Process Mapping Catherine Blackaby National Improvement Lead Introductions and outline of the session As this stage, you might like to gauge some idea of how many delegates have process mapped before. Suggested exercise: Ask all to stand up. Next ask those who have never heard of process mapping before coming on this course to sit down. Next ask those who have heard about it, but never actually attended a session to sit down. So everyone left standing should have actually attended a mapping session – you may want to ask a couple of these people to give a comment about it – something they thought was good about it, what were they mapping etc? Next those who have attended a mapping session but never actually run or assisted at one to sit down. Perhaps ask anyone still standing – what would be their key tip, or the key challenge etc The aim of this session is to give an introduction to process mapping that should equip delegates with the tools and tips for organising their own events – add to this the need to help out and see other events prior to running their own. They should also use this as an opportunity to share each others experiences and benefit from real life examples given by the trainer throughout the session.

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

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

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 Spoken or unspoken Purpose – what is ours? Patient value n

People see things differently But people will see it differently

organisational/departmental boundaries E 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 B C D E A Stroke process Diagnostic process Points to stress patients pass though many departmental / organisational boundaries out patient process is on part of total patient process of care good place to start explain what a handoff is everyone in health care working hard - often chasing their own tales doing rework because of the system Colorectal cancer process 9

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 So… Process mapping makes visible that patient process, which is the purpose, understand what actually happens (not what should/ what we think)

Versions of a process What you think it is What it should be What it could be VERSIONS OF A PROCESS There are four major stages of a complete Process Map. First what individuals who work in the process think it is. Think of a blind man touching three different parts of an elephant. He could think that it is three different animals. Individuals may have similarly different perceptions of a the map of a process. It is important to reveal the thinking of each individual within a team as to what they think the process is first. After this, it is important to reconcile what the assumed process map is to what it really is. This is the second stage of the process. These first two stages of the process make up what is referred to as the “As Is” process map. A thorough “As Is” process map is one of the short-term goals of good process mapping. As you get deeper into the mapping and do process analysis and problem-solving, eventually you will create the third stage of the process map - the “Should Be” map. This will be combined with a check that customer needs and requirements will be met or exceeded. If it is not possible to improve the existing process sufficiently to meet customer needs, then entire process must be reengineered (i.e. redesigned from scratch) which would result in the fourth stage, the “Could Be” process map. What it actually is Versions of a process

How do we do it?

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.

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

Agree the scope Start and stop points Patient Presents Patient Discharged Very basic simple Process maps can be drawn with two symbols; oval/circle, and a rectangle. The first to indicate the start and end of the Process. The second to show the steps in the process. Start and Stop points are usually depicted in a circle

Add process steps Patient Presents Assess-ment Tests Discharge Medication Patient Discharged Tests Very basic simple Process maps can be drawn with two symbols; oval/circle, and a rectangle. The first to indicate the start and end of the Process. The second to show the steps in the process.

Simple Process Maps Let phone ring Lift receiver Dial Number Say Hello Have Conversation Hang up receiver Say Good Bye Very basic simple Process maps can be drawn with two symbols; oval/circle, and a rectangle. The first to indicate the start and end of the Process. The second to show the steps in the process.

Simple Process Maps No Let phone ring Yes Dial Number Lift receiver Answered? Say Hello No Key Start \ Finish Hang up receiver Process maps usually are drawn with four symbols; oval/circle, rectangle, diamond and arrow. The Diamond is the most important symbol in Process Mapping as it shows when there is choice and a decision to be made, or when the process splits into different paths depending on circumstances and conditions. Usually a Diamond will have two exit paths as shown on the slide with the Decision or Condition shown on each path. A Diamond can have three exit paths if this is appropriate. Very often in Process Mapping a series of Diamonds will be linked together to show the detail of a series of decisions during a process, e.g. taking details from a Patient in A&E Task Decision or Choice Say Good Bye Have Conversation Direction of flow

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 Key points Get the name of the person completing the task or step Only record what is done in 80% of cases – exclude one-offs ‘test’ the map with other people

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 Process mapping is a process of logically drilling down through processes. Processes can be analysed further by going down to sub process analysis. Each level will give different information – it is normally important that a high level process map is determined prior to a process map event as this will define the start and end points and clarify sections of the patient journey (often no more than 5 - 10 steps). A process map event is usually done at medium level, giving the team more information in terms of breaking down the larger steps. Certain sections of the patient pathway or service may then require detailed level process mapping due to the complexity of that service – the time may not be available at the process map event itself, so the organiser may have to go back to do this. Enters room Takes history Leaves room Etc Medium Asst patient onto scales Zero scales Take reading Low Etc Etc

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

Map the pathway

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

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? Key points when analysing a process map – it may be worth asking some of these questions to staff at the event unless it appears obvious. 73

Critical Analysis

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? ……… ……… Key points – to consider when analysing a process map. The person analysing the map may wish to: count number of steps and write on flip chart in prominent position circle other problems with coloured pens colours used are not important so long a everyone knows what is what These tips should make it easier to visually identify individual steps that require further consideration. 73

Analyse your map

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

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

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

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

The complexity problem Probability of success, each element No. of elements 0.95 0.99 0.999 0.9999 1 25 0.28 0.78 0.96 0.998 50 0.08 0.61 0.995 100 0.006 0.37 0.90

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.

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?

How could you simplify your process?

Where are the delays?

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

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

Remove Waste and Delays

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

Value and Waste Value Added Activity Non-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 Any activity that absorbs resources but adds no value is a Waste MUDA is a Japanese word, which stands for “Waste” Activities that add no value, add cost and time Waste is a Symptom; need to find root causes and eliminate them Waste points to problems within the system Maximize

Non Value Add (Waste) 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

Spaghetti Diagram Guidelines Note the time, date and process being evaluated, but not the name of the individuals Explain to the team what's being done and ask for a volunteer Trace the actual steps taken Note any stops with sequential numbers and mark the time for each stop Note any awkward elements in the line taken Mark any inherent interruptions in the path - such as gowning up Note why certain trips are made eg getting necessary supplies or signatures Ask questions and seek suggestions from the team - the best ideas often come from those who live the process

(from receipt to results available) 62 minutes Up to 2 hours 38 Metric Before change After change Ideal state Improvement Saving £££ a year Turnaround time (from receipt to results available) 62 minutes Up to 2 hours 38 30 minutes 40% reduction 2 beds a day A&E targets met Specimen pick up time Specimens waiting to be picked up 13 minutes Up to 50 minutes 1 minutes Up to 4 minutes 93% reduction £10,000 Double handling (Labelling only) 40 minutes a day 0 minutes a day Totally eliminated At least £3000 Hereford Hospitals Trust pathology team achieved significant results. Also NB nurses –10 nurses working an 8 hour shift, save 24 minutes wasted time a day, equals 240 minutes = another nurse shift. For a trust of 800 nurses that makes 38 nurses’ time In 7 days turnaround times were reduced by 40%. In is contributing to shortening length of stay and saving £365,000 a year. 2 more patients a day can be discharged. © NHS Institute for Innovation and Improvement

What waste and delay can you identify?

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 Small changes are quick to implement, easier to persuade people to make, and less difficult to correct if they don’t work. Success breeds success – if they work people are more inclined to try another 43

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! Try to link the PDSA concept of managing change ideas i.e. testing small scale – it is very easy at a process mapping event to generate a vast array of ideas that will change the service. These need to be prioritised and agreed. Also be realistic – some ideas need not be tested and can just be implemented – great for quick wins!

Reduce steps / hand-offs Identify bottlenecks 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 Action planning is an important part of process mapping, particularly to engage staff groups and establish some form of ownership over this process. Action planning should take the ideas and issues identified and use them to address the above areas identified on the process map. It is important to note that further analysis of the map (in addition to low level process mapping) may be required before action planning is complete. This will depend largely on the time available at the event itself.

Sample impact matrix High Major projects Easy wins Leave till last Low hanging fruit Impact / importance Ease of implementation Low High

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? Often where previous process mapping events have failed are as a result of then being isolated events with staff groups having never seen the map again! The map should be shared for all of the reasons on this slide in addition to other points for consideration. Communicate any improvements made – perhaps have a discussion about how to do this

Running your event

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

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 Summarises process mapping detail levels. Key point – when actual process mapping, try to get times of each step included on map as this is useful when it comes to analysis.

Process Mapping Facilitation What are we doing? Challenge - keep asking “why?” But never challenge the person – only their view Reflect their comments back to them to check you understand what they mean Clarify scope at the beginning Keep focussed on what happens now – not on what they would like Agree ground rules Key points for the facilitator of an event.

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.

Process mapping in action

“To change an organisation, the more people you can involve, and the faster you can help them understand how the system works and how to take responsibility for making it work better, the faster will be the change” Allow time for this quote to be read and understood Key point The beauty of process map events is exactly this that it helps the people involved to understand the wider system better, and to take responsibility for improving it Martin Weisboard Training and Development Journal

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