Useful QI Methods: Process Mapping and Flow Charts

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Useful QI Methods Process Mapping and Flow
Charts

• Judy Huska

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Redesigning the clinic visit

• We redesign processes to
• Decrease the length of the visit (cycle time),
  getting the waste out of the clinic visit
• Increase efficiency, getting the wait out of
  the patient visit stand
• Increase productivity and throughput without
  working harder
• Increase provider, team, and room capacity
• Increase care effectiveness

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Patient enters clinic
Registration
Pre-Red Zone
Clinic Room
Cycle time
Provider-Patient Interaction
Red Zone
Completion of procedures/orders
Post-Red Zone
Checkout
Non-appointment time
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Patient flow through the clinic
Patient enters clinic
Registration
Pre-Red Zone
Clinic Room
Cycle time
Provider-Patient Interaction
Red Zone
Completion of procedures/orders
Post-Red Zone
Checkout
Non-appointment time
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Begin process redesign by mapping out the process

• Complete a process walk-through
• Have a staff member pose as a patient and walk
  through a clinic process
• Tell the staff about the walk-through and ask
  them to act normally
• Start the process with the pre-process step and
  continue the process through to completion
• Document the starting time of each step in the
  process, what works well, what does not work
  well, what thoughts you have for improvement,
  what feelings you experienced during the process
  
• Map the process

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Clinic walk-through data collection form
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Key
Process
Key
Process
Key
Process
Key
Process
Key
Process





 
 
 
 
 
Beginning
Beginning
Beginning
Beginning
Beginning
Process flow
mapped
Step 1
Step 3
Step 2
 First Step
Step 4
Decision
Step 5
Step 6
Last Step
Step 7
 
 
 
 
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Example getting an appointment
Automatic recording answers, patient. inputs 4
Registration answers, asks questions, and puts
the patient on hold
Patient calls the Centers main to make an
appointment
Checks with MA for next possible appt time
Registration tells pt that the MA will talk with
him to discuss his symptoms/related appt and puts
pt on hold
MA interviews pt to determine need for appointment
Checks with RN for next possible appt time
MA tells pt that the RN will talk with him, puts
the pt on hold
RN talks with pt about his symptoms, says he will
get an appointment, puts pt on hold
Tells registration to give pt an appt
Registration gives patient an appt time
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Use redesign principles

• Do tasks in parallel
• Use multiple processes
• Minimize handoffs
• Synchronize
• Use a pull system
• Move steps closer together

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Use redesign principles cont.

• Use automation
• Consider people to be in the same system
• Use multiple processing units
• Have specialists do only the tasks that require
  their specific skills
• Convert internal steps to external steps that do
  not require direct provider supervision

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Do tasks in parallel

• To complete a process correctly, most tasks or
  steps of the process do not need to be done
  sequentially
• Examples
• Have the patient fill out the self-assessment
  form while the front office staff is pulling the
  chart
• Have the patient review the billing and income
  qualification information while the staff is
  updating the registration information

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Use multiple processes

• Use multiple processes to handle patient needs
  according to age, condition, and presenting
  problem
• Examples
• Physical exams
• Immunizations
• Group visits for patients with chronic illness
• Education sessions for new patients that need to
  fill out forms and be oriented to the clinic
  processes
• Special education sessions

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Minimize handoffs

• Minimizing the number of staff that is involved
  with a visit process decreases process time, and
  errors
• Accomplish this by consolidating tasks,
  decreasing handoffs, and cross training the staff
  so that one person can handle as many
  non-provider tasks as possible
• Examples
• During the visit have a consistent staff member
  room the patient, gather clinical data, hand
  patient to the provider, and receive patient from
  the provider to complete the visit process
• Have a staff member complete the entire chart
  preparation process including identification of
  individual patient needs

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Synchronize

• All steps of the clinical process are
  synchronized around one point when the patient
  is ready in the room for the provider
• Example If clinic visit starts at 100 pm, the
  following actions should occur
• 1) Patient should arrive right before 100 pm,
• 2) Registration person greets patient at 100 pm,
  asks for updates in information, gets patients
  chart
• 3)105 pm registration person should handoff
  patient and chart to the Medical Office Assistant
  who takes the patient to the room, takes the
  patients blood pressure and weight, confirms the
  patients medications

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Synchronize cont.

• 4) At 115 pm the Medical Office Assistant
  patient takes and hands off the patient to the
  provider
• 5) The synchronization point is 115 pm the
  patient is ready for the provider and the
  provider is ready for the patient at 115 pm

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Use a pull system

• Use a strategy that pulls the patient into and
  through the clinic in deference to pushing the
  patient from thewaiting room
• Pushing denotes pushing against all kinds of
  resistance and bottlenecks
• Example The Medical Office Assistant lets the
  front office know when the room is ready so that
  when the front office completes the sign-in
  process, the Medical Office Assistant is right
  there to greet the patient and escort them back
  to the clinic room

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Move steps closer together

• If support departments are geographically far
  apart from each other, moving them closer
  together save time
• Example
• The laboratory is moved closer to clinic rooms
• The laboratory technician comes into the patient
  room to draw the specimen
• The business office is located close to the
  clinic rooms, so that insurance verification can
  be expedited

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Use automation

• Use a computerized system to manage a process
• Example
• Electronic Medical Record interfaces with the
  laboratory and radiology and reports
  areautomatically generated
• Clinic room documentation is done by the provider
  to prevent double charting and errors

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Consider people to be in the same system

• All staff are accountable for a smooth and
  efficient flow process whether they work in
  clinical or support departments
• Example
• All support departments are represented on the
  access and redesign improvement team
• All staff have an important and valuable role to
  play
• All staff must work together to coordinate the
  process and care

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Use multiple processing units

• Using a number of clinical care units or teams to
  manage components of the patient load
• Examples
• Three pods within a large clinic
• Admission is a process separate
• Chronic disease management is done in group visits

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Have specialists do only the tasks that require
their specific skills

• Each team member needs to work to the highest
  level related to their education, training, and
  capability so the work of the team and each team
  member can be maximized
• Providers should do provider tasks, nurses do
  nurse tasks, Medical Assistants do Medical
  Assistant tasks, etc.
• Example Licensed Practical Nurses doing
  immunizations, Medical Assistants doing LEAP
  exams

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Convert internal steps to external steps that do
not require direct provider supervision

• A provider-driven protocol outlines tasks and
  related staff responsibility. Staff is trained to
  complete the task safely with indirect provider
  supervision.
• Examples
• The nurse holds a medication prescription renewal
  clinic to manage med renewal per protocol
• The nurse manages an immunization clinic
  according to protocol

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Now lets apply these redesign principles to
your selected process

• Map out a personal process
• Use the REDESIGN PRINCIPLE worksheet to redesign
  it
• Share the result