Process mapping

A guide for health service staff Victorian Quality Council June 2007

Index
Introduction What is process mapping? Process mapping as a quality improvement tool Benefits of process mapping How to conduct process mapping Decide on process to be mapped and the project aim Define the scope of the process Select the working group Conduct the mapping meetings Document the current process Analyse the existing process Determine action required and draw the new process map Implement the new process and complete the quality cycle messages Key messages about process mapping Appendices Appendix 1: Glossary Appendix 2: Model for improvement Appendix 3: Tips for the process mapping project leader Appendix 4: Examples of process maps Appendix 5: Flowcharts Appendix 6: Additional questions for use in analysis References 11 12 13 15 17 18 19 3 3 4 4 5 5 6 6 7 8 9 9 10 10

Introduction
The need to constantly improve the quality and safety of services delivered to consumers is well recognised in health care. However, it is not always easy to know exactly how best to bring about improvement. Having a variety of methods, or quality improvement tools, to guide activities, can make the process simpler and more logical for all involved. Process mapping is one such improvement tool. As the name suggests, it is used to look at processes, so they can be better understood, simplified and improved. An engineer, Frank Gilbreth, invented the original process mapping system in the early 1900s. It is a particularly valuable tool for use in health in that:

health care delivery is complex and involves multiple, interlocking processes. service processes have had to adapt quickly as practices changed and organisations grew or were reorganised: in these circumstances, quick-fix solutions have often been put in place, rather than fully planning new processes. most processes involve multiple professional or service groups. there is rarely one owner of a process. very few individuals get to see the entirety of a process, although consumers will usually get to see more than most!

Therefore, any method that helps us to assess process is likely to be a useful improvement tool. This paper is designed to assist anyone who wishes to review processes in their workplace, using a structured approach. It:

outlines basic process mapping steps provides suggestions on how some commonly experienced problems might be overcome provides some simple examples of process maps.

What is process mapping?

Process mapping involves developing a simple visual picture, or map, of a process. It is a relatively simple tool that can help an organisation better understand how parts of the organisation work, and assist with analysing how it could work better. Any process can be mapped. For example, the process of seeing a new movie involves a number of steps: Decide to go to movies Review movie options and select movie Drive to cinema Purchase ticket

View movie Leave cinema

Process mapping as a quality improvement tool

Process mapping must be considered within a quality model or framework (refer to Appendix 2 for a simple model) to actually bring about improvement. This will help ensure the project is worthwhile and effective and hence ensure valuable use of time and energy. It also means a number of steps beyond the simple mapping of a process are required. Key aspects of the quality framework as they relate to process mapping are covered in this paper. For more detailed information, refer to the Victorian Quality Councils A safety and quality framework for Victorian health services (2005).

Benefits of process mapping

In most settings, health care delivery is complicated and requires input from a range of personnel. This can lead to a situation where each team member focuses on the steps for which they are responsible. Process mapping allows us to see the whole picture. Process mapping can help teams to:

develop a complete, shared understanding of a process document, as simply as possible, the steps or actions involved in the process (process map) determine if the current process is the best it can be highlight areas for improvement.

Particular benefits of process mapping include:

helping to focus on how the end customer (patient/user) views the process; this is particularly important as it may be the first time the whole team realises how complicated the process is from the patient's/users perspective taking a holistic approach, helping explore the inter-relationships of the process and those within it helping the team to understand what is actually happening, rather than what individuals thought was happening providing an opportunity for staff, who may not normally have an opportunity, to express their views clarifying responsibilities and ownership highlighting departments or specialists needed to complete key tasks such as decision-making, conducting tests or completing forms assisting staff to understand how they contribute, which can instil pride and highlight areas for improvement assisting to identify how resources are used assisting to identify inefficiencies and how to eliminate them

providing baseline data for measuring how well any changes implemented have worked.

The limitations of process mapping generally relate to project implementation; selecting a process that is not a priority to most of the team, selecting too large or too small a process, not involving key staff members, and poor planning or failure to evaluate the impact of process changes. Hints on how to overcome these issues are dealt with throughout this paper.

How to conduct process mapping

There are a number of critical steps in process mapping. As with most processes, if any step is overlooked, problems are likely to arise.

Decide on the process to be mapped and the project aim

What to map is often one of the most difficult decisions to make. When selecting a process to improve, it is useful to ask questions commonly used when setting priorities for any other quality improvement activity. This initial set of questions is likely to generate a list of processes that could be analysed.

What do we do a lot (high-volume work)? Where and when have things gone wrong for patients or services, adverse events? Patient outcomes are less than desired or expected, based on the literature or experience. What do patients complain about? What creates problems for staff? Where do we think resources are wasted?

Once a list of possible processes is generated, further questioning can help decide on the best process to select. Consider the following for each process.

To whom is it a priority? Why is it a priority? How will we know if the process is improved? How much difference will it really make to those involved? How committed is the team to the topic and to change, particularly the key stakeholders? Will it actually be possible to make any identified necessary changes? What will it take to improve in terms of resources, money, time, skills and effort, and do we have these resources?

Once the process has been decided, the aim of the mapping process needs to be determined. This could include:

decreasing same-day cancellations of elective surgery due to patient unfitness for surgery by 50 per cent decreasing average patient wait time in radiology by 15 minutes increasing the speed of diagnosis for those with suspected bowel cancer by one day.

All of these aims have specific targets. Not all teams will have enough information to set targets initially. However, as more information comes to light, it is useful to set specific targets as this helps choose the most appropriate changes to implement.

Define the scope of the process

It is clear that many processes overlap and intercept. However, to successfully map any process, boundaries must be established, with a clear starting point and a defined endpoint. This is known as the scope. The scope will largely be determined by the overall project aim. Getting the scope right is important. If the boundaries are not clear, the map may never be complete as more and more tasks or steps are examined. If the process selected is too large:

the exercise will become too complicated it will be difficult to keep on track it may prove too difficult to come up with specific areas for improvement it will take too long and those involved could lose interest.

If the process selected is too small:

the exercise may appear trivial the team may be tempted to jump to conclusions about required solutions it may be difficult to demonstrate any worthwhile improvements.

However, when first starting to do process mapping, it is usually better to choose a smaller, well-defined process.

Select the working group

As with all improvement activities, it is useful to have a project sponsor or champion This is usually a champion. senior person who:

sanctions the mapping activity, including time and resource allocation, and supports required changes can engage others or encourage active participation can facilitate links to others outside the mapping team can handle any power issues conveys support and allays any fears.

Another key role is project leader They must have sufficient time and be able to manage and lead the leader. team. Some suggested specific tasks for the project leader are outlined in Appendix 3. Selecting the mapping team can now begin. Inclusions will depend upon the selected process, the scope, and the staff groups involved in the process. There is generally a balance required between keeping the group size to a manageable number (group sizes of between eight and 12 work best) and having appropriate representation from all key stakeholders. It is also critical to ensure managers are 6

actively involved in the selection process. The most important thing to understand is that the people who work in the process should do the mapping. How consumer input will be gained should also be considered. This could range from including consumers as a central part of the mapping team from the beginning, to seeking their input at specific stages such as when the initial map is completed, or when the draft map of a redesigned process has been developed. Ensuring all members of the mapping team are clear about their role before they agree to become part of the team is useful.

Conduct the mapping meetings

Apart from having someone to plan and facilitate these meetings (refer to Appendix 3 for more specific tips for the project leader), the next major decisions to make are:

how long should the meetings be? how many meetings will be needed?

This depends on:

the process to be mapped and its scope the current knowledge of how things work any data or information available how much change may be required.

However, a rule of thumb would be that it takes half a day to map a process, then another four hours to analyse the process, suggest and test changes, remap the changed process, and agree on procedural changes. This relies on the project leader being able to complete much of the support work outlined in Appendix 3. Most of the meetings can be quite short. However, the initial meeting to try to map the process generally needs to be at least two hours. If there are difficulties getting the team together for this length of time, consider revisiting:

the process selected - is it of sufficient importance to invest time and energy? the project sponsor - have they made it clear how important this project is, and how valued each team members input is? the team selection - have the right people been chosen? the planning - have practical issues such as providing enough lead time for meetings, position back-fill and the timing of meetings been considered?

If, after addressing all of these potential stumbling blocks, time commitment is still an issue, it is possible that shorter meetings with small numbers of the team may provide enough input. However, it will generally take more overall meeting time as the map has to be redrawn and adapted after each of these meetings and then represented to the remainder of the team.

Document the current process

Before commencing the more detailed mapping process, it can also be useful for the team to do the following:

Draw a high level map (the big picture) - putting the whole process on a single piece of paper gives the team an idea of the process parameters. This can then be used to determine if the mapping process is getting off track. Draw a picture of the ideal process - if you were starting a new service, with no constraints, how would this process work? When the process has been remapped, it is interesting to compare it with this initial ideal process.

There are three critical issues to keep in mind in this stage: 1. Map the process as it actually occurs, not how it is supposed to happen or how the team may want it to happen. This is when many of the team are surprised by what actually does happen! It is also important that no fault-finding occurs in this stage. Remember, this is about trying to fix problems, not add to them. 2. Make sure the map is the simplest possible picture of how the process works. The aim of process mapping is to make things clear. There is generally no need to use complex symbols and shapes or computer-generated pictures (these will often distract the team), simple boxes and arrows are all most processes require. 3. The questions asked when mapping and what happens after mapping are what matter. There is questions value in adding any observations or data about times, volumes, or bottlenecks on the map. As questions get asked, and data gathered, the map will have to be drawn and redrawn a number of times. Hence, one of the best ways of beginning the more detailed map is to use Post-it notes, arranged on a wall. For this process:

get team members to write their own steps or activities. only put one step on each Post-it note. the notes can also be colour-coded for different functions, professional groups and tasks. get the person who wrote the note to place it where they think it comes in the process. add to the steps and rearrange as the teams discusses what they know about the process.

Alternatively, teams can work on paper or a white-board. The important thing is to make sure everyone is involved and the steps are being recorded in a logical sequence. It is important to recognise when the map is complete, as there is a risk that too much detail will stall the group. The team will need to agree when they believe the majority of the key steps have been mapped and that they have a sufficient picture to begin analysing the process. Examples of some simple process maps are included in Appendices 4 and 5.

Analyse the existing process

At this stage the team has established what is happening in the process as opposed to what they thought was happening. The team now has to be prepared to ask questions that challenge the status quo and be prepared to change ( see the VQCs Successfully Implementing Change, 2006). The team will need to ask the following questions:

Could this be simpler, faster, less confusing, or more efficient? If a colleague from a similar service or a customer observed the event, would they feel it was working in the best way? Could this be changed to improve outcomes? Are there any unnecessary steps? Are there any obvious bottlenecks or points where things slow down? Are there any steps where errors tend to occur? Is the care or service being given at the right time, in the right place and by the right person? Are there times when the process works better than others? Why? How? How should the process work, what should it look like? How can the problems identified above be overcome?

Appendix 6 has a number of additional questions that teams may find useful.

Determine the action required and draw the new process map
Once the team agrees on the answers to the above questions, the process can begin to be redesigned to meet the project aims. Key questions for the team to discuss and come to consensus include the following.

What can we change? Are there any risks in changing the process? What changes will make the biggest impact? Who will the changes impact on most? If steps are changed, could there be a positive or negative impact on other processes? Will the change be worth it?

When the required changes have been agreed upon, the new process can be mapped and an implementation plan determined. Note: It is important to redraw the map, as it will highlight any potential problems in the proposed new process. It also provides an important tool when discussing proposed changes with the remainder of the team and when the project is being evaluated.

Implemen complete Implement the new process / changes and complete the quality cycle
Once the team has agreed on the changes, the remainder of the quality improvement cycle must be completed (keeping in mind change implementation strategies). This includes: standardise the new way of working and develop new procedures implement the changes evaluate the changes celebrate what has been achieved continue to look for ways to improve the process.

Key messages about process mapping

Process mapping is not difficult! Process mapping allows teams to understand the whole process not just the parts with which they are familiar. The most value comes from honestly describing what is happening and then seeking ways of improving it. The least value comes if individuals or departments are blamed or criticised. Process mapping is just one of the many improvement tools and techniques available. Process mapping is fun and it is immensely satisfying when the impact of the improved processes is seen!

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Appendix 1: Glossary
Flowchart a map of a process that uses conventional symbols to represent different activities (refer to Appendix 5 for an explanation of the symbols used) an event or circumstance which could have resulted, or did result, in unintended or unnecessary harm to a person and/or a complaint, loss or damage a series of connected steps or actions to achieve an outcome or a result a visual depiction of a process the steps involved in developing an understanding of a process and developing a process map the starting and end point of the process to be examined those people and organisations who may affect, be affected by, or perceive themselves to be affected by, a decision or activity

Incident*

Process Process map Process mapping

Scope Stakeholder*

System improvement* the result or outcome of the culture, processes and structures that are directed towards the prevention of system failure and the improvement in safety and quality * Runciman W B, 2006

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Appendix 2: Model for improvement

Planning for how are we going to achieve the change should be done at the same time as planning who or what is involved. During planning, the indicators of success should answer the question: How will we know it worked? As well as showing the intended and unintended impact of the change, it can demonstrate if the resources, time and energy invested represent value for money. Ongoing evaluation can demonstrate the extent to which changes have been sustained. (NHS Managing the human dimensions of change, 2005) A commonly used model for improvement is the IHI model, also known as the Nolan model and modified from quality improvement leaders including Deming and Juran.

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Appendix 3: Tips for the process mapping project leader

Role of the project leader
The process mapping project leader should be able to:

lead, support and encourage the team project manage the process including developing the plan, organising and leading the mapping meetings, ensuring deadlines are met and communication maintained.

The process mapping project leader should be able to provide specific support through working with managers and other key people to:

decide the process to be mapped and the project aim define the scope of the process develop a project plan gather available data in preparation for any meetings identify key people for the mapping team conduct the mapping meetings document outcomes from the meetings and other activities including drafting reconfigured process map investigate implications of proposed changes and seek agreement from managers and other affected parties draft, re-write procedures ensure implementation of agreed changes evaluate the project.

Tips for process mapping team facilitation ocess

Be prepared by:

making sure everyone who should be in the team has been invited in enough time (at least a month in advance), has sent an RSVP, has been reminded making sure all invitees are clear about what is happening and why, why they are coming and what will be expected of them planning the meetings. It is important to understand that, especially in the early meetings, there will be a lot of discussion. Hence, set realistic expectations on what can be achieved gathering any available data and information eg how long does it take for patients to be given test results (average, best-case, worst-case). If possible, with one or two other team members, walk through a process, talking to people who work in the process, seeing what actually happens prepare the materials (butchers paper, white-boards, pens, Post-its, refreshments) and the room

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During the session, ensure you:

confirm the process to be mapped, including project aim, scope and identify any specific targets to be met either for that day or for the project stay focused on the problem and the scope follow the brainstorming rules (below) ensure that no train of thought is followed for too long encourage people to develop other's ideas or use other ideas to create new ones summarise what has been accomplished and what happens next stick to the time allocated, start on time and finish on time(people will get used to it).

Follow up by:

clarifying the next actions, meeting time writing brief notes from the meeting, including process mapped to date and homework any members are to do reminding the team of homework and next meeting sharing the map or findings with the rest of the team once you have a draft.

Brainstorming
Brainstorming is a technique that attempts to create an environment in which team members ideas are able to build and bounce off each other. It uses the experience and creativity of all members. When individual members reach their limit, another member can take the idea to the next stage. Brainstorming in a group can be risky for individuals. Some useful rules are:

ensure participants come from a wide range of disciplines - this brings broad experience and increases creativity ensure that no one criticises or evaluates ideas during the session, encourage an enthusiastic, uncritical attitude in the group try to get everyone to contribute, including the quiet members let people have fun encourage people to raise as many ideas as possible, from solidly practical to wildly impractical build and bounce appoint one person to note ideas on a flip chart study and evaluate after the initial brainstorming session, not during.

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Appendix 4: Examples of process maps

elective Example 1: Patient deemed fit for elective orthopaedic surgery
It is known in your hospital that there are a frustratingly high number of cases where the patient is deemed unfit for elective orthopaedic surgery only once they have been admitted to the ward. Your team decides to investigate the process as it currently occurs. Note, you have limited the scope to steps related to their fitness for surgery and chosen not to examine all the other aspects of their admission. This helps to focus on how this particular problem could be improved. Patient assessed in orthopaedic clinic as fit for surgery Patient booked for elective admission Patient told to notify hospital if health changes prior to surgery Patient arrives at admission office and is admitted Transferred to ward and nurse conducts nursing assessment Patient deemed fit by nurse and prepared for surgery Patient assessed by orthopaedic registrar and deemed fit for surgery Patient assessed by anaesthetic registrar and deemed fit for surgery Patient sent to surgery and operated on At first glance the team may feel the process should be working well. However, as the team discusses the situation, a number of process gap factors may come to light as the different team members tell their stories. For example: patients do not always know what the clinic staff mean when they say changes to health as patients are not provided with a set of specific health issues to assess patients are worried about delays in having surgery so turn up on the day hoping they will be OK the nursing staff think the orthopaedic registrar is doing a complete fitness for surgery check but the registrar thinks the nurses complete some details and hence does not include these in their assessment the anaesthetists think all patients are contacted the day before surgery and their health status checked at this stage. However, while this was suggested eight months ago at a staff meeting, the procedures were not formally changed, the pre-admission staff ran out of time when another clinic was added and therefore the checks stopped after the first two weeks.

The team agree they can improve this process. They decide to: gather some more information on the impact of surgery rescheduling if theatre time was not being wasted by last minute cancellations review the fitness-for-surgery checks assess the resource implications of making telephone checks before admission day meet in one month to consider how the process can be improved.

Every health service has different processes and issues. However, by just considering this basic example, you can begin to understand how simple, but powerful process mapping can be to any team.

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Example 2: Anticoagulant Blood Testing

The Improvement Network - East Midlands Health Area
http://www.tin.nhs.uk/index.asp?pgid=1179

Notice that the map is very simple. The only symbols that have been used here are a box and an arrow. Someone has been writing observations about times and volumes on the map. Some good questions have obviously been asked. As more information about the process is gathered this also can be written on the map, making the map more of a working document than a polished finished article. Looking at this map, opportunities for improvement would hopefully be obvious!

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Appendix 5: Flowcharts
Flow-charting is a specific approach to process mapping. Rather than just using arrows and boxes, it uses conventional symbols to represent different activities or tasks. These symbols can convey more meaning and assist with analysis. For example:

who is making decisions and about what how many pieces of paper are generated in different places for one process where unexpected delays are occurring.

The most commonly used symbols are: Symbol Arrow Descriptor Connects all the symbols and shows the direction of flow of the process Indicates a task or a step in the process such as admission details recorded. Usually only one arrow should come out of a task rectangle. If there is more than one arrow, a diamond or question symbol may be needed instead Indicates the beginning and end of the process such as the patient walks into emergency Indicates a yes/no question must be asked or a decision has to be made such as triage category 4 or 5? Indicates a delay in process such as the patient waits for result Document is produced, such as a referral form

Rectangle

Oval

Diamond Semi-oval

Rectangle with wavy base

There are many ways of drawing a flowchart but to make analysis easier, it is recommended that you try to construct the flowchart so that the preferred process goes down the left side of the page. Hence, when a decision has to be made, you are trying to elicit a yes answer such as: Are notes available? Is the patient is in good enough health to have the planned operation? Have risk factors been assessed? When the answer is no the team can see the number of steps required to get the process back on track and therefore what needs to be improved.

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Appendix 6: Additional questions for use in analysis

Ten good questions to ask when mapping a process
1. Are there any wasteful handovers in the process? 2. Could one person instead of several people carry out some tasks? 3. Are tasks carried out for our benefit or the patient's? 4. Should some tasks that are performed in another process be performed here? 5. Is the process measured according to activity or purpose? 6. Are the people who work in the process allowed to make decisions? 7. Which tasks help to achieve the purpose and which ones create waste? 8. Is there any duplication of work? 9. Are there any bottlenecks? 10. How much error correction (rework) is being carried out? Extracted from: NHS The Improvement Network - East Midlands website, UK Department of Health, available at http://www.tin.nhs.uk/index.asp?pgid=1179

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References
Gilbreth, F 1916, The effect of motion study upon the workers, Annals of the American Academy of Political and Social Science, Vol. 65, Personnel and Employment Problems in Industrial Management (May), pp. 272-276. Madison, D 2005, Process Mapping, Process Improvement and Process Management: A Practical Guide to Enhancing Work and Information Flow, Paton Press, Chico Runciman W B 2006 Shared meanings: preferred terms and definitions for safety and quality concepts, The Medical Journal of Australia, 184: S41-S43. Outline of definitions devised by the former Australian Council for Safety and Quality in Health Care, available at Australian Commission on Safety and Quality in Healthcare website: http://www.safetyandquality.org/internet/safety/publishing.nsf/Content/former-pubs-archivedefinitions National Health Service (NHS) The Improvement Network East Midlands, Process mapping, UK Department of Health, available at http://www.tin.nhs.uk/index.asp?pgid=1179 National Health Service (NHS) Modernisation Agency 2005, Improving Flow: Process and systems thinking, UK Department of Health, available at http://www.wise.nhs.uk/sites/toolandtechniques/ILG/Building%20on%20the%20Basic%20Tools%2 0and%20Techniques/1/2.3IF.pdf Victorian Quality Council 2005 Better Quality, Better Health Care: A Safety and Quality Improvement Framework for Victorian Health Services, Department of Human Services, Melbourne.

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