Transcript How to process map - Canadian Patient Safety Institute

Using Process Mapping to Identify
Improvement Opportunities
Presented by:
Rosmin Esmail and Tanis Rollefstad
Improvement Associates Ltd.
Purpose
• 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
Improvement Associates Ltd.
June 2007
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Systems 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
Improvement Associates Ltd.
June 2007
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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
Improvement Associates Ltd.
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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
Inputs
Process
Outputs
Source: NHS: Improvement Leaders’ Guide to Process mapping, analysis and redesign
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What is a process map?
•
A “picture” of a
process, showing
the connections
and actual
sequence of steps
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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
Source: NHS: www.modern.nhs.uk/improvementguides Managing the Human Dimensions of Change
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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
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Common Symbols
A
Start
End
Beginning or end of a process
Process Step
Off-page link to
sub process
System/ Database
Decision point
Boundary between
roles
Document or file
Process interaction
- direction of work
Delay or wait state
Looping
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
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Types of process maps
Increasing Detail
• Detailed flow chart (micro)
• Cross functional map
(deployment)
• Relationship map (macro)
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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
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Day Surgery Relationship Map
FP Office
Surgeon’s
Office
Admitting
Client in the
Community
Day surgery
Recovery
Room
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Operating
Room
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Cross-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
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Cross Functional Process Map
Physician
Portable / Mobile X-Ray Process
Start
Assess patient
condition, X-ray
required
DI General
Duty
Technologist
PCU Clerk
PCU Nurse
Portable
Order?
Yes
Change in Patient Condition or
Routine Assessment
Enter
order in
order
entry
system
No
Place
order
receipt
in bin
Assist
with
exam
Use
Page DI
STAT
for
standard
portable page if
exam
STAT
request
Phone
PCU
for
more
info
Phone
PCU to
alert of
arrival
If not right after
original page
Pick up
order
receipt
from
bin
Pick up
mobile
X-ray
equip.
Check
in with
pt’s
nurse
Complete
exam
2
Creating 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
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Client
PHN
X
Start – client enters service
New Client?
X
X
Start new chart or pull chart
Assess client
Existing services required?
X
Provide services
Follow-up required? Arrange for f/u
Document in chart
Send Chart to Clerk
X
X
X
Enter into database
Send back to program
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End
– File Chart
Clerk
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X
X
X
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Then……..
• Draw swim lanes on another piece of flipchart paper
• Label swim lanes with roles/departments
• Place each Post-it Note in the appropriate
swim lane
• Draw arrows to indicate process flow
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Community
Sample Cross Functional Map
Client
start
Client enters
service
PHN/Outreach worker
New client?
yes Start new chart
no
Program X
Pull chart
Assess client
Existing services
required?
Services
provided
no
Follow-up
req’d?
no
Document
in chart
Clerk
System
yes
System
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June 2007
yes Arrange for f/u
Send chart
to clerk
File chart
Enter into
database
Send back
to program
XYZ database
end
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Flow Chart
• Document sequence of events e.g.
investigating sentinel event
• Most detailed map – shows process detail
• Useful for process steps of single individual
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Flowchart of Process of Obtaining Antibiotics
from Pharmacy at FMC- May 28 2004
Flow Chart of Process for Obtaining Antibiotics from Pharmacy at FMC-May 28, 2004
START
Order Acyclovir (Antibiotic)
on TDS in the ICU
Order is printed in
pharmacy and on
computer in ICU
immediately
Order printed on
printer in ICU and
pharmacy.
Pharmacy
technician checks
printer every 2 to
10 minutes
DELAY in picking
up order by
pharmacy
technician
*Order states
drug, dose, how
to administer, it
is a STAT, any
allergies
*STAT is
highlighted on
the bottom of
page
DELAY if entering
pharmacy
technician not
there
Entering pharmacy
technician enters
order in pharmacy
system BDM
*The hospital is
divided up into 2
sides (ICU is
side #2).
Entering
pharmacy
technician signs
order and puts it
on the desk
*Patient is
looked up,
patient bed, ID#,
doctors name,
drug selected,
dose, labels are
printed.
Mixing pharmacy
technician enters
Mixing Pharmacy
information in the
technician makes
computer in Word
drugs in hood
for labels, order
filled in
Notes:
*Wash up = 10
1. Process for a STAT drug if it does not need to be made= ½ hour.
mins
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 except *Clean hood=10
mins
mornings (730, 8, 830, 9, 930).
3. Night cupboard-code phoned in, porter gets print out, porter gets drug from *Takes 5 to 10
cupboard (approximately 12 to 14 orders on average a night), and delivers drugminutes to make
drug
to unit. Pharmacist on call (called in once per week).
4. Days-five pharmacists until 11am, 4 pharmacists until 330, 3 pharmacists
until 1030pm. Weekends-5 pharmacists until 11am, 4 pharmacists until 330, 2
pharmacists unitl 1030pm.
5. Six pharmacy techs during day (2 entering, 2 filling and 2 mixing techs, 6
pharmacy assistants). All can be different for each drug order. Number of techs
varies 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.
Mixing pharmacy
technician writes
up order at table at
back
Pharmacist checks
the order on TDS
to make sure it is
right i.e profile,
check allergies,
not interacting with
anything, look up
microbiology if
resistant
Pharmacist signs
the order
Order is taken to
pharmacist to
review and check
Pharmacist may
not be there
DELAY
Filling
pharmacy
technician picks up
the order if it’s
STAT
DELAY in picking
up order
Mixing pharmacy
technician making
2 to 3 drugs
DELAY
Filling pharmacy
technician picks up
the labels
Filling pharmacy
technician checks
cupboard for
Acyclovir
Need to phone
doctor?
NO
Pharmacist sticks
a red flag for STAT
on order and puts
in grey box at
entering pharmacy
technician’s desk
Pharmacist tries
to find entering
pharmacy
technician to do
this right away for
STAT
Filling pharmacy
technician brings
drug to front table
and signs order
Pharmacist
checks drug and
signs order.
Order filed in
pharmacy
YES
Pharmacist calls
the doctor and
clarifies-this can
take up to 20
minutes to 1 hour
DELAY
Need to make
drug?
*Labels for IV
and pills are
printed on
separate
printers.
NO
YES
Mixing pharmacy
technician takes to
filling pharmacy
technician at front
table
Mixing pharmacy
technician checks
order, order filed
Nurse administers drug to
patient
END
DELAY in unit
clerk telling
nurse or take to
bedside and no
nurse there
Filling pharmacy
technician labels
drug and signs
order
Pharmacy
assistant puts
STAT drug in blue
box at desk A and
tells unit clerk
*Pharmacy assistant
is paged by
pharmacy
technician. Arrives
within 15 minutes
STAT red flag
removed and
pharmacy
assistant takes
drug to ICU right
away
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
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Steps
• 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
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Steps
• 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
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Using Process Maps
•
•
•
•
•
•
•
•
•
Remember our Quality definition:
right service for the
right patient at the
right time by the
right provider with a
minimum of waste and rework
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
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Analysis of Flowchart / Process
Redesign
• 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?
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Example of improvement – blood donation
Donor
arrives
Donor is
interviewed
and fills out
form
Donor’s veins
are checked in
waiting room
Rejected
Veins
OK ?
Doctor
evaluation
occurs
Yes
Donor goes to
donor room
Phlebotomist
checks
veins
Yes
Health
OK ?
Yes
Veins
OK ?
Rejected
No
No
No
Plasma
drawn
Rejected
Redesigned
Donor
arrives
Donor is
interviewed
and fills out
form
Rejected
Doctor
evaluation occurs
and phlebotomist
checks veins
Health
and veins
OK ?
No
Donor goes to
donor room
Plasma
drawn
Yes
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Source: The Improvement Guide. Langley et al. 1996
Example of improvement – blood donation
Donor
arrives
Donor is
interviewed
and fills out
form
Donor’s veins
are checked in
waiting room
Rejected
Veins
OK ?
Doctor
evaluation
occurs
Yes
Donor goes to
donor room
Phlebotomist
checks
veins
Yes
Health
OK ?
Yes
Veins
OK ?
Rejected
No
No
No
Plasma
drawn
Rejected
Redesigned
Donor
arrives
Donor is
interviewed
and fills out
form
Rejected
Doctor
evaluation occurs
and phlebotomist
checks veins
Health
and veins
OK ?
No
Donor goes to
donor room
Plasma
drawn
Yes
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Source: The Improvement Guide. Langley et al. 1996
Example of improvement – ovarian cancer
clinic
Clinic
Hospital for
ultrasound
Clinic
Hospital for
blood test
Clinic
Hospital to see
physician
Hospital for
chest x ray
Simplication
Clinic
Hospital for
blood test,
ultrasound,
chest x - ray
Hospital to see
physician
Source: NHS: Improvement Leaders’ Guide to Process mapping, analysis and redesign
June 2007
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Example of improvement – ovarian cancer
clinic
Clinic
Hospital for
ultrasound
Clinic
Hospital for
blood test
Clinic
Hospital to see
physician
Hospital for
chest x ray
Simplification
Clinic
Hospital for
blood test,
ultrasound,
chest x - ray
Hospital to see
physician
Source: NHS: Improvement Leaders’ Guide to Process mapping, analysis and redesign
June 2007
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Tips
• 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
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Tips
• 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
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Software
• Low Tech Stickies
• Visio
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Some Examples
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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.
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Outreach Documentation
Attending
Attending
MD
MD
UnitRN
RN
Unit
OutreachMD
MD Outreach
OutreachRRT
RRT Outreach
OutreachRN
RN
Outreach
Pt. Assessment
Interventions by
Outreach Team
1. Enter STAT
orders into
SCM*
Assess
patient
2. Administer
medications as
ordered.
Documentation
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 ♦
Provide pt.
history
Enter STAT
orders into
SCM*
Work
collaboratively
with Outreach
Team
* Depending on patient
condition any one of these 5
would perform this function.
08/02/2007
Recommendations
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
Distribution of documents
1. Print out SBAiR
document from Tablet:
leave copy on patient chart.
Other
When ordering meds
retroactively, order all at
once. Do NOT mark as
“done”, but sign on e-MAR
for actual time given.
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.
Document fld intake
& output on flow
sheet in SCM. (Any
v/s completed by unit
RN are documented
in SCM
1. Review
recommendations
2. If decision is to proceed
with recommendations
enter orders into SCM
♦ Code Blue
When any of the following interventions are performed
Code Blue documentation will be completed:
1. Chest compressions
2. Defibrillation
3. Electrical Cardio-version
4. Intubation
5. Assisted ventilation (including bagging for apnea, but
not simply providing oxygen through a bagging unit)
Wound Care (DRAFT)
Physician
Registered Nurse
Wound Care Clinician
Wound identified
Complete wound
assessment and
initiate Wound
Care Flowsheet
No
Implement
VAC
dressing
protocol
Wound
pressure
related?
Wound
pressure
related?
Advanced wound
management required?
Yes
Wound identified
Complete wound
assessment
Notify
physician
utilizing
SBAR
framework
Assess wound
Allied Health (OT, PT, RT)
No
Consult
RN
Yes
No
yes
Consult OT/
PT/RT
Does the
wound appear
infected?
Develop care
plan and
reassess as
indicated
no
Consult others
as needed
yes
Swab wound
for C&S
Do I have the
competencies to
determine appropriate
wound care?
Culture positive?
Yes
Order appropriate
antibiotics
No
yes
no
Apply appropriate
dressing and initiate
individualized
careplan
Consult wound
care clinician using
SBAR framework
Assist with
identifying
appropriate
dressing choices
and in
individualizing
patient care plan
Has wound
resolved?
No
Reassess
wound. Contact
Physician and
wound care
clinician
yes
Discontinue wound
care
Follow-up as
appropriate
© 2007, BC Children’s Hospital, C&W
“How can you possibly improve
something unless you know how it
works”
Improvement Associates Ltd.
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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