Audiology Improvement

Service Improvement Tools and Techniques

Process Mapping

Understanding processes

A process is a series of connected steps or actions to achieve an outcome. For the 18 week target, we are normally interested in the process from initial referral to beginning definitive treatment, however, we should never forget that the patient experiences the whole process right through from presenting symptoms to the end of their treatment.

A clinical process may be a short and simple sequence of actions by one person, such as taking someone’s chest x-ray, or it could be a complex set of activities involving many different people over time, such as care for patients with heart disease.

What are the benefits of mapping the process?

A map of the patient’s journey will give you:

  • A key starting point for your improvement project, tailored for the specific organisations you are working with.
  • The opportunity to bring together people from primary, secondary, tertiary and social care from all roles and professions to create a culture of ownership, responsibility and accountability for improving the process.
  • An overview of the complete process, helping staff to understand, often for the first time, how complicated the system can be for patients.
  • An aid to help plan effectively where to test ideas for improvements (see Change Ideas and PDSA cycles) that are likely to have the most impact on achieving the 18 week target.
  • Inspired ideas from members of staff who don’t normally have the opportunity to contribute to service planning, but who really know how things work.
  • An interactive event that gets people involved, motivated and talking to each other.
  • An end product – the process map – which is highly visual and easy to understand.

People’s views about the process will change and develop as more information becomes available. Most people have an idea (a ‘mental map’) of the process they are a part of, but as the process map is developed, it becomes clear that their personal view is different to that of others in the same process. So the map of the current process (the situation ‘as is’) may differ from the mental maps that individuals in that process have always believed. Agreeing the ‘as is’ process is an important step in moving forward to redesign and developing a new process that will work better for patients and staff.

What does a process map look like?

This is an example of a completed process map, for generating referral letters from a cardiac catheter lab.

Compicated Process Map

This process was over-complicated, and included many unnecessary steps, bottlenecks, waste activities and avoidable delays. Once the process was redesigned, it looked like this:

Redesigned Process Map

… which, as well as being simpler, was much quicker for the patient, took less administrative and clinical time and cost less.

How to map a process – organising an event
As an improvement leader, you will need to devote time, effort and energy to all stages of organising the event. Developing and maintaining good relationships will be crucial.

Points to consider in preparing a process mapping event include:

  • Define the objectives, scope (start and end points for the process you are studying) and focus for the process mapping workshop.
  • Meet with managerial, clinical and service leaders beforehand so that they feel involved in the process. Use these meetings to agree the scope that you will work on and the three or four basic steps that you will explore in detail at the workshop.
  • Identify the staff groups that are involved at each step in the journey. Include clinical, managerial, administrative and support staff – the people who actually deliver the process.
  • Organise a half day event to draw out the map and a half day to analyse and look for improvement opportunities. You can run these together as a full day event or as two half days not more than two weeks apart.
  • Arrange a suitable venue, preferably off-site, as this provides a neutral setting and people are less likely to be interrupted.
How to map a process – drawing the map
  • Allow plenty of time for setting up – at least an hour before the planned start time of the event.
  • Ask one of the lead clinicians to open the event, emphasising their own commitment to learning about and redesigning the process.
  • An independent facilitator, not connected with the pathway, can be really useful. Choose someone with service redesign skills and experience, possibly from the relevant clinical network team.
  • Use a roll of brown paper or wallpaper, fixed firmly to the wall – make sure you have plenty of room. Use post-it notes to write in the steps in the process so that you can stick them to the background, but move them if you need to squeeze in some extra steps.
  • You will also need at least one flipchart and plenty of coloured marker pens.
  • It is helpful to start with some main headings mapped out on the wallpaper – these might include: ‘presenting symptoms’, ‘referral’, ‘diagnosis’. ‘outpatients’ etc – the ‘high level’ steps in the process. This can help to remind people that the purpose of the event is to map the whole of the journey, not just the elements they are familiar with.
  • Focus the discussion on identifying the steps in the process. If other problems or issues are raised, or problems which cannot be resolved in the room, keep a flipchart ready to ‘park’ these, to be addressed later.
  • Agree the next steps before closing the workshop, so that people can see the purpose and that their time has been used well.

Further actions could include:

  • Which parts of the process need to be mapped in more detail and how this should be arranged.
  • Who should communicate with people who have not been able to attend the event.
  • When and how change ideas will be generated and tested.
Points to consider…

What level of detail?

  • You may map a process at ‘high level’ to obtain a clear outline of the major steps involved:

Process Map - High Level

  • Or at a more detailed level to identify the constituent steps in one or more stages of the journey, for example, if you were planning to work on matching capacity and demand at one stage of the process, you would need to understand this in great detail:

Process Map - Detailed Level

How to map a process – analysing the map for change ideas
  • Once the group has mapped the patient journey, check the typed version with those who attended, and with others who were unable to attend the event.
  • Send a copy of the notes and agreed next steps to each participant and to those who didn’t attend.
  • Meet the key service leader and lead clinician to agree what will happen next.
  • Review the agreed actions with the participants at regular intervals to assess progress, capture learning and address problems.
  • Examine the map for any bottlenecks, constraints and inefficiencies together with the presence of any ‘non value adding’ activities such as unnecessary hand offs, transfer to queue or excessive administrative checks.
  • Measure or time the process steps in order to set the baseline for improvement and also to understand the relationship between value added, value enabling and non value added process steps. Processes that exhibit significant non value added activity provide immediate improvement opportunities.
Gaining support

To achieve the level of change that will be necessary to meet the 18 week target, you will need the support of a number of people across all of the organisations you are working with.

Sponsors – These are the senior leaders in the organisations concerned who will sanction the process mapping event and support the resulting changes. These are the people who can make connections across organisations and resolve any ‘power’ issues. They will need to be prepared to devote time, energy and action to the cause.

Project leaders/change agents – These are the respected managerial and clinical staff who will facilitate the change, provide support and expertise and ensure agreed actions are implemented and deadlines are met. They are essential for maintaining the relationships across the process and ensuring effective communication.

Champions – These are the respected clinical leaders who believe in the improvement project and are prepared to support this publicly and who are willing to test out new ideas. These are the people you will need help from in reaching out to their colleagues who do not support the change, and who will contribute their own expertise and experience.

Another way to gather the data

There are a number of different approaches to process mapping. The method described above has been used in the health service for many years, introduced by the NHS Modernisation Agency and a number of collaborative programmes. An alternative method may be to use a sequence of one to one interviews with key personnel along the patient journey and then the resulting draft map is validated across the whole process by the project team. The advantages of this approach are:

  • No need to bring everyone together at a fixed time, or to organise an event.
  • You meet people at a time that suits them – causing minimal disruption to the service.
  • Some people feel more comfortable making their contribution in private – so this tends to generate lots of improvement ideas at the same time.
  • You can target specific people who may not have been able or willing to attend the group event.
  • There is the opportunity to ask many questions and gather very detailed information, supporting papers and documentation.

There are clearly advantages and disadvantages to each process mapping approach depending on the circumstances that you find yourself in.

Summary - How to generate a process map
You will need to gather together representatives from as many of the groups as possible which are involved in the process, and host a facilitated discussion to identify each point in the process, including those that are unproductive or contradictory.

You will be able to produce a rough map at the workshop by sticking post-it notes that represent each step onto a long piece of paper (such as a roll of lining paper or brown paper). After the event, you can have this typed up into a visual form that everyone can read and understand. After the event, get the participants to check that this is an accurate representation of the process and then you can analyse the map to begin to identify ideas for improving the process.

Further work
Once you have mapped the process, you are in a position to identify the change ideas you want to test to redesign the process. You may wish to employ one or more of the service improvement techniques described elsewhere in this document, including:

Key terms used

Key terms used

Links to further resources
For information on improvement knowledge and skills and on measurement for improvement, see the Improvement Leaders’ Guides produced by the NHS Institute for Innovation and Improvement at: www.institute.nhs.uk/Products/ImprovementLeadersGuidesBoxSet.htm

The series of guides covers general improvement skills, process and systems thinking and personal and organisational development in 13 booklets.

All of the service improvement tools and techniques training materials can be accessed by going to: www.heart.nhs.uk/trainers_resource_pack.htm

Further information on all service improvement tools and techniques are also available at: www.institute.nhs.uk


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