Process Mapping Heidi Johns, Quality Leader, BCPSQC July, 2013

Objectives To better understand: Understand why mapping is useful in healthcare improvement Understand the steps to building a process map Feel confident leading a process mapping session Understand how to analyse and extract learning from a process map

“The problems in organizations often occur between changeovers, when one process step flows to another process step in a different department or to a different specialist…..processes are like a relay race, with the baton passing from one person to another within the organisation. The Olympic relay teams don’t practice running together, they only practice the baton changes.” Bsi Effective Process the High Performance Organisations Ltd.

What is Mapping – review InputProcessOutput

Mapping Types Maps are pictorial representations of a process Various forms of maps some are: Patient Journey Mapping Value Stream – current state and future state Swim lane Relationship Functional

Health Matters

Why is mapping chosen for Improvement work? Relationships Illustrate gaps or confusion Illuminate bottlenecks Aha moments Perspective Common language – interdisciplinary Clinical and patient perspective

Where to start? Know the scope and boundaries of the process. How would you break the 5 year cancer patient journey down? What are you wanting to improve?

Process Best Practice Money Knowledge People Equipment Buildings Counselling Session Admissions Referral A wait X-ray Prescription

Source: Intermountain Health

High Level Map Example

Building a Process Map

Agreement on scope Multiple maps will connect

Home and Community Care Home Support Program Community Home Workers Scheduling Home Health Development of Process Map What is the process for the Community Home workers to receive their daily work assignments and client information?

Map symbols Decision Point Process Flow Decision or Question No Answer to question and flow Yes Start and Finish of the Process

Mapping Techniques Time and flow movement left right Pareto principle Be consistent in the level of detail Active language Source: NHS Institute for Innovation and Improvement: Improvement Leaders’ Guide, Process mapping, analysis and redesign

Activity At your table you have the steps of a process. Using the map symbols map the process as outlined.

Map symbols Decision Point Process Flow Decision or Question No Answer to question and flow Yes Start and Finish of the Process

High Level Process Map: Cardiac Cath Lab Pt arrives and register form on chart Moved to wait area Nurse brings to exam Cardiology assessment Consent form and discussion consent added to chart Anaesthesia Exam IV started RN Pt changes Oral pre med given RN Needs Anaesthetic Needs Anaesthetic Nursing Assessment IV started by RN Pt changes No Yes Source:isixsigma.com Anaesthetist Delivers drug Anaesthetist Delivers drug Anaesthetist Delivers drug Anaesthetist Delivers drug Porter moves patient Pt called day before exam Procedure room

Planning a Session Maps purpose is clear. Scope is clear. Who should be invited?

Planning a session cont’d Where do you hold the session?

What is the time commitment? Planning a session cont’d

Points to consider: Clarity of function Pre-work Facilitation Awareness of unit culture Planning a session cont’d

Participant Information – before mapping Invitation Expectations Location Who owns the process - introductions

Supplies list Post-it notes Painters tape/masking tape Roll of brown butchers’ paper Sign in sheet with all contact information fields (including position) Felt pens, markers Kleenex Pipe cleaners Beverages and/or food

How to run a session - 5 steps Agreement of scope Solicit input Work with group to agreement Create ‘parking lot’ for unanswered questions Preliminary analysis of map

Activity In your group map one of the following health care activities. 1.Blood work to be completed at the hospital lab 2.X-Ray to be completed at diagnostic and imaging department at hospital 3.2 month baby immunization and well baby check 4.Community Mental Health Rehab appointment

Activity debrief What worked well? What was a challenge? What were some of the questions? Facilitation, any suggestions? Where there any assumptions made? Debrief in your group:

Activity Part 2 Take 2 minutes and look at the other groups map. What was each groups experience?

Map Analysis

Analysis Techniques Post-it notes Colour markers Dots Group Process Individual with debrief

Analysis – Activity Choose new facilitator Using the Analysis questions - analyze the map

Map Analysis potential questions What are the number of steps to get through the process? Is there ability to remove or simplify the number of steps? What are the stops and starts? Patient handoffs? Who is doing what function in the process? How many people are doing the same function? Could you combine functions? Does that person need to be doing that step who else could do it is there a better fit?

At the end of the session a) have opportunities for improvement in the maps through preliminary analysis by the group, or b) use follow-up session to indicate the opportunities Set a date for a review session with the group.

End of session tips Check- in Patient debrief separately Contact information

Post session Complete maps - share all the maps in draft form Gather consensus that the map clearly depicts the discussion of the day

Follow - up session Review the maps Look for opportunity Establish work teams for PDSA cycles Start date

The Human Factor Do any of you have “Tips” to share with the group? How do you work with the ‘nay-sayer and yes- but’ person in the room? What is the best way to re-direct a conversation? How would you encourage participation from all disciplines? What do you do if a potential ethical or practice issue is surfaced?

Questions?