Process Mapping

1. Process Mapping Midwest Cluster Phase 2 Conference Call January 16, 2007 Tracy Jacobs, RN, BSN Institute for Healthcare Improvement

2. Topics to be covered • What is process mapping? • How is it done? • Why is it useful? • What constitutes waste and specific change ideas to deal with it

3. What is a process? • A continuous and regular action or succession of actions, taking place or carried on in a definite manner, and leading to the accomplishment of some result; a continuous operation or series of operations, Caulkin 1989 • The care you provide is made up of dozens of separate - though integrated - processes.

4. What is process mapping? A process map is considered to be a visual aid for picturing work processes which show how inputs, outputs and tasks are linked It is the “most important and fundamental element of business process re-engineering” Anjard, 1998; Soliman, 1998

5. Process mapping steps • Choose a process • time consuming • error prone • critical to success • Assemble a team • Map out the way work is currently done • Identify gaps first, then work on problem areas (waste) • Keep in mind the goal of the process • Brainstorm solutions • develop PDSA cycles

6. Process Mapping Using the Flip Chart Paper Approach • Shows the “Big Picture” • Describes a process as it works today; an “as-is” model • High touch, low-tech • Identifies gaps, strengths and opportunities • Captures the complexity and disconnects of key operational issues • Identifies outside areas involved in the process

7. Benefits • Highlights gaps in care • Puts a spotlight on problems (waste) • Streamlines work processes • Promotes deep understanding • Defines and standardizes the steps and sequence • Builds consensus

8. Patient given FOBT cards Results notification mailed No Positive? Yes Lab gives results to PCP immediately. PCP calls and refers for colonoscopy RN enters patient name and date into log (in lab) But what about….? Returned cards are processed by lab staff and results entered into log RN schedules appointment

9. Patient given FOBT cards Results notification mailed No Positive? Yes RN enters patient name and date into log (in lab) • Gaps addressed: • Follow up for FOBT cards that have not been returned • Ability to track if patient received colonoscopy and get results and plan to PCP Lab gives results to PCP immediately. PCP calls and refers for colonoscopy Log checked q 2 weeks for follow up phone calls needed RN schedules appointment and places reminder in tickler file Returned cards are processed by lab staff and results entered into log Medical records checks tickler and calls for results; reports no-shows to RN

10. What is waste? • Everything that does not bring value to the patient • In health care organizations, up to 40% of all cost may represent waste and in most systems; 60% of activities add no value

11. Seven Forms of Waste • Overproduction---Producing more than needed or producing faster than needed • Waiting---Time when a person is idle • Transportation---Any movement of material or information not essential for the process • Processing---Operations that in reality do nothing • Inventory---Anything more than immediate needs • Motion---Motion of man or machine that is unnecessary • Defects---Anything requiring correction, rework or inspection

12. Waste Analysis (a foray into the Value Stream) • Explore your flow through the lens of each type of waste: • Overproduction-examples of staff waiting • Waiting-where are there bottlenecks causing waits • Transportation-where do you move materials or information unnecessarily • Extra processing- which steps can be eliminated • Inventory-where are supplies unnecessarily stored; stock levels • Motion-draw the actual movement of staff and patients • Defects-what errors or delays can occur at each step

13. Post-it Notes Patient walks in and introduces himself. Staff asks patient to sign log Step #1 Who: Registration Clerk Jones Time: 30 seconds Value/NVA: NVA

14. Change concepts to address waste • Standardize the environment • Drive work away from the constraint* • Find and remove bottlenecks* • Move process steps closer together • Eliminate unnecessary process steps* • Use technology • Synchronize clinicians, patients, and information*

15. Drive work away from the constraint • Disruptions and distractions • Work someone else can perform • Waiting for x-rays, reports, etc. • Searching for supplies • Waiting to get patients in rooms • Getting off-track with certain patients

16. Find and remove bottlenecks • People • Facility/space • Paperwork • Re-work • Equipment/supplies

17. Eliminate unnecessary process steps • Checking another’s work • Multiple sign-offs • Making multiple copies • Redundancy • Patient path

18. Synchronize patients, providers, and information • Start the first appointment of the day on time • Check charts for completeness in advance • Use standard checklists for supplies • System should have the patient ready before the PCP walks in • Use technology prompts to anticipate potential needs • Use huddles to plan as well as make mid-course corrections

19. Map a process • Use one sticky note for each step in the process • Write down what happens in each step at who does it • Place arrows to illustrate the flow of the steps • Map first, then go back and begin to review the process • Identify missing steps and problem areas (waste) • Brainstorm ideas to impact the problem areas identified (use the “Key Questions for Evaluating Process Steps”) • Evaluate the ideas, then decide on one or two to start with • Develop PDSA cycles to run when you return to your clinic

20. Remember: Look through the patient’s eyes for value • Observation “through the patient’s eyes” • Details to look for: • Patient’s time with staff • Facility barriers & equipment inadequacies • Paperwork • Duplication and re-work: questions/processes • Handoffs that may reduce continuity • Where waits occur

21. The results • Elimination of errors or gaps in care • Increased efficiency that optimizes resource use and minimizes waste • Allows for substitution of processes that add value to the patient in place of those that don’t • Leads to more time for the productive patient interactions of planned care

22. Key Questions for Analyzing Process Steps

23. Questions?