Understanding the Patient Journey Process Mapping and Value Stream / Flow Analysis

1. Understanding the Patient Journey Process Mapping and Value Stream / Flow Analysis

2. Some context ‘80% of the problem is in the system not the people’Deming We design in the system capability

3. Why do Process Mapping?

4. Process Mapping Views the system from the patient perspective following their journey across organisational boundaries Helps staff understand how complex and confusing processes are Diagnostic and used as a basis for redesign, actively involving frontline staff in the process

5. Looking at patient processes 30 - 70% of work doesn’t add value for patient up to 50% of process steps involve a ‘hand-off’, leading to error, duplication or delay no one is accountable for the patient’s ‘end to end’ experience job roles tend to be narrow and fragmented

6. Looking at patient processes Organisational /departmental boundaries E B C D A Emergency care process Diagnostic process Treatment process

7. Increasing level of detail High level

8. Patient process and parallel processes Patient process Parallel process: Organising the X-ray Patient told they need an X ray Patient waits Patient taken to X-ray

9. Demonstrate complexity visually(chest x ray- 62 tasks, 12 hand offs) finish film storage secs office x ray room central office radiologist office start

10. Remember the following... Define where the process starts and ends Consider who you would involve in the mapping exercise Use post-its to record the activities including time Assemble the post-its to create the journey (remembering that some activities happen in parallel) Keep a note of issues and opportunities

11. Analysing the Map • How many steps in your process? • How many duplications? • How many hand-offs? • What is the approx. time of, or between, each step? • Where are possible delays? • Where are major bottlenecks? • How many steps do not ‘add value’ for patient? • Where are the problems for patients and staff?

12. 1 Consultant requests CT 3 2 Request arrives in dept Request arrives in dept 4 5 Consult. sees report Consult sees report Patient receives the result Consult sees report

13. Hand offs Triage Nurse Doctor Patient enters A&E reception Plaster Technician Discharged Home Nurse X-ray

14. Probability of performing perfectly Improve the quality of each step Remove the steps…. Probability of Success, Each Process Step No. process steps 0.95 0.990 0.999 0.999999 1 0.95 0.990 0.999 0.9999 25 0.28 0.78 0.98 0.998 50 0.08 0.61 0.95 0.995 100 0.006 0.37 0.90 0.99 Carol Haraden IHI

15. occurs when a step is the limiting rate of the process The step takes a significant time, and slows the whole process down. Process bottlenecks

16. occur when a resource is used by more than one process Functional bottlenecks

17. Look for batching Dr sees patients individually Results return in batches Requests sent in batches

18. Opportunities for redesign

19. When undertaking a Process Mapping session think about… • Scope - where does the process start and where does it end? • Who to involve in the mapping exercise? • Decide the level of detail

20. High level process map - 6-12 steps • generate in set time e.g. 20 minutes • use to establish scope and identify problems • no rework loops and minimum complexity • Detailed process map - dozens of steps • to establish loops and complexity • good to establish roles and relationships within process • use again in later phase to effect show of redesign

21. Defining patient groups Runners No. in each category within the group Specials Strangers Group of patients

22. Tools for defining patient groups • Runners • share common characteristics • high volume • fast throughput • highly predictable • ‘standardised’ patient routes • up to 90% pre-scheduled • Specials • ‘customised’ • lower volume • predictable • share some steps but require • extra steps • standardised patient routes • can be pre-scheduled • Strangers • low volume, unique requirements • unpredictable demand patterns • route unpredictable and complex • throughput time tends to be longer

23. No. of times that condition or procedure occurs Possible conditions or procedures within a specialty or group of patients Use the Pareto Principle to find the high patient volumes in your department Conduct a high level analysis of the process

24. ‘Ground rules’ for the Process Mapping workshop Everything is confidential Everyone has a valuable contribution to make Value the diversity of the group Think creatively/generate ideas Focus on ideas and opportunities ‘Park’ issues Keep to time

25. Patient tracking Validate or challenge Process Map High volume runners Blank sheet to record process steps and true complexity of journey At least 25 patients to be tracked per high volume runner group

26. Walk the patient journey for yourself

27. What do we mean by patient flow?

28. About patient flows: • Defined by process not clinical conditions • Reflect systematic process steps required by the • majority of patients (high volume groups), total length of journey and complexity across whole systems • Apply the 80:20 rule to redesign for maximum impact • Consider patient need not service provision • Ensures that you do not improve one part of the service at the expense of another

29. Improving flow Understand the processes and the system Identify measures for improvement Simplify and standardise the process Control the variation Reduce the variation Make the system safe

30. What is flow analysis?

31. 3 stages to flow improvement 1 - See the current state 2 - Analysis 3 - Take action to apply flow improvement principles

32. Stage 1: Current state

33. Flow Analysis Tool:4 elements Desegregation into: process steps communication steps responsible clinically responsible for each part of the process

34. Flow Analysis Tool:Process steps

35. Flow Analysis Tool:Information & communication steps

36. Flow Analysis Tool: Clinical responsibility

37. Flow Analysis Tool: Responsible for making each part of process happen

38. Flow Analysis Tool

39. Stage 2: Analysis

40. Add value Remove waste Understanding your map

41. TIME: 5 Total Time = 188 Value added Value added time = 13 20 120 Quantifying valueValue and non-value added stepsValue added time v non-value added time 3 5 35

42. Waiting Mistakes Uncoordinated activity Stock Transportation Motion Inappropriate processing Opportunities to remove waste

43. Analysis summary Steps Total number steps Number of value steps Value steps as % total steps Time Total time Hrs:Mins Time of value steps Value Time as % total time • Waste • Waiting • Mistakes • Uncoordinated activity • Stock • Transportation • Motion • Inappropriate processing

44. Waiting is the most important of all the wastes because: the process STOPS it inhibits FLOW it does not add value for the PATIENT Waiting

45. Stage 3: Take action to apply flow improvement principles

46. 4 characteristics of smooth flow: 1 Small batch sizes 2 Linked processes 3 Setting the pace 4 Overall co-ordination Next - helping the value-adding steps flow

47. Current processes often operate in isolation from each other, particularly departments and directorates Each area needs to be linked to the one before, to ensure that they always have capacity to deal with what they are receiving Linked processes

48. Linkages are important both within each individual process... …and between processes Endpoint Endpoint

49. Key stages that need to be set or balanced are often identified by the value adding line For example - clinical assessment - investigations - clinical decision - admission - treatment - discharge Setting the pace

50. If 5 patients arrive an hour, 5 patients need to move between each step each hour Clinical assessment Investi-gations Clinical decision Admi-ssion Treat-ment Dis-charge If 10 patients arrive an hour, 10 patients need to move between each step each hour Setting the pace