Welcome to Core Skills 3

Objectives of the day Understand Systems and Processes –Process Mapping –Value Stream Mapping –Flow Understand the purpose, application and structure of the Model for Improvement To appreciate the importance of Measurement for Improvement

Understanding the Patient Journey Process Mapping and Flow Analysis

CONTEXT We design in the system capability ‘80% of the problem is in the system not the people’ Deming

Why Process Map?

Process mapping…. Views the system from the patient perspective following their journey across organisational boundaries Helps staff understand how complex and confusing processes appear to the patient Organisation specific Diagnostic and used as a basis for redesign, actively involving frontline staff in the process. (Shows how things actually are)

High level process map 6 – 12 steps –Generate in set time e.g. 20 minutes –Use to identify scope and identify problem –No rework loops and minimum complexity Low Level or 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 show effect of redesign

Appts. An Hospital Tertiary GP Cons - Cons AN other Hospital Appts. AN Hospital Register on System Consultant Secretary Consultant Screening Referral 1 – 3 days Consultant Secretary Appt. made Letter sent Patient Attends OPD Appts. AN hospital 1 – 3 days 1 Day -12 weeks GP Referral – Attend OPD Appointment High Level Map

Appts. An Hospital Tertiary GP Cons - Cons AN other Hospital Appts. AN Hospital Register on System Consultant Secretary Consultant Screening Referral 1 – 3 days Consultant Secretary Appt. made Letter sent Patient Attends OPD Appts. AN hospital 1 – 3 days 1 Day -12 weeks GP Referral – Attend OPD Appointment Increasing level of detail Low level Map

When undertaking a process map session think about!!!! 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

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

‘Ground rules’ for the Process Mapping workshop Everything is confidential Everyone has a valuable contribution to make Value the diversity of the group ‘Park’ issues Keep to time

Activity In groups try some process mapping… -Read through the instructions -Then take 20 minutes to map the process for Clinic B

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

Stage 2: Analysis

Analysing the process map How many steps in your process? How many duplications? How many hand-offs? What is the approximate time of or between each step? Where are possible delays? Where are major bottlenecks? How many steps do not add value for patients? Where are the problems for patients and staff?

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.

Functional Bottlenecks occur when a resource is used by more than one process

Look for Batching Dr sees patients individually Requests sent in batches Results return in batches

Identify examples of: 1- batching 2- bottlenecks 3- waiting 4- duplication Activity:

Examples bottlenecks All forms are returned to nearest centre Every patient appt is 30 mins 1 physio to triage referrals Phyllis multi-tasking / no cover for AL. batching GP dictating at end of day Mail picked up daily Phyllis had 10 appts to make Physio reading all referral letters at once

Examples waiting Referrals are posted on to the centre No cover while Phyllis on AL May 1st-May 4 th - 3 days to process referral. 1 st appt received on May 6 th – new appt sent out May 23 rd. duplication Electronic and paper systems Rebooking of patient appointment.

Walk the Patient Journey for yourself

Value adding The activity transforms the patient and moves them towards the next defined outcome The activity is something that the patient cares about Non-value adding Do not serve any purpose (aim to remove these) Necessary non-value adding Do not directly benefit patient but are necessary e.g. completion of forms, logging patient details onto systems, numerous checks of details Value / non-value adding steps

Non value added steps for patient

▲The process STOPS ▲Inhibits FLOW ▲Does not add value for the PATIENT ▲As a Clinician do you see the wait? Waiting

Waste Is a Sensitive Issue Its critical to eliminate “waste” Its also critical to recognise that the non value adding activities may have been a core part of someone job for many years It’s the activities that are non value adding not the person

Categories of Waste TransportMoving “stuff” InjuriesDamage to people MotionUnnecessary human movement Inventory“Stuff” waiting to be done WaitingPeople waiting for “stuff” to arrive Over processing“Stuff” we have to do but doesn’t add value Over productionProducing too much “stuff” Defects“Stuff” that’s not right and needs fixing StaffUntapped potential

Analysis Summary Steps Total number of steps Number of value steps Value steps as % of total steps e.g. 2/24 = 8% Time Total time Hrs:Mins Time of value steps Value Time as % of total time e.g. 40/119520=0.03% Waste Transport Injuries Motion Inventory Waiting Over processing Over production Defects Staff

Stage 3: Redesigning Processes

Focus on the future process Think creatively/generate ideas Focus on ideas and opportunities Are the right people involved? – whole system approach where needed

Defining patient groups Runners Specials Strangers Group of patients No. in each category within the group

Tools for defining patient groups RunnersSpecials Share common characteristicsCustomised High volumeLower volume Fast throughputPredictable Highly predictableShare some steps but require Standard –patient routesextra steps Up to 90% pre-scheduledCan be pre-scheduled Strangers Low volume, unique requirements Unpredictable demand pattern Route unpredictable and complex Throughput time tends to be longer

Opportunities for Redesign

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 Linked processes

Add value Remove waste Remember always aim to

Activity Read side 2 of the scenario At your table, answer the questions at the end of the scenario

Key elements to Process mapping Map what actually happens – most of time Time Lines Identify the types of waste? What value/waste is in the process? Include parallel processes Display the maps so all can see –Allow comments Don’t redesign for redesign sake

Discuss How you will go about doing this? Who will you ask to attend? When will you hold it? Where will you hold it? What obstacles might you face? How will you address them? What will your role be during the session? What will Mark’s role be? What will the outcome of the session be if it is successful?

Questions?