1 Mapping: Taking a look at Current State, and Creating a Better Future StateMargie Wiebe, BScN, PCCN Primary Health Care Developer (NH) Quesnel T: Willis, D.R., (2005) 1

2 Learning objectives - mappingOur LAT aim in mapping Why we use process mapping & what a process is How to create a current state process map What process mapping looks like from a customers point of view (patient journey mapping) Analyze our current state through value and non value analysis How to create a future state map & make high impact changes

3 Overall Mapping Aim To understand our current state (suicidal response process for children and youth) and design improved integrated future state We start by creating current process maps at key organizations ER & inpatient MCFD (CYMH, protection services, disability ) RCMP Schools Create a current state patient journey map Then analyze current state maps using value stream mapping We end by creating improved future state maps (protocols)

4 Why Map a Process Highly visual tool to see all steps of a current process Current state process map is baseline for improvements It is a powerful tool to help plan high impact changes It is a simple exercise; useful to solve particular process problems (“aha moments”) Once mapped, the bottlenecks, time delays, duplicates, handoffs, value added and non value added steps… “jump right out” 4

5 What is a Process? A process is a series of connected steps or actions that achieve an outcome A process has a starting point and end point One process is usually linked with other processes in other systems It has a defined group of users (ie youth with suicidal ideation) Has a purpose or aim (crisis response to suicidality) 5

6 What is Process Mapping“A process map is essentially a breakdown of a (all the steps in a) process to determine how it flows and, ultimately, how effective it is.” Chron.com

7 Process Mapping: Understanding the flow or sequence of eventsConventional symbols represent different activities: Oval - the start and end of the process Box - the tasks or activities of the process Diamond - a question is asked; a decision is required Arrow - the direction or flow of the process 7

8 Steps in Process MappingDefine what to map Define a start and end point (scope) Try to capture every step in the process Map only what is currently is done Map what happens 80% of the time Honesty is key No blame or judgement is also key

9 Mapping Symbols = start or end point = direction of the flow= step in the process = a decision  = value added as defined by customer  = non value added but required or law  = non value added

10 Example of the high level process for referring a student to MCFD (CYMH)Child with behavioural problems Parent notified Parent teacher meeting Screened for learning disabilities Confidentiality forms Doctor assessment A process has a flow CYMH calls parent CYMH referral req Pt seen at CYMH Modified from Langley et al, (2009) Improvement Guide, p. 37

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12 Customer’s PerspectiveNow, when we are determining value, LEAN methodology invites us to consider our work from the customer’s perspective (aka, client/patient) This is important, because it is ultimately the customer who will determine whether something is valuable or not, and it is the customer/patient/client who we are being paid to serve As healthcare providers, we may have certain perceptions of our services. For example, we may conceive of “registration” in a hospital to be a particular location. However, from the patient’s perspective, the task of registering in our health system also involves other steps, such as driving to a facility, parking the car, finding your way to the registration area, finally getting registered, then going to the procedure area. Conceiving processes in this way also helps us see how complex things can be, and how we might need to “scope” a quality improvement project (e.g., limit the amount of things we are going to try to improve so that we don’t overwhelm ourselves). Lastly, it is noteworthy to point out that there are many customers in a system. Potential Question to Audience: Who are some of your customers in your work? 12

13 Parallel processes Example: generate a referral letter and get appointment details to patient Parallel processes often are the cause of delays for patients and frustration for staff Mapping, analyzing and improving parallel processes will deliver great benefits Separate the parallel process from the patient process (e.g. map with different color) Map the parallel process alongside, but separate from the patient process (see p. 20 in NHS process mapping) GP tells patient they need a hosp. appt GP dictates referral letter Patient waits Hospital appoint-ment clerk posts letter to patient Patient receives appt

14 Hand-offs Up to 50% of steps involve a “hand-off” (NHS)90% of errors, duplication, delays in a journey occur at the point when the patient or paper work is handed from one person, department or organization to another (NHS) Around 90% of the errors, duplication and delay in patient processes are at the point of “hand-off” – where responsibility for the patient is handed from one professional or department or agency to another. Up to 50% of the steps in a typical patient process involve a “hand-off”

15 Taken from NHS slide deck

16 How do we improve current state?Value stream mapping Root cause analysis for BIG problems

17 Value Stream Mapping Determine Value from the Customers perspectiveValue is: What the patient/client would be willing to pay for Something that improves service in some way Something that is done right the first time Is the activity valuable to the patient? = Value Added Is the activity waste? = Non-Value-Added

18 Defining Value Value added: Make direct contribution to what the customer values Non value added but essential: required to allow value added steps to occur or by law Non value added: Everything else

19 Example of defining value in ERValue added: Make direct contribution to what the customer values Procedure Pt. interaction Non value added but essential: required to allow value added steps to occur or by law or regulations Registration Triage Lab test processing Non value added: Everything else Wait

20 transferred to safe care 3hoursValue stream 3 hrs days Opportunity time: all non value added time = 75hrs Value added time: all value added and required = 4hrs 20 mins Lead time: Non value + value added 79hrs 20 minutes Registration 20 mins Assessment hour transferred to safe care 3hours

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22 Future state map Review Hot spots on the value stream mapnon value added hand offs Opportunity times – especially wait times Root cause analysis for each BIG problem ask why 5 times this will get to the root of the problem Then think of pdsa change ideas …for what is at the root of each problem area

23 Summary We map to visually see each step of our current stateWe analyze our current state Asking, “ is this a value added step to customer?” Calculate value and opportunity (non value) time Determine root causes of BIG problems with 5 whys We create a future state: Reduce hand-offs Design value added processes

24 Glossary Value added: Define value from the customers perspective, actually adds value to the patients journey Value Stream: map all the steps, value added and non value added, that bring service/product to the customer Perfection: the complete elimination of waste so all activities create value for the customer Backlog: Previous demand that has not yet been dealt with, showing itself as a queue or waiting time Queue: Work waiting to be done at a given point, patients waiting to be seen or wait list for procedures/treatments Hand-off: When a patient is passed on from one health care provider to another Parallel process: Different activities that take place in the same time period Constraint: The actual cause of the bottleneck, usually a necessary skill or piece of equipment Bottleneck: Part of the system where patient flow is obstructed, causing waits and delays Lead time: The time it takes for a patient to move all the way through a process Batching: Piling up a type of work as it comes in until a later time when all this type of work is done together NHS leaders guide process mapping, analysis, and redesign p. 30

25 Resources NHS Institute for Innovation and Improvement, (2010) Process Mapping, Analysis, and redesign. Impact BC (Nov 26, 2009) a step by step presentation on mapping Willis, D. (2005) Making Every Minute Count

26 Resources Garret, D.V. (2007) Quick ways to maximize your office practice, AAFP. P Willis, D.R. (2005) Making every minute count: tools to improve office efficiency. AAFP, p NHS leaders Guide For Mapping: NHS 10 High Impact Changes leaders Guides: NHS information on improvement mapping: Mercey care NHS process mapping: National Managers Tools: 26