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Using Process Mapping to Identify Improvement Opportunities Presented by: Rosmin Esmail and Tanis Rollefstad Improvement Associates Ltd. Purpose • By the end of this session, participants will have: – A better understanding of the tool – Experience in using the tool – Ideas on how to apply process mapping to clinical processes Improvement Associates Ltd. June 2007 2 Systems and processes “Every system is perfectly designed to get the results it gets. “If we want better outcomes, we must change something in the system. To do this, we need to understand our systems.” Don Berwick Improvement Associates Ltd. June 2007 3 What is a System? • Collection of parts and processes organised around a purpose • Health care organisations are – complex - many and varied relationships – adaptive systems - people in the systems can change in response to new conditions Source: NHS: www.modern.nhs.uk/improvementguides - Working in Systems Plsek, 2000 Improvement Associates Ltd. June 2007 4 What is a process? • A sequence of repeatable steps that lead to a desired end or output • All work is a process • Many processes are not designed – they evolve • 40- 60% of activity in a large complex process may be non – value adding Inputs Process Outputs Source: NHS: Improvement Leaders’ Guide to Process mapping, analysis and redesign Improvement Associates Ltd. June 2007 5 What is a process map? • A “picture” of a process, showing the connections and actual sequence of steps Improvement Associates Ltd. June 2007 6 Feels like an Elephant? “The thing that was astounding was the mapping. We all thought we knew how the system worked but none of us had a clue. Many times an hour my mouth was just falling open because I didn’t realize what a mess it was …” Lead Clinician Cancer Services Collaborative Source: NHS: www.modern.nhs.uk/improvementguides Managing the Human Dimensions of Change Improvement Associates Ltd. June 2007 7 Why use process maps? • Communication and understanding – – – – make work ‘visible’; common understanding show how work currently gets done serves as a training aid for new team members establish performance measures • Quality Improvement – identify risks, inefficiencies and improvement opportunities – standardize work processes, decrease variation • Process Redesign/Development – show how you want work to be done e.g. planning Improvement Associates Ltd. June 2007 8 Common Symbols A Start End Beginning or end of a process Process Step Off-page link to sub process System/ Database Decision point Boundary between roles Document or file Process interaction - direction of work Delay or wait state Looping Exercise (work on your own) • Choose a process you are familiar with e.g. getting to work in the morning • What are the steps? • Start=you get up • End=you are at work • What is the sequence? • Time (10 mins) • Report out Improvement Associates Ltd. June 2007 10 Types of process maps Increasing Detail • Detailed flow chart (micro) • Cross functional map (deployment) • Relationship map (macro) Improvement Associates Ltd. June 2007 11 Relationship Maps (Macro) • ‘High level’ organizational view of: – functions – what we do – inputs – e.g. where we get clients from – outputs – e.g. where we send clients, services provided • Facilitates understanding of the system and how/where one department fits with another Improvement Associates Ltd. June 2007 12 Day Surgery Relationship Map FP Office Surgeon’s Office Admitting Client in the Community Day surgery Recovery Room Improvement Associates Ltd. June 2007 Operating Room 13 Cross-functional maps Illustrate: • How work gets done in an organization across departments • Departments, functions, or roles that perform each step- people: process interface • Inefficiencies e.g. hand-offs Improvement Associates Ltd. June 2007 14 Cross Functional Process Map Physician Portable / Mobile X-Ray Process Start Assess patient condition, X-ray required DI General Duty Technologist PCU Clerk PCU Nurse Portable Order? Yes Change in Patient Condition or Routine Assessment Enter order in order entry system No Place order receipt in bin Assist with exam Use Page DI STAT for standard portable page if exam STAT request Phone PCU for more info Phone PCU to alert of arrival If not right after original page Pick up order receipt from bin Pick up mobile X-ray equip. Check in with pt’s nurse Complete exam 2 Creating a Cross Functional Map • Identify start/end points • Draw table on flip chart • Label columns with all departments/roles involved in process • List process steps on ‘Post-it Notes™’ • Place Post-it’s in order in first row of table • For each process step, place check mark in column of person/department responsible Improvement Associates Ltd. June 2007 16 Client PHN X Start – client enters service New Client? X X Start new chart or pull chart Assess client Existing services required? X Provide services Follow-up required? Arrange for f/u Document in chart Send Chart to Clerk X X X Enter into database Send back to program Improvement Associates Ltd. End – File Chart Clerk June 2007 X X X 17 Then…….. • Draw swim lanes on another piece of flipchart paper • Label swim lanes with roles/departments • Place each Post-it Note in the appropriate swim lane • Draw arrows to indicate process flow Improvement Associates Ltd. June 2007 18 Community Sample Cross Functional Map Client start Client enters service PHN/Outreach worker New client? yes Start new chart no Program X Pull chart Assess client Existing services required? Services provided no Follow-up req’d? no Document in chart Clerk System yes System Improvement Associates Ltd. June 2007 yes Arrange for f/u Send chart to clerk File chart Enter into database Send back to program XYZ database end 19 Flow Chart • Document sequence of events e.g. investigating sentinel event • Most detailed map – shows process detail • Useful for process steps of single individual Improvement Associates Ltd. June 2007 20 Flowchart of Process of Obtaining Antibiotics from Pharmacy at FMC- May 28 2004 Flow Chart of Process for Obtaining Antibiotics from Pharmacy at FMC-May 28, 2004 START Order Acyclovir (Antibiotic) on TDS in the ICU Order is printed in pharmacy and on computer in ICU immediately Order printed on printer in ICU and pharmacy. Pharmacy technician checks printer every 2 to 10 minutes DELAY in picking up order by pharmacy technician *Order states drug, dose, how to administer, it is a STAT, any allergies *STAT is highlighted on the bottom of page DELAY if entering pharmacy technician not there Entering pharmacy technician enters order in pharmacy system BDM *The hospital is divided up into 2 sides (ICU is side #2). Entering pharmacy technician signs order and puts it on the desk *Patient is looked up, patient bed, ID#, doctors name, drug selected, dose, labels are printed. Mixing pharmacy technician enters Mixing Pharmacy information in the technician makes computer in Word drugs in hood for labels, order filled in Notes: *Wash up = 10 1. Process for a STAT drug if it does not need to be made= ½ hour. mins 2. Process for a STAT drug if it does needs to be made=1 to 1½ hour. 3. Process for ASAP drug-deliveries made on the ½ hour every hour except *Clean hood=10 mins mornings (730, 8, 830, 9, 930). 3. Night cupboard-code phoned in, porter gets print out, porter gets drug from *Takes 5 to 10 cupboard (approximately 12 to 14 orders on average a night), and delivers drugminutes to make drug to unit. Pharmacist on call (called in once per week). 4. Days-five pharmacists until 11am, 4 pharmacists until 330, 3 pharmacists until 1030pm. Weekends-5 pharmacists until 11am, 4 pharmacists until 330, 2 pharmacists unitl 1030pm. 5. Six pharmacy techs during day (2 entering, 2 filling and 2 mixing techs, 6 pharmacy assistants). All can be different for each drug order. Number of techs varies at night and on weekends. 6. Most antibiotics in fridge or desk A, B in ICU. 7. Dispensary extremely noisy, chaotic, lots of people, inadequate room to fill, store, too many distractions, located in basement. Mixing pharmacy technician writes up order at table at back Pharmacist checks the order on TDS to make sure it is right i.e profile, check allergies, not interacting with anything, look up microbiology if resistant Pharmacist signs the order Order is taken to pharmacist to review and check Pharmacist may not be there DELAY Filling pharmacy technician picks up the order if it’s STAT DELAY in picking up order Mixing pharmacy technician making 2 to 3 drugs DELAY Filling pharmacy technician picks up the labels Filling pharmacy technician checks cupboard for Acyclovir Need to phone doctor? NO Pharmacist sticks a red flag for STAT on order and puts in grey box at entering pharmacy technician’s desk Pharmacist tries to find entering pharmacy technician to do this right away for STAT Filling pharmacy technician brings drug to front table and signs order Pharmacist checks drug and signs order. Order filed in pharmacy YES Pharmacist calls the doctor and clarifies-this can take up to 20 minutes to 1 hour DELAY Need to make drug? *Labels for IV and pills are printed on separate printers. NO YES Mixing pharmacy technician takes to filling pharmacy technician at front table Mixing pharmacy technician checks order, order filed Nurse administers drug to patient END DELAY in unit clerk telling nurse or take to bedside and no nurse there Filling pharmacy technician labels drug and signs order Pharmacy assistant puts STAT drug in blue box at desk A and tells unit clerk *Pharmacy assistant is paged by pharmacy technician. Arrives within 15 minutes STAT red flag removed and pharmacy assistant takes drug to ICU right away How to start mapping… • Determine intended use of process map – e.g. measurement, quality improvement, process re-design • Decide how to collect information – e.g. self generate,1 on 1 interviews, team interview • Select an appropriate team • Decide the level of map • Identify boundaries – start & end points Improvement Associates Ltd. June 2007 22 Steps • Agree to start & end points, customers, and measures • Agree to appropriate levels of detail. • Brainstorm process participants (if using cross-functional flowchart) • Brainstorm all possible activities, inputs, outputs and decisions using appropriate symbols • Sequence the steps Improvement Associates Ltd. June 2007 23 Steps • Use “swim lanes” to distinguish departments (if using a cross-functional flowchart) • Add arrows and symbols • Test for completeness by – comparing it with what is actually happening – asking content experts • Finalize the chart Improvement Associates Ltd. June 2007 24 Using Process Maps • • • • • • • • • Remember our Quality definition: right service for the right patient at the right time by the right provider with a minimum of waste and rework Bottlenecks Delay Errors and work-arounds Rework loops – to fix errors Role ambiguity - don’t know who… Cycle time – too long, variation Duplication - of data entry, work steps Unnecessary steps – non-value added for staff or client Inappropriate decision steps – too many steps or too many people making similar decisions Smith, M.L. BOLO (Be On Look Out) List for Analyzing Process Mapping. No date www.isixsigma.com/library/content/c040301a.asp Improvement Associates Ltd. June 2007 25 Analysis of Flowchart / Process Redesign • Can it be standardized? • Does every step or activity add value? • Is there duplication of work? • Are there invalid assumptions? • Is it possible to simplify? Improvement Associates Ltd. June 2007 26 Example of improvement – blood donation Donor arrives Donor is interviewed and fills out form Donor’s veins are checked in waiting room Rejected Veins OK ? Doctor evaluation occurs Yes Donor goes to donor room Phlebotomist checks veins Yes Health OK ? Yes Veins OK ? Rejected No No No Plasma drawn Rejected Redesigned Donor arrives Donor is interviewed and fills out form Rejected Doctor evaluation occurs and phlebotomist checks veins Health and veins OK ? No Donor goes to donor room Plasma drawn Yes June 2007 27 Source: The Improvement Guide. Langley et al. 1996 Example of improvement – blood donation Donor arrives Donor is interviewed and fills out form Donor’s veins are checked in waiting room Rejected Veins OK ? Doctor evaluation occurs Yes Donor goes to donor room Phlebotomist checks veins Yes Health OK ? Yes Veins OK ? Rejected No No No Plasma drawn Rejected Redesigned Donor arrives Donor is interviewed and fills out form Rejected Doctor evaluation occurs and phlebotomist checks veins Health and veins OK ? No Donor goes to donor room Plasma drawn Yes June 2007 28 Source: The Improvement Guide. Langley et al. 1996 Example of improvement – ovarian cancer clinic Clinic Hospital for ultrasound Clinic Hospital for blood test Clinic Hospital to see physician Hospital for chest x ray Simplication Clinic Hospital for blood test, ultrasound, chest x - ray Hospital to see physician Source: NHS: Improvement Leaders’ Guide to Process mapping, analysis and redesign June 2007 29 Example of improvement – ovarian cancer clinic Clinic Hospital for ultrasound Clinic Hospital for blood test Clinic Hospital to see physician Hospital for chest x ray Simplification Clinic Hospital for blood test, ultrasound, chest x - ray Hospital to see physician Source: NHS: Improvement Leaders’ Guide to Process mapping, analysis and redesign June 2007 30 Tips • Use a group knowledgeable about the process and interested in improvement • Use a facilitator • Don’t focus on solutions - keep a ‘parking lot’ for issues, solutions • Adopt ‘rough draft’ principle – get it down, then get it good • To clarify steps: go to the program and observe the process, consult with clients/staff Improvement Associates Ltd. June 2007 31 Tips • Use post-it notes for ease of mobility • Keep the flowchart simple using basic symbols • Be consistent with levels of detail • Ensure flowchart represents process as it really is, not how it ought to be • Use “verb noun” structure for activities Improvement Associates Ltd. June 2007 32 Software • Low Tech Stickies • Visio Improvement Associates Ltd. June 2007 33 Some Examples Improvement Associates Ltd. June 2007 34 Example: Dodek P et al. Translating family satisfaction data into quality improvement (Critical Care Med 2004 Vol. 32, No. 9) Figure 1. Key processes in patient/family/clinician interactions in the intensive care unit (ICU). This flowchart illustrates the general trajectory and possible outcomes for patients and families of patients in an ICU. Improvement Associates Ltd. June 2007 35 Outreach Documentation Attending Attending MD MD UnitRN RN Unit OutreachMD MD Outreach OutreachRRT RRT Outreach OutreachRN RN Outreach Pt. Assessment Interventions by Outreach Team 1. Enter STAT orders into SCM* Assess patient 2. Administer medications as ordered. Documentation 1. Document Code 66 call on the Tablet, including vital signs & fluids 2. Print out SBAiR form to leave on patient’s chart. 3. Document Meds administered on e-MAR in SCM 4. Document on Code Blue form as per Code Blue definition ♦ Provide pt. history Enter STAT orders into SCM* Work collaboratively with Outreach Team * Depending on patient condition any one of these 5 would perform this function. 08/02/2007 Recommendations 1. Enter recommendations into Outreach document. 2. Print out a copy of the SBAiR (recommendations are treated like a consult). 3. Place a copy of the recommendations (SBAiR) printout in MDPR section Distribution of documents 1. Print out SBAiR document from Tablet: leave copy on patient chart. Other When ordering meds retroactively, order all at once. Do NOT mark as “done”, but sign on e-MAR for actual time given. 2. Print out Code 66 sheet for ICU attending to review, and identify patients for follow-up. 3. Forward any paper documents to Outreach Coordinator after they have been entered into the Tablet. Document fld intake & output on flow sheet in SCM. (Any v/s completed by unit RN are documented in SCM 1. Review recommendations 2. If decision is to proceed with recommendations enter orders into SCM ♦ Code Blue When any of the following interventions are performed Code Blue documentation will be completed: 1. Chest compressions 2. Defibrillation 3. Electrical Cardio-version 4. Intubation 5. Assisted ventilation (including bagging for apnea, but not simply providing oxygen through a bagging unit) Wound Care (DRAFT) Physician Registered Nurse Wound Care Clinician Wound identified Complete wound assessment and initiate Wound Care Flowsheet No Implement VAC dressing protocol Wound pressure related? Wound pressure related? Advanced wound management required? Yes Wound identified Complete wound assessment Notify physician utilizing SBAR framework Assess wound Allied Health (OT, PT, RT) No Consult RN Yes No yes Consult OT/ PT/RT Does the wound appear infected? Develop care plan and reassess as indicated no Consult others as needed yes Swab wound for C&S Do I have the competencies to determine appropriate wound care? Culture positive? Yes Order appropriate antibiotics No yes no Apply appropriate dressing and initiate individualized careplan Consult wound care clinician using SBAR framework Assist with identifying appropriate dressing choices and in individualizing patient care plan Has wound resolved? No Reassess wound. Contact Physician and wound care clinician yes Discontinue wound care Follow-up as appropriate © 2007, BC Children’s Hospital, C&W “How can you possibly improve something unless you know how it works” Improvement Associates Ltd. Application (working in teams) • Identify a clinical process affected by the changes you are trying to introduce • What is the starting point? End point? • What are key activities (verb, noun)? • What is the sequence? • Create a flow chart of the process – Use a post-it note for each step – Find a large space on which to work – Leave symbols off until your steps are complete • Time: 20 mins • Report out-what worked well, what were challenges? Improvement Associates Ltd. June 2007 39