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
Process
Output
Definition - a process is a series of connected
steps or actions to achieve an outcome
Looking at Patient Processes
• 30 - 70% of work
doesn’t add
value for patient
• up to 50% of
process steps
involve a “handoff”, 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
A
B
C
D
Emergency care process
Diagnostic process
Treatment process
E
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
GP Referral – Attend OPD Appointment
Referral
1 – 3 days
1 – 3 days
Tertiary
GP
Cons Cons
Appts.
AN
Hospital
Register
on
System
Consultant
Secretary
Consultant
Consultant
Secretary
Screening
Appts. An
Hospital
High Level Map
1 Day -12 weeks
AN other
Hospital
Appts.
Appts.
AN
hospital
Appt.
made
Letter
sent
Patient
Attends
OPD
GP Referral – Attend OPD Appointment
Referral
1 – 3 days
1 – 3 days
Tertiary
GP
Cons Cons
Appts.
AN
Hospital
Register
on
System
Consultant
Secretary
Consultant
Consultant
Secretary
Screening
Appts. An
Hospital
Increasing level of detail
Low level Map
1 Day -12 weeks
AN other
Hospital
Appts.
Appts.
AN
hospital
Appt.
made
Letter
sent
Patient
Attends
OPD
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?
Community Physiotherapy scenario – high level process map
12 weeks
Jim goes to see
GP
Secretary posts letter
and referral form
Jim attends GP on May 2nd
Jim attends physio on July 22nd
12 weeks for whole process
Jill reads through
the referrals
Places referral letter
into
appropriate box
Keys to map
Orange high level steps
Yellow steps added value steps for patient
Jim receives new
appointment
Jim attends
appointment
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
??
1 working day
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
See next arrow
Secretary
completes
physio referral
form
Secretary
posts letter
and referral
form
Mail picked
up at end of
day
1-2 working days
Phyllis types
Jim’s details
into computer
Enters details into
an electronic diary
Enters details into
a paper diary
17 days
Phyllis sends out
new appointment
Phyllis prints off
appointment letter
2 working days
Phyllis adds
appointment time
to letter
Places referral
letter into
appropriate box
59 days
Jim receives new
appointment
Jim attends GP on May 2nd
Jim attends physio on July 22nd
12 weeks for whole process
Letter and
referral form
arrive at
Centre B
Jim attends
appointment
Keys to map
Total process steps - 24
Orange high level steps -6
Yellow steps added value steps for patient- 2
Letter goes into
post
Jim receives
appointment letter
Jill reads
through the
referrals
Jill gives
referrals to
Phyllis
1 working day
Jim calls up to
change
appointment date
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
Activity:
1234-
Identify examples of:
batching
bottlenecks
waiting
duplication
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 4th- 3 days to process referral. 1st
appt received on May 6th – new appt sent out
May 23rd.
duplication
Electronic and paper systems
Rebooking of patient appointment.
Walk the Patient Journey for
yourself
Value / non-value adding steps
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
Community Physiotherapy scenario – high level process map
12 weeks
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
Non value added steps for patient
Jim attends GP on May 2nd
Jim attends physio on July 22nd
12 weeks for whole process
Keys to map
Orange high level steps
Yellow steps added value steps for patient
Total process time =83 days= 119520
mins
Value added time for patient= 40 mins
(appt time with GP and Physio)
Waiting
▲The process STOPS
▲Inhibits FLOW
▲Does not add value for the PATIENT
▲As a Clinician do you see the wait?
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
Transport
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 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
No. in each category within the group
Defining patient groups
Group of patients
• Tools for defining patient groups
Runners
Specials
Share common characteristics
High volume
Fast throughput
Highly predictable
Standard –patient routes
Up to 90% pre-scheduled
Customised
Lower volume
Predictable
Share some steps but require
extra steps
Can be pre-scheduled
Strangers
Low volume, unique requirements
Unpredictable demand pattern
Route unpredictable and complex
Throughput time tends to be longer
Opportunities for Redesign
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
Remember always aim to
Add value
Remove waste
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?