1. Process Mapping Midwest Cluster Phase 2 Conference Call January 16, 2007 Tracy Jacobs, RN, BSN Institute for Healthcare Improvement

2. Topics to be covered What is process mapping? What is process mapping? How is it done? How is it done? Why is it useful? Why is it useful? What constitutes waste and specific change ideas to deal with it What constitutes waste and specific change ideas to deal with it

3. What is a process? A continuous and regular action or succession of actions, taking place or carried on in a definite manner, and leading to the accomplishment of some result; a continuous operation or series of operations, Caulkin 1989 A continuous and regular action or succession of actions, taking place or carried on in a definite manner, and leading to the accomplishment of some result; a continuous operation or series of operations, Caulkin 1989 The care you provide is made up of dozens of separate - though integrated - processes. The care you provide is made up of dozens of separate - though integrated - processes.

4. What is process mapping? A process map is considered to be a visual aid for picturing work processes which show how inputs, outputs and tasks are linked It is the “most important and fundamental element of business process re-engineering” Anjard, 1998; Soliman, 1998

5. Process mapping steps Choose a process Choose a process –time consuming –error prone –critical to success Assemble a team Assemble a team Map out the way work is currently done Map out the way work is currently done Identify gaps first, then work on problem areas (waste) Identify gaps first, then work on problem areas (waste) Keep in mind the goal of the process Keep in mind the goal of the process Brainstorm solutions Brainstorm solutions –develop PDSA cycles

6. Process Mapping Using the Flip Chart Paper Approach Shows the “Big Picture” Shows the “Big Picture” Describes a process as it works today; an “as-is” model Describes a process as it works today; an “as-is” model High touch, low-tech High touch, low-tech Identifies gaps, strengths and opportunities Identifies gaps, strengths and opportunities Captures the complexity and disconnects of key operational issues Captures the complexity and disconnects of key operational issues Identifies outside areas involved in the process Identifies outside areas involved in the process

7. Benefits Highlights gaps in care Highlights gaps in care Puts a spotlight on problems (waste) Puts a spotlight on problems (waste) Streamlines work processes Streamlines work processes Promotes deep understanding Promotes deep understanding Defines and standardizes the steps and sequence Defines and standardizes the steps and sequence Builds consensus Builds consensus

8. Patient given FOBT cards RN enters patient name and date into log (in lab) Returned cards are processed by lab staff and results entered into log Lab gives results to PCP immediately. PCP calls and refers for colonoscopy Positive? Results notification mailed No Yes RN schedules appointment But what about….?

9. Patient given FOBT cards RN enters patient name and date into log (in lab) Lab gives results to PCP immediately. PCP calls and refers for colonoscopy Positive? Results notification mailed No Yes Log checked q 2 weeks for follow up phone calls needed Returned cards are processed by lab staff and results entered into log RN schedules appointment and places reminder in tickler file Medical records checks tickler and calls for results; reports no-shows to RN Gaps addressed: 1.Follow up for FOBT cards that have not been returned 2.Ability to track if patient received colonoscopy and get results and plan to PCP

10. What is waste? Everything that does not bring value to the patient Everything that does not bring value to the patient In health care organizations, up to 40% of all cost may represent waste and in most systems; 60% of activities add no value In health care organizations, up to 40% of all cost may represent waste and in most systems; 60% of activities add no value

11. Seven Forms of Waste Overproduction---Producing more than needed or producing faster than needed Overproduction---Producing more than needed or producing faster than needed Waiting---Time when a person is idle Waiting---Time when a person is idle Transportation---Any movement of material or information not essential for the process Transportation---Any movement of material or information not essential for the process Processing---Operations that in reality do nothing Processing---Operations that in reality do nothing Inventory---Anything more than immediate needs Inventory---Anything more than immediate needs Motion---Motion of man or machine that is unnecessary Motion---Motion of man or machine that is unnecessary Defects---Anything requiring correction, rework or inspection Defects---Anything requiring correction, rework or inspection

12. Waste Analysis (a foray into the Value Stream) Explore your flow through the lens of each type of waste: Explore your flow through the lens of each type of waste: –Overproduction-examples of staff waiting –Waiting-where are there bottlenecks causing waits –Transportation-where do you move materials or information unnecessarily –Extra processing- which steps can be eliminated –Inventory-where are supplies unnecessarily stored; stock levels –Motion-draw the actual movement of staff and patients –Defects-what errors or delays can occur at each step

13. Post-it Notes Patient walks in and introduces himself. Staff asks patient to sign log Step # 1 Who: Registration Clerk Jones Time: 30 seconds Value/NVA: NVA

14. Change concepts to address waste Standardize the environment Standardize the environment Drive work away from the constraint* Drive work away from the constraint* Find and remove bottlenecks* Find and remove bottlenecks* Move process steps closer together Move process steps closer together Eliminate unnecessary process steps* Eliminate unnecessary process steps* Use technology Use technology Synchronize clinicians, patients, and information* Synchronize clinicians, patients, and information*

15. Drive work away from the constraint Disruptions and distractions Disruptions and distractions Work someone else can perform Work someone else can perform Waiting for x-rays, reports, etc. Waiting for x-rays, reports, etc. Searching for supplies Searching for supplies Waiting to get patients in rooms Waiting to get patients in rooms Getting off-track with certain patients Getting off-track with certain patients

16. Find and remove bottlenecks People People Facility/space Facility/space Paperwork Paperwork Re-work Re-work Equipment/supplies Equipment/supplies

17. Eliminate unnecessary process steps Checking another’s work Checking another’s work Multiple sign-offs Multiple sign-offs Making multiple copies Making multiple copies Redundancy Redundancy Patient path Patient path

18. Synchronize patients, providers, and information Start the first appointment of the day on time Start the first appointment of the day on time Check charts for completeness in advance Check charts for completeness in advance Use standard checklists for supplies Use standard checklists for supplies System should have the patient ready before the PCP walks in System should have the patient ready before the PCP walks in Use technology prompts to anticipate potential needs Use technology prompts to anticipate potential needs Use huddles to plan as well as make mid-course corrections Use huddles to plan as well as make mid-course corrections

19. Map a process Use one sticky note for each step in the process Use one sticky note for each step in the process Write down what happens in each step at who does it Write down what happens in each step at who does it Place arrows to illustrate the flow of the steps Place arrows to illustrate the flow of the steps Map first, then go back and begin to review the process Map first, then go back and begin to review the process Identify missing steps and problem areas (waste) Identify missing steps and problem areas (waste) Brainstorm ideas to impact the problem areas identified (use the “Key Questions for Evaluating Process Steps”) Brainstorm ideas to impact the problem areas identified (use the “Key Questions for Evaluating Process Steps”) Evaluate the ideas, then decide on one or two to start with Evaluate the ideas, then decide on one or two to start with Develop PDSA cycles to run when you return to your clinic Develop PDSA cycles to run when you return to your clinic

20. Remember: Look through the patient’s eyes for value Observation “through the patient’s eyes”Observation “through the patient’s eyes” Details to look for:Details to look for:  Patient’s time with staff  Facility barriers & equipment inadequacies  Paperwork  Duplication and re-work: questions/processes  Handoffs that may reduce continuity  Where waits occur

21. The results Elimination of errors or gaps in care Elimination of errors or gaps in care Increased efficiency that optimizes resource use and minimizes waste Increased efficiency that optimizes resource use and minimizes waste Allows for substitution of processes that add value to the patient in place of those that don’t Allows for substitution of processes that add value to the patient in place of those that don’t Leads to more time for the productive patient interactions of planned care Leads to more time for the productive patient interactions of planned care

22. PurposeWhat?What is done?Eliminate Why?What is the purpose? Is the purpose accomplished? Why is it necessary? What if it were eliminated? What would make it unnecessary? Combine Rearrange PlaceWhere?Where is it performed? What alternate locations are viable? Can the departments be reorganized? SequenceWhen?What other sequences would work? Can it be combined with another event? What are the implications of other sequences? PersonWho?Who performs the task? Who else could perform it? MeansHow?What other methods are available? What other process technologies exist? Can smaller scale processes be used? Simplify Key Questions for Analyzing Process Steps

23. Questions?