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?