Superheroes can do magical things that ordinary people cannot. Captain America has his shield, Green Lantern a power ring, and Iron Man a suit.
In Lean, pictures and visualization are powerful communication tools—they’re your super tools. In the Lean Improvement Model for Health Care, there are “action tools” and “see tools.” A process map, also known as a flow chart, is a “see tool” because it shows the activities, steps, or tasks that transform an activity.
When striving to make improvements by identifying potential ways to simplify, streamline, or redesign, the process map is frequently the first team activity. The map of how things are done now creates the current state. Work in health care is often performed in a silo where there is little knowledge about or understanding of what happens before or after a task is completed.
While creating the current state process map, team members experience a true understanding of the whole process. It is important that the team establish boundaries or project scope. This defines where the process starts and finishes. The focus of the team will be to map the activities within these boundaries.
How to create a process map
Creating a process map employs four common mapping symbols and use of office supplies like sticky Post-it notes:
An action verb and subject is on each Post-it and placed in the appropriate sequence. Sticky Post-it notes make easy work of process mapping. They make it easy to modify the location of the steps of an activity:
There are many variations, but the process map and swim lane are our favorites:
- Process map (flow chart): identifies activities
- Swim lane diagram: identifies handoffs
- SIPOC diagram:
- Starts with the customer
- Identifies outputs, process, inputs, and supplier
- IDEF process map: Identifies controls and resource details
- Value stream map: Identifies value added activities
Use of a process map is also important, for it displays where decisions are required. Decision points are binary responses such as yes or no. The figure below shows the use of symbols in process mapping. The diamond represent binary decision points.
Andrea Swenson, MD
Mapping in action
Mapping is generally done to improve a process or identify waste. However, a neurology team used process mapping to establish a new clinic process. Andrea Swenson, MD, clinical associate professor and neurology and Resident Program director, created a program for neurology residents to meet the Accreditation Council for Graduate Medical Education (ACGME) standard for engaging in quality improvement and patient safety efforts.
Swenson reports that residents work with their mentors all year and give presentations in December and June. Dan Anderson, DO, R3, was to develop standard work for the newly created Lumbar Puncture (LP) Clinic. Although LPs have been performed in the Neurology Clinic for decades, a Lumbar Puncture Clinic, staffed by residents with oversight from neurology attendings, was established. A team made up of all stakeholders—residents, nurses, medical assistants, and scheduling and billing personnel—was created.
Dan Anderson, DO
Anderson sums up his experience with this initiative: “The power of the process map really came in having a thorough understanding of the responsibilities of every team member. Prior to doing the process map I only had an understanding of the resident’s point of view. I previously had no knowledge of scheduling, checking patients in, or preparing the procedure room. In addition, we also found several things in our process that were missing completely and having the map allowed us to identify this easily.”
Outcomes
During the creation of the process map, the team stopped at almost every step. The team generated ideas for improvement and identified crucial safety measures.
Create:
- Epic order set for LP
- Interval History and Physical (H & P) or H & P clinic note
- LP screening template
- LP procedure template
- Post-LP headache protocol
Define management for:
- CJD patients
- High volume NPH LP (20-40c)
The process map is a visual tool for communicating the Lumbar Puncture Clinic workflow to all of the residents. In the end, the process map promoted standard work, minimized potential errors by reducing practice variabilities, avoided delays by anticipating problems in the work flow, addressed patient and staff safety concerns, and promoted the efficiency of the health care team. The improvement in efficiencies would allow for future volume growth. Knowledge of the current workflow will allow for future service enhances such as incorporating ultrasound.
Using lean thinking and quality tools, a team can accomplish what others might think impossible. Nothing is impossible once you learn the magic of applying quality tools and embracing continuous improvement.
Acknowledgements
Neurology team members
Daniel Anderson
Don Ball
Courtney Hansen
Keith Kohout
Sarah Tucker
Cindy Weber
Suzy Hammer-White
Sue Zaleski
