Quality Improvement Project Guide

Acute Care Hospital Experience
Quality
Improvement
Guide
A resource designed to guide you through
the 3 phases of an improvement project:
Improving the

Planning
Project management for QI: developing a blueprint for success

Reflecting
Analyzing current processes: where to begin and what you can
do to make change

Executing
Strategies, tools, and tips for turning ideas into action

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P: 306-668-8810 F: 306-668-8820
E: info@hqc.sk.ca
W: www.hqc.sk.ca

ISBN 1-897155-17-4

Some of the material in this quality improvement guide was supplied by and is used with the kind permission
of other organizations, who retain copyright over their original work.

© 2006 Health Quality Council

Please contact the Health Quality Council for written permission to distribute or copy this document, in whole
or in part. Permissions do not extend to any materials within this document that are used with the permission
of a third party.

Please use the following citation style when referring to this document:
N Wohlgemuth, S Oosman, S Furniss. Improving the Acute Care Hospital Experience: Quality
Improvement Guide. Saskatoon: Health Quality Council. June 2006.

Health Quality Council also wishes to acknowledge the valuable contributions of other team members to the
development of this guide:
• Catherine Delaney, Knowledge Exchange Consultant
• Laurie Gander, Program Director
• Mary Smillie, Senior Knowledge Exchange Consultant
• Katherine Stevenson, Senior Knowledge Exchange Consultant

Project Checklist
Are you ready to launch a quality improvement project?

You may find this checklist a helpful reference in planning your improve-
ment project. As you go through the list, check the box if you can answer
“YES” to the statement. This will quickly identify areas where you might
need some further planning before you get started.

We have a clear goal and scope of the project.
We have agreement in the senior clinical and management community that there is
a gap between where we are now and where we could be.
We have active support from senior clinical and managerial leaders.
We have completed the Blueprint for Success or project plan.
A leadership team is established and members are aware of their roles and respon-
sibilities. (LIST)

Our project sponsor(s) is confirmed.

We have explicitly described the necessary commitment required and specific roles
and responsibilities of front-line team members. As well, we have described our
expectations and the expected benefits for the organization and the front-line
team(s). (LIST)

We have measurement and reporting systems set up.
We know how and when we will involve patients, caregivers, and other users of the
system we want to improve.
We have a process for recruiting the front-line team(s).

We have recruited the required front-line team(s) with a designated team leader.
a. The front-line team(s) and the team leader(s) is:

b. The team(s) will be assembled by: (DATE)

Patient Experience Survey: Quality Improvement Guide
Health Quality Council 2006

Project Checklist
The team(s) is able to focus on the project and not get side tracked by other
demands.

We have secured the necessary budget and other resources required to support all
elements of the project.

We have completed a “quality improvement skills” training needs assessment for
front-line team(s) members.

We have support available for the front-line team(s) members to develop the neces-
sary quality improvement skills and to complete the project Improvement Charter.

We have the necessary support available to enable the front-line team(s) to analyze
current care processes. For example, using such tools as process mapping or
cause/effect diagram.

We know how we are going to launch the project.

We are already planning how we will acknowledge the quality improvement
achievements made by the front-line team(s).

We are already planning how to ensure that the improvements made are continued.

We are already planning how to spread the improvements to other parts of the
organization.

Used with permission by the NHS Modernisation Agency, subject to Crown copyright protection. Available from URL:
http://www.modern.nhs.uk/improvementguides/reading/collaborative.pdf

Patient Experience Survey: Quality Improvement Guide

Phase One
Included in this section is information on:

• Key elements of an improvement project
• Creating a “blueprint for success”
• Developing effective teams

Patient Experience Survey: Quality Improvement Guide P—1

Introduction to QI Planning
Lloyd Provost (co-author of the Model of Improvement and the
Improvement Guide) identifies three key elements to achieve significant
improvement:
• The will to do what it takes to change to a new system;
• Ideas on which to base the design of the new system; and,
• A clear plan of execution of the ideas.
(L. Provost, Telehealth Presentation, October 5, 2005)

While we often have a strong will to improve and many ideas (from the
literature and our own experiences), execution—organizing, supporting,
sustaining and spreading improvement—is a challenge we all share.

This section of the QI Guide provides a blueprint for success: an out-
line of the key elements needed to organize and support an improve-
ment project in the acute care setting. This blueprint combines project
management and improvement science principles.

You may already have your own project planning tool; use the format
you prefer. To better plan for success, you might want to ensure that
your plan includes:
• An explicit statement of what is expected from the improve-
ment effort;
• What supports the improvement team can expect from the
organization;
• Any limitations or constraints that must be taken into consid-
eration; and,
• An individual or team providing overall regional leadership for
the improvement of patient experience.

After completing this form, you should have a good start on your
improvement journey. The next steps will be working with facility/unit
level teams in analyzing current processes, identifying opportunities for
improvement, and testing ideas on a small scale.


Blueprint for Success
Please see the Notes to the Blueprint on page P—5 for more informa-
tion on completing this form.
1. Determine priority area (s). You may wish to look at survey results and your organizational goals.

2. Identify RHA leadership team members.

Name: Role:
.

Name: Role:
.

Name: Role:
.

Name: Role:
.

Name: Role: .

3. Improvement aim(s) for region. Aim should be clear, specific, measurable, time-specific, and patient-centred.

4. Project deliverables. What will success look like?

a. What numerical target are you striving for on repeat survey (patient perspective)?

b. What changes in the system are you expecting (provider behavior perspective)?


Blueprint cont’d
Please see the Notes to the Blueprint on page P—5 for more informa-
tion on completing this form.
5. Outline project scope. What are the project boundaries?

a. Time frame of project:

Start date: End date:

b. Number of teams necessary to achieve aim:

c. Number of facilities and units to be involved:

d. Staff time limits for the duration of the project:

Hours per week

FTE per month

e. Cost limits: $

6. Determine project sponsor(s).

7. Expectations for reporting between RHA leadership team and front-line team(s).

8. Project links to broader RHA goal(s).

Project linked to the following RHA goal(s):


Notes to the Blueprint
1. Determine priority area
Consider your results from the Patient Experience Survey, as
well as broader organizational/regional goals. Examples of prior-
ity areas from the survey include discharge planning, provider-
patient communications, pain management, etc.

2. Identify RHA leadership team members
Some key points to keep in mind when establishing your team:
• Ideal team size is 6-12 people
• Try to find a range of expertise
• Include both the “keen” and “not so keen”
More information on teams is included in Additional Information,
starting on page P—7.

4. Project deliverables
What will success look like? Consider both:
• An outcome goal, or numerical measure. For exam-
ple, if your improvement area is discharge planning
your goal might be: 100% of our patients will know
what side effects to watch for at home.

• A process goal, something that will show you if
changes to process are resulting in more effective
care. For example, if your improvement area is pain
management, your goal might be: All patients will
have a pain management plan completed and at-
tached to their chart.

5. Project scope
Determine how many resources (money, time) can be devoted to
the project to achieve your aim. Consider:
• Project timeframe—when does it start and end?
• How many front-line teams need to be established?
• How many facilities will be involved and which ones?
• Staff time limits—how many FTE hours?

6. Project sponsor(s)
The project sponsor can be an individual or a group. The role of
the sponsor is to be the liaison between the front-line team and
RHA leadership, and to help teams overcome obstacles.


Additional
Information

Additional Information: Team Development
1. Team size

It’s important to consider size when developing QI teams. A team that is
too large may have difficulty coordinating schedules for meetings, and
meetings may involve lengthy discussions and little consensus.

On the other hand, a team that is too small may be missing representa-
tion from key groups, and might feel overwhelmed by having to accom-
plish so many tasks with so few resources.

The optimal team size is between 6 and 12 members.

Optimal team size: not too big, not too
small—just right!

2. Types of expertise

Including the right people on the QI team is critical to successful im-
provement efforts. Recruit staff and care providers from all aspects of
the patient experience you are trying to improve. For example, if your
improvement focus is on discharge planning, your team might include:
nurses, physicians, occupational therapists, physiotherapists, social
workers, and pharmacists. Each discipline will provide a unique perspec-
tive on the processes of care involved in safely transitioning patients
from hospital to home.

There are three basic areas of expertise that should be part of any team.
These include expertise in organizational authorization, clinical or techni-
cal expertise, and someone with knowledge about the system of care.
You may have one or more individuals with each kind of expertise, or an
individual with expertise in more than one area. Regardless, try to en-
sure that all three types are represented on your team.

Team Sponsor
The Team Sponsor should have enough authority in the organi-
zation to implement suggested changes and overcome barriers.
The Team Sponsor understands the implications of the proposed
change on the various parts of the system, as well as the more
remote consequences a change might trigger.

It is important that the Team Sponsor have authority in all areas
affected by the change, and the authority to allocate resources
(time, people, money) needed to achieve the aim.

Clinical/Technical Experts
A Clinical or Technical Expert is someone who knows the subject
matter intimately and who understand the processes of care. For
Patient Experience, you may want to consider team members
who are Technical Experts in your priority area (see page P—11
for a provider-priority area chart). Brainstorming about the proc-
ess should help you in selecting appropriate team members. Indi-
vidualize your teams to ensure they represent your region/facility/
unit and the variations in the processes of care.

Patients should also be considered Technical Experts; your pro-


ject will be stronger if the patient voice is included on the team.
Please see page P—10 for more information on involving
patients.

Day-to-Day Leaders
The Day-to-Day Leader is the driver of the project; they ensure
that tests are implemented and data are being collected. It is
important that the Day-to-Day Leader understands not only the
details of the system, but also the effect changes will have on the
system. For Patient Experience, the Day-to-Day Leader may be
someone within the unit who is knowledgeable about staff and
care processes, but also has the authority to make decisions
regarding care and staffing (for example, a nurse or unit
manager).

Helpful Tool!
Assess Your Team
This team assessment tool can help your Regional Leadership
team in brainstorming members for the facility/unit QI team. As
each name is suggested, add them to the following matrix and
determine their areas of expertise. This will show you at a glance
if your team is well-rounded, and give you an idea of your team’s
strengths and potential gaps.
Name Team Sponsor Technical Expert Day-to-Day Leader Additional Strengths

Jane Doe √ √

John Smith √

You may want to begin by suggesting a few names at the Re-
gional Leadership level, then ask these front-line people to select
the rest of the team.
Used with the permission of the Institute for Healthcare Improvement (IHI), c2005. Available from URL: http://
www.ihi.org/IHI/Topics/Improvement/ImprovementMethods/HowToImprove/formingtheteam.htm


3. Involving patients

Your efforts to improve the patient experience will be more successful if
you include the patient voice on your team. The National Health
Services (NHS), based in the United Kingdom, has done extensive work
in the area of the “expert patient”.

Some of their tips on approaching patients or caregivers to participate on
a QI team:
• Have clear aims and objectives
• Explain project constraints and potential outcomes
• Involve more than one patient/caregiver on the team
• Be clear about the role of the patients/caregivers on
the team
• Be aware that involving current or recent patients may
present some difficulties
• Identify patients/caregivers who will help you meet
your aims
• Involve patients/caregivers early on in the project

http://www.cgsupport.nhs.uk/Patient_Experience/4@How_to_involve_people.asp

Web site resource
The NHS has resources and tips for working with patients on quality improvement.
Go to: www.cgsupport.nhs.uk and click on the Patient Experience hotlink.


4. Matching team members to priority areas

When developing your QI teams, it may be helpful to consider your prior-
ity area. The chart below shows health care providers who might be
included on a team that is planning to focus on a specific priority area.

Role Provider-Patient Pain Discharge Hospital Food
Communications Management Planning
Patient √ √ √ √
Physician √ √ √
Nurse Manager √ √ √ √
Front-line Nurse √ √ √ √
LPN √ √ √
Pharmacist √ √ √
Unit Clerk √ √
Dietary Staff √
Director of Food Services √
Dietitian √
Food Services Manager √
Others (e.g., physiothera- √ √ √ √
pists, occupational thera-
pists, social workers, etc.)–
depending on priority areas
and processes within spe-
cific facilities


5. Stages of team development

After members are selected, participants must move from being a group
to becoming a team. The three stages of team development are forming,
storming, and performing. Each stage is described in the table below.
Stage What it looks like

Forming • Members are concerned with inclusion and acceptance.
• Interactions are polite and superficial—overt conflict is rare.
• Conformity tends to be high.
• Group struggles to define its boundaries; establish who is or isn’t part of this group.
• Members rely on leader for direction and support.
• Goals are not clear.
Storming* • Members are concerned with having their unique contributions recognized.
• Participation increases; members want to exercise some influence in the group.
• Conformity and compliance decrease.
• Open conflict increases.
• Members begin to take a critical look at the power structure in the group and question
how decisions are made.
• Members may challenge the leader directly or indirectly.
• Members begin to wonder if they can trust others to “pull their weight,” to make
meaningful contributions.
• Clarification of roles and goals begins.
• Ground rules are established.
Performing • Members have built a sense of trust and safety within the group.
• Members are more friendly and supportive of one another.
• All contributions are recognized and appreciated.
• Members are clear about their roles and responsibilities.
• Conflict is handled openly and constructively.
• Members develop a sense of cohesiveness and group identity.
• Leader’s role has become less directive and more supportive as members actively take
responsibility for setting and achieving group goals.
* As uncomfortable as this stage may be, the conflict is a prerequisite to
effective group functioning in the final stage. Groups unwilling to work
through the storming phase remain dependent on their leader, maintain
relatively superficial relationships, and are unable to work effectively be-
cause no one is willing to voice differing opinions or points of view.

Adapted from: Renz, MA and Greg, JB (2000). Effective small group communication theory and practice. Toronto: Allyn
and Bacon Canada.


6. Effective meetings

Team meetings are an important part of a quality improvement project.
Holding both traditional and informal meetings (known as “huddles”) will
help move your project forward. The tips listed below can help make
your meetings more effective.

Starting the meeting
It is essential to start meetings with some type of Introduction Exercise
or Icebreaker. When you have a large group, or you have a very full
agenda, it may seem like a waste of time to conduct personal introduc-
tions. But introductions are crucial to the overall comfort, trust, and risk-
taking ability of the group. Introductions give group members a way to:
• Get to know one another.
• Gain a deeper appreciation of each other as individuals.
• Understand the mindset of different group members on the
meeting day.

Some examples of introduction or icebreaker activities:
• Have participants meet the person sitting next to them; they
then introduce each other to the larger group.
• Have each person take something out of his or her wallet,
pocket or bag, and explain why it is important.
• Have each person in the group identify themselves with a
musical instrument, cartoon character, animal, etc (choose
one) and explain why.
• Ask people to identify themselves and then tell what they had
for breakfast that morning.

Getting organized
It’s important to have an agenda, to make sure that all the necessary
discussion takes place, and that the meeting stays on track. The agenda
is usually set before the meeting—most often by the person who will
lead the meeting. It helps meetings run more smoothly if the agenda is
posted in a visible place.

An agenda can be changed during the meeting. Sometimes items are
added or deleted, or the order of discussion is changed. The chairperson
should ask group members if they have additions or changes to the
agenda at the beginning of the meeting. It’s also a good idea to assign


times to each item so that you will know approximately how long the
meeting will take.

Agendas come in various formats and styles; choose the one that will
work best for your meeting and group. For example, you might want to
use a grid style that includes “person responsible” and “outcome
needed” for each item.

Roles and responsibilities
• Chairperson. The chairperson takes responsibility for many
tasks that keep the meeting running smoothly. The role may
be assigned based on position in group or may be shared
and rotated among the members. Responsibilities include:
• Arranging for the room and refreshments
• Setting and distributing the agenda
• Starting on time
• Leading the meeting
• Keeping the group on track
• Ending on time

• Note-taker. The note-taker records the important comments
and decisions that the group makes during the meeting.
Notes may be written discretely during the meeting, but many
groups prefer to take notes on large flipcharts, so that notes
are visible to everyone throughout the meeting. Members can
repeat or reword statements for accuracy and better under-
standing. It’s important for the notes to be distributed to the
group before the next meeting.

• Timekeeper. The role of the timekeeper is to keep track of
time during the meeting. If an item is taking longer than
planned to discuss, the timekeeper would flag this so that the
group can decide to defer an item, speed up discussion, or
take another tack. Sometimes the chairperson functions as
timekeeper, but often this is a separate role.

Setting the stage
Every meeting should have ground rules. Ground rules are the ex-
pected rules of conduct that are important for the group’s full participa-
tion and success. Involve the group members in setting the ground rules,


and then post them on a large piece of paper in the meeting room. This
will serve as a visual reminder of what the group has agreed on for
meeting conduct.

It is not unusual for people to get side-tracked during a meeting. When
people either talk about or have questions about something that is not
on the agenda, you can write it down on a large piece of paper marked
“Issues Bin” or “Parking Lot”. Later, when you have time, the group
can return to the “parked” issues. It can be difficult to decide when is-
sues belong to the Parking Lot or if they need to be discussed immedi-
ately. The chairperson needs to exercise judgment, but can also ask the
group for their opinion.

It’s very important to include break time on the agenda. People lose
interest if they sit too long, so set aside time to stretch and grab a snack
or drink. If it’s a short meeting, people may choose not to take a break. It
should always be up to the group to decide. You will also find that
providing refreshments for the meeting fosters a caring, relaxed atmos-
phere.

Closing the meeting
Renegotiating time and agenda
It’s not unusual to find that there is not enough time to discuss all
the items on the agenda, or that important items (not on the
agenda) come up for discussion during the meeting. The group
may decide to defer items to another meeting, meet for a longer
time, eliminate items from the agenda, or take some other action.

Next steps or action planning
It’s a good idea to spend some time at the end of a meeting to
clarify any action that needs to be taken, and who will be respon-
sible for taking that action. Important decisions/action items can
be recorded in the meeting notes.

Evaluation techniques
Meeting evaluation can be simple or complex. A very simple
technique is to have a large piece of paper divided into two
columns: “What Was Good About the Meeting” and “How To
Improve the Meeting”. The chair elicits and records comments
from the group.


More formal techniques include a written set of questions with a
rating scale, agree/disagree, or open-ended formats for mem-
bers’ responses. Typical questions include: Do you think we met
our objectives for meeting? Did we abide by our ground rules?

Another option is to use imagery for creative and somewhat
humorous evaluation. For example, ask participants to rate the
meeting with reference to different cars:
• Did this meeting operate like a Cadillac DeVille—
smooth, easy perfection, purring right along?
• Or was it like a Ford Escort—predictable, dependable,
chugging but getting the job done?
• Or was it like the old Edsel—dysfunctional, poorly
planned, and unproductive?
Was your meeting an Edsel? Ask the group!

Adapted from the System for Adult Basic Education Support (SABE) guide, Running Effective Meetings and Facilitating
Groups (July 2002). Available from URL: http://www.sabes.org/resources/facilitationguide.pdf


Huddles
Huddles are designed to keep teams informed about the project
progress, review previous accomplishments, and make plans for the
next steps. Because huddles are more informal than traditional meet-
ings, they can occur more frequently. They allow for greater participation
of front-line staff, who often can’t arrange schedules to attend longer
meetings. They are great for keeping the momentum going. Many teams
use them for reviewing and revising Plan-Do-Study-Act cycles.

Keys to successful huddles:

• Discuss the huddle concept with the team and explain how
huddles can be used as a tool to speed improvement.
• Agree on a time and place where regular huddles will occur.
• Choose a huddle location that is convenient for the team
members, particularly those who have the least time available
for meetings.
• Have a clear set of objectives for every huddle.
• Limit the duration of the huddle to 15 minutes or less.
• Review the objective of the huddle for that day, then review
the work done since the last huddle. Act on the new informa-
tion and plan next steps.
• Huddle frequently, even daily—particularly when many PDSA
cycles are being tested and the team needs to share informa-
tion regularly.

If you want people to attend meetings, try to make them more convenient!

Used with the permission of the Institute for Healthcare Improvement (IHI), c2005. Available from URL: http://
www.ihi.org/NR/rdonlyres/74A9CD6C-B15A-45A1-87DE-FD7E6CE1F23C/654/Huddles1.pdf


7. Ten essential ingredients for successful teams

Although conflict is to be expected in any team, some common group
difficulties can be prevented when teams ensure they have the following
essential ingredients:

1. Clarity in team goals. A team works best when everyone under-
stands its purpose and goals. If there is confusion or disagree-
ment, effective teams work to resolve the issues rather than
ignore or sidestep them.

2. Established ground rules. Highly effective teams outline how
they will work together and establish behavioural expectations for
team members.

3. A work plan. Successful teams outline who will do what and
when. Clear action plans help the team identify what resources,
materials or training are needed throughout the project so that
they can plan accordingly. Work plans also flag uneven distribu-
tion of tasks among team members.

4. Clearly defined roles. Teams operate most efficiently if they tap
everyone’s talents and all members understand their duties and
know who is responsible for what issues and tasks. Roles may
need to be re-visited periodically (e.g., as new tasks come to
light, member workloads shift, etc.)

5. Balanced participation. One or two members taking responsi-
bility for the team’s efforts is neither effective nor sustainable. All
members should participate in discussions and decisions, share
commitment to the project’s success, and contribute their talents.

6. Open communication. Effective teams share information,
thoughts and ideas in an open and direct manner. Team mem-
bers seek to understand one another’s perspectives.

7. Beneficial team behaviours. Successful teams encourage all
members to use behaviours that make discussions and meetings
more effective, such as initiating discussion, listening to others,
and working through conflict.


8. Established decision-making methods. A team should always
be aware of the different ways it reaches decisions, and the
consequences of using those methods. For example, when the
designated leader makes the decision, others may not fully
understand the decision or feel committed to implementing it.

9. Experimentation/creativity. An effective team experiments with
different ways of doing things and is creative in its approach.

10. Evaluation. Successful teams evaluate both their functioning
and their accomplishments.

Portions of these materials are copyrighted by Oriel Incorporated, formerly Joiner Associates Inc and are used here with
permission. Further reproductions are prohibited without written consent of Oriel Incorporated. Call 1-800-669-8326.


Reflecting
Phase Two
This section has information on analyzing current
processes, including:

• Process mapping
• Brainstorming
• Focus groups
• Fishbone diagrams

Patient Experience Survey: Quality Improvement Guide R- 1

Introduction to Reflecting
Understanding Systems
To make effective changes, first we need to understand how our system
currently works. We don’t intentionally design systems that are flawed,
but a well-designed system can become unsatisfactory over time

Anyone who has not kept up with the changes in telephones, for exam-
ple, knows that a rotary dial telephone limits easy access to services
within many organizations. As our culture and technology changes, our
systems also need to change.

What Is a System?
Systems exist all around us: The cardiovascular system; the London
underground subway system; the hockey draft system. Systems are
defined as a collection of parts and processes organized around a
purpose.

All systems have three components:
• Structures: Things you can touch and see, such as
equipment, facilities, committees, roles.
• Processes: Steps or actions to achieve the outcome, such
as patient pathways.
• Patterns: Repetitive features, often cultural, such as
behaviours, conversations, and waiting times.

Often we get caught up in the “do”; implementing changes without a
complete understanding of where change will be most effective. Analyz-
ing your current processes can help to make your improvements more
meaningful and effective. Remember: All improvement involves change,
but not all change will lead to improvement.

This section has information on methods to analyze and understand
your processes:
• Process mapping
• Brainstorming
• Focus groups
• Fishbone diagrams


Process Mapping
Overview
Every process has a start and an end. In order to map a process, it is
essential to clearly define each of these points. Processes can be simple
and short, or complex and long. Processes are usually governed by
rules, and they are usually linked with other processes.

For example, a process might begin with the symptom and end with
resumption of good health. Similarly, a process might begin with the
request for an X-ray and end with the results.

When examining a process, it is important to detail every point in the
chain of action. Be sure to include everyone involved in that process, so
that no point of action is missed. Often, no one person knows the entire
process. By including everyone in the discussion, we may find that what
we think is going on may not, in fact, be what is actually happening! By
analyzing the process from start to finish, we identify all the opportunities
to make improvements. We also avoid the pitfall of focusing on just one
perspective.

When mapping a process, it is important to consider the view of all
stakeholders, including patients and caregivers:
• The only one who knows the whole process is the
patient.
• Up to 50% of process steps involve a hand-off, leading to
the possibility of error, duplication, or delay.
• 30 to 70% of what we normally do does not add value for
the patient.
(Dr. John Bibby)

Start by gathering together representatives of all the stakeholders, i.e.,
everyone who takes part in the process from start to finish. Using a white
board or sticky notes, write down the task and the name of the person
who carries out that task.

Arrange the steps in order, but feel free to add new steps and move
steps around at any point. Watch the patterns emerge that may indicate
the root of a problem. You may be surprised!

Please see the next page for a diagram of a process map.


Process Mapping
Record each step of the process from
start to finish. Write down the steps in
the sequence they occur.

Request Complete Results
START FINISH
for chest x-ray X-ray communicated

Complete req. Take films X-rays to Dr.
MD Tech Patient

Pt info process films Determine plan
Receptionist Tech Dr
Begin by defining where
the process starts and
Undress Bill Sask Health
ends.
Patient Secretary

Pay for services
Sk Health
Each step may have several
sub-steps. Capture these and
list them under the main step.

Why Process Map?
A map of the patient’s journey will give you:
• Key starting point to any improvement project, large or small,
which is tailored to suit your own organization or individual
style.
• The opportunity to bring together multi-disciplinary teams and
bring together people from all roles and professions to create
a culture of ownership, responsibility, and accountability.
• An overview of the complete process, helping staff to under-
stand, often for the first time, how complicated the system
can be for patients. For example, how many times a patient
has to wait (often unnecessarily), how many visits they make
to hospital, and how many different people they meet.
• An aid to effectively plan where to test ideas for improvement
that will likely have the greatest impact on the improvement
aims.


Process Mapping
• Brilliant ideas, especially from staff who don’t normally have
the opportunity to contribute to service organization, but who
really know how things work.
• An event that is interactive, that gets people involved and
talking.
• An end product, a process map which is easy to understand
and highly visual.

http://www.modern.nhs.uk/improvementguides/process/4.htm#

How To Run A Process Mapping Session
Setting up the meeting
• Identify the scope of the process you want to map, including pa-
tient group, start point and end point.
• If you are unsure which part of the patient’s journey you want to
map, start by mapping a high “macro” level process, to identify
parts of the process that require more attention. For example –
general patient journey from presentation in the ED to discharge
from hospital. (You might then follow this up by looking more
closely at the decision to admit general medicine patient to when
patient arrives on ward.)
• Identify all stakeholders. It is essential that all the stakeholders
involved in any part of the patient’s journey develop the process
map. If the map is reflective of what actually happens, it will be
easier to secure “buy-in” when it comes to improvements.
• Convene a workshop. Allow at least 3 hours for the workshop, in
order to carry out both a high “macro” level map, and a low
“micro” level map. You will need a suitable meeting room where
the team can work free of interruptions.
• Send out invitations. In the invite, clearly explain the purpose of
the meeting. Include contact information so invited participants
can reply, but make sure the contact is someone who can an-
swer questions or concerns prior to the event.
• Facilitation. You will need a facilitator for the session, ideally
someone who is viewed as being independent. The facilitator’s
role is to keep the session on time and to identify any issues or
solutions as they arise. He or she does not directly provide input
into the process map, but ensures everyone makes a contribu-


Process Mapping
tion. It might also be useful to have another person on hand to
take notes.
• Shortly before the meeting, follow up with people who have not
yet responded.

On the day
• Gather your resources. You will need: post-it notes, pens,
name labels, white board/large paper.
• Group introductions.
• Introduce the ground rules: No blame, respect diversity of opin-
ion. Limit discussion on a particular issue to 5 minutes, then park
it for follow up later. Focus on what happens 80% of the time.
Focus on patient experience.
• At the beginning of the session: gain agreement from the group
on the scope of the map and record this on the paper.

Map the process
• Ask participants to individually record each step of the process
from their own perspective – what they know happens 80% of
the time. (See Pareto Principle, bottom of page.)
• Participants should then stick the post-it notes on the wall.
Duplicate steps should be placed under one another. Participants
should move steps around until they are happy with order.
• The facilitator should review each step with the group and trans-
fer each step to the white board, to form an agreed upon map.

Pareto Principle
The Pareto Principle describes the 80:20 relationship of cause and effect, efforts and rewards, inputs and out-
puts. It is a way to focus your improvement efforts:

• Look at any complaints about your service. The Pareto Principle predicts that most of the complaints (80%)
will be for a few causes (20%). So that is probably the place to start.
• Look at the types of requests a department receives e.g. pathology and radiology. The Pareto Principle pre-
dicts that most of the requests (80%) will be for relatively few of all the examinations or tests the department
offers (20%). Again, showing you where you might start and have the most effect.

So the 80:20 rule, or Pareto Principle, will help you and your improvement aim focus on the areas that will have
the biggest impact when improved.


Process Mapping
• As a group, analyze each step in the process (either during or at
the end of the mapping). Identify: Decision points and hand-offs;
main bottlenecks and delays – how long does this process take?;
gaps; necessary and unnecessary steps; problems for patients;
problems for staff.

Next steps—where to now?
• Ask yourself: Is the map accurate? Or do you need more in-
put from others? What issues were identified? What are the
areas for improvement?
• With your redesign team, look at the process map. Discuss
how the process can be simplified, what steps can be modi-
fied and deleted. Prioritize the issues and develop an action
plan for how you are going to tackle them.

Source: Clinical Excellence Commission website. Available from URL: http://
www.health.nsw.gov.au/nursing/pdf/moc-cec-prcss_mpng_guide.pdf

Handy Tip!
Use different coloured post-it notes to differentiate the process
(yellow) from problems/issues (purple) and solutions/ideas (blue).
This will help keep the focus on the current process while captur-
ing all the comments.

Used with permission by the NHS Modernisation Agency, subject to Crown
copyright protection. Available from URL: http://www.modern.nhs.uk/
improvementguides/process/4.htm#

Key Messages for Participants

• Processes are all around us, but in healthcare our roles limit us to seeing only one small part of
the whole patient process.
• It’s not about blaming or criticizing anyone or any department.
• It’s only the starting point and will lead to lots of other improvement tools and techniques.
• It’s fun.

Used with permission by the NHS Modernisation Agency, subject to Crown copyright protection. Available from
URL: http://www.modern.nhs.uk/improvementguides/process/4.htm#


Process Mapping
Analyzing the Process Map
Once the process is mapped, analyze it. For each step, answer these
questions:
• Can it be eliminated?
• Can it be done in some other way?
• Can it be done in a different order?
• Can someone else do it?
• Can it be done somewhere else?
• Can it be done in parallel?
• Can any “bottlenecks” be removed?
• Is the most appropriate person doing it?

After you have mapped and analyzed the process, it is time to turn to the
Model for Improvement and devise a plan to test ideas for positive
change. It’s best to try a small change in one step of the process and
see if it leads to an improvement. Several small PDSAs can be run con-
currently, and each one should spark a hunch for a new PDSA.

Other Process Analysis Questions
• How many steps are there for the patient? This is often a real
revelation for staff.
• How many times is the patient passed from one person to
another (handed-off)?
• What is the approximate time taken for each step (task time)?
• What is the approximate time between each step (wait time)?
• What is the approximate time between the first and last step?
• How many steps add no value for the patient? Imagine that
you, or your parent or child, is the patient. What steps add
nothing to the care being received?
• Where are the problems for patients? What do patients
complain about?
• Where are the problems for staff?
http://www.modern.nhs.uk/improvementguides/process/6.htm


Process Mapping
Other Ideas for Process Mapping
Activity and Role Lane Mapping
For the parts of the process that are causing problems, consider activity
and role lane mapping. To do this, take the role out of the activity so that
“nurse records vital signs” becomes “record vital signs”. List the process
activities and the roles involved and ask, “who does this now?” as in the
diagram below. This could be followed by a discussion around who
could do each activity if it were redesigned.

Activity and role lane mapping – current situation in outpatient clinic
Activity/role Clerk Nurse Porter Doctor
Move patient X X
Record details X X
Record vitals X X
Take history X X
Examine patient X
Write imaging request X


Tracking the Patient Journey
Tracking the patient journey through the health care system is a simple
way of understanding where problems are and how the service looks
through the eyes of a patient. This exercise complements the process
mapping exercise and allows you to identify waits and delays in real life.
There are two ways of doing this:
• Physically walking through the patient’s journey with a patient.
Determine with your team the start and end point of the journey
you want to track. In order to gain a true picture of the journey, it
is recommended to track patients who arrive both in and out of
regular hours. It might also be beneficial to dress in the clothes
you would wear as a patient so as not to draw attention. You will
need to gain permission from the patient in order to accompany
them. During the walk through, note both the positive and the
negative experiences, as well as any surprises. What was frus-
trating? What was confusing? (See sample tool, next page.)


Process Mapping
Sample Patient Tracking Tool
Date/Time: 04/04/04, 11:00 am
Start Point (location): ED Triage End Point (location): Patient leaves ED for home
Patient Presenting Problem: Foreign body in eye
Time Activity Where Who Additional Comments
All time needs Where was the Who Positives/Negatives/Surprises/
to be activity carried undertook the Frustrations
accounted for out activity
e.g. waiting
11:00 Patient sees Triage office ED nurse Nurse friendly and cheerful but
am ED triage called away halfway through the
nurse consultation as someone came in
by ambulance.
11:30 Patient filled in Standing at Patient and
am info form reception clerk •

• Asking patients to keep a diary of their journey.
The patient diary allows patients to track their journey and
comment about their experiences along the way. It is particularly
useful for in-patients, where it is not possible for them to be
tracked by a staff member. We have included a sample patient
diary tool; patients can carry this form on a clipboard throughout
their visit. (See sample, below.)
Sample Patient Diary
D a te T im e A c tiv ity a n d L o c a tio n C o m m e n ts
0 5 /0 4 /0 4 9 :15 a m A d m itted to w a rd M , n u rse took H a d a lrea d y g iv en
m ed ica l history . m ed ica l history in E D la st
n ig h t d on ’t k n ow w hy sh e
cou ld n ’t rea d th a t
9 :2 5 a m A t en d of h istory n u rse sa id I I d on ’t k n ow w h en I w ill
n eed ed ch est x-ra y , d octor w ou ld h a v e th e chest x-ra y , n u rse
refer m e. sa id sh e w asn ’t su re
10 :0 0 a m A sk ed for cu p of tea
11:3 0 a m M y d a u g hter a rrives
12 :0 0 pm M y d a u g h ter a sk ed th e n u rses T h ey w ere v ery v a g u e th is
w h en th e d octor w ou ld be com in g to a ftern oon , bu t th is n u rse
see m e. w a s v ery polite a n d
frien d ly

Source: Clinical Excellence Commission. Available from URL: http://www.health.nsw.gov.au/nursing/pdf/moc-cec-
prcss_mpng_guide.pdf


Process Mapping
Some Final Tips and Questions
Tips for Successful Process Mapping
• DO analyze the current process, NOT your ideal
process.
• DO focus on what happens to most of the patients
most of the time. OMIT the one-off cases that aren’t
normal. The faciliatator will need to pull people away
from drilling down into too much detail.
• DO include every stakeholder in the process,
including patients and caregivers.
• DO respect all contributions.
• DO raise issues and questions. Debate is good.
• DON’T assign blame.

Frequently Asked Questions
What happens if we can’t get everyone together at the same time?
Consider any of the following variations on process mapping:
• Process mapping can take place with very small groups or
even getting one or two people to walk through and record
the patient’s journey. Then take this map to other small
groups or individuals for their comments.
• Issue the instructions on how to map and set up the blank
map in a place where people go for their coffee breaks. En-
courage them to keep adding to the map over a two-week
period and then produce a tidied up version for final amend-
ments.
• Organize a process mapping day, inviting all relevant staff to
“drop in” at any point within a given timeframe. Cakes and
chocolate are always a powerful way to draw people.

How do I persuade colleagues of the value of spending time mapping
the service?
Explain that this is the best way to start making improvements
and perhaps refer them to other services/colleagues who have
done it. Stress the importance of understanding their contribution
to the work of the service. Also consider if the team is ready for
change and whether the problem with arranging a meeting is
really a reluctance to be involved. In which case, engage your
change agents, champions or sponsors.


Process Mapping
How will all this really help us?
The combination of process mapping and analysis, measurement
for improvement, matching capacity and demand and improving
flow will result in system improvements for patients. Seeing
improvement is a great boost for the team and gets other people
interested. All process steps needing improvement are identified.
The results of your improvement activities may also provide the
necessary information to support the business case for extra
resources.

What if the team can’t agree on the process map?
• Check that you are mapping the current process, not the
ideal.
• Check that you are mapping what happens 80% of the time.
• Are there actually two different processes? Does the morning
team work differently than the evening shift? If so, capture
both of these processes.
• Gather information on the current process. For example, use
the patient tracking tool (see page R—10) to see how
patients move through the system. You do not need to track a
significant number of patients—just enough to satisfy the
team they have accurately captured the process.

Case Studies
Case Study #1
An Example of a Patient Journey Map
Who does what to the patient?
• GP tells patient that they are being referred to the hospital
• GP tells patient to go home and wait
• Appointment letter is delivered via mail to patient
• Patient arrives at the hospital for the appointment
• Clinic Clerk receives the patient and checks their details
• Nurse checks the patients details before they see a doctor
• Doctor examines patient
• Doctor refers the patient to the relevant department(s) for
diagnostic tests
http://www.modern.nhs.uk/improvementguides/process/5_3.htm


Process Mapping
Case Study #2
Discharge Process – University Hospital Lewisham
The University Hospital in Lewisham, England wanted to reduce the vari-
ability of the discharge process for patients on the orthopedic ward. They
began by measuring number of patients discharged each day from the
ward, and the average length of stay for 80% of patients discharged
each week. The measures helped them see two interesting things in
their current process:
• There were very few patients discharged on Saturday and
Sunday – clearly there were two different processes in place
for weekdays versus weekends, but there was no real benefit
to having two systems.
• The current process did not ensure that patients waiting for
transport (hospital or relative) were transferred to the dis-
charge lounge by 10 AM. Since typically emergency patient
demand peaked after 2 PM, this meant that although patients
were leaving, there still weren’t any free beds.
Used with permission of the Institute for Healthcare Improvement (IHI), c2005. Available from URL: http://www.ihi.org/
IHI/Topics/Flow/PatientFlow/ImprovementStories/
ImprovingPatientFlowbyReducingVariabilityintheDischargeProcessatUniversityHospitalLewisham.htm

Resources
The web sites listed below have helpful resources for process mapping:
• BOLO (Been On Look Out For). This is a list for analyzing the
process map. http://www.isixsigma.com/library/content/
c040301a.asp
• Process Mapping Case Study. This article looks at the process
Valley Baptist Medical Center in Harlingen, Texas went through
to improve their discharge planning. http://
healthcare.isixsigma.com/library/content/c040915a.asp
• TeamFlow software - a free software download for creating an
electronic process map. Great for putting together a final agreed
up on version of the process map. http://www.teamflow.com/
downloads.html
• Running A Process Mapping Session Guide – includes patient
diary and Patient Tracking Tool. http://www.health.nsw.gov.au/
nursing/pdf/moc-cec-prcss_mpng_guide.pdf
• Improvement Leaders Guide for Process Mapping, National
Health Services. http://www.modern.nhs.uk/improvementguides/
process/


Brainstorming
Overview
What Is Brainstorming and How Can It Help?
Brainstorming is an idea-generation tool designed to produce a large
number of ideas through the interaction of a group of people. Some of
the positives to using this tool include:
• It allows every member of the group to participate.
• It encourages many people to contribute, instead of just one
or two people.
• It sparks creativity in group members as they listen to the
ideas of others.
• It generates a substantial list of ideas, rather than just the few
things that first come to mind; categorizes ideas creatively;
and allows a group of people to choose among ideas or
options thoughtfully.

Brainstorming Steps
Step 1: Getting Started
• The session leader should clearly state the purpose of the
brainstorming session.
• Participants call out one idea at a time, either going around
the room in turn, which structures participation from every-
one, or at random, which may favour greater creativity.
Another option is to begin the brainstorming session by going
in turn and after a few rounds, open it up to all to call out
ideas as they occur.
• Refrain from discussing, complimenting, or criticizing ideas as
they are presented. Consider every idea to be a good one.
The quantity of ideas is what matters; evaluation of the ideas
and their relative merit comes later. This tool is designed to
get as many ideas generated in a short period of time as
possible. Discussing ideas may lead to premature judgment
and slow down the process.
• Record all ideas on a flipchart, or self-adhesive notes, so that
all group members can see them.
• Build on and expand the ideas of other group members.
Encourage creative thinking.
• Keeping going when the ideas slow down in order to create
as long a list as possible and reach for less obvious ideas.
• After all ideas are listed, clarify each one and eliminate exact
duplicates.


Brainstorming
• Resist the temptation to “lump” or group ideas. Combining
similar ideas will come next.

Step 2: Affinity Grouping
The next step in brainstorming is for participants to organize their ideas
and identify common themes.
• Take the list of ideas from Step 1 and write each one on indi-
vidual cards or adhesive notes.
• Randomly place cards on the table or place notes on flip
chart paper taped to the wall.
• Without talking, each person looks for two cards or notes that
seem to be related and places these together, off to one side.
Others can add additional cards or notes to a group as it
forms, or re-form existing groups. Set aside any cards or
notes that become contentious.
• Continue until all items have been either grouped or set
aside. There should be fewer than 10 groupings.
• Now discuss the groupings as a team. Generate short,
descriptive sentences that describe each group and use
these as title cards or notes. Avoid one or two-word titles.
• Items can be moved from one group to another if a consen-
sus emerges during this discussion.
• Consider additional brainstorming to capture new ideas using
the group titles to stimulate thinking.

Step 3: Multivoting
The final step in brainstorming is multivoting. Multivoting is a structured
series of votes by a team, in order to narrow down a broad set of options
to a few actionable ones.
• Take the combined similar items (grouped in affinity group-
ing) and number each item.
• Each person silently chooses one-third of the
Multivoting Table items. Tally votes.
Group size (number of people) Eliminate items with less than “x” votes • Eliminate items with few votes. The table be-
4 to 5 2 side will help you determine how to eliminate
6 to 10 3
items. Repeat the multivoting process with
10 to 15 4
remaining items, if necessary.
15 or more 5

Used with permission of the Institute for Healthcare Improvement (IHI), c2005. Available from URL: http://www.ihi.org/
IHI/Topics/Improvement/ImprovementMethods/Tools/Brainstorming+Affinity+Grouping+Multivoting.htm


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