Margie Wiebe, RN

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Patient Journey Mapping To Make High Impact
Changes

• Margie Wiebe, RN
• Improvement Advisor
• Impact BC
• Email mwiebe_at_impactbc.ca
• T 604 761 8184

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Why Map a Process or Journey?

• A simple exercise useful in problem solving to
  workout a particular process
• Provides an overview of a complete process or
  journey
• Once mapped, the bottlenecks, time delays, and
  duplicate efforts jump right out
• A highly visual tool to see all steps of the
  whole journey
• Mapping each step in the process is the baseline
  for improvements
• A powerful tool to help plan high impact changes
  in redesign

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Why Map a Process or Journey? (contd)

• Gets multiple care providers together to improve
  understanding of each others roles and services
• When mapping with patients, it is neutral ground
  (from the patients perspective)
• One of the most powerful ways for
  multidisciplinary teams to understand the real
  problems from the patients perspective
• Enables every single person to work with others
  to improve their part of the service

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What is a Process?

• Processes are all around us, but in healthcare
  our roles limit us to seeing only one small part
  of the whole patient process
• A series of connected steps or actions that
  achieve an outcome
• Has a starting point and end point
• Has a defined group of users e.g. patients with
  diabetes
• Has a purpose or aim
• Is usually linked with other processes
• Can be simple and short or long and complex

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Process Mapping Understanding the flow or
sequence of events
Conventional symbols represent different
activities

• Oval - the start and end of the process
• Box - the tasks or activities of the process
• Diamond - a question is asked a decision is
  required
• Arrow - the direction or flow of the process

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Example Map (Penticton)

• It is okay if you dont use all the symbols
• boxes and arrowswork just fine!

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Example Map Quesnel

• What a maze!
• Colors are effective to show repetition

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Step 1 Start With Quality Improvement
Guideposts

• What are we trying to accomplish?
• Develop an aim
• How will we know change is an improvement?
• What measures are you going to use
• What changes can we make that will result in
  improvement?
• Choose a few potential changes that will make a
  big improvement
• Test change using the Plan-Do-Study-Act short
  cycle change method
• See 10 High Impact Changes for Service
  Improvement and Delivery (in this slide package)

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Step 1 (contd)

• 1. When defining the aim include
• the group of patients you are considering
• what your team wants to achieve
• clear numerical targets

• Team targets should be consistent with national
  and local targets, plans and frameworks
• Be bold in aspiration

To map, from a patient perspective, the steps
of a person with diabetess journey through the
healthcare services in Quesnel, from worrisome
concern to treatment plan, and then use the map
for health care redesign to improve the patient
journey.
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Step 1 (contd)

• 2. How will we know change is an improvement?
• What measures will you use?
• How will you report progress to all the
  interested parties?
• To get advice on
• What to measure
• How to measure
• How to present the data to interested parties
• refer to Measurement for Improvement Leaders
  Guide www.modern.nhs.uk/improvementguides

Example of a measure Every step of a the
journey is mapped, a representative from care
provider department is on the mapping team,
representative group of patients is on the
mapping team, top problems for patients are
identified, 3-5 PDSAs are identified to address
top problems
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Step 1 (contd)

• 3. What changes can we make that will result in
  improvement?
• Choose potential changes that will make a big
  improvement
• See 10 High Impact Changes for Service
  Improvement and Delivery (in this slide package)
• Are parallel processes a problem?
• Use the Plan-Do-Study-act short cycle method to
  test change

PDSA Example Plan decrease amount of steps
in the patient journey by conducting one stop
shopping group medical visits. Do Held our
first group medical visit for 15 of Dr. Xs
patients with diabetes. Study The group medical
visit cut out 6 steps, 3 parallel processes and
10 hours waiting time for patients. 98 of the
patients and 100 of the providers preferred
group medical visits over traditional 11 visits.
Act Try 3 more group medical visits before
implementing into permanent practice
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Step 2 Preparation before Mapping

• Preparation
• Identify patient group who would benefit most by
  redesign
• Gather the team (everyone involved in the
  process/journey)
• Meet with the department head managers before
  hand
• Invite consumers (representative sample of
  patients)
• Emphasize contribution each participant is
  expected to make
• Hold orientation meeting with the team to explain
  mapping, determine team aim, measures, goal,
  objectives, and define scope

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Step 2 (Contd)

• Preparation
• Organize the mapping event for one full day, or
  two half days no more than two weeks apart
• Arrange a suitable venue, preferably offsite
  (prevents people from dropping in and out)
• Give participants at least a months notice of the
  event

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Example of a Mapping Team for Diabetes

• Doctor
• Medical office assistant
• Doctors clinic manager
• Diabetes educator
• Chronic disease clinic receptionist
• 5 people with diabetes
• Community pharmacists
• Dietician
• Lab (private and hospital)

• Social worker
• Key community stakeholder (e.g. optometrist,
  podiatrist)
• Nurses (acute care, ER , ICU, public health,
  etc.)
• IHN or PSP or Care North coordinator
• Hospital administrator
• Funder (if there is funding)

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Step 3 Define Your Goal

• To empower patients to be equal partners in
  health care redesign
• To create a document that would demonstrate all
  the steps of the journey from a patients
  perspective
• To plan for ongoing development of the tool and
  its applications in health care systems redesign 

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Step 4 Define Your Objectives
Measurable outcomes including dates
quantifiable changes

• Recruitment of expert patients as team members
  for the development of the map
• Map all the steps of a patient with diabetess
  journey
• Identify all barriers, gaps, and overlaps that
  impede a patients ability to achieve their
  treatment goals
• Test changes in one clinic
• Revise the map when changes are implemented
• Use the navigation tool as a living document for
  continual redesign
• Disseminate tool to a much broader community and
  health authority as a sample of the power of
  mapping a patient journey

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Step 5 Define Your Scope

• To map from every step of the journey (start to
  finish)
• From feeling unwell to self management

Processes are all around us, but in healthcare
our roles limit us to seeing only one small part
of the whole patient process NHS Improvement
Leaders Guide Process Mapping, Analysis and
Redesign, p. 15
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Sample Agenda for the Event

• Introductions 10-20 minutes
• Leader reviews 30 minutes
• Logistics (breaks, bathrooms, etc.)
• Aim for the day
• Context why mapping is needed, what will be
  mapped
• How to map, show some maps
• Simple rules (e.g. respect if we cant decide in
  5 minutes, park it, etc.)
• Map (patient journey) from start to finish
  2-4hrs
• Analyze 1-2 hours
• Discuss/agree that the journey map is correct
• Identify what is done well and what could be done
  better
• Look for opportunities to make improvements
• Action items 30 minutes
• Decide on a 3-5 PDSA tests of change
• Who, what, where, when, how

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Step 6 Running the Event

• Allow at least one hour to set up before
  participants arrive
• Get the lead clinician or senior manager to
  attend and preferably open or chair the event
• Get an independent facilitator to do the mapping
  exercise
• Someone removed from the process can ask more
  challenging questions without creating a
  breakdown in working relationships
• Create an environment in which people feel safe,
  to encourage honesty
• Emphasize the need to understand the journey from
  the patients perspective

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Step 6 Running the Event (contd)

• Resources
• A roll of white paper to record the map on
• Lots of post-it notes in several colors
• Flip chart
• Coloured markers
• Dont lose any comments have an extra pair of
  hands ready to help record comments on a flip
  chart
• Document issues, ideas, car parks topics, etc.
  (this will allow you to focus on the job at hand)

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Step 6 Running the Event (contd)

• Dont be tempted to solve problems until you have
  fully mapped the process and analyzed it
• Make the event practical, visual, and fun
• spacious, comfortable, good lighting, all can see
  the map, plan for snacks/meals, and interesting
  breaks
• Agree on next steps before the event finishes

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Step 7 Creating the Map

• Cover a good long portion of one wall with roll
  paper
• Draw a vertical axis along the left side (people
  axis)
• Along the bottom draw a horizontal axis (time
  line axis)
• Using post-it notes, begin to lay out every step
  of the process beginning with first person
  involved then the second person, etc., until
  whole journey is complete
• Now draw on the paper using the symbols
• Enter wait times at each step and between steps
• Source http//www.managers-gestionnaires.gc.ca/d
  ocuments/chartier/toolkit_e.pdf

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Example
(Time Axis) 1 day ... 3
months.... 6 months...1 year....etc.
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Tips

• Respect the diversity of the group
• Use five minute rule if group cannot agree
  about what happens within five minutes, park the
  issue and follow up after the session
• Emphasize that patient journey mapping is about
  trying to understand the patient experience at
  each step in their journey and there is no blame
  attached
• Record on post-it notes who does what to the
  patient
• Only one step per post-it-note
• There will be variations only record what
  happens 80 of the time

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Tips (contd)

• Add estimates of time for each step and between
  steps
• Concentrate initially on what happens to the
  patient, not referral forms, etc.
• Use different colour post-it notes to
  differentiate the process
• Yellow process or step in journey
• Red problems or issues
• Green solutions or ideas

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Step 8 Analyse the Patients Journey
Next, the team can use different color markers
and work directly on the map to make
recommendations around red tape, unplugging
bottlenecks and eliminating duplicate effort

• Analyse the map by considering the following
• How many steps are there for the patient?
• How many times is the patient passed from one
  person to another (hand-off)?
• What is the approximate time taken for each step
  (task time)?

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Step 8 (contd)

• What is the approximate time between each step
  (wait time)?
• What is the approximate time between the first
  and the last step?
• When is the patient put on a waiting list?
• Do these delays occur on a regular basis?
• How many steps add no value for the patient?
• Where are there problems for the patient? What do
  patients complain about?
• Where are there problems for the staff?

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Step 8 (contd)

• Ask
• Is the patient getting the most appropriate care?
• Is the most appropriate person giving the care?
• Is the care being given at the most appropriate
  time?
• Is the care being given in the most ideal place?

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Step 9 Implement Changes That will Make
Improvement

• Will the changes address top problems identified
  by patients?
• What effect will one change have on another part
  of the system or on a different system?

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Parallel Processes
Example generate a referral letter and get
appointment details to patient

• Parallel processes often are the cause of delays
  for patients and frustration for staff
• Mapping, analyzing and improving parallel
  processes will deliver great benefits
• Separate the parallel process from the patient
  process (e.g. map with different colour)
• Map the parallel process alongside, but separate
  from the patient process (see p. 20 in NHS
  process mapping)

GP tells patient they need a hosp. appt
GP dictates referral letter
Patient waits
Hospital appoint-ment clerk posts letter to
patient
Patient receives appt
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Consider 10 High Impact Changes (NHS)

• Access to tests
• Effective follow-up
• Grouping patients with similar needs
• Systematic care for people with chronic conditions
  
• Reduce steps
• Reduce bottlenecks/waits
• Redesign/extend roles
• 3 examples of tests to start with
• Bottlenecks
• Patient flow
• Redesign/extend roles
• http//www.institute.nhs.uk/index.php?optioncom_j
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10 High Impact Changes (NHS)

• Treat day surgery (rather than inpatient surgery)
  as the norm
• Improve access to key diagnostic tests (improve
  flow)
• Manage variation in patient discharge time
  (reduce length of stay)
• Manage variation in patient admission process
• Avoid unnecessary follow-up provide necessary
  follow-up in right setting
• Increase reliability in therapeutic interventions
  (through care bundle approach)
• Systematic approach to chronic conditions
• Improve access by reducing number of line ups
• Optimizing flow through service bottlenecks,
  using process templates address current waiting
  times
• Redesigning and extending roles in line with
  efficient pathways to attract and retain an
  effective workplace

http//www.institute.nhs.uk/index.php?optioncom_j
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Implement the Changes that will Make
Improvements (NHS)
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Step 8 Celebrate

• Congratulate the team and celebrate success
• A celebration dinner builds team spirit for
  redesign

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Step 9 Take it Forward

• Take a picture of the map
• Send a copy of notes and agreed next steps to
  each participant as well to those who could not
  attend
• Send a picture of the map with a brief
  explanation to
• All doctors in community
• Health authority leaders
• Think big provincially who would be interested

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Step 10 Evaluate

• Plan to evaluate from the beginning
• Satisfaction survey for mapping day
• Look at the improvement leaders guide on
  evaluating improvement
• Look for ways to continue to improve the patient
  journey
• Meet to map again to see if the journey has
  improved after PDSAs are implemented

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Resources

• NHS leaders Guide For Mapping
• http//www.institute.nhs.uk/option,com_joomcart/It
  emid,26/main_page,document_product_info/products_i
  d,295.html
• NHS 10 High Impact Changes leaders Guides
• http//www.institute.nhs.uk/index.php?optioncom_j
  oomcartItemid194main_pagedocument_product_info
  products_id213
• NHS information on improvement mapping
• http//www.tin.nhs.uk/index.asp?pgid1179
• Mercey care NHS process mapping
• http//www.merseycare.nhs.uk/services/corporate/sd
  t/Process_mapping.asp
• National Managers Tools
• http//www.managers-gestionnaires.gc.ca/documents/
  chartier/toolkit_e.pdf