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

2. Agenda
Project Management
Process Mapping

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

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

5. 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

6. 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

7. 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)

8. 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%

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

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

11. 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

12. 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?

13. 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

14. We’ve all done at least one PDSA

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

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

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

23. 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

24. 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

25. 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

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

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

28. Questions? ? ? ?

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

30. Agenda
Project Management
Process Mapping

31. 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

32. 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

33. 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

34. 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!”

35. 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

36. 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

37. 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

38. 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

39. 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

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

41. 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

42. 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

43. 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

44. 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?

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

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

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

48. 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

49. 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

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

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

52. Improve 52

53. 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

54. 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

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

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

57. 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

58. 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

59. Improve – always aim to….
Add value
Remove waste

60. Patient Journey Mapping

61. 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

62. 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!

63. 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?

64. 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?

65. 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

66. 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

67. Resources
Improving NHS Scotland:
Going Lean in Healthcare, Institute for Healthcare Improvement
HM Government, Customer Experience Mapping