Process mapping: A cornerstone of quality improvement
Dear QA Q&A,
As laboratory director, I receive frequent complaints from treating clinicians about the prolonged turnaround time for diagnostic results. I initially thought that our pathologists were slow at diagnosing their cases, but after an analysis of turnaround times by testing phase, I am now concerned that pre-analytic steps are the main culprit contributing to our problematic turnaround time. Our accessioners and technologists insist that we are understaffed, and we may well be, but I don't see us getting any new positions approved this year. How do my team and I figure out whether technical inefficiencies and waste exist in our current workflow? Ideally, we hope to make our frontline feel empowered rather than criticized and support them in effecting change.
Dear reader,
The first step in analyzing a process for waste is mapping out the process to understand each specific step. A simple tool called a process map can help you and your team to achieve many of your stated goals.
What Is a Process Map?
A process map, also known as a flowchart, is a diagrammatic representation of a sequence of actions for a given activity. The map helps to explain and visualize all steps of a process with graphical illustrations. Symbols in various shapes denote different types of steps. Ovals represent starting points and endpoints, rectangles describe actions, inverted triangles indicate waiting, and diamonds refer to decision points. Symbols are linked by lines and arrows to reflect interactions and the direction of the process flow (see Fig. 1).
Process map template.
As health care embraces various process improvement methods such as Lean, Six Sigma, and rapid-cycle improvement from manufacturing and information technology industries, process mapping has become a more prevalent tool, and it has begun to play a fundamental role in improving health care quality and operational efficiency.1
Providing timely and accurate diagnostic results is a team effort. Laboratory technologists, administrative staff, pathologists, and trainees are all critically important players. The swim-lane process map, a variation of a traditional process map, has the capacity to illustrate the sequence of actions and visualize the interactions/hand-offs between different team players. In an example from our laboratory, the anatomic pathology sign-out workflow is presented as a diagram divided by lanes, with one lane for administrative staff (orange) and another for pathologists (blue; see Fig. 2).
Anatomic pathology sign-out process map created in MS Visio. Dx indicates diagnosis.
Why Adopt Process Maps?
A map is worth a thousand words
Standard operating procedures (SOPs) are typically written in a narrative format, making workflow analysis and redesign challenging. In addition, SOPs do not address the frequent problem of workarounds or regular SOP deviation. Process maps provide a tool for understanding the true process efficiently and rapidly. Visual illustrations are more effective than oral or written formats because graphical examples register faster in the human brain.2 Process maps consist of symbols, lines, and arrows, which enable us to display workflow steps in a clearer and more concise way. This helps people to follow the process flow without difficulty.
SOPs are often siloed by health care professional groups and tend to center on each individual provider type, such as the cytotechnologist, pathologist, or accessioner. Unlike swim-lane process maps, SOPs are not able to reflect the relationships and hand-offs between different players in a single format. Swim-lane process mapping connects all process team members and guarantees that the overall process is represented in an integrated visual diagram. A consolidated process map contains richer, more complete, and more accurate information in comparison with traditional narrative SOP formats.
Understanding the status quo lays the groundwork for future improvements
Understanding vulnerabilities and limitations in the current workflow provides a solid foundation for potential interventions and innovations. Most validated improvement models begin with an understanding of the current status.3 Process maps allow us to uncover non-value added activities and to pinpoint bottlenecks in health care delivery.
For instance, by mapping the workflow in our laboratory, we can more easily recognize potential targets for improvement, or non-value added activities. These can be as simple as identifying wait times, inefficient hand-offs, and unnecessary duplication or complexity of work (see Fig. 2).
A process cannot be managed and improved if it is not first measured. Understanding the status quo with process maps allows for better baseline data collection and analysis. Digital time stamps can be used to perform time cycle analysis and calculate “wasted” time. These data then serve as baseline evidence for evaluating the effectiveness of future interventions.
Process mapping is a process of building consensus
A process map is a product of collective intelligence. It often requires group brainstorming sessions involving stakeholders from each relevant care segment. Process mapping is not only about drawing the chart itself but is also a process of building trust and consensus.4 We all know very well about the workflows in our own fields, but we rarely pay attention to others' workflows, which are equally important as we are work toward common health care goals. This knowledge gap may trigger hidden risks such as blame shifting when complaints are received. Pathologists may think that the transcriptionists are the holdup in the process, whereas the transcriptionists may actually be quite efficient at transcribing the diagnosis. However, as the map indicates in the example, the culprit may be a surprise. In the example, it was not the productivity of individual employees but rather the waste created by the reliance on paper requisitions in the sign-out workflow. With representatives from every involved area sitting in the same room and openly talking about their parts of the process, process mapping helps to minimize blame, builds trust between players, and helps them to form a consensus on where the actual problems lie within the workflow.
Creating a Process Map Step by Step
Select the process and define the scope
If the scope is not defined, a process map can be indefinitely complex. To avoid unnecessary work, process mapping should begin with the following questions: What process shall be the focus? Where does the workflow start? Where does it end? What level of detail is needed in the chart display? Keep scope clear and reasonable.
Identify stakeholders and engage frontline staff
With clear boundaries of the process in mind, identify different stakeholders in the process. Process maps are a product of collective intelligence, so representatives from each involved area should be invited to participate in process mapping. In particular, frontline staff should be encouraged to offer their insights because critical workflow information can be captured only if the people closest to the work are asked.
Conduct a brainstorming session with sticky notes
Schedule a brainstorming session that involves every stakeholder. The purpose of the brainstorming session is to have the group recall all of the steps that may take place in the workflow. Sticky notes are an extremely helpful instrument to assist this process. Sticky notes of different colors may be selected to visually represent different stakeholder groups, and they can be easily moved around on the basis of the workflow consensus. In the example, we used blue sticky notes for pathologists and trainees and orange ones for administrative staff. We asked every participant to write down in detail his or her activities in the process, with 1 step per note (see Fig. 3)
Brainstorming the activities with sticky notes. LIS indicates laboratory information system.
After all activities/notes are gathered together on a wall or table, the next step is to arrange them in the correct order, which should reflect the real-life workflow. Because it is nearly impossible to create the perfect flowchart on the first try, participants are encouraged to get a first draft out, with revisions made later if needed. The ability to move sticky notes around freely allows us to make revisions/iterations in the process map during the brainstorming session until consensus is achieved. Then, arrows can be drawn for the process flow (see Fig. 4).
Sticky notes in correct order. LIS indicates laboratory information system.
Validate the draft process map by walking the gemba
Gemba is a Japanese term that refers to “the real place” in Lean methodology. A gemba walk requires us to go where the real work takes place and gain firsthand insight into how processes are performed.5 Direct observation of the actual workflow helps to ensure that the draft map accurately represents the real work by identifying discrepancies from brainstorming sessions. If necessary, the gemba walk can be repeated to capture variations in the workflow (eg, on off-hours or weekends). The process map thus needs to be updated accordingly to reconcile these discrepancies or variations.
Finalize the process map into an electronic version
Once the process map is finalized, the draft should be converted into an electronic document. Various software products are available in the market. MS Visio (Microsoft Corporation, Redmond, Washington) is one of the most popular programs for professional process mapping, and it is highly recommended for those complex maps with swim lanes. It not only offers multiple flowchart templates but also has a user-friendly drag and drop feature with preset symbols designed for process mapping. If you do not have access to MS Visio, there are plenty of other choices such as MS PowerPoint (Microsoft), SmartDraw (SmartDraw Software LLC, San Diego, California), and Minitab (Minitab, Inc, State College, Pennsylvania). Figure 2 shows an electronic process map of the case example created with MS Visio.
Evaluate the current workflow and form plans for next steps
With the help of a process map, we are able to thoroughly assess the status quo and to identify delays, redundancies, problematic hand-offs, or other issues in the workflow. If needed, further analysis of the cycle time or value streams can be performed on the basis of the map. After the process map is finalized, plans for targeted quality improvements can be developed.
Conclusions
Process mapping is the first and most important step in digesting complex workflow information, understanding the status quo, and identifying opportunities for improvement. By providing visual representations of data, process maps highlight waste and vulnerable process steps.
Finally, after creating a process map, stakeholders are already assembled and invested in designing effective solutions to complex workflow challenges in the laboratory.
FUNDING SUPPORT
No specific funding was disclosed.
CONFLICT OF INTEREST DISCLOSURES
The authors made no disclosures.
Biographies
Yael K. Heher, MD, MPH, is an anatomic pathologist and the Director of Quality and Safety (Anatomic Pathology/Clinical Pathology) in the Department of Pathology at the Beth Israel Deaconess Medical Center and Harvard Medical School in Boston, Massachusetts. Her main focus is the role of quality improvement and patient safety in pathology, including performance and metric assessment, adverse event management, transparency, effective change, and leadership.
Yigu Chen, MPH, PMP, is a quality and process improvement specialist in the Department of Pathology at Beth Israel Deaconess Medical Center. He has a keen interest in propelling value-driven improvements in patient safety and health care quality. He oversees quality and operations data analytics, leads root cause analyses of adverse events, and facilitates improvement initiatives in the laboratory and across laboratory-related services.
