Process Mapping Catherine Blackaby National Improvement Lead

1. Process MappingCatherine BlackabyNational Improvement Lead

2. Process Mapping • One of the most useful tools in improvement work • Works within and/or between organisations • Understand current systems • Identify areas to investigate/change/improve - particularly ‘handoffs’, duplication and “why on earth do we do that?” steps which do not add value for the patient • Identify process waste • Team-building process - helps shared understanding and building links • Frame of reference for future

3. “Every system is perfectly designed to get the results it achieves.” Paul Batalden Dartmouth Medical School, New Hampshire, USA.

4. Any process has … • A start and end point – the scope • A purpose or aim for the outcome • Rules about standards / quality or inputs in the process • Linked to other processes • Can be simple or complex, short or long

5. People see things differently

6. 30 - 70% of work • doesn’t add value for patient • up to 50% of process steps involve a “handoff”, 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 organisational/departmental boundaries E B C D A Stroke process Diagnostic process Colorectal cancer process

7. Why process map? • Define & understand the current patient process • To discover what really happens now • Identify: • Key issues in the way we deliver the service • Delays, bottlenecks & duplication • Where to begin measuring demand & capacity • Redesign the patient process - identify improvements that will have the biggest impact

8. What you think it is What it should be What it could be What it actually is Versions of a process

9. How do we do it?

10. Ground Rules • If you share something that you want to be confidential then please say so - and everyone else will respect it. • Everyone has a valuable contribution to make • We are not here to blame people • Collective responsibility • Thinking creatively • It is important to ‘listen’ to what other people say and feel. • If an issues is being discussed for more than five minutes - it will be put on the ‘issues’ chart.

11. where does it end ? Map the process where does it start ? • Where are the bottle necks? • What / who are the constraints? • How do you manage them?

12. Agree the scope Start and stop points Patient Presents Patient Discharged Start and Stop points are usually depicted in a circle

13. Add process steps Patient Presents Assess-ment Discharge Medication Patient Discharged Tests

14. Simple Process Maps Let phone ring Lift receiver Dial Number Say Hello Have Conversation Hang up receiver Say Good Bye

15. Simple Process Maps Let phone ring Yes Dial Number Lift receiver Answered? Say Hello No Key Start \ Finish Hang up receiver Task Decision or Choice Say Good Bye Have Conversation Direction of flow

16. Compiling a patient process map Name of person completing task + verb • who does what to the patient • “quick and dirty” • what do you do in 80% of cases • test it with other people

17. Different Levels of Mapping Overall parameters Enters OPD All Internal Processes Leaves OPD Sees admin Sees nurse Sees Consultant Has Tests Sees Consultant High Etc etc Take weight , BP etc Asst with undress Enters room Takes history Leaves room Etc Medium Asst patient onto scales Zero scales Take reading Low Etc Etc

18. Some helpful hints • Define the scope • What process are you going to map? • What are the start and end points? • Make sure everyone comments – if not, why not? • Try not to get too “cognitive” – keep it based on practical actions • Try and get a first draft of the high level map in six or seven steps, then pick aspects to map in more detail

19. Map the pathway

20. Diagnostic tests Treatment planning Presentation History Examination Diagnosis Staging Treatment Discharge Follow up Paliative care Death Process Mapping: High level

21. Analysing The Map • Are we doing the right thing? (is it clinically effective) • Are we doing them in the right order? • Is the right/best person doing it? • How co-ordinated is the patients journey? • What information do we give to patients at what stage? Is the information useful? • Baseline measurement: how often / how many / how much?

22. Critical Analysis

23. Analysing a Process Map • How many steps in your process? • How many hand-offs? • What is the approx. time of or between each step? • Where are possible delays and why? • How many steps do not “add value” for patient? • Where are the problems for patients and staff? ……… ……… ………

24. Analyse your map

25. Diagnostic tests Treatment planning Presentation History Examination Diagnosis Staging Treatment Discharge Follow up Paliative care Death Process Mapping: High level

26. Consultant requests test Patient receives the result Map the process at the bottleneck in detail Define the start • The steps performed • by one person • in one place • at one time Define the end

27. Consultant requests X-ray Patient receives the result 1 3 2 4 5

28. Reducing complexity • Can we eliminate any steps? • Can we combine any steps? • Can we simplify any steps? • Can we change the sequence of steps?

29. The complexity problem

30. How good is 99.9%? • No water, heat or electricity for 8.6 hours per year • Unsafe drinking water for 15 minutes each day • One short or long landing at any major airport every day. • 315 entries in Webster's Dictionary will be misspelled. • 20,000 incorrect drug prescriptions will be written this year. • 880,000 credit cards in circulation will turn out to have incorrect cardholder information on their magnetic strips.. • 5.5 million cases of soft drinks produced will be flat. • 12 newborns will be given to the wrong parents daily. • 291 pacemaker operations will be performed incorrectly.

31. Questions to ask about activities • Who are the customers of the process? • Who performs each activity? • What generates the process/task? • What forms and reports are used? • What computer systems and files are used? • How do we do it? Why do we do it? • What decisions are made in the process? • What happens next? What is the sequence of activities? • Who reviews it and when? • How long does it take? • What is the nature, frequency and cause of errors/problems? • How are errors/problems/exceptions handled? • What is the output? How many? • Where does the output go?

32. How could you simplify your process?

33. Where are the delays?

34. Consultant requests X-ray Patient receives the result 1 3 2 4 5

35. Take bloods Nurse 5 mins Seen by Dr 10 mins Prepare chemo Pharmacist 20 mins 45 mins 80 mins 50 235 20 mins Start Chemo Nurse 10 mins Porter to carry drugs 5 mins 40 mins Chemotherapyexample = 20% value added time ! 80% of the patients’ precious time is being wasted!

36. Remove Waste and Delays

37. Patient arrives at reception Patient waits for Phlebo Patient has blood taken Patient waits to see Doctor, Patient sees oncologist Chemo ready Pharmacy prepares chemo Script sent to Pharmacy. Dr prepares script Porter collects chemo Patient returns to waiting area and waits for chemo Chemo prepared in clinic Chemo checked in clinic Patient leaves clinic Patient in to get chemo Patient given chemo

38. Value and Waste • Value Added Activity • Any activity that changes the form, fit, or function of a product/transaction • — OR — • Something customers would be willing to pay for • Non-Value Added Activity • Any activity that absorbs resources but adds no value is Waste Eliminate Minimize Unnecessary Waste Necessary Waste Value Maximize

39. Look out for steps in your process map that don’t add value to the patient. Find out what goes on and why Clues to Non Value Adding steps… Check Rework Retype Repeat Recall Return Remeasure Retrieve Redo Approve Bottlenecks Delay Wait Move Audit Handoffs Set up Inspect Non Value Add (Waste)

40. Spaghetti Diagram

41. © NHS Institute for Innovation and Improvement

42. What waste and delay can you identify?

43. What changes can we make? The secret of getting ahead is getting started. The secret of getting started is breaking your complex overwhelming tasks into small manageable tasks, and then starting on the first one. Mark Twain

44. Plan Do Study Act cycles • Process map helps to show parts of patient journey needing refinement • Small changes tested on small groups of patients • Some of the change ideas are obvious - just do them!

45. Develop change ideas • Reduce steps / hand-offs • Identify bottlenecks • Reduce non-value added activity • If it’s obvious, just do it! • Make plans to test new ideas, with names, dates & follow up • Arrange any further mapping needed • Identify priorities

46. Sample impact matrix High Impact / importance Ease of implementation Low High

47. Use the map... • Share the map with the team and with patients • Keep it as a tool for further use • Identify complex processes for low level mapping • Use for comparison if mapping at a later date • Identify improvements – measure as you go • Follow up with individuals/ teams missing • More detailed process maps to understand problems • Action planning – when, where, who? • Feed back on improvement – when, where, who, how?

48. Running your event

49. Resources checklist • Communication: why, what, when, where • Space (including wall space) and time • The right people from across the pathway • Brown paper, blue tack and post its • Pens and flip charts • Sellotape • Facilitators • Refreshments

50. What level? • High level process map - 10 -15 steps • generate in set time e.g. 20 minutes • use to establish scope and identify problems • no rework loops and minimum complexity • Low level or 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