RN are documented

in SCM

1. Print out SBAiR document from Tablet: leave copy on patient chart.

2. Print out Code 66 sheet for ICU attending to review, and identify patients for follow-up.

3. Forward any paper documents to Outreach Coordinator after they have been entered into the Tablet.

Other

When ordering meds retroactively, order all at once. Do NOT mark as

“done”, but sign on e-MAR for actual time given.

* Depending on patient condition any one of these 5 would perform this function.

♦ Code Blue

When any of the following interventions are performed Code Blue documentation will be completed:1. Chest compressions2. Defibrillation3. Electrical Cardio-version4. Intubation5. Assisted ventilation (including bagging for apnea, but not simply providing oxygen through a bagging unit)

08/02/2007

© 2007, BC Children’s Hospital, C&W

Wound Care (DRAFT)Physician Registered Nurse Wound Care Clinician Allied Health (OT, PT, RT)

Wound identified Wound identified

Complete wound assessment and initiate Wound

Care Flowsheet

Does the wound appear

infected?

Notify physicianutilizing SBAR

framework

Assess wound

Swab wound for C&S

yes

no

Order appropriate antibiotics

Do I have the competencies to

determine appropriate wound care?

yes

Consult wound care clinician using SBAR framework

no

Assist with identifying appropriate

dressing choices and in

individualizing patient care plan

Wound pressure related?

Develop care plan and

reassess as indicated

yes

Wound pressure related?

No

Consult OT/PT/RT

Yes

Has wound resolved?

Discontinue wound care

yes

No

Complete wound assessment

Yes

Apply appropriate dressing and initiate

individualized careplan

Reassess wound. Contact Physician and wound care

clinician

No

Consult RN

Culture positive?

Advanced wound management required?

Yes No

Implement VAC

dressing protocol

Consult others as needed

Follow-up as appropriate

No

Improvement Associates Ltd.

““How can you possibly improve How can you possibly improve something unless you know how it something unless you know how it

works”works”


Application (working in teams)Application (working in teams)

• Identify a clinical process affected by the changes you are trying to introduce

• What is the starting point? End point? • What are key activities (verb, noun)?• What is the sequence? • Create a flow chart of the process

– Use a post-it note for each step– Find a large space on which to work– Leave symbols off until your steps are complete

• Time: 20 mins• Report out-what worked well, what were challenges?

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