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)
Process has inputs and outputs
Input OutputProcess
Definition - a process is a series of connected steps or actions to achieve an outcome
A
Diagnostic process
B
Looking at Patient Processes
C D E
• 30 - 70% of work doesn’t 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 patient’s “end to end” experience
• job roles tend to be narrow and fragmented
Organisational /departmental boundaries
Emergency care process
Treatment process
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 HospitalAppts.
Appts.AN
Hospital
Register on
System
Consultant Secretary Consultant Screening
Referral1 – 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 HospitalAppts.
Appts.AN
Hospital
Register on
System
Consultant Secretary Consultant Screening
Referral1 – 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 sessionthink 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?
Jim goes to see GP
Secretary posts letter and referral form
Jill reads through the referrals
Places referral letter into
appropriate box
Jim receives new appointment
Jim attends appointment
Community Physiotherapy scenario – high level process map
12 weeks
Keys to mapOrange high level steps
Yellow steps added value steps for patient
Jim attends GP on May 2nd
Jim attends physio on July 22nd
12 weeks for whole process
Total process time =83 days= 119520 mins
Value added time for patient= 40 mins (appt time with GP and Physio)
Community Physiotherapy scenario – detailed process map
Jim phones for GP
appointment
Jim goes to see GP
Jim goes home
GP dictates letter to physio
Surgery secretary types up
dictated letter
Secretary prints out
physio referral form
Secretary completes
physio referral form
Secretary posts letter and referral
form
Mail picked up at end of
day
Letter and referral form
arrive at Centre B
Jill reads through the
referrals
Jill gives referrals to
Phyllis
Phyllis types Jim’s details
into computer
Enters details into an electronic diary
Enters details into a paper diary
Places referral letter into
appropriate box
Letter goes into post
Phyllis adds appointment time
to letter
Phyllis prints off appointment letter
Jim receives appointment letter
Jim calls up to change
appointment date
Phyllis sends out new appointment
Jim receives new appointment
Jim attends appointment
Keys to mapTotal process steps - 24
Orange high level steps -6 Yellow steps added value steps for patient- 2
1 working day See next arrow
1-2 working days 2 working days 1 working day
17 days 59 days
Jim attends GP on May 2nd
Jim attends physio on July 22nd
12 weeks for whole process
??
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- batching2- bottlenecks3- waiting4- duplication
Activity:
Examples bottlenecks All forms are returned to nearest centreEvery patient appt is 30 mins1 physio to triage referralsPhyllis multi-tasking / no cover for AL.batchingGP dictating at end of dayMail picked up dailyPhyllis had 10 appts to makePhysio reading all referral letters at once
Examples
waitingReferrals are posted on to the centreNo cover while Phyllis on ALMay 1st-May 4th- 3 days to process referral. 1st
appt received on May 6th – new appt sent out May 23rd.
duplicationElectronic and paper systemsRebooking 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
Jim goes to see GP
Secretary posts letter and referral form
Jill reads through the referrals
Places referral letter into
appropriate box
Jim receives new appointment
Jim attends appointment
Community Physiotherapy scenario – high level process map
12 weeks
Keys to mapOrange high level steps
Yellow steps added value steps for patient
Jim attends GP on May 2nd
Jim attends physio on July 22nd
12 weeks for whole process
Total process time =83 days= 119520 mins
Value added time for patient= 40 mins (appt time with GP and Physio)
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 WasteTransport Moving “stuff”
Injuries Damage to people
Motion Unnecessary human movement
Inventory “Stuff” waiting to be done
Waiting People waiting for “stuff” to arrive
Over processing “Stuff” we have to do but doesn’t add value
Over production Producing too much “stuff”
Defects “Stuff” that’s not right and needs fixing
Staff Untapped potential
Analysis SummaryStepsTotal number of stepsNumber of value stepsValue steps as % of total
steps e.g. 2/24 = 8%
TimeTotal time Hrs:MinsTime of value stepsValue Time as % of total timee.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 e
ach
cate
gory
with
in th
e gr
oup
• Tools for defining patient groups
Runners SpecialsShare common characteristics CustomisedHigh volume Lower volumeFast throughput PredictableHighly predictable Share some steps but requireStandard –patient routes extra stepsUp to 90% pre-scheduled Can be pre-scheduled
StrangersLow volume, unique requirementsUnpredictable demand patternRoute unpredictable and complexThroughput 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?