Process mapping the patient journey: an introduction
BMJ 2010; 341 doi: https://doi.org/10.1136/bmj.c4078 (Published 13 August 2010) Cite this as: BMJ 2010;341:c4078
- Timothy M Trebble, consultant gastroenterologist1,
- Navjyot Hansi, CMT 21,
- Theresa Hydes, CMT 11,
- Melissa A Smith, specialist registrar2,
- Marc Baker, senior faculty member3
- 1Department of Gastroenterology, Portsmouth Hospitals Trust, Portsmouth PO6 3LY
- 2Department of Gastroenterology, Guy’s and St Thomas’ NHS Foundation Trust, London
- 3Lean Enterprise Academy, Ross-on-Wye, Hertfordshire
- Correspondence to: T M Trebble tim.trebble{at}porthosp.nhs.uk
- Accepted 15 July 2010
Healthcare process mapping is a new and important form of clinical audit that examines how we manage the patient journey, using the patient’s perspective to identify problems and suggest improvements.1 2 We outline the steps involved in mapping the patient’s journey, as we believe that a basic understanding of this versatile and simple technique, and when and how to use it, is valuable to clinicians who are developing clinical services.
What information does process mapping provide and what is it used for?
Process mapping allows us to “see” and understand the patient’s experience3 by separating the management of a specific condition or treatment into a series of consecutive events or steps (activities, interventions, or staff interactions, for example). The sequence of these steps between two points (from admission to the accident and emergency department to discharge from the ward) can be viewed as a patient pathway or process of care.4
Improving the patient pathway involves the coordination of multidisciplinary practice, aiming to maximise clinical efficacy and efficiency by eliminating ineffective and unnecessary care.5 The data provided by process mapping can be used to redesign the patient pathway4 6 to improve the quality or efficiency of clinical management and to alter the focus of care towards activities most valued by the patient.
Process mapping has shown clinical benefit across a variety of specialties, multidisciplinary teams, and healthcare systems.7 8 9 The NHS Institute for Innovation and Improvement proposes a range of practical benefits using this approach (box 1).6
Box 1 Benefits of process mapping6
A starting point for an improvement project specific for your own place of work
Creating a culture of ownership, responsibility and accountability for your team
Illustrates a patient pathway or process, understanding it from a patient’s perspective
An aid to plan changes more effectively
Collecting ideas, often from staff who understand the system but who rarely contribute to change
An interactive event that engages staff
An end product (a process map) that is easy to understand and highly visual
Several management systems are available to support process mapping and pathway redesign.10 11 A common technique, derived originally from the Japanese car maker Toyota, is known as lean thinking transformation.3 12 This considers each step in a patient pathway in terms of the relative contribution towards the patient’s outcome, taken from the patient’s perspective: it improves the patient’s health, wellbeing, and experience (value adding) or it does not (non-value or “waste”) (box 2).14 15 16
Box 2 The eight types of waste in health care13
Defects—Drug prescription errors; incomplete surgical equipment
Overproduction—Inappropriate scheduling
Transportation—Distance between related departments
Waiting—By patients or staff
Inventory—Excess stores, that expire
Motion—Poor ergonomics
Overprocessing—A sledgehammer to crack a nut
Human potential—Not making the most of staff skills
Process mapping can be used to identify and characterise value and non-value steps in the patient pathway (also known as value stream mapping). Using lean thinking transformation to redesign the pathway aims to enhance the contribution of value steps and remove non-value steps.17 In most processes, non-value steps account for nine times more effort than steps that add value.18
Reviewing the patient journey is always beneficial, and therefore a process mapping exercise can be undertaken at any time. However, common indications include a need to improve patients’ satisfaction or quality or financial aspects of a particular clinical service.
How to organise a process mapping exercise
Process mapping requires a planned approach, as even apparently straightforward patient journeys can be complex, with many interdependent steps. 4 A process mapping exercise should be an enjoyable and creative experience for staff. In common with other audit techniques, it must avoid being confrontational or judgmental or used to “name, shame, and blame.”8 19
Preparation and planning
A good first step is to form a team of four or five key staff, ideally including a member with previous experience of lean thinking transformation. The group should decide on a plan for the project and its scope; this can be visualised by using a flow diagram (fig 1⇓). Producing a rough initial draft of the patient journey can be useful for providing an overview of the exercise.
Fig 1 Steps involved in a process mapping exercise
The medical literature or questionnaire studies of patients’ expectations and outcomes should be reviewed to identify value adding steps involved in the management of the clinical condition or intervention from the patient’s perspective.1 3
Data collection
Data collection should include information on each step under routine clinical circumstances in the usual clinical environment. Information is needed on waiting episodes and bottlenecks (any step within the patient pathway that slows the overall rate of a patient’s progress, normally through reduced capacity or availability 20). Using estimates of minimum and maximum time for each step reduces the influence of day to day variations that may skew the data. Limiting the number of steps (to below 60) aids subsequent analysis.
The techniques used for data collection (table 1⇓) each have advantages and disadvantages; a combination of approaches can be applied, contributing different qualitative or quantitative information. The commonly used technique of walking the patient journey includes interviews with patients and staff and direct observation of the patient journey and clinical environment. It allows the investigator to “see” the patient journey at first hand. Involving junior (or student) doctors or nurses as interviewers may increase the openness of opinions from staff, and time needed for data collection can be reduced by allotting members of the team to investigate different stages in the patient’s journey.
Data collection in process mapping
Mapping the information
The process map should comprehensively represent the patient journey. It is common practice to draw the map by hand onto paper (often several metres long), either directly or on repositionable notes (fig 2⇓).
Fig 2 Section of a current state map of the endoscopy patient journey
Information relating to the steps or representing movement of information (request forms, results, etc) can be added. It is useful to obtain any missing information at this stage, either from staff within the meeting or by revisiting the clinical environment.
Analysing the data and problem solving
The map can be analysed by using a series of simple questions (box 3). The additional information can be added to the process map for visual representation. This can be helped by producing a workflow diagram—a map of the clinical environment, including information on patient, staff, and information movement (fig 3⇓).18
Box 3 How to analyse a process map6
How many steps are involved?
How many staff-staff interactions (handoffs)?
What is the time for each step and between each step?
What is the total time between start and finish (lead time)?
When does a patient join a queue, and is it a regular occurrence?
How many non-value steps are there?
What do patients complain about?
What are the problems for staff?
Fig 3 Workflow diagram of current state endoscopy pathway
Redesigning the patient journey
Lean thinking transformation involves redesigning the patient journey.21 22 This will eliminate, combine and simplify non-value steps,23 limit the impact of rate limiting steps (such as bottlenecks), and emphasise the value adding steps, making the process more patient-centred.6 It is often useful to trial the new pathway and review its effect on patient management and satisfaction before attempting more sustained implementation.
Worked example: How to undertake a process mapping exercise
Preparation and planning
South Coast NHS Trust, a large district general hospital, plans to improve patient access to local services by offering unsedated endoscopy in two peripheral units. A consultant gastroenterologist has been asked to lead a process mapping exercise of the current patient journey to develop a fast track, high quality patient pathway.
In the absence of local data, he reviews the published literature and identifies key factors to the patient experience that include levels of discomfort during the procedure, time to discuss the findings with the endoscopist, and time spent waiting.24 25 26 27 He recruits a team: an experienced performance manager, a sister from the endoscopy department, and two junior doctors.
The team drafts a map of the current endoscopy journey, using repositionable notes on the wall. This allows team members to identify the start (admission to the unit) and completion (discharge) points and the locations thought to be involved in the patient journey.
They decide to use a “walk the journey” format, interviewing staff in their clinical environments and allowing direct observation of the patient’s management.
Data collection
The junior doctors visit the endoscopy unit over two days, building up rapport with the staff to ensure that they feel comfortable with being observed and interviewed (on a semistructured but informal basis). On each day they start at the point of admission at the reception office and follow the patient journey to completion.
They observe the process from staff and patient’s perspectives, sitting in on the booking process and the endoscopy procedure. They identify the sequence of steps and assess each for its duration (minimum and maximum times) and the factors that influence this. For some of the steps, they use a digital watch and notepad to check and record times. They also note staff-patient and staff-staff interactions and their function, and the recording and movement of relevant information.
Details for each step are entered into a simple table (table 2⇓), with relevant notes and symbols for bottlenecks and patients’ waits.
Patient journey for non-sedated upper gastrointestinal endoscopy
Mapping the information
When data collection is complete, the doctor organises a meeting with the team. The individual steps of the patient journey are mapped on a single long section of paper with coloured temporary markers (fig 2⇑); additional information is added in different colours. A workflow diagram is drawn to show the physical route of the patient journey (fig 3⇑).
Analysing the data and problem solving
The performance manager calculates that the total patient journey takes a minimum of 50 minutes to a maximum of 345 minutes. This variation mainly reflects waiting times before a number of bottleneck steps.
Only five steps (14 to 17 and 22, table 2⇑) are considered both to add value and needed on the day of the procedure (providing patient information and consent can be obtained before the patient attends the department). These represent from 13 to 47 minutes. At its least efficient, therefore, only 4% of the patient journey (13 of 345 minutes) is spent in activities that contribute directly towards the patient’s outcome.
Redesigning the patient journey
The team redesigns the patient journey (fig 4⇓) to increase time spent on value adding aspects but reduce waiting times, bottlenecks, and travelling distances. For example, time for discussing the results of the procedure is increased but the location is moved from the end of the journey (a bottleneck) to shortly after the procedure in the anteroom, reducing the patient’s waiting time and staff’s travelling distances.
Fig 4 Workflow diagram of future state endoscopy pathway
Implementing changes and sustaining improvements
The endoscopy staff are consulted on the new patient pathway, which is then piloted. After successful review two months later, including a patient satisfaction questionnaire, the new patient pathway is formally adopted in the peripheral units.
Further reading
Practical applications
NHS Institute for Innovation and Improvement (https://www.institute.nhs.uk)—comprehensive online resource providing practical guidance on process mapping and service improvement
Lean Enterprise Academy (http://www.leanuk.org)—independent body dedicated to lean thinking in industry and healthcare, through training and academic discussion; its publication, Making Hospitals Work23 is a practical guide to lean transformation in the hospital environment
Manufacturing Institute (http://www.manufacturinginstitute.co.uk)—undertakes courses on process mapping and lean thinking transformation within health care and industrial practice
Theoretical basis
Bircheno J. The new lean toolbox. 4th ed. Buckingham: PICSIE Books, 2008
Mould G, Bowers J, Ghattas M. The evolution of the pathway and its role in improving patient care. Qual Saf Health Care 2010 [online publication 29 April]
Layton A, Moss F, Morgan G. Mapping out the patient’s journey: experiences of developing pathways of care. Qual Health Care 1998; 7 (suppl):S30-6
Graban M. Lean hospitals, improving quality, patient safety and employee satisfaction. New York: Taylor & Francis, 2009
Womack JP, Jones DT. Lean thinking. 2nd ed. London: Simon & Schuster, 2003
Notes
Cite this as: BMJ 2010;341:c4078
Footnotes
Contributors: TMT designed the protocol and drafted the manuscript; TMT, MB, JH, and TH collected and analysed the data; all authors critically reviewed and contributed towards revision and production of the manuscript. TMT is guarantor.
Competing interests: MB is a senior faculty member carrying out research for the Lean Enterprise Academy and undertakes paid consultancies both individually and from Lean Enterprise Academy, and training fees for providing lean thinking in healthcare.
Provenance and peer review: Not commissioned; externally peer reviewed.