SIS: Group B Project Aims, Theories of Change, Change ideas: Module – Diagnostic tools: Process mapping: Facilitators

There are many different diagnostic tools that can help generate change ideas. In this session, we are just going to look at process mapping.

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Aim of this moduleAs stated in this learning outcome on next slide

Key messagesProcess mapping is one tool that can help us to identify the best way to achieve our aimImportance of context – the same process may work well in one context, but not in another. People who map the current state and proposed future state must be familiar with the context.

Lead facilitatorWith all diagnostic tools, we are in this part of the System of Profound Knowledge: Theory of Knowledge.Generating ideas for possible changes, we are developing our knowledge around change, answering the Model for Improvement Question 3: What change can we make that will result in improvement?

Often we tend to jump in to an improvement project with an idea for change, without thinking through in detail whether that is the best way to achieve our aim. This may be because we’ve had the idea ourselves, or we’ve heard about it being used elsewhere, or if our work is linked to an SPSP collaborative, or an organisation-wide programme, they have already done much of this work for us. However, every context is different and we need to identify a number of potential changes for our

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setting, and then prioritise the ones likely to bring the most benefit.

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Lead facilitator read through briefly, or as participants to read.

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Discovery

AimFor those new to Lean have a brief background to process mappingTo find out and acknowledge who in the room is already familiar with Lean

Key messagesProcess mapping originates in Lean thinking.Lean thinking involves determining the value of any given process by distinguishing value added steps from non-value-added steps, and eliminating waste so that every step adds value to the process.

TimingMax 5 minutes for this slide

Lead facilitator

Process mapping is a tool associated with Lean.Elicit – who has experience of Lean? How have you use it, and in what context? What has been the impact of using it?Talk through the 5 principles briefly:

First, establish value – what is it in the eyes of your service users?

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Then, map the total value stream. To do this, you map your process first, then assign values. What is a process map? A series of actions. Start by mapping your current state – what actually happens, not what is supposed to happen. Depending what kind of process it is, physically walking through the steps can be very revealing. Mapping the value stream then assigns a value to each step (in the eyes of your service users), and a time for each step.Next, make improvements to create a future state map. To do this, you look for ways to:-Make value flow with no interruptions: analyse the obstacles that prevent the process from flowing freelyFor example the flow of patients through the hospital or clinic should be continuous. To achieve continuous flow of patients, Lean tries to: load level patient demand; bring services to the patient just when they are needed; and stop the process when problems occur. Healthcare has been described as having 7 flows: flow of patients, clinicians, medication, supplies, information, equipment, and flow of process engineering. - Pull what you want when you want it: rather than eg pushing patients from one queue to another and creating blockages- Search for perfection with no waste – a waste is any step that does not add value (as you have defined value in the eyes of your service users).

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Aim

Participants to be able to list different kinds of waste in the context they work in (not necessarily using the terms on the slide)

Key messages

Waste is a symptom, not a cause, of a problem. We need to find the causes of waste in our system, and eliminate those causes.

Timing

5 minutes, or longer if you use local examples and/or elicit.

Lead facilitator

Talk through this briefly – the following provide some examples you may wish to use, but there is no need to go through all this detail. OR use examples from your own context, if participants are all from the same organisation or workstream. OR if more time available, elicit examples from participants, filling any gaps with these or your own examples.

Animation – one bullet comes up on each click, and a further click for the ‘staff’ image.

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Transportation

•Moving a patient to an inpatient bed for review at post-op ward round and then to another ward for discharge

•Moving a patient for tests or to see the physiotherapist.

•Moving ‘stuff’ – any kind of equipment, medication etc eg patient records from one place to another, information leaflets, paper for printers.

Inventory (ie stock)

•Using inpatient beds for patients who are waiting for tests but could be discharged safely

•Ordering excess material because the supply is unreliable

•Retaining material beyond its useful life eg an audiology unit may have 6000 moulds, many of which are useless because they shrink over time.

Movement – unnecessary movement of staff

eg around a room, from room to room, from building to building

Waiting

•Patients waiting in queues at the surgery

•Patients or staff waiting for tests

•Making sure all the equipment is ready for an operating list

Overproduction

•Requesting tests and referrals to outpatient clinics ‘just in case‘

•Carrying out tests/assessments in order to cut waiting lists, but not having capacity to follow through once results of tests/assessments are available.

Overprocessing

•Things we find ourselves doing that don’t add value for the patient eg re-testing, chasing late paperwork

Defects – Things that are not right and need fixing

•in orthopaedics you may have prostheses that are damaged or missing or don’t fit/wrong.

This is the standard list of Lean ‘wastes’. Some people add another:

Staff – ie untapped potential

•Staff having the capacity to work in a more effective way, but the system (structures, processes, culture) doesn’t allow them to do that.

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AimTo apply these ideas to an exampleTo discuss an example of an everyday process that everyone is familiar with, before showing a more complex healthcare example later.To ensure participants are actively engaged following 10+ minutes of input/trainer talking.

Key messagesFeatures of a process map: start/finish points; actions; decision pointsA process doesn’t have to be scary; it’s a way of representing how we do something, and provides a basis for discussion.

TimingQuick pace – about 6-7 minsAim is for this to be a quick intro, then spend much more time on the Portering example.

Materials1. Making a cup of tea process map2. Questions on whiteboard sheet or flip chart prepared earlier.•Is this how you make tea?•What wastes are there?•Which steps don’t add value?

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•How could you improve it?

Lead facilitatorFirst, looking at a non-healthcare example.Elicit: Do you drink tea? Anyone who doesn’t, ask what they do drink. Likely to be similar process.A process = sequence of actionsThere are many different ways to represent a process. These are some common conventions:Square/rectangle = actionDiamond = decision point – always ask a yes/no questionCurved shapes – beginning/end

Elicit: How many action steps are there here? (10)How many decision points are there here? (5)

Give handout.Show questions on flipchart/whiteboard.Return slide to previous Waste slideDiscuss in pairs/tables.

Support FacilitatorsLight touch facilitation around the room – participants may have some questions initially eg about the shape conventions. Apart from that, leave them to it.

Lead facilitatorDebrief in plenary Elicit responses re: wastes, value, improvements.Highlight importance of being clear about your criteria eg here criteria are probably time and quality – need to reduce time as much as possible without compromising quality.Benefits of using a process map here:If I had asked you to identify possible wastes in making a cup of tea, do you think you would have come up with as many ideas?

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AimTo provide a context for the Portering process map laterTo show different levels of process map, and different designs (appropriate to the level of analysis)

Key messagesFocus on the interests of service users

TimingThis sequence of 5 slides (before Portering Process) is designed to be quick – just a few minutes to provide context and person-centredness.

Lead facilitatorProcess maps can be used at different levels.To ensure that our focus is always on improvements that will be of interest to patients, we should start by looking at patient journeys.Another reason to start with a high level map is to make sure that we are aware of the potential for improvement of many parts of a process – the first part of a process that we think of working on in detail may not be a priority for our service users.At this level we normally start with a simple sequence of actions.In this example, we’re looking at Susan’s journey from identifying a healthcare need to completion of treatment in response to that need.We could do an analysis at this level, looking at patient flow, and wastes, and for

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example information about patient satisfaction relating to different steps in the journey.The arrows at both ends indicate that this is a section of an ongoing patient journey -for the individual, this is in the context of health issues before and after too – but this is a chunk that we may look at depending on where we fit in in relation to it.

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AimAfter introducing the idea of value as one of the 5 Lean principles, this looks at value in more detail – criteria to identify whether a process step is of value to our service users.

Key messagesFocus on what is of value to service users.These three questions provide one way to find out what that is.

Timing2 mins

Lead facilitatorFor a step in a process to be value adding, each of these questions should get a ‘yes’ answer.

So, we should be looking to remove as many steps as possible that are not directly experienced by service users. If they don’t want something to happen, or if they would like it to be changed, it is a suitable focus for improvement.Of course there are some activities in health and social care systems that are not directly experienced by service users that we cannot eliminate completely. Those can also be targets for change – to reduce wastes relating to those steps.

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From the high level process map of Susan’s journey, we need to focus down on something that she would want to happen differently or would like to be changed (go to next slide)

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Lead facilitator

We can take one of the steps in the high level map – one that has been identified as having steps that include wastes, and that do not add value.

Here, looking at the day surgery step (the blue box). We now break this down into more detailed steps, in sequence, and look to work on one that includes wastes or activities that do not add value. (However, remember that all these are interdependent, so changing one may involve changing others too).

A question may be asked about why the convention of different boxes is not used in this series of process maps. If so, point out that the aim of these higher level maps is to ensure that we are focussing on the right area/priority, before looking at a process in detail.

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AimThis slide is only to indicate which of the steps in the mid-level process map we are going to look at in detail.

Lead facilitatorLet’s work on this one.

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AimTo put the swim-lane process map in context – to show how it would have been developed

Key messagesProcess mapping as a collaborative process

Timing1 – 2 minutes

Lead facilitatorIn real life, mapping a process might start like this.This is an example of a process map being developed by a team (for example at a Rapid Improvement Event), before it’s all recreated neatly using appropriate software. Benefits of creating a process map collaboratively:- Different perspectives- Find out what actually people actually do, not what procedures, protocols etc say

they should do- Get buy in of key stakeholders, as they are involved in mapping the desired future

state as well as the current state.Tips:- Start with post it notes – you’re likely to need to move them around a lot

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- Before you take it away, use clear sellotape to stick the post it notes down, as here (this one is in the process of being packed away)

Continue with another example on the next slide.

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AimTo show there is not just one way to create a process map.The different stages – process mapping and value stream mapping

Timing1 – 2 minutes

Lead FacilitatorHere the process map has been created with pale yellow post its.Then the value stream has been mapped using different colour post its – here orange, pink and blue will each represent a measure of value or waste.

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Practice

AimTo gain some familiarity with how process maps are organised.To practise applying some of the principles of process mapping and improvement.

Key messagesUse the process map to identify activities in your system that do not add value.Then use your deeper understanding of the system to generate change ideas.Importance of not doing this alone. Include subject matter experts – people familiar with the context.

Timing10 – 15 minutes

Material1. Portering process map – this is adapted from real ‘current state’ portering process maps from NHS hospitals.2. Whiteboard sheet or flipchart sheet prepared earlier – list of Wastes

Lead facilitatorThis process map uses ‘swim lanes’. Each swim lane represents a person or department. You might start creating a process map knowing that you are going to

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use swim lanes (in which case, indicate these on the background paper you put the post its on), or the usefulness of swim lanes may emerge as you build the process map. Elicit: When would swim lanes not be useful? (eg if only a single person following the process eg making yourself a cup of tea)Analyse this ‘current process’ using the questions on the slide. Work along for a few minutes, thinking about all the questions. Then discuss in pairs or 3s.In 10 minutes I’ll ask you to share your change ideas, and explain your reasoning.

FacilitatorsMonitor around the room and support as necessary.

Lead facilitator: plenary debrief:Either: Elicit some responses to the questions – it is not necessary to go through each question separately as the answers will overlap.OR Elicit some ideas for changes to improve this process, with reasons

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Practice

AimTo wrap up the Portering process map activity, and possibly deepen the debrief by requiring participants to commit to an opinion.To create a visual representation of a ‘theory of knowledge’ by linking the change ideas to secondary drivers.

Timing5 – 10 minutes

MaterialsCards for driver diagram (aim, primary and secondary drivers) either already on the wall from Developing theories of change, or put up on wall before this activity.Cards with change ideas, in two sets:Set 1 – link to the ‘improved process’ primary driverSet 2 – link to the ‘resource management’ primary driver

Lead facilitatorDistribute Set 1 cards amongst participants. Ask them to put them up next to the relevant secondary driver (and add arrows, if you are using them)

Support Facilitators

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One or more facilitators at the wall, with Set 2 cards. Once all the Set 1 cards are up, in agreed positions, distribute Set cards and facilitate discussion as participants decide where to put them.OR If two or more facilitators are available, consider giving both Sets 1 and 2 out together, and one facilitator each to focus on the two sections of the driver diagram.As with the Developing theories of change driver diagram activity, allow for different matches from those in the key, so long as a good justification is provided.

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Project

Optional slide and activityIf you are doing a series of modules using other diagnostic tools as well as process mapping all within a day or two, you may prefer to leave project work until after you’ve looked at all the diagnostic tools, as in the full Scottish Improvement Skills programme.

AimFor participants to start thinking about applying this tool in the context of their own project.

Timing5 minutes

MaterialsPlain A3 paper or flip chart sheets – one per participantSticky notes – small and medium sizes, multiple colours, total approx 1 pad per participant

Lead facilitatorNow think about how you might use process mapping in your own project.Take a few minutes to work through these questions.

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Remember the ‘principle of the system boundary’ (Senge – see Module XXX): consider the ‘interactions that are most important to the issue at hand, regardless of parochial organizational boundaries’ – this will affect your choice of people to work with you on this.

Support FacilitatorsFacilitate around the room. Respond to any queries that arise, or intervene if you notice people rushing to detailed processes.

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AimTo briefly recap the session content:- to support a sense of learning and accomplishment - to aid memory of the session laterAn opportunity for participants to ask any outstanding questions from any part of the session.

Timing1 – 5 minutes, depending on time available

Lead FacilitatorElicit what content was covered for each of the bullets eg:What are the 5 Lean principles?What are the 7 wastes? And the 8th one that we added?What does a rectangle represent? A diamond? An oval? What are the two options coming off a decision point?What are the 3 questions we should ask to find out if an activity adds value for service users?Why shouldn’t we create a process map alone? (other perspectives, find out what really happens vs what is supposed to happen, get buy-in by involving key stakeholders)Why should we start with a high level process map, not go straight to detail?

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