1. Using Process Mapping to Identify Improvement Opportunities
Presented by:
Rosmin Esmail and Tanis Rollefstad

2. 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
June 2007

3. 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
Any work that occurs within organizations, can be categorized into systems and processes. The next slides will explain what we mean by this.
June 2007

4. 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
A dictionary definition of a “system” is this………”a group of independent but interrelated elements comprising a unified whole”.
In other terms….all systems are made up of structure – the people that do the work, or the things that support the work being done. They are also made up of processes, or the steps that occur when people actually do the work. Finally, systems have outcomes, or end results. These end results can be good or bad, and are what happens when all the components of the system come together.
Source: NHS: - Working in Systems Plsek, 2000
June 2007

5. 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
Process
Inputs
Outputs
Source: NHS: Improvement Leaders’ Guide to Process mapping, analysis and redesign
June 2007

6. What is a process map?
A “picture” of a process, showing the connections and actual sequence of steps
Damn funny!
June 2007

7. 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
When a QI team comes together to complete a process map, it is often the first time they have ever discussed things as a group, and made the realization that things appear different than they first imagined.
The picture of the elephant refers to an old Fable from India where a group of blind men stumble across an elephant. Not realizing things are connected, or what they have come across, one man touches the elephants tail, and makes the conclusion that this “thing” must be a snake. Another man feels the elephants leg, and concludes that it must be a tree. Another feels the elephants side, and thinks that it must be a brick wall.
The point of this story is that our first perceptions, viewed or observed in isolation from each other, can often be misleading and inaccurate.
When a team comes together and sees the entire process from the eyes of others, and truly realizes how each small part relates to the whole, it can be a revolutionary moment! As the above quote from a QI team member states – “we all thought we knew how the system worked, but none of us had a clue”.
Source: NHS: Managing the Human Dimensions of Change
June 2007

8. Why use process maps? make work ‘visible’; common understanding
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
Process maps provide us with a visual representation of the steps involved in a particular process – they help to give us a picture of how we do our work.
June 2007

9. Common Symbols A Start End Beginning or end of a process
Off-page link to sub process
Process Step
System/ Database
Decision point
Process interaction
- direction of work
Document or file
Delay or wait state
Looping

10. 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
June 2007

11. Types of process maps Detailed flow chart (micro)
Cross functional map (deployment)
Relationship map (macro)
Increasing Detail
There are different types of process maps – these can vary from a very simple or birds eye view type map which may outline only a handful of steps, to a very complex and detailed version which may contain hundreds of steps.
June 2007

12. 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
The next slide provides a high level or birds eye view of the critical lab value communication process we have referred to before. This map is simple in nature, and includes seven distinct “steps” or sections.
June 2007

13. Day Surgery Relationship Map
Here is another example of a high level, birds eye view type map………
June 2007

14. 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
Cross functional maps illustrate the inter-relationship that often occurs between different departments. This type of map can often provide teams with the realization that they do not operate in isolation, and what they do (or don’t do) can greatly effect the next person, department or work area.
June 2007

15. Cross Functional Process Map

16. 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
June 2007

17. X X X X X X X X X X Client PHN Clerk Start – client enters service
New Client?
Start new chart or pull chart X X
Assess client
Existing services required?
Provide services X
Follow-up required? Arrange for f/u X X
Document in chart X
Send Chart to Clerk X
Enter into database X
Send back to program X
End – File Chart
June 2007

18. Then…….. Draw swim lanes on another piece of flip-chart paper
Label swim lanes with roles/departments
Place each Post-it Note in the appropriate swim lane
Draw arrows to indicate process flow
June 2007

19. Sample Cross Functional Map
Client
Community
Client enters
service
start
PHN/Outreach worker
New client?
yes
Start new chart no
Pull chart
Assess client
Existing services
required?
yes
Services
provided
Program X no
Follow-up
req’d?
yes
Arrange for f/u no
Document
in chart
Send chart
to clerk
File chart
end
Clerk
Enter into
database
Send back
to program
System
System
XYZ database
June 2007

20. Flow Chart
Document sequence of events e.g. investigating sentinel event
Most detailed map – shows process detail
Useful for process steps of single individual
This type of map gets into the fine details of a process, and can often become or appear very complicated! Don’t be afraid, though – process maps are your friends!
June 2007

21. Flowchart of Process of Obtaining Antibiotics from Pharmacy at FMC- May 28 2004

22. 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
June 2007

23. 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
June 2007

24. 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
June 2007

25. Using Process Maps Bottlenecks Delay Errors and work-arounds
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
June 2007

26. 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?
June 2007

27. Example of improvement – blood donation
Several additional steps are outlined in this process…….can you spot any of them?
The next slide will illustrate a simplified process.
June 2007
Source: The Improvement Guide. Langley et al. 1996

28. Example of improvement – blood donation
June 2007
Source: The Improvement Guide. Langley et al. 1996

29. Example of improvement – ovarian cancer clinic
Does this map represent an efficient process? Can you see any areas of duplication, or re-work? What would it feel like to be a patient who must navigate a process like this? What could be done to make it more efficient – and eliminate or combine a few of the steps?
Lets take a look at the next slide, and see what an improved process could look like.
Source: NHS: Improvement Leaders’ Guide to Process mapping, analysis and redesign
June 2007

30. Example of improvement – ovarian cancer clinic
Several inefficient steps have been removed from the initial process. The resulting process is simpler for the patient, and removes the “running around” that they previously had to do…..now, it is more like a “one-stop” shop.
Source: NHS: Improvement Leaders’ Guide to Process mapping, analysis and redesign
June 2007

31. 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
June 2007

32. 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
June 2007

33. Software
Low Tech Stickies
Visio
June 2007

34. Some Examples
June 2007

35. 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.
June 2007

38. “How can you possibly improve something unless you know how it works”

39. 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?
June 2007