process mapping and patient journey guide

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Understanding the Patient Journey
Process Mapping and Value
Stream / Flow Analysis

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Some context

• 80 of the problem is in the system not the
  people Deming
• We design in the system capability

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Why do Process Mapping?
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Process Mapping

• Views the system from the patient perspective
  following their journey across organisational
  boundaries
• Helps staff understand how complex and confusing
  processes are
• Diagnostic and used as a basis for redesign,
  actively involving frontline staff in the process

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Looking at patient processes

• 30 - 70 of work doesnt add value for patient
• up to 50 of process steps involve a hand-off,
  leading to error, duplication or delay
• no one is accountable for the patients end to
  end experience
• job roles tend to be narrow and fragmented

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Looking at patient processes

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High level
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Patient process and parallel processes
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Demonstrate complexity visually(chest x ray- 62
tasks, 12 hand offs)
x ray room
central office
radiologist office
start
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Remember the following...

• Define where the process starts and ends
• Consider who you would involve in the mapping
  exercise
• 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

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Analysing the Map

• 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?

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Consult sees report
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Hand offs
Nurse
X-ray
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Probability of Success, Each Process Step
No.
process
steps
0.95
0.990
0.999
0.999999
1
0.95 0.990 0.999 0.9999
25
0.28 0.78 0.98 0.998
50
0.08 0.61 0.95 0.995
100
0.006 0.37 0.90 0.99
Carol Haraden IHI
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Process bottlenecks

• occurs when a step is the limiting rate of the
• process
• The step takes a significant time, and slows the
• whole process down.

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Functional bottlenecks

• occur when a resource is used by
• more than one process

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Look for batching
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Opportunities for redesign
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When undertaking a Process Mapping session think
about

• Scope - where does the process start and where
  does it end?
• Who to involve in the mapping exercise?
• Decide the level of detail

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• 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

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Defining patient groups
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Tools for defining patient groups
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Conduct a high level analysis of the process
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Ground rules for the Process Mapping workshop

• Everything is confidential
• Everyone has a valuable contribution to make
• Value the diversity of the group
• Think creatively/generate ideas
• Focus on ideas and opportunities
• Park issues
• Keep to time

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Patient tracking

• Validate or challenge Process Map
• High volume runners
• Blank sheet to record process steps and true
  complexity of journey
• At least 25 patients to be tracked per high
  volume runner group

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Walk the patient journey for yourself
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What do we mean by patient flow?
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About patient flows

• Defined by process not clinical conditions
• Reflect systematic process steps required by the
• majority of patients (high volume groups),
  total length of journey and complexity across
  whole systems
• Apply the 8020 rule to redesign for maximum
  impact
• Consider patient need not service provision
• Ensures that you do not improve one part of the
  
  service at the
  expense of another

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Improving flow

• Understand the processes and the system
• Identify measures for improvement
• Simplify and standardise the process
• Control the variation
• Reduce the variation
• Make the system safe

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What is flow analysis?
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3 stages to flow improvement

• 1 - See the current state
• 2 - Analysis
• 3 - Take action to apply flow improvement
  principles

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• Stage 1
• Current state

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Flow Analysis Tool 4 elements

• Desegregation into
• process steps
• communication steps
• responsible clinically
• responsible for each part of the process

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Flow Analysis Tool Process steps
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Flow Analysis ToolInformation communication
steps
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Flow Analysis Tool Clinical responsibility
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Flow Analysis Tool Responsible for making each
part of process happen
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Flow Analysis Tool
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• Stage 2
• Analysis

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Understanding your map

• Add value
• Remove waste

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Quantifying value Value and non-value added
stepsValue added time v non-value added time
3
5
35
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Opportunities to remove waste

• Waiting
• Mistakes
• Uncoordinated activity
• Stock
• Transportation
• Motion
• Inappropriate processing

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Analysis summary

• Steps
• Total number steps
• Number of value steps
• Value steps as total steps
• Time
• Total time HrsMins
• Time of value steps
• Value Time as total time

• Waste
• Waiting
• Mistakes
• Uncoordinated activity
• Stock
• Transportation
• Motion
• Inappropriate processing

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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

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• Stage 3
• Take action to apply flow improvement principles

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Next - helping the value-adding steps flow

• 4 characteristics of smooth flow
• 1 Small batch sizes
• 2 Linked processes
• 3 Setting the pace
• 4 Overall co-ordination

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Linked processes

• Current processes often operate in isolation from
  each other, particularly departments and
  directorates
• Each area needs to be linked to the one before,
  to ensure that they always have capacity to deal
  with what they are receiving

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Linkages are important both within each
individual process... and between processes
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Setting the pace

• Key stages that need to be set or balanced are
  often identified by the value adding line
• For example - clinical assessment -
  investigations - clinical decision - admission -
  treatment - discharge

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Setting the pace
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Overall co-ordination

• Flows that have a single individual/team/area
  responsible for the whole flow from start to
  finish work best
• It makes clear the notion of the flow as the unit
  rather than each individual department as the
  unit
• This enables action to be taken at the place
  where problems are being experienced quickly

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Remember always aim to

• Add value
• Remove waste

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Questions?