Process Mapping Process Mapping

A W5 Approach

T. Rollefstad QI ConsultantOct 14, 2003

A W5 Approach

T. Rollefstad QI ConsultantOct 14, 2003

Objectives Objectives

A W5 approach to process mapping

What is ‘Flow charting’ ?

When would this tool be used?

Who should be doing flow charts?

Where to start?

Why did we do this again?

Flow Charts… What?Flow Charts… What?

Step-by-Step schematic pictures of a process

Boxes show the steps in the procedure arrows indicate the logical flow

Symbols have specific meanings to help understand the process

Start

09/Oct/2003

Emergency Admitting - Flow diagram

ER MD decides to admit

ER MD writes order Orders

ER clerk call Admitting

Admitting identifies/calls appropriateNursing Unit

ER Nurse calls Unit Nurse

RoomAvailable?

No

YesAdmit

Orders

Special case? ER Nurse & assistant transport

Yes

No

ER Clerk calls transport

Transport arrives & takes patient

Patient arrives on unit

End

Flow Charts… What?Flow Charts… What?

Flowcharts can document:

Flow of information Movement of a patient Delivery of a service Any combination of the above

When to Use this Tool?When to Use this Tool?

Provide a Common Understanding Identifying Root Causes Defining Projects Designing Remedy Implementing Holding the Gains

Types of Flow ChartsTypes of Flow Charts

Macro Flow Chart Sometimes called a

top down chart Documents major

steps - usually no more that 6 steps

Below each major step, list the major sub-steps

Micro Flow Chart Describes most/all of

the steps Level of detail

dependant on ability to see problems on a higher level

Use sparingly A ‘Drill’ tool into

problem area of a process

Macro Flow ChartMacro Flow Chart

Promotes focus on essential steps Represents only useful work Helps Identify what should happen Faster/more efficient that detailed

flowcharting Used as quick overview of a new

process/project

PATIENT TRANSFER PROCESSFMC EMERGENCY -to- PLC HOSPITALIST

Find a bed Arrange transfer Transfer

1. FMC ED doc: decision to admit

2. FMC ED doc: checks PLC census

3. FMC ED doc: pages PLC Hospitalist

4. PLC Hospitalist: calls FMC ED doc

5. PLC Hospitalist: calls PLC Adm itting

(b ed assigned immediately1)

6. PLC Hospitalist: calls FMC ED doc to

acce pt transfer

7. PLC Admitting: c alls & fa xes FMC ED

UC to advise bed information

8. FMC ED doc informs FMC ED UC

1. Pt. Transport: dispatches vehicle

2. Pt. Transport: arrives FMC

3. Pt. Transport: colle cts chart/patient

4. Pt. Transport: receives report

5. Pt. Transport: transports patient

6. Pt Transport: arrives PLC Admt’g

7. PLC Adm itting: re gisters patient

8. Pt. Transport: transport to unit

9. Pt. Transport: check-in with UC

10. Pt. Transport: report to RN

11. PLC UC: page s Hospitalist

Notes: red ind icates new steps indicates eliminated steps

1. PLC Hospitalist: calls ‘report’ to inpatient unit 2

2. PLC Hospitalist: books Patient

Transport

3. FMC ED UC: puts PLC fax on pt chart

4. FMC ED doc: writes order

5. FMC ED RN/UC: comp letes tra nsfer

checklist

6. ED RN: completes Adm ission Shee t

7. ED RN: give s Admission Sheet to ED UC

8. ED UC: enters into Log Boo k

9. Admission Sheet to FMC Admitting

10. FMC Admitting: calls PLC Admitting

11. PLC Hospitalist: informs PLC Admitting

12. PLC Ad mitting: assigns bed

13. PLC Ad mitting: calls FMC Admitting

14. FMC Admitting: advises ED UC

15. ED UC: advises RN

16. ED RN: phone s report to PLC unit

Acute MIdischargesummary

STEMI Criteria Evaluate data

volumes byhospital and byEMS by time ofday and area ofcity

Talk withEmergencydoctors andCardiologistsre: concerns.This will be forthe SteeringCommittee todo

Presentconcept atRounds

Look in to aprogrammablepager

Teamrecruitment

Outline adiagram of thedream pathwayas well as theactual pathwayin a flow chart

Education re:pathway,treatment

Look at EMSdatabase andlook at whatthey collect andflow chart thierportion ofmoving apatient from thehome to anemergencydepartment

Evaluate theirUnit resources

AddressEmergencydoctorsconcerns withdata

What is the AMIprocess andflow chart for allthree sites

Educate themabout theactivation of thepager and thepathway

Look at adedicated AMIvirtual bed inthe ED

Look at CallSchedule andmake sure thatwe haveenough peopleon call for thevolume

Look at CathTeamresponse times

Structure ofCath Lab teamand their joband flow chartthis informationso thateverything isstandardized

Look at howthe presenttimes arecollected forthe Cathdatabase andstandardize therecording ofthese times

Develop andAMI Bed

Look at ordersets tostandardizecare for AMIpatients. Weneed to look atcommunityresourceconnections atthis point andconnectingthese patientsto someone inthe community

ED patients thatare low riskpost PCI wouldbe transferredback to theCCU in theoriginal hospitalundercardiology

Look atdischargeeducation andconnectingthese patientswith thecommunity

Look at if wehave low riskpatientsmonitored onthe ward for12 hours dowe use patientcare Unit 82as a stepdown

Look at anacute MIcoordinator tolook at thecommunity ofcare and theplan of careand followthese patientsthrough theirhospital stayand connectthem to thecommunity

Look at havingan acute MIclinicconnection tothecardiologist.Need to beable tomeasureoutcomes

STEMI/PCI Preliminary Steps

Pre-WorkWorkingwith EMS

EmergencyDepartment

Cath Lab CCU Ward

AssessmentTeams/

CommunityResources

Friday, October 10, 2003

Page 1

Project Team Stages

Quick Fix/solutionMentality

We justneedmoreStaff

Bkgd

Data

“I know whatwill fix this”

Realistic view ofthe problem

( Scope)

“O My”

Problem > thanjust 1 solution* Dept in > crisisthan thought* No writtenstandards*Teachingexpectations largeand growing* Very complexproblem

Fous'daim

Getting to thebottom of the

problem

Recognize othercontributors areExpectations of

staff/techs in Deptnot clear

*Can’t tackle flowuntil we support

current workloads

“What’s thecause?”

Recognizing wecan changesomething

Can standaraizeexpectations* can look atways to improvework* Sponsors dosupport &empower thisgroup to makechange* can take somerisks here

Rev.Charter

EmpowermentRole of

Sponsors/ QICouncil

Develop a Visionof a New

Department

Charter is partof that vision* thinking ofwhat we’d like tosee

Mtgsponsor

s

Make a plan toreach the vision

V2of

Charter

ThinkingBeyond What

Is

Brainstorming Ideas* PlanningPDSAcycles*actuallymakingchanges

Make ActualChange

3 Questions

Tweaking theplan in

Evaluation

Evaluatewhatworks &spread*Keep inmind 3Improvementquestions

PDSA’s

EvaluateChanges &

Spread

BreakthroughChange

SuccessfulChange

* 1st Visionrealized

Macro Flow Chart Transporting Project

Friday, October 10, 2003

HH Test Order Booking HH Test Preparing PatientTransporting

PatientPatient Arrival @

HH Test

Test CompletedReturning Patient

to UnitGenerating HH

Test Report

CommunicatingResults/applying to

chart

Delays in HHTests

End of ProcessScope

People’sExperiences

Transporting DataBase

Transporting DataBase

* wrong order* portering staffshortage (rare)* incorrect prep

for test ordered

* miscommunicati btwnNurse & U/C

* Too few Dr.’s readingtests, increases time to

generate reports

* type of test misinterpretedwhen booking

* type of testmisinterpretedwhen booking

* miscommunicati btwnNurse & U/C

* patient not readywhen porter arrives

* patient not readywhen porter arrives

* portering not initiatedproperly/ say not on

system

* waiting @destination for test to

be done

* elevator delays dt firedrills,, staff using service

elevators

* Doctor Delays

* Patient needing assistance totransfer/ communication issueIE: should be on a stretcher

* Tech called away on portablestat call

* Patient needs off teleorder as no staff to go with

patient

* Orders not clear/ in correctplace to be seen

* Tech calls for patient @shift change, porter not

booked* porters don’t know name ofpatient they are picking up, ifseveral patients to go, wrong

priority

Bookingrecords for HH

Tests

Manual input data fortime test read/reported

* Order forms not completeand faxed

Prepared by T. Rollefstad Feb 22nd/2003

*CCU books Cath butdoesn’t tell PLC unit ordocument on the chart

* ECHO/Thallium ordered don’tsay if can go monitored/ must

wait to get d/c tele order if can’tbe monitored

*Tests called for @ shiftchange and Nights forgetsto communicate with day

shift re: booked test

* no priority system inplace so can’t predictwhen porter will come

* mixed expectations ofporters role in gettingwheelchairs. Variable

levels of assistance, someporters go when wait toolong and don’t come back

* If pt. requires RNto accompany couldthey have priority?

* sending pt direct toother tests ratherthan up to unit in

between. Thereforecommunicationbetween tests

* wait in hall upon return asnoone communicated pt

returned/ RN not avail to assistpt. back to room

* Tests orderedbut not booked

* prep not completed

* departmentdidn’t get needfor test booked

* Ordered reason notspecified so report not

mentioning what Dr. wantedto check for

* HH test results put indifferent places on thechart, on different units

Manual input data fortime test completed

*operator puttingnurse on hold to call

for stat ECG’s

*Req not filled out withindications so can

prioritize

* Pts being kept inhospital for test

results

* No one toreceived early

cath lab patientswhen transferedfrom other sites

Micro Flow ChartingMicro Flow Charting

Includes detailed information re: every stage in process

Includes loops caused by rework Can get lost- so define the level of detail

required Ensure all the players of the process are

involved May need to validate - peer review, TIM

Study

RGH EMS ARRIVAL

Yes

Patient stable ?

No

EMS brings slipfrom PCR to TRNand gives report

Process follows aswith other patientsie: patient sent to

AC

Patient broughtinto trauma room

Admitting comesto trauma room to

determineidentification

John Doe chartinitiated and chart

made upaccordingly

TRN goes back andstarts EATR. RN intrauma room takes

over and continues tochart on EATR

AC checks ADT forrecord and followsusual process for

admitting patient to ED

Yes No

Patientidentified?

Req received viaTDS /PC/fax

ECHO Inpatient Flow ChartUrgent Inpatients M-F 07-15

Has test beendone?

Y/N

Does test needto be redone?

Y/N

YesTech prioritizes

requestStat, Urgent,

Elective

No

Yes

Cancel Req bywriting

“duplicate”

Put in tray byclerk

No Clerk deletesduplicate test in

Oscar

Echocompleted

today?

Determined asUrgent case

Tech calls unitfor patient 1 hour

beforeanticipated test

Yes

No

Yes Tech completestest

No

Patient waitsRoom prepared/

tech found

Preliminaryreport generated

by Doc

Tech reviewsfinal report

clinical content

Clerk reviewsfinal report for

demographics &spelling

Final report sentto mail room

Unit receivesfinal report

Final reportplaced on chart

ECHO Doc readsECHO

Is patient d/c’d

Unit sends finalreport to MR

No Yes

Dictated reporttranscribed

Preliminaryreport faxed tounit by clerk?

Case reprioritizedby ECHO Doc

Patient arrives inECHO

department

Is ECHOroom/Tech

ready?Tech calls porter

Patient returnedto unit

Is the testportable?

No

Tech take sthemachine to the

unit

Yes Is patientready?

Yes

RN preparespatient

Tech waits

Tech completestest

Tech returns tothe departmentwith machine

No

Correctionsneeded?

Yes

No

Corrections doneby

Transcriptionist

AMI Care Across the ContinuumProposed pathway EMS to Cath Lab

911 call to EMSEMS arrival on

scene

EMS Assessmentwith algorhythm & 5 point criteria for

STEMI

Decision to divertto FMC made inconsult with ER

Doc

ECG faxed/transmitted to

ER Doc

ER Doc activatesAMI pager

On callInterventionalistanswers within

10 min

Interventionalistactivates Cath lab

staff

Patient arrives @FMC

Patient takendirect to Cath lab

Interventionalistcalls admitting for

direct admit to cathlab

Streamlined cathprocedure to allowballoon first inflate

quickly

Post cath admit toCCU/?PCU 82 tele

or back tooriginating hospital

If patient stablepost PCI,

anticipatedLOS 2-3 days

ER Doc may/maynot need to see pt.consider stabilityDecision made enroute

comm. With ER Doc

Follow-up apptbooked with

cardiologist within1 week ( booked in

hospital)

All appropriatemeds prescribed,standard orderset

on TDS

D/C teaching inhospital only that

re: post PCI

In hospital, Apptmade with Cardiac

Rehab within 1week of

D/C for lifestyleteaching

D/C summary faxed to primaryfamily Physician including all

meds, required followup tests,results of events in hospital etc.

Within 10minutes

Within 15minutes

Load & Transportto FMC

All appropriate Txgiven enroute withcomm as approp.

With ER Doc

Approx. 10minutes

Within 5minutes

Potentialvirtual CCU

bed if cath labstaff not yet

in/ busy

Cath Lab staffarrival/set up room

Within 20minutes

Some aggregate reportback to EMS re: 911 tofirst inflate times andgeneral pt. outcomes

Monitor indicators:911 - balloon, % appropriate

meds , # rehab appts completed, #cardiologist appts, within 1 wk # D/C

summ faxes received

Steering Committee/Sponsors for STEMI/PCI Project

Proposed Structure for STEMI InitiativeCardiac Sciences

Purpose:> Provide expertise in medical content of solutions> Facilitate implementation, resources necessary for identified solutions> Provide sign off to the QI work team> Provide guidance to work team re: possible options for process change> Establish a work team for process change

Potential ParticipantsDr. Dean TraboulsiDr. Merril KnudtsonDr. Gil CurryDr. Bruce McLeodDr. Wayne WarnicaDr. Peter GiannaccaroDr. Tim BoyneLynn HansonSue ConroyDr. Andy AntonDr. Robert Sheldon

90 minutes to PCI !

QI Work Team

Dr. Dean Traboulsi Interventional Cardiologist & Team LeadDr. Abbi Arun ED PhysicianDwayne Clayden EMS SupervisorLana Shewchuk Interventional CoordinatorLinda Fundytus Cath Lab NurseLeanne Norrena ER Nurse/ for RVGHSimone Emmond ER Nurse for FMCDr. James McMeekin QI Doc/ CardiologistTanis Rollefstad QI Consultant Cardiac Sc.Dr. Tom Rich QI Doc EDJamie Jones QI Consultant ED Dr. Sandeep Aggarwal Cardiologist &

Cardiac Wellness repKaren Foudy APCM CICU FMCDebra Lundberg AMI data base Coordinator

50% STEMIPopulation

walk-in to ED

50 % STEMIPopulation to ED

via EMS

Establishpriority

population

Collectbackground

data on presentperformance,

patientvolumes, EMS

times

Flowchart presentprocess from 911to cathlab balloon

inflation

Complete processchange for direct

to PCI

Evaluate newlycreated process

Spreadimplementation to

include walk-inSTEMI patient

population

1

2

3

45

6

7

8

9

10

11

12

Make processchange for ED to

PCI

13

Prepared by Tanis RollefstadQI Consultant for Cardiac Sciences

Flowchart presentprocess from 911through ED’s tocathlab balloon

inflation

Note:

- Implement small scale change- Tweak process using PDSA- Spread change to full implementation for this population

14

Plan

Do

Study

Act

Who should be doing Flow charts?Who should be doing Flow charts? EVERYONE :)

“How can you possibly improve something unless you know how it works?”

Include all those intimately involved in the process

Often helps ID those who should be on the team

Beginning or end of a process

Work activity

Document symbol

Decision point

Movement of process or looping

Delay or wait state

Flow Chart SymbolsFlow Chart Symbols

Start

09/Oct/2003

Emergency Admitting - Flow diagram

ER MD decides to admit

ER MD writes order Orders

ER clerk call Admitting

Admitting identifies/calls appropriateNursing Unit

ER Nurse calls Unit Nurse

RoomAvailable?

No

YesAdmit

Orders

Special case? ER Nurse & assistant transport

Yes

No

ER Clerk calls transport

Transport arrives & takes patient

Patient arrives on unit

End

Where to Start?Where to Start?

Tips for Flow Charting

1. Decide on level of detail up front

2. Get basic process down first

3. Chart the process the way it is now

4. Define boundaries

5. Use standard symbols - keep it simple

6. Should be only one output arrow - if more may need decision box

Where to Start?Where to Start?

Discuss intended use of flow diagram Decide on desired outcome -

› what do we want to find out› how detailed do we need to get› Use a macro chart first › zero in on specific area using micro

chart PRN

Where to Start?Where to Start?

Define the boundaries of process Document each step in sequence Ask questions like:

› Does a decision need to be made?› How many times does this occur?› Does the next step involve waiting

for anyone/anything?› Do we really know or are we

supposing?

Where to Start?Where to Start? Use appropriate symbols Draw process from top to bottom or left

to right Decision points - complete arms

sequentially Review completed chart If unsure - Verify

› observe process directly› interview knowledgeable persons› Peer review

How’s your Brain so far?How’s your Brain so far?

Why did we do this again?Why did we do this again?

Analysis

Step 1: Examine Each Decision symbol

Step 2: Examine Each Rework Loop

Step 3: Examine Each Activity Symbol

Step 4: Examine Each Document/Data symbol

Why did we do this again?Why did we do this again?

Ask these questions: Can it be standardized? Does every step add value? Is there duplication of work? Is it possible to simplify? - forms,

procedures Can the time required to complete be

reduced? Is there accidental bureaucracy?

Flow Chart Analysis Practice

Flow Chart Analysis Practice

Macro flow charts

Micro flow charts

Macro flow charts

Micro flow charts

PATIENT TRANSFER PROCESSFMC EMERGENCY -to- PLC HOSPITALIST

Find a bed Arrange transfer Transfer

1. FMC ED doc: decision to admit

2. FMC ED doc: checks PLC census

3. FMC ED doc: pages PLC Hospitalist

4. PLC Hospitalist: calls FMC ED doc

5. PLC Hospitalist: calls PLC Adm itting

(b ed assigned immediately1)

6. PLC Hospitalist: calls FMC ED doc to

acce pt transfer

7. PLC Admitting: c alls & fa xes FMC ED

UC to advise bed information

8. FMC ED doc informs FMC ED UC

1. Pt. Transport: dispatches vehicle

2. Pt. Transport: arrives FMC

3. Pt. Transport: colle cts chart/patient

4. Pt. Transport: receives report

5. Pt. Transport: transports patient

6. Pt Transport: arrives PLC Admt’g

7. PLC Adm itting: re gisters patient

8. Pt. Transport: transport to unit

9. Pt. Transport: check-in with UC

10. Pt. Transport: report to RN

11. PLC UC: page s Hospitalist

Notes: red ind icates new steps indicates eliminated steps

1. PLC Hospitalist: calls ‘report’ to inpatient unit 2

2. PLC Hospitalist: books Patient

Transport

3. FMC ED UC: puts PLC fax on pt chart

4. FMC ED doc: writes order

5. FMC ED RN/UC: comp letes tra nsfer

checklist

6. ED RN: completes Adm ission Shee t

7. ED RN: give s Admission Sheet to ED UC

8. ED UC: enters into Log Boo k

9. Admission Sheet to FMC Admitting

10. FMC Admitting: calls PLC Admitting

11. PLC Hospitalist: informs PLC Admitting

12. PLC Ad mitting: assigns bed

13. PLC Ad mitting: calls FMC Admitting

14. FMC Admitting: advises ED UC

15. ED UC: advises RN

16. ED RN: phone s report to PLC unit

ECHO @ FMC Inpatient Case #2 Mar3/03Time in Motion Flow Chart

Origin of OrderTDS

Dob Stress ECHO

PCU 81 receivesorder

Feb 28th @1353

Is orderentered into

TDS?

CV Lab ECHOreceives order

Feb 28th @ 1353

Yes

ECHO Techorganizes test

equip & personnel

Can ECHO dotest when we want

it?

Yes

No

No

Feb 28@1510CV Lab ECHO

calls PCU 81 to letknow test bookedfor Mar 3 @ 1300

UC PCU 81 pre-books porterFeb 28 @ 1515

ECHO Techprioritizes patients

for the day

Is standardlead time met?

(45 min)

Yes

No

HH porterbooked?

Yes

NOTE:Presumed RNnotified in report ofpre-booked test for1300 Mar 3.

ECHO did not callfor patient

Central porterarrives (1312)

Delay of 27 min

No

Is patientready?

No

Yes

Porter latearrival

RN preparespatient

Patient ready fortransport(1313)

Porter waits1 minute

Patient arrives inECHO lab

(1316)

Intransport

Porterwaiting

3 Min

Is ECHO roomready?

No

Yes

Patient waits4 Min

Patientwaits

ECHO test started(1320)

ECHO testcompleted

(1430)

Tech calls porter(1430)

HH porterbooked?

Yes

No

Patient waits8 Min

Central Porterarrives(1438)

Mar 3 portershortage,bumped tocentral

Patient returned tounit

(1442)

4 Min

Portercommunicatespatient return?

No

Yes

Preliminary reportfaxed(1415)

same day

NOTE:Porter placed chart on

desk & UC present

Is final reporton chart prior

to D/C?

Yes

No

Final Report onchart > 5 days

MD receivedresults prior to

hard copy?

No

Evidence MDreceived

preliminary resultssame day

Yes

Porter arrival delay in min Pre: 27 min Post: 8 min

Time in transport: Pre: 3 min Post: 4 min

Porter waiting time in min Pre: 1 min Post: 0 min

Patient waiting time in min Pre: 4 min Post: 8 min

ECHO Delays ProjectFlow Chart After Hours/WE

On call Tech getspage

Is page fromCardiologist or

Intensivist?

Tech respondsimmediately &

Travels to hospital

Yes

No

Tech pages ECHODoc on Call for

approval

On Call ECHODoc gets page

ECHOapproved?

Yes

Tech arrives indept and picks up

machine

Tech or ECHO Doc callsrequester and informs to

book through regularchannels ?

No

Tech goes to unitwith machine

Is patientready?

RN preps patient

No

Yes

Test completed

Tech calls ECHODoc on call

ECHO Docresponds, gets

report

Tech waits

Does ECHODoc need to

come in now?

Is Docavailable to

come in now?

Yes

No No

ECHO Doc on callpages Tech (only ifsequence initiated

with Doc)

Entry point 1Entry point 2

ECHO Doc on calltravels to hospital

Report delay& Possible

pt.management

delay

Note: Notavailable dueto clinically

busy on 3 sites

Tech asked to giveverbal message to

consulting Doc

ECHO Doc on callgoes to read study

Is furtherprocedure

necessary?

Yes

No

Echo read sameday or possibly

next

Preliminary handwritten reportgenerated by

ECHO Doc, faxedor verbal given to

consulting Doc

Report dictatedMonday

Reporttranscribed

Clerk reviews finalreport for

demographics &spelling

Tech reviews finalreport for clinical

content

Are correctionsneeded?

Are correctionsneeded?

No

YesCorrections doneby transcriptionist

Corrections doneby transcriptionist

No

Yes

Final report sent tomail room

Unit receives finalreport

Is patientd/c’d?

Unit sends finalreport to MR

Final report placedon chart

Yes

No

Questions?Questions?

“The journey of a1000 miles begins with just

one step”Tao

“The journey of a1000 miles begins with just

one step”Tao