INTRODUCTION:

Many clinical pathways are complex in nature, which makes it difficult to clearly identify the issues or problems that affect their efficiency and the patient experience. As Kerridge (2012) noted, it is often difficult to pinpoint exactly what is wrong and use this information to develop a solution to put it right. Using a process map makes the pathway more transparent as each step is described, making it easier to highlight the problems and propose solutions. Having a map also prevents assumptions being made about the problems, which can result in solutions that do not address the actual issues.

Process mapping is a valuable and useful way for teams to reflect on the way they work, diagnose and understand problems and identify areas where they can improve. Creating a visual representation of the steps involved in a clinical pathway enables everyone involved to see the overall picture.

A key to successful process mapping is seeking clarification for the reasons behind a step or decision made during the clinical pathway. A useful technique for obtaining more detailed responses when talking to those involved is using the “5Wsand 1H”, which refers to open questions starting with why, what, when, who, where or how. It can also be beneficial to map a process that is unfamiliar as it averts the temptation to make assumptions about the pathway or process.

Process mapping:

A process is a series of connected steps or actions that achieve an outcome (III, 2008)

Process mapping can be used not only to map existing practice, but also to evaluate the impact of the change project. Spaghetti diagram can be used to demonstrate distances travelled in a department and establish the most efficient layout. When writing up a process map, it is useful to use the standard flowchart symbols to clearly indicate activities and decisions through the process (Fig 3); annotated notes can be used to provide patient observations or additional information, particularly if the process map is complex.

Taylor and Randall (2007) describe process mapping as a simple but powerful tool to unpick the many layers to both service processes and patient pathways, which involve a number of staff in different roles and departments. It is a valuable method of identifying issues, developing solutions and enabling interdisciplinary teamwork (Taylor and Randall, 2007).

A successful process mapping exercise should reveal:

· Unnecessary steps, handovers, delays;

· Any waste – duplication of effort;

· Things that do not add value to the Patient journey;

· Bottlenecks and constraints;

· Unhelpful variation;

· Potential to create safer care;

· Understanding of the patient experience;

· Where further analysis

Why Process Map?

It is important to understand how patients proceed through the care delivery system. The best way to achieve this is through process mapping. Process maps are an effective way to identify constraints and bottlenecks, rework (activity required to correct situations that could have been avoided) and unnecessary process steps (duplication, waste and error).It is unlikely that any one member of staff will fully understand the whole service until the process has been mapped. Process mapping is the single most useful diagnostic tool for determining where problems lie. Understanding the process from the patient perspectives essential if patient focused service improvements are to be made.

The process map must always depict the total number of steps taken, as well as the total number of people involved, the total time taken to perform the process step, and all documents used.

What are the Stages?

There are two stages to process mapping. First, These include waste, error and duplication or parts of the process which would flow better if undertaken in a different order.

4 key points:

1. Care pathways often evolve over time and changes do not always improve the patient experience

2. Pathway and process reviews aim to identify problems and what could solve them

3. Process mapping can identify what works well for patients and what doesn’t

4. Involving patients in mapping allows the observer to see the process from their point of view

Types:

Observational process mapping:

Observational process mapping involves observing the clinical pathway first hand so the observer can note patients’ experiences while mapping the pathway; “go and see for yourself” is a useful message.

When using observational process mapping it is important to capture the patient’s perspective without preconceived ideas (NHS III, 2008). The observer should try, where possible, not to intervene in the steps of the clinical pathway. For example, if a patient arrives in a department and is not greeted immediately by a receptionist or nurse, the role of the observer is not to initiate

Communication, but to wait with the patient to see what happens “in reality”.

This, however, should be balanced with a duty of care to ensure the patient is not adversely affected by this passive approach.

Conventional process mapping:

Conventional process mapping involves bringing together a range of people who represent different roles and functions associated with the clinical pathway.

The group is involved in mapping the pathway using a table-top exercise where everyone has opportunity to discuss the steps taken through the pathway from their perspective. The overall outcome is the same as observational process mapping; a visual representation of the steps is produced but this is without the patient’s perspective unless a patient is involved in the mapping exercise.

Spaghetti diagram:

A spaghetti diagram is a helpful tool to establish the optimum layout of a department or ward based on the distances travelled by patients or staff.

These diagrams often expose inefficient layouts and can identify large, unnecessary distances that patients need to travel between stages in the pathway (NHS III, 2008). The simplest way to create a spaghetti diagram is to draw a simple map of a layout, then lines indicating flows. The

diagram can be used to redesign a process by showing how the flow can be improved

or reduced.

Basic flowchart symbols:

Numerous software programmes can be used for mapping processes, some of which are free. Although these are useful they are not essential; most process maps can be written up using Microsoft Word or Excel. There are some standard basic flowchart symbols used to identify specific activities in the map (Fig 1).

Fig 1. Basic flowchart symbols

Steps to create process mapping:

1. Set the parameters. Decide which process will be mapped and designate scope and boundaries. This includes defining the inputs, outputs, human interactions and the organizational levels involved.

2. Select a mapping team. Teams should include no more than 10 employees, but enough to represent each stage in the process map. The manager responsible for the process should also be a team member.

3. Choose the map format. Process maps can be created on paper, on a white board, with sticky notes or on a computer. Computerized mapping options can also vary in complexity from document-design programs to specialized process-mapping software. Decide which is best for your purposes. Sticky notes will be explained here, but the steps are interchangeable with any of the above options.

4. Prepare a spot on a wall or poster board to create the process map. Gather your team, and spend adequate time explaining the uses and creation of a process map.

5. Brainstorm the various stages of the process with your team. Write each step on a sticky note and place it sequentially on the board. For maps that cross organizational levels, different colors of sticky notes can be used. For example, yellow notes could be the interactions on the main floor, blue notes can represent managerial involvement, green can be suppliers and pink can represent human resources.

6. Walk through the process again with your team. Depending on the level of detail, add missing or additional information. This may include the time it takes to complete a task, emotional responses to each step or customer perceptions.

7. Run the team through each process step inside your facility. Check for any missed steps or additions.

8. Number the stages in the process map sequentially. Steps that occur simultaneously can be denoted with the same number and lower-case letters. These notes can be stacked vertically in a horizontal map or horizontally in a vertical map.

9 Discuss the results. Brainstorm ways to make the process more efficient. Innovate with your team to streamline or better the process.(figure:2)

On completing the observational or conventional process-mapping exercise and write-up, the problems and possible solutions often become self-evident. However, the following questions may be useful to assist with analysis (NHS Institute, 2008):

· How many steps does the patient have to complete and are they all necessary?

· How many times is the patient passed from one person to another?

· How long does each step take and what is the time between steps?

· How long does the whole pathway take?

· What are the delays – do they occur regularly?

· Where are problems for patients and staff?

Key causes of delays:

Handoffs:

This is where patient care or information is handed from one individual to another.

Bottlenecks and Constraints:

A bottleneck is any part of the system where patient flow is obstructed causing waits and delays. It interrupts the natural flow and hinders movement along the care pathway. However there is usually something that is the actual cause of the bottleneck and is the constraint. This is usually a skill or piece of equipment.

CONCLUSION:

Process mapping is a vital tool used in service improvement to clearly understand each step of a clinical pathway or process.

Patient pathways often result from the evolution of complex pathways that may not always be as efficient as they could be and do not offer the best care in terms of patient experience.

Mapping a process is useful as it offers, often for the first time, an objective, visual representation of the patient journey highlighting the problems; this activity often generates solutions. There are two methods of process mapping: observational, involving first-hand experience of the patient’s journey by following the patient; and conventional process mapping, that is, a table-top exercise involving all stakeholders who map out each step.

REFERENCES:

1. Hong CW (2010) New Year -new tool: process mapping. International Journal of Therapy and Rehabilitation; 17: 1: 6-7.

2. Kerridge J (2012) Leading change 1: identifying the issue. Nursing Times; 108: 4: 12-15.

3. NHS Institute for Innovation and Improvement (2008) Improvement Leaders Guide: Process Mapping Analysis and Redesign. Warwick: NHS III.tinyurl.com/NHSI-leaders

4. Taylor A, Randall C (2007) Process mapping: enhancing the implementation of the Liverpool Care Pathway. International Journal of Palliative Nursing; 13: 4, 163-167.

Received on 15.11.2013 Modified on 10.12.2013

Asian J. Management 5(1): January–March, 2014 page 79-83