Step 5b - Where does the problem lie? - Process Mapping
Many of our clinical processes are a sequence of steps, undertaken by different professionals. As junior doctors we come into contact with only a few of these steps and although we are aware of our important roles as part of a larger picture, we often do not completely understand the entire process in detail.
[Let’s say for example, you’re an FY2 working on a general surgery placement and you feel there to be a problem with outliers being missed. The steps you would likely take are for the patient to be transferred from ED to the outlying ward, nursing staff on that ward contact you as the on-call doctor, you would clerk the patient, if critically ill you would call your registrar, if not you would decide on a clinical plan yourself and communicate it to the ward staff who would begin to act on it, you would add the patient to the surgical patient list, the patient would be discussed at handover in the morning, they’d then be seen on ward round and further plan made, that plan may involve transfer to a more appropriate ward or to theatre – the steps would continue until discharge.]
Let’s say for example, you’re an FY2 working in a GP practice and you want to refer someone for an endoscopy. The steps you would likely take are to clinically assess the patient, document your plan in the patient record, complete an endoscopy referral, print it, and send it to the practice secretaries to be processed. What happens after that is often a mystery to us, as we’ve done what we needed to do in our role. However there are further steps, and these are important to understand if in your project you’re looking to improve this process. To continue our example, the ward clerk may send the referral to the endoscopy department via fax/mail/electronically, it will be received by the booking office, it may be sent to someone else in the endoscopy department to be triaged, then sent back to the booking office to get a date and time booked, a letter will then be generated, this sent to the patient’s address, the patient then needs to receive and read the letter, then arrange to get to the hospital, then all the steps involved in actually doing the endoscopy (safety checks, equipment checks, staff availability etc.), then the endoscopist writes a report, this then gets sent to hospital secretaries, who send it back to the GP practice, who arrange an appointment with the patient to discuss the results.
The above example is hypothetical and in many systems some of these steps will be removed through the use of technology. Also this is a cross-organisation process, beyond the scope of a typical QI project a junior doctor would be expected to undertake. However it illustrates a few things:
– There are steps in most processes we are unaware of
– If there is a problem at any one of these steps, the entire process comes to a halt
– Multiple professionals in different roles are needed for the process to work
– The entire process is hard to visualise when laid out in written text as above
These points will hold true for most aspects of care you could look to improve, even if on a single ward. Therefore to help identify problem steps you may want to construct a process map.
Here is a different example to the above text:
Figure 5.1, An Example of a Process Map. This hypothetical example is the steps in reviewing and developing a clinical plan for a surgical patient out-lied to a medical ward. This could be relevant to a project looking to overcome the problem of outliers often being missed. By producing the process map you may realise that the crux of problem is in doctors forgetting to add patients to the list, and therefore could structure your project around this aspect.
A process map is simply a flowchart-like depiction of a process. It should be objective, i.e. everyone involved in it should agree what the steps are. Also you should try and break down steps to a moderately detailed level, as keeping each step too broad may mean you miss ‘smaller’ parts of the process that are in fact the problem areas (what if the printer seems to always have no paper, for example). From the diagram you can then see where the problem might lie, and then build the SMART aim of your project around this aspect of care (step 5b).