Process MappingProcess Mapping

Midwest Cluster Phase 2 Conference CallMidwest Cluster Phase 2 Conference CallJanuary 16, 2007 January 16, 2007

Tracy Jacobs, RN, BSNTracy Jacobs, RN, BSNInstitute for Healthcare ImprovementInstitute for Healthcare Improvement

Topics to be coveredTopics to be covered

What is process mapping?What is process mapping? How is it done?How is it done? Why is it useful?Why is it useful? What constitutes waste and What constitutes waste and

specific change ideas to deal with specific change ideas to deal with itit

What is a process?What is a process?

A continuous and regular action or A continuous and regular action or succession of actions, taking place or succession of actions, taking place or carried on in a definite manner, and carried on in a definite manner, and leading to the accomplishment of some leading to the accomplishment of some result; a continuous operation or series of result; a continuous operation or series of operations, Caulkin 1989operations, Caulkin 1989

The care you provide is made up of The care you provide is made up of dozens of separate - though integrated - dozens of separate - though integrated - processes.processes.

What is process What is process mapping?mapping?

A process map is considered to be A process map is considered to be a visual aid for picturing work a visual aid for picturing work processes which show how inputs, processes which show how inputs, outputs and tasks are linked outputs and tasks are linked

It is the “most important and It is the “most important and fundamental element of business fundamental element of business process re-engineering”process re-engineering”

Anjard, 1998; Soliman, 1998Anjard, 1998; Soliman, 1998

Process mapping Process mapping stepssteps

Choose a processChoose a process– time consumingtime consuming– error proneerror prone– critical to successcritical to success

Assemble a teamAssemble a team Map out the way work is currently doneMap out the way work is currently done Identify gaps first, then work on problem Identify gaps first, then work on problem

areas (waste)areas (waste) Keep in mind the goal of the processKeep in mind the goal of the process Brainstorm solutionsBrainstorm solutions

– develop PDSA cyclesdevelop PDSA cycles

Process Mapping Using the Process Mapping Using the Flip Chart Paper ApproachFlip Chart Paper Approach

Shows the “Big Picture”Shows the “Big Picture” Describes a process as it works today; an Describes a process as it works today; an

“as-is” model“as-is” model High touch, low-techHigh touch, low-tech Identifies gaps, strengths and opportunitiesIdentifies gaps, strengths and opportunities Captures the complexity and disconnects of Captures the complexity and disconnects of

key operational issueskey operational issues Identifies outside areas involved in the Identifies outside areas involved in the

processprocess

BenefitsBenefits

Highlights Highlights gapsgaps in care in care Puts a spotlight on problems Puts a spotlight on problems

(waste)(waste) Streamlines work processesStreamlines work processes Promotes deep understandingPromotes deep understanding Defines and standardizesDefines and standardizes the the

steps and sequencesteps and sequence Builds consensusBuilds consensus

Patient given FOBT cards

RN enters patient name and date into log (in lab)

Returned cards are processed by lab staff and results entered into log

Lab gives results to PCP immediately. PCP calls and refers for colonoscopy

Positive?

Results notification mailed

No

Yes

RN schedules appointment

But what about….?

Patient given FOBT cards

RN enters patient name and date into log (in lab)

Lab gives results to PCP immediately. PCP calls and refers for colonoscopy

Positive?

Results notification mailed

No

Yes

Log checked q 2 weeks for follow up phone calls needed

Returned cards are processed by lab staff and results entered into log

RN schedules appointment and places reminder in tickler file

Medical records checks tickler and calls for results; reports no-shows to RN

Gaps addressed:

1. Follow up for FOBT cards that have not been returned

2. Ability to track if patient received colonoscopy and get results and plan to PCP

What is waste?What is waste?

Everything that does not bring Everything that does not bring value to the patientvalue to the patient

In health care organizations, up to In health care organizations, up to 40% of all cost may represent 40% of all cost may represent waste and in most systems; 60% waste and in most systems; 60% of activities add no valueof activities add no value

Seven Forms of WasteSeven Forms of Waste

OverproductionOverproduction---Producing more than needed ---Producing more than needed or producing faster than needed or producing faster than needed

WaitingWaiting---Time when a person is idle---Time when a person is idle TransportationTransportation---Any movement of material or ---Any movement of material or

information not essential for the process information not essential for the process ProcessingProcessing---Operations that in reality do nothing ---Operations that in reality do nothing InventoryInventory---Anything more than immediate needs---Anything more than immediate needs MotionMotion---Motion of man or machine that is ---Motion of man or machine that is

unnecessary unnecessary DefectsDefects---Anything requiring correction, rework or ---Anything requiring correction, rework or

inspectioninspection

Waste Analysis (a foray Waste Analysis (a foray into the Value Stream)into the Value Stream)

Explore your flow through the lens of each Explore your flow through the lens of each type of waste:type of waste:– OverproductionOverproduction-examples of staff waiting-examples of staff waiting– WaitingWaiting-where are there bottlenecks -where are there bottlenecks

causing waitscausing waits– TransportationTransportation-where do you move -where do you move

materials or information unnecessarilymaterials or information unnecessarily– Extra processing-Extra processing- which steps can be which steps can be

eliminatedeliminated– InventoryInventory-where are supplies -where are supplies

unnecessarily stored; stock levelsunnecessarily stored; stock levels– Motion-Motion-draw the actual movement of staff draw the actual movement of staff

and patientsand patients– DefectsDefects-what errors or delays can occur at -what errors or delays can occur at

each stepeach step

Post-it NotesPost-it Notes

Patient walks in and introduces himself. Staff asks patient to sign log

Step # 1Who: Registration Clerk JonesTime: 30 secondsValue/NVA: NVA

Change concepts to Change concepts to address wasteaddress waste

Standardize the environmentStandardize the environment Drive work away from the Drive work away from the

constraint*constraint* Find and remove bottlenecks*Find and remove bottlenecks* Move process steps closer togetherMove process steps closer together Eliminate unnecessary process Eliminate unnecessary process

steps*steps* Use technologyUse technology Synchronize clinicians, patients, and Synchronize clinicians, patients, and

information*information*

Drive work away from Drive work away from the constraintthe constraint

Disruptions and distractionsDisruptions and distractions Work someone else can performWork someone else can perform Waiting for x-rays, reports, etc.Waiting for x-rays, reports, etc. Searching for suppliesSearching for supplies Waiting to get patients in roomsWaiting to get patients in rooms Getting off-track with certain Getting off-track with certain

patientspatients

Find and remove Find and remove bottlenecksbottlenecks

PeoplePeople Facility/spaceFacility/space PaperworkPaperwork Re-workRe-work Equipment/suppliesEquipment/supplies

Eliminate unnecessary Eliminate unnecessary process stepsprocess steps

Checking another’s workChecking another’s work Multiple sign-offsMultiple sign-offs Making multiple copies Making multiple copies RedundancyRedundancy Patient pathPatient path

Synchronize patients, Synchronize patients, providers, and information providers, and information

Start the first appointment of the day Start the first appointment of the day on timeon time

Check charts for completeness in Check charts for completeness in advance advance

Use standard checklists for suppliesUse standard checklists for supplies System should have the patient ready System should have the patient ready

before the PCP walks inbefore the PCP walks in Use technology prompts to anticipate Use technology prompts to anticipate

potential needspotential needs Use huddles to plan as well as make Use huddles to plan as well as make

mid-course correctionsmid-course corrections

Map a processMap a process Use one sticky note for each step in the processUse one sticky note for each step in the process Write down what happens in each step at who Write down what happens in each step at who

does itdoes it Place arrows to illustrate the flow of the stepsPlace arrows to illustrate the flow of the steps Map first, then go back and begin to review the Map first, then go back and begin to review the

processprocess Identify missing steps and problem areas (waste) Identify missing steps and problem areas (waste) Brainstorm ideas to impact the problem areas Brainstorm ideas to impact the problem areas

identified (use the “Key Questions for Evaluating identified (use the “Key Questions for Evaluating Process Steps”)Process Steps”)

Evaluate the ideas, then decide on one or two to Evaluate the ideas, then decide on one or two to start withstart with

Develop PDSA cycles to run when you return to Develop PDSA cycles to run when you return to your clinicyour clinic

Remember: Look through Remember: Look through the patient’s eyes for valuethe patient’s eyes for value

• Observation “through the patient’s eyes”Observation “through the patient’s eyes”• Details to look for:Details to look for:

Patient’s time with staffPatient’s time with staff Facility barriers & equipment inadequaciesFacility barriers & equipment inadequacies PaperworkPaperwork Duplication and re-work: Duplication and re-work:

questions/processesquestions/processes Handoffs that may reduce continuityHandoffs that may reduce continuity Where waits occurWhere waits occur

The resultsThe results

Elimination of errors or gaps in careElimination of errors or gaps in care Increased efficiency that optimizes Increased efficiency that optimizes

resource use and minimizes wasteresource use and minimizes waste Allows for substitution of processes Allows for substitution of processes

that add value to the patient in that add value to the patient in place of those that don’tplace of those that don’t

Leads to more time for the Leads to more time for the productive patient interactions of productive patient interactions of planned care planned care

Purpose What? What is done? Eliminate

Why? What is the purpose?Is the purpose accomplished?Why is it necessary?What if it were eliminated?What would make it unnecessary?

CombineRearrange

Place Where? Where is it performed?What alternate locations are viable?Can the departments be reorganized?

Sequence When? What other sequences would work?Can it be combined with another event?What are the implications of other sequences?

Person Who? Who performs the task?Who else could perform it?

Means How? What other methods are available?What other process technologies exist?Can smaller scale processes be used?

Simplify

Key Questions for Analyzing Process Steps

Questions?Questions?