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What is Process Mapping & how it is done in hospital?

Article · November 2019

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Madhav Madhusudan Singh Ph.D

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 *RFHHA MANAGEMENT TIP OF THE DAY FOR HOSPITAL ADMINISTRATORS
1240*

*What is Process Mapping & how it is done in hospital? *

A process is defined as set of interrelated and interacting activities which

transforms inputs into outputs. A process is defined as “a series of steps which
convert one or more inputs into one or more outputs.”

A process has three key components.

1. Inputs.
2. Processes-Activities/steps that transforms inputs into outputs.
3. Outputs-end result of processes.

An output of a process can be input of next process. It is understood that the

output or final outcomes depends on not only the inputs but also the processes
we employed to convert them into output.

Whenever going for improving quality of healthcare services, more often than not
we tend to concentrate on INPUTS-Infrastructure, Human Resources and
Finances. We need to understand that ‘mere provision of resources is not enough’.
Effective and efficient utilization of available resources is equally important if not
more, for improvement of quality of healthcare services.

What is a Process Map?

A process map is a graphical representation of series of steps of a process. The
map is used to document the step-by-step activities involved in providing a
service. A common saying is “A picture is worth a thousand d words”. Also all of
us have visual memory. Hence it is always helpful if we project facts in picture and
figures. A process map visually represents the entire process from start to finish.
It provides a common understanding of the entire process and specific roles and
contributions of the process participants. Furthermore, process maps helps in
identification of problem areas and opportunities for process improvement.
Process maps are great Problem solving tools. They help us to determine what the
problem is/what it is not.

The purpose of process mapping is to use diagramming to understand the process

we currently use and ask what is expected of us; what should we be doing to
provide better customer focus and satisfaction.

It will identify what best practices we need to incorporate and find appropriate
benchmarks for measuring how we can arrive at better ways of communicating
our services.

When we map hospital processes and look at patients’ perspective, we will find
that:
 30 - 70% of work doesn’t add value for patient
 up to 50% of process steps involve a ‘hand-off’, leading to error, duplication
or delay
 no one is accountable for the patient’s ‘end to end’ experience
 Job roles tend to be narrow and fragmented.

How to do Process mapping?

Step 1: Determine the Process to be mapped and its Boundaries
a. Where does a process begin?
b. Where does a process end?
Step 2: List the Steps
a. Use a verb to start the task description.
b. The flowchart can either show the sufficient information to understand the
general process flow or detail every finite action and decision point.
Step 3: Sequence the Steps
Locate the steps of the process in their proper sequence. Map what actually
happens. Record the activities including time. Create the journey (remembering
that some activities happen in parallel)
Step 4: Draw Appropriate Symbols
There are numerous symbols available for process mapping but we will stick with
the basic symbols required for mapping hospital processes:

i. Ovals show input to start the process or output at the end of the process.

ii. Boxes or rectangles show task or activity performed in the process.

iii. Arrows show process direction flow.

iv. Diamonds show points in the process where a yes/no questions are asked or a
decision is required. Usually “yes/no” (binary) decisions. Divides the continuing
process flow into two separate paths in response to the question inside the
diamond usually there is only one arrow out of an activity box. If there is more
than one arrow, you may need a decision diamond.

v. If there are feedback arrows, make sure feedback loop is closed; i.e. it should
take you back to the input box.

Step 5: Inputs/Outputs: Represent the output of each box or diamond as an

appropriately labeled arrow leading to the next step in the process

Step 6: Number: Number the boxes for reference

Step 7. Keep a note of issues and opportunities at each step.

Step 8: Check for Completeness

Sample Flowchart

Step 9. Identify the bottlenecks. Now the map is complete. Let us now identify
the bottlenecks. There are two types of bottlenecks; Process bottlenecks and
Functional bottlenecks.
Process Bottlenecks: Occurs when a step is the limiting rate of the process The
step takes a significant time, and slows the whole process down.

Functional bottle necks Occurs when one functional resource is required for
more than one processes.

For example Lab. Services are required by OT, Labour room, wards, ICU, etc.

Step 10: Identify VALUE / NON-VALUE ADDING STEPS

Value adding activities: The activity that transforms the patient and moves them
towards the next defined outcome. The activity is something that the patient
cares about and is willing to pay.
Non-value adding: Do not serve any purpose (aim to remove these)
Necessary non-value adding: Do not directly benefit patient but are necessary
e.g. completion of forms, logging patient details onto systems, numerous checks
of details.
Remember: It’s the activities that are non value adding not the person. It is also
critical to recognize that the non value adding activities may have been a core
part of someone job for many years

Step 11: Identify the wastes in the processes.

Waste is a sensitive issue. Lean philosophy advocates removing the wastes from
the processes. Quality of any process can be improved without doing anything
extra or different, simply by removing the wastes.

Common wastes in the Hospitals are:

1. Confusion:
 Nurses spend 65% of their time looking for things they could not find,
clarifying unclear instructions and doing redundant paperwork. (Jimmerson
et al. 2005). Confusion includes questions like:
 What do I do with this requisition? Is it Inj. Fortum or Inj. Fortwin.
 What does this order mean?
 Where do I have to store this item?

2. Motion/conveyance:
 Physical movement required to get a simple task done and to move people
from place to place.
 Redundant reaching for items.
 Walking to another location only to return to the starting point.
 Conveyance of patients and materials from room to room or department to
department.
3. Waiting: Waiting for :a procedure to be done, a medication to arrive, or a
doctor’s order to be given.
4. Over processing: Doing more activities than is necessary to complete a work.
Eg. Multiple entries of patient’s demographic details during the hospital visit.
5. Inventory: Stored supply that are: Obsolete, Duplicated, Unnecessary. E.g.
missed charges for items used.
6. Defects: For example: Medication errors. Wrong site surgery. Leaving
instruments in patient’s body. Wrong blood group errors. Bed sores. Incidence of
fall from bed.

Step 12: Analyse the processes Map:

 How many steps in your process?
 How many duplications?
 How many hand-offs?
 What is the approximate time of or between each step?
 Where are possible delays?
 Where are major bottlenecks?
 How many steps do not add value for patients?
 How many types of wastes are there between each step?
 Where are the problems for patients and staff?

Step 13: Redesign the Process: After analyzing the Process, “TO BE” process may
be developed by:
 Eliminate non-value-added activities
 Eliminate duplicate activities
 Combine related activities
 Identify and remove waste at each step.
 Use decision-based, alternative process flow paths.

Facts &Tips:
 Process mapping is basic and simple — the best way to learn it is to do it!
 Process mapping is a repetitive process; maps should never be thrown
away but reviewed and updated.
 Display the maps so all staff can see them and contribute to ongoing
improvements.
 There is no right or wrong way to process map. Adapt to your organization
and individuals availability.
  Only record those steps which you carry out MOST of the time (80/20 rule).
 Keep the steps SMALL.
 Make it fun but productive

LIMITATIONS OF PROCESS MAPPING:

1. Process mapping is not panacea for all healthcare service delivery
problems.
2. Process mapping is no substitute for knowledge, skills, attitudes and
competence.
3. Process mapping are as good as you want them to be. If you have missed
the critical details/activities of a process, you will not be able to improve
the process.
4. Process mapping can help in improving quality even with limited inputs. But
is of no use when inputs are not available at all.

*Dr Madhav M Singh*

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