Workshop 3 Managing QI Projects Process Mapping Quality Improvement Development for NHSScotland Organisational Development Leads Workshop 3 Managing QI Projects Process Mapping

Agenda Project Management Process Mapping

1. What is a Project? All projects have a beginning, a middle and an end Beginning Middle End

Definition Beginning Middle End Timeline “A temporary endeavor undertaken to create a unique product, service or result” Project Management Institute Deliverable

Projects have a common set of characteristics A target outcome A defined life span Cross organisational participation New or unique Time, Cost and performance requirements Projects have a common set of characteristics ….which can also be defined by what they are not

What a project isn’t Explorations Go on indefinitely One team or one person working alone Creating the same thing multiple times No constraints on time, cost or performance

Benefits of good project management Better control of financial, physical, and human resources Improved customer relations Lower costs Higher quality and increased reliability Improved productivity Higher employee morale (less stress)

Project Management Maturity Model Best Practice Competent Success rate > 75% aware Aware Success rate of 45-75% e Seat of pants Success rate of 30-45% Success rate < 30%

? ? ? Why do projects fail? Poor planning Inadequate monitoring & control Moving goalposts Poor communications Disappearing staff Lack of support ? ? ?

Most problems created here Where projects fail Initiate Plan Execute Close Most problems created here Most problems discovered here Most problems caused at beginning!

Learnings for Project Management Able to apply Plan, Do, Study, Act (PDSA) in projects Apply a simple framework for managing projects Understand of the stages and steps in more detail Identify relevant tools to use in project management Know where to find further resources and information

Projects can look very daunting when starting out Why? What? How? When? Who? Lot of questions to be answered:- Why is this project happening? Why now? Why us? What solution needs to be put in place to achieve the goals? What work needs to happen to build the solution? What will it cost? How do we get this solution in place? How do we know when we’re done? When do work activities happen? What do we need to do first? What’s last? Who do we need to deliver this project successfully?

Plan Do Study Act – PDSA It was created in the 1950s as a scientific method of hypothesis, experiment and evaluation First used as a method of continuous improvement & later as a problem solving tool or approach Plan Study Do Act 13

We’ve all done at least one PDSA

Why test? To learn whether the change will result in an improvement To predict the amount of improvement possible To learn how to adapt the change to different environments To understand the costs and impact of change To reduce resistance

Test on a small scale Use interviews or calculations to test feasibility Use volunteers or team members to do the tests Use a small sub-population Use one location Short period of time

What is a PDSA? A structured approach for making small incremental changes to systems (“bite-sized chunks”) A full cycle for planning, implementing, testing and identifying further changes A common sense, easy to understand tool for bringing about change A tool which can reduce anxiety to change

Model for improvement Plan Act Study Do What are we trying to accomplish? How will we know that change is an improvement? What change can we make that will result in an improvement? Plan Study Do Act

Gain customer approval PDSA Cycle – Plan Scope – IN and OUT – time location, population Confirm SMART goals Agree deliverables Agree budget Communication plan Plan activities – focus on deliverables (added value) Tools:- Project Charter Constraints Risk analysis Resources Plan Study Do Act Gain customer approval 19

Smart goals Specific – objectives should specify what they want to achieve Measurable – capable of being measured Achievable – can get a result Relevant – applicable to what you want to achieve Time-bound – clear dates for reviews and end of project

Project Charter Individually:- Discuss in pairs 15 minutes Review charter Fill in scope Fill in goals Discuss in pairs 15 minutes 10.45

PDSA Cycle – Do “Just do it” Document problems Feedback and control Tools: Flash reports Plan Study Do Act Time Scope Cost 22

PDSA Cycle – Study Plan Act Study Do What worked? Do you need to carry out another PDSA? Do you need to involve more people? Do you need to generate more ideas? What didn’t work and why? Do you need to change the plan? Do you need to tweak the original PDSA? What effect did change have? Predict outcome for full project Plan Study Do Act 23

PDSA Cycle – Act Act on the results of the Study Plan Report results and status Standardise activity into process Modify and improve Input into next planning for next cycle Plan Study Do Act 24

PDSA Improvement Framework Identify area for change Measure, learn and continue to improve Bring together a small team Deliver service improvements Come up with ideas on how things could be different Analyse and understand current system (so know that change an improvement) Test ideas and experiment with different ways of working

PDSAs for Quality Improvement Implementing new procedures & systems – sustaining change Ideal Final Result Testing and refining systems Accumulating information and knowledge Good idea

Multiple PDSA streams Good idea Service improvement ? Service improvement ? Good idea

Questions? ? ? ?

Summary PDSA – small bite-sized projects Planning reduces time, effort and risk Aim small and can achieve more

Agenda Project Management Process Mapping

Learnings Learn the value of process mapping Gain understanding of process mapping tools and techniques How to build a process map Understand how process maps can be used for future change initiatives

Impact of lean in industry Productivity improved 45-75% Costs reduced 25-55% Throughput increased 60-90% Defects reduced 50-90% Inventory reduced Space reduced 35-50% Lead time reduced Source: Going Lean in Healthcare, Institute for Healthcare Improvement

Why do process mapping in healthcare? Views the system from the patient perspective Helps staff understand how complex and confusing processes are Diagnostic and used as a basis for redesign, actively involving frontline staff in the process 33

Patient perspective 30 - 70% of work doesn’t add value for patient Up to 50% of process steps involve a ‘hand-off’, leading to error, duplication or delay Handovers has high risk of error No-one is accountable for the patient’s ‘end to end’ experience Difficulty in finding someone who knows what is happening Job roles tend to be narrow and fragmented “That’s not my job!”

From Functional to Process View Successful service improvement requires a shift from function to process Stage 1 Stage 2 Stage 3 A&E Theatres Wards A&E Theatres Wards Emergency care process P a t i e n t s Diagnostic care process Treatment Functions drive the business Processes are acknowledged, but Functions dominate Processes drive the business

What is Process Mapping? Process mapping is a tool that is used to understand, analyse and document activities in an organisation and assist in identifying opportunities for improvement A process map displays the sequential steps involved in converting a specific input into the required output

High level process map - 6-12 steps generate in set time e.g. 20 minutes use to establish scope and identify problems no rework loops and minimum complexity 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

GP Referral – Attend OPD Appointment 1 – 3 days 1 – 3 days Tertiary GP Cons - Cons Appts. AN Hospital Register on System Appts. An Hospital Consultant Secretary Consultant Screening Consultant Secretary High Level Map Increasing level of detail Low level Map 1 Day -12 weeks AN other Hospital Appts. Patient Attends OPD Appts. AN hospital Appt. made Letter sent

Steps when undertaking process mapping session SCOPE – where does the process start and end? What demand is placed on it Who should be involved in the mapping process? Decide the level of detail Map what actually happens

Compiling a Process Map Name of the person completing task + verb Who does what and when?

Rules for Process Mapping workshop Everything is confidential – Chatham House Everyone has a valuable contribution to make Value the diversity of the group ‘Park’ issues Keep to time

Exercise In groups process map visit to GP Remember:- 30 minutes Define where the process starts and ends Map how it is – current state – not how you would like it to be Use post-its to record the activities including time Assemble the post-its to create the journey (remembering that some activities happen in parallel) Keep a note of issues and opportunities 30 minutes

Running mapping session Plan Stakeholders Gather prior info Venue/materials/logistics Map Decide on key for actions/decisions/issues Physical/information flows Map current state Analyse Where are duplications? Multiple hand-offs? Blockages? Wastes? Improve Map future state

Questions to ask 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 sequence are the activities performed in? 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?

Analysing the Map Analyse How many steps in your process? How many duplications? How many hand-offs? 45

Patient discharged home Hand-offs Patient arrives A&E Patient discharged home

Probability for error The more steps the lower the probability of overall success: e.g. - 10 steps, each with 95% probability of success Overall probability = only 60% success!

Analysing the Map Analyse How many steps in your process? How many duplications? How many hand-offs? What is the approx. time of, or between, each step? Where are possible delays? Where are major bottlenecks? 48

Process bottlenecks occurs when a step is the limiting rate of the The step takes a significant time, and slows the whole process down 49

Functional bottlenecks occur when a resource is used by more than one process 50

Look for batching Dr sees patients individually Requests sent in batches Results return in batches 51

Improve 52

Analysing the Map Analyse How many steps in your process? How many duplications? How many hand-offs? What is the approx. time of, or between, each step? Where are possible delays? Where are major bottlenecks? How many steps do not ‘add value’ for patient? Where are the problems for patients and staff? 53

Quantifying value Value and non-value added steps Value added time vs non-value added time 5 20 120 Value added Total Time = 188 TIME: time = 13 3 5 35

Lean – 7 Wastes Waiting Mistakes Uncoordinated activity Stock Transportation Motion Inappropriate processing

Exercise In groups Try 7 Waste on your GP map Select 2 topics and work through map 15 mins

Waiting 7 Wastes - Waiting Waiting is the most important of all the wastes because: the process STOPS it inhibits FLOW it does not add value for the PATIENT

Running mapping session Plan Stakeholders Gather prior info Venue/materials/logistics Map Decide on key for actions/decisions/issues Physical/information flows Map current state Analyse Where are duplications? Multiple hand-offs? Blockages? Wastes? Improve Map future state

Improve – always aim to…. Add value Remove waste

Patient Journey Mapping

Department of Health used simple descriptions and pictures for each step of the journey to map the potential impact of a communication campaign for weaning babies

Constructing patient journey map Confirm Journey and Customer Confirm type of journey, with start and end points Ensure definitions are clear Identify Key Journey Steps Use Post-It notes to define key steps (ideally 6-10) Ensure you are clear about which channels people use at each point Actions, Feelings, Thoughts, Reactions For each point take patients’ viewpoint – what they do, how they feel, what they think Use their actual words where possible Touchpoints Identify touchpoints – each point where you have some interaction with patient Think about physical interactions (buildings), human contact (face-to-face or remote) and communications Moments of Truth Look at whole journey and identify moments of truth Key points where customers may pause, evaluate the experience or make a crucial decision; be judicious!

Critical questions for you to ask patient General Tell me about… What did you think when…? How did you feel when…? What were the high and low points…? What really stood out for you (good or bad)? If you could change one thing what would it be? Why? (5 Why tool) Process improvement What parts of the journey were essential? Where did things get held up or took too long? Did you have to do the same thing more than once? Were any steps unnecessary? Were you clear about who you were dealing with at every point?

Critical questions for you What are the top 3 questions about this journey that you can’t answer? How typical is this person’s journey? Is anything unique? Who or what aspect of the process influences them most? What are their real passion points? What surprised you about what you heard? What was new?

Patient experience in A&E There was so much information to take in about care of the wound; I was really confused Had difficulty in finding a parking place; very stressed Receptionist was very off-hand; she didn’t realise how upset I was I had to trek away across the hospital; it took me quite a while to find it! The nurse was very good; she held my hand while I was stitched up Moment of truth Moment of truth

Summary Project Management: Process Mapping: PDSA – small bite-sized projects Planning reduces time, effort and risk Aim small and can achieve more Process Mapping: Plan, Map, Analyse, Improve Add Value – Remove Waste

Resources Improving NHS Scotland: www.improvingnhsscotland.scot.nhs.uk/programmes/improvement_toolkit/Pages/Improvement_skills.aspx Going Lean in Healthcare, Institute for Healthcare Improvement HM Government, Customer Experience Mapping