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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
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