Examples of daily activities as processes

1. Examples of daily activities as processes Driving to work Getting a blood analysis Paying bills

2. Example of the process for obtaining a spirometry Need for spirometry determined Lab requisitions Lab requisition delivered to lab Pt. called With spirometry date Spirometry scheduled Spirometry Test done Reports Printed Reports Delivered to Dr Results analyzed Modified from Langley et al, (2009) Improvement Guide, p. 37

3. Steps to guide HOW to conduct Patient Journey Mapping

4. Step 1: Start with quality improvement guideposts • What are you trying to accomplish? (Aim) • How will you know change is an improvement? (measures) • What changes can you make that will result in improvement?

5. Aim • Include: • The group of patients you are considering • What your team wants to achieve • Scope • Clear numerical targets

6. AIM TEMPLATE: We aim to improve _________(name the process or topic) in _____(location) so that _________ (a numerical goal). By working on the process, we expect ____________(list benefits). It is important to work on this now because ________(list imperatives.) Some things we have to keep in mind as we work are _______ (guidance & scope). Taken from Davis, C charter template

7. Measures 2. Include • a balanced set of measures • Outcome measure • Process measure • Balancing measure

8. Tests of Change 3. Include: • Orientate participants to plan-do-study-act short cycle changes • After mapping: • decide on 3-5 small tests of change that will make a big improvement for each top problem identified • Use NHS 10 high impact changes

9. Step 2Preparations before mapping • Delegate a project champion • Facilitation skills • Patient journey mapping skills • Project management skills • Quality improvement skills

10. Step 2Preparations before mapping 2. Identify the patient group to be mapped • Share common characteristics • Who present in relatively high volume • Whose care could be relatively fast if you took out all waits and delays • Whose care could be mainly pre-scheduled

11. Step 2Preparations before mapping • Build your team • Everyone involved in COPD care • Target department head managers • Emphasize each participants contribution-create ownership • See Managing Human Dimensions of Change NHS leaders guide • Invite a representative sample of patients • Can they advocate for themselves? • Will they be able to sit on health boards? • Have you considered their unique needs • See Involving Patients and Carers NHS leaders guide

12. Step 2 cont’d Preparation before mapping 4. Conduct an orientation for all participants • Explain the why and how of mapping • Show some maps • Get team input for aim, measures & scope • Teach “5 whys”, root cause analyses • Set mapping date

13. Step 2 cont’dPreparations before mapping 5. Arrange a venue (preferably off-site) 6. Get an un biased facilitator for mapping • Preferably not part of the system • Able to “square” each step with patient participants • Able to help quiet people talk and not let talkative dominate • Able to create collaborative dialogue

14. Collaborative Dialogue • Assume that others have pieces of the answer • Listening to understand • Bring up your assumptions for inspection and discussion • Re-examine all points of view • Admit that others’ thinking can improve yours • Discover new possibilities • Collaborative means attempting to find common understanding Citizens’ Dialogue on the Ontario Budget Strategy 2004-2008

15. Step 2 cont’dPreparations before mapping 7. Create a mapping day agenda • Introductions-and group rules • Nominate a second pair of hands-documenter • Set the context-background & progress • Agree on aim for the day & mapping scope • Map the patient journey • Discuss and agree that the map is correct • Analyse the map • Orientate PDSA method to use for tests of change • Plan actions and further work NHS leaders Guide p.36

16. Step 2: cont’dPreparations before mapping 8. Gather Resources • A roll of white table cover paper • Flip chart • Coloured markers • Camera

17. Step 3: Creating the map • Cover a long portion of wall with roll paper • Draw a horizontal time axis along bottom • Define first and last step of journey (scope) • Draw every step of the process using symbols • Start mapping keep asking “what happens next?” • Guesstimate time for each step & between each step-with different color markers • Square with patients “is this what happens” • Record who does what to patient in different marker • * star top problems as you go along

18. Symbols used in mapping Oval – demonstrates the start and end of the process Box – demonstrates a tasks or activity of the process Diamond – demonstrates a decision is required Arrow - demonstrates the direction or flow of the process

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

20. Tips • Use different color markers to differentiate processfrom problems • Variations? Record what happens 80% of the time • You can’t resolve issues in 5 minutes? parking lot • Map what is happening – not what should be • Focus on what happens to the patient don’t get side-tracked by what happens to a referral form • Focus on mapping the journey not solutions • Use the map to improve the journey never to direct the journey

21. Our map patient patient

22. Quesnel’s Map Transposed

23. STUDY Diagnosis: A serious case of Maze Madness!

24. Heart Attack Journey with Chronic Disease

25. Step 4: Analyse the map Work directly on the map with different color markers • Note approximate times at each step (task times ) • Note approximate time between each step (wait time) • What are the (bottlenecks/constraint) causing the wait? • unavailability of equipment or provider • Where does the patient experience a wait? • Note time from first to last step on time axis • Count how many steps there are for the patient • Note which activities add value? which don’t? • Use “5 whys” for top problems

26. Step 4: Analyse the map • Note Bottlenecks • “Bottlenecks are part of the system where patient flow is obstructed, causing waits and delays” • Map in more detail those parts of the process where there are particular waits and delays, these are often parallel processes…” (NHS, 2005, p.19,39) Photo taken from Garrett, D.V., 2007

27. Parallel process demonstrated in a referral letter • Parallel processes cause delays for patients and frustration for staff • Mapping, analyzing and improving parallel processes will deliver great benefits • 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

28. Step 4: Analyse the map • Note how often there are “hand-offs” • Up to 50% of steps involve a “hand-off” (NHS) • 90% of errors, duplication, delays in a journey occur at the point when the patient or paper work is handed from one person, department or organization to another (NHS)

29. Step 4: Analyze (cont’d) Other Questions to 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?

30. Step 5: Follow-up • Create a pictorial • Distribute pictorial to participants and those unable to attend for comments and corrections • Confirm top problems with more patients through surveys

31. Step 6: Coach Teams to Make High Impact Changes • Will the changes address top problems? • Will one change affect another part of the system? • Use PDSA format to test change • Consider 10 High Impact Change http://www.ogc.gov.uk/documents/Health_High_Impact_Changes.pdf

32. NHS - 10 High Impact Changes Three changes to start with • Bottlenecks • Patient flow • Redesign/extend roles • 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

33. Share your maps Powerful for steering through political arenas • Senior administrators • Doctors • Health Authorities • Practice Support Program Cramp, G.J, (2006)

34. Step 4: Celebrate Gather the team to celebrate and show summary of findings

35. Thank-you to all the people who taught me the most about mapping: Judy Huska who told me “you have to do this”PHSA who taught me,Irene Kopetski who was project manager, the 5 patients and the Quesnel Mapping Team

36. References • Citizens’ Dialogue on the Ontario Budget Strategy 2004-2008 • Davis, C (n.d.) Charter Template retrieved Feb 28th from: http://www.impactbc.ca/sites/default/files/resource/n158_ibc_improvement_charter_template_2009.doc • Langley G. J., Moen R.D., Nolan K.M., et al (2009), The Improvement Guide. • NHS (2004) High Impact Changes http://www.ogc.gov.uk/documents/Health_High_Impact_Changes.pdf • NHS (2005) Improvement Leaders Guide: Process mapping analyses and redesign • NHS (2005) Managing Human Dimensions of Change retrieved Feb 28th from: http://www.institute.nhs.uk/index.php?option=com_joomcart&Itemid=194&main_page=document_product_info&cPath=65&products_id=305 • NHS (2005) Involving Patient and Carers. Retrieved Feb 28th from: http://www.institute.nhs.uk/index.php?option=com_joomcart&Itemid=194&main_page=document_product_info&cPath=65&products_id=305

37. Lunch

38. Smoking Cessation Dr. Fred Bass

39. Overview • Strategy in clinical tobacco intervention • The results of a recent pilot in which front-office personnel took the lead in clinical tobacco intervention (CTI) • Checklists and tools you can use for clinical tobacco intervention • QuitNow services to help your patients stop smoking

40. Strategies: Clinical tobacco intervention • Tobacco smoking a chronic condition; relapse is the rule! • Clinical tobacco intervention is vital for COPD patients; it is under-performed! • A systematic, team-based approach combined with medication and brief counseling is highly effective • New ways of using stop-smoking medication are summarized in Alligator article

41. ImpactBC’s Health Coordinator Pilot 2008-10 • Recruited, trained, supported one front-office staff person in 6 practices • Role: help practice identify, assist and follow-up all smoking patients • Target: tobacco and three related risks—physical inactivity, at-risk alcohol use, depression—and charting all work • For 8hrs/week HCs implemented the “5 A’s” of brief intervention—Ask, Assess, Advise, Assist and Arrange follow-up.

42. Results, Health Coordinator Pilot 2008-10 ManeuverBaselineFollow-upp N smokers = 332 288 Chart-reminder 20% 94% <.001 Advised to stop 34% 79% <.001 Self-mgmt (incl. Rx) 14% 57% <.001 Quit date 5% 11% <.02 Referral 6% 11% <.04 Follow-up date 7% 42% <.001

43. Checklists • Practice • Clinician • Patient Tools • BCMJ article: Training the inner alligator • Clinical Tobacco Intervention Options • Smoker’s Guide (for patients)

45. Recap • Strategy in clinical tobacco intervention • The results of a recent pilot in which front-office personnel took the lead in clinical tobacco intervention (CTI) • Checklists and tools you can use for clinical tobacco intervention • QuitNow services to help your patients stop smoking

46. Action plan: Supporting smoking cessation with patients • Use the Practice Checklist to identify areas to test • Use the Patient Checklist • Train MOA to support smoking cessation in GP office • Consultation and support available from ImpactBC

47. Developing an Office Approach Dr. Chris Rauscher

48. Office re-design for proactive shared care • Need to understand work flow and processes as they exist and improve --> MOA is the expert • CDM Office System: • Registry • Clinical tool for care management and monitoring (e.g. Flow sheet; Action-exacerbation plan) • Recall • Analysis: Run charts

49. Office re-design for proactive shared care • Shared Care • Communication • Referral  Consultation • New ways of working - e.g. telephone • Handoffs: Discharge, Re-Referrals

50. The patient registry • A list of all patients with a particular condition • e.g. Diabetes, COPD • Based on registry, can set up system to organize care and monitor patients’ progress (e.g. using flow sheets) • Can recall patients per the patient registry