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Process Mapping - Alternative Conventional Methods 

What is it and how can it help me?

Mapping part of the patient journey will enable you to look for opportunities for improvement by identifying points of inefficiency. It can capture the reality of a process and identify duplication, variation, and unnecessary steps. The process also prompts good ideas and helps a team to know where to start to make improvements that will have the biggest impact for patients and staff. Our guide to mapping whole patient journeys will help you do the process thoroughly, however, this alternative guide is a shortcut to get you started.

When does it work best?

Process mapping can be used to capture the reality of detailed parts of the patient journey and their experience at every stage. This enables you to identify problem areas such as bottlenecks. Tackling these can help to remove unnecessary delays and improve patient experience.

How to use it

Firstly, decide whether you have the time and energy to do this thoroughly, you will get better results if you do. If so see our guide to mapping whole patient journeys.

Introduction:
You may be wondering why this section is here?  In our visits to Trusts to develop our work, we came across staff who seemed embarrassed about the way they had done process mapping.  They said "...but we have not done it properly". They also said "but it did help us to make improvements."  So this is a valid approach as it gets results. 

What did they do differently?
Instead of conventional process mapping, they invited less people (5-10 attendees versus 15 - 20 in a more comprehensive exercise). They thought carefully about who to invite and recognised that the final map was good enough for service improvement although it may miss out some things.  However, using a more limited and therefore quicker approach, meant they had a good starting point. 

The approach described here is effective if you:

The suggestions below will help you to ‘have a go'; to give you a feel of what you are doing and what is going on in your service/department. This will provide you with good enough information to start generating ideas for improvement.

Where do I start?
Some things to think about when starting to plan a smaller scale mapping session:

Other different approaches:
1. Walking through the patient journey yourself.
2. Set up a mini process mapping session.
3. Follow a patient.
4. Be a patient.

1. Walking through the patient journey yourself
Get some pens and paper and physically start at the patient's journey. As you are standing there, ask the staff what happens. Record who, what, where, when, why, and how long does each step take? Include the obvious stuff as well as what appears to be irrelevant. Then go to the next stage and repeat this again and again until you get to the end of the patient journey. Try not to get distracted, make sure you explain what you are doing to colleagues, and allocate a specific time to it.

Our experience has shown that even this ‘one man band' approach will reveal opportunities for improving the patient experience and reducing waste in the system (e.g. waiting while a nurse searches for a dressing as the cupboard has not been filled up, revealing that the supply process needs improving). It also demonstrates how some staff experience difficulties due to a process that has been set up for their convenience. It will give you a clear overview of who is involved and where. If possible take photos of the different steps and make a note of the people who you meet.  This could also be a good way to do a stakeholder analysis.

2. Set up a mini process mapping session
Get a few colleagues together, or use a staff meeting and ask them to describe the patient journey and all the steps in it. Map it out on some long paper (lining wall paper is cheap and ideal), start off at a high level then get them to write on some of the detail.
  
Creating simple maps:
The aim of process mapping is to make things clear and to provide insight. The best map is the simplest map that provides that insight. It can be very useful to start with a high level process map of say 5 to 10 steps which you set a time limit to achieve e.g. 20 minutes. This helps to establish the scope of the process and identify significant issues.

For example the map below, has been drawn entirely using only a box and an arrow. The box represents the task or activities of the process. The arrows represent the direction of flow of the process. If you need to, you can also use a diamond shape to indicate a question, or decision point, for example:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3. Follow a patient: 

It is recommended that an external person do this. They would approach a patient and explain that you are trying to find out everything that happens to a patient when undergoing this experience, to see if you can improve their experience and make things more efficient to reduce delays: Ask if it is okay to acompany with them for part of the journey. Keep a detailed record of the journey, who what where when and the times. Note all the things that went well and things that could have gone better. If a patient gets stuck in the process or a stage is going to take too long to stick with the patient, move onto another patient who has completed that stage and so on until the end of the journey. You could as an insider simple sit and observe what is happening this can be very revealing and is an established technique used by organisation that design/redesign products and processes. See Getting Patients Perspectives for more information.

 

4. Be a patient: Two types of approaches:
a) Don your ‘civvies' and be a patient, allow plenty of time, and record all the steps etc as above, chat to the staff & patients along the way, to gather more information. Be honest and share what you are doing, record everything.
b) Team up with another department and be a mystery patient. Get them you send you an appointment letter and go through the whole experience, clearly this will be a modified process, you won't get treated and appointment slots will be only a few minutes. For example 2 community services teamed up to do this; Podiatry and Speech and Language Therapy. The podiatrist as a S&LT patient got lost in the hospital so was late for their appointment and couldn't understand the patient information, so all these issues were addressed. Staff felt more comfortable with the process in their early days of improving the service as they had a ‘critical friend'.

 
Examples

What should I map during the session?

Creating detailed maps:
For complex processes you may follow the simple process map with a more detailed process map, identifying all steps and re-work loops. It is also helpful to establish roles and relationships within the more detailed process map. This detailed map can be used again in a later phase to show of the impact of your improvement and redesign work.

What questions should I ask when analysing the map?

2. If you are doing it as a 'one man band' a clipboard with numbered sheets of paper will be handy and a reminder of the symbols may help
 
A box or rectangle to show the tasks or activities of the process.

A diamond represents the stages in the process where a question is asked or a decision is required.

An oval shows the start of the process and the inputs required and also shows marks the end of the process with the results or outputs. The symbol is the same for the start and end of a process to emphasis interdependency.
Arrows show the direction or flow of the process.

3. Don't map everything. Only map the process that you have chosen to improve.
4. Let your process map cross-functional boundaries. You want to see the whole, end-to-end process, not just the piece of the process inside your department. Improving one department or section does not always improve a service that flows through several departments. It is always much more important to manage the interactions between departments than it is to manage the actions inside each department.
5. The people who work in the process should be involved in the mapping.
6. Always map what actually happens in the current process rather than what you would like to be happening, or what should be happening according to the book.

What next?

Using the process map to initiate re-design:
Once the process map has been drawn the next step is to identify where the process can be improved by re-designing or removing elements of it.

The key to success here is to keep the patient at the centre of your plans and to consider the potential for a ripple effect through the organisation. Getting your part of the system right does not help the patient if another part of their journey is made worse as a result. Testing your ideas for improvement will help to show you potential unwanted side-effects of your changes. To help you understand the potential impact of a change, you may use the PDSA cycle.

The process mapping Improvement Leaders' Guide will help you here, it outlines some suggested change ideas for this phase of work:

Other useful tools and techniques on this website

Additional resources

Resource Documents:
The East Midlands Improvement Network encourages users to produce a simple map to illustrate the patient journey, it is a password protected area: Process Map
 

Websites:

NHS Scotland's Centre for Change and Innovation covers measurement, analysis, techniques and solutions for service improvement in health, including a section on process mapping.

The NHS Institute for Innovation and Improvement provides a range of materials relating to the application of lean principles to healthcare. This area of our website includes a presentation on lean, which covers the principles of lean, and some examples of the application of lean in health, including value streams, eliminating waste, improving flow and mistakes versus defects.

Background

The technique described here originates from manufacturing.  

Our knowledge about how to apply process-mapping approaches to improve health services is developing all the time. The foundation of this guide originates from the NHS Modernisation Agency, the National Clinical Governance Support Team and the learning and experience of work by NHS organisations. There is strong influence from Lean and six sigma approaches to mapping pathways, procedures and work processes in health care. 

The other strong influence on health services is the development of evidence based clinical pathways. These are being developed as standardised pathways, using evidence developed by organisations like the National Institute for Clinical Excellence (NICE).

Mapping has been used to illustrate the world and how things work pretty much since the beginning of time. Humans navigate by maps, as well as using them to illustrate and make sense of the world. Different maps have different perspectives and uses - which all combine to give us a more balanced overview of any given situation. 

Acknowledgements / sources

The foundation of this guide originates from the ‘Improvement Leaders Guides', NHS Institute for Innovation and Improvement.

© Copyright NHS Institute for Innovation and Improvement 2008