Quality-improvement projects have big benefits, but knowing where to start or how to identify potential problems can be difficult. Current-state process flow maps help.
ABSTRACT: Quality-improvement projects in health care can lead to successful interventions and reductions in waste. However, knowing where to start these projects or how to identify and define potential problems can be difficult. A tool called a current-state process flow map helps identify areas for potential projects. This map can spotlight issues that need further study and definition to measure and analyze a potential problem. Work-to-benefit ratios then can be assessed to prioritize improvement projects.
As health care quality and cost come under increasing scrutiny, quality improvement methods popular in other fields are becoming more prevalent.1-4 Lean principles, which are used to identify and eliminate waste, first were developed in the automotive industry,5-9 and this methodology has been implemented successfully in health care to increase quality, increase flow and decrease errors.1,3,5,10-12
Waste (also called muda) can be categorized into seven domains: motion, overproduction, waiting, waste of overprocessing, defects, inventory, and waste of transportation.11 Previously studied Lean interventions in health care have focused on waiting, overprocessing, defects, waste of transportation and inventory.3,5,11,13
Knowing how and where to start quality improvement/Lean projects can be quite difficult.13 Quality improvement projects can be broken into steps: defining the problem, measuring the problem, analyzing the problem, improving the problem, and controlling the problem.14 Defining the problem can be difficult, and knowing the appropriate tools to aid in this step is paramount, because the key for successful improvement is proper identification of waste or process breakdown.
A current-state process flow map is an effective tool in identifying waste, inefficiency and areas for quality improvement. It is a Lean tool in which the entire targeted process is mapped in steps.9 This process ideally is done with a stakeholder from each major portion of the process, to obtain complete input.13 This allows identification of areas for potential quality improvement, which can further be studied before initiating Plan-Do-Study-Act projects. Process flow maps have been shown to be appropriate quality-improvement initiation points in medicine as well as manufacturing.7,9 The current-state map also is an appropriate educational tool for residents.14
In this article, we present three current-state process flow maps, involving the operating suite, emergency department and ambulatory office. We describe how these maps directed our efforts in quality-improvement initiation.
A multidisciplinary team was assembled for each current-state process flow map development.
Operating room map: Two perioperative nurses, the OR manager, the materials manager, a hospital administrator and a surgeon.
Emergency department map: Two ED charge nurses, chief of staff, a hospital administrator, the ED manager and a materials manager.
Ambulatory clinic map: Office physician, administrator and medical assistant.
The targeted process for each map was patient flow. Each team spent approximately eight hours, or one working day, with the targeted process. Each session was led by the same team member, who had significant Lean methodology training and experience. Meeting agendas were determined by the team leader, with the goal of the initial meetings to develop a map to expose inefficiencies in the targeted system. The importance of defining measurable and auditable targets were stressed as part of the process evaluation.
During this time, the team tracked a patient through its area, documenting and discussing each step (see photo). Each step was examined thoroughly and meticulously. As discussions occurred, areas of waste or safety issues were further examined.
Once the discussion was finished, one person took the hand-drawn maps and created computer renderings. Team meetings continued to study the identified issues and more definitively examine these areas and ultimately implement Plan-Do-Study-Act projects. These projects took place in a 72-bed, rural hospital.
Five areas for safety and quality improvement were identified in the surgery map (see Figure 1). The first was lack of standardized scheduling, which led to frequent scheduling mistakes. The second was materials management. Nurses were ordering materials on a nonscheduled basis — that is, when there was time. These orders then followed this chain: OR manager, materials manager, chief financial officer, materials manager. This process led to stockouts, expired inventory and a need for expedited shipping. The third was preoperative workup. Variable preoperative workup among individual physicians was found, as were excessive cancellations. The fourth was preoperative preparation — errors in consenting, site marking and preoperative antibiotics were found in 1.5 percent of patient charts. The fifth was having surgeons in the room at the proper time. Surgeons wouldn’t be in the operative area, leading to unnecessary anesthesia times and surgical delays.
The emergency department map initially yielded four areas for further study (see Figure 2). The first involved supplies, as nurses had to leave the emergency department to get frequently used supplies for up to 10 minutes each hour. The second involved delay in laboratory reporting. Routine lab tests were taking longer than expected to return. (Blood samples, for example, would travel with technicians through the hospital on multiple draws until the technician returned to the lab, causing delays of up to an hour.) The third involved moving admitted patients out of the ED — an 84-minute delay from decision to admit to transportation to the floor that likely caused a bottleneck in the ED by occupying rooms and keeping others in the waiting room. The fourth involved timely discharge of patients from the ED. The ED manager and charge nurses noticed a significant delay, up to 110 minutes, from decision to discharge until the patient left, again causing bottlenecks.
The ambulatory clinic map identified three major areas for improvement. The first involved new patients and their paperwork. If the patient didn’t fill out the paperwork before the visit or took too long to do so, the appointment was delayed. The second involved patients waiting on physicians. Sometimes, physicians were delayed with other patients — lengthy patient visits increased waiting times for subsequent patients. The third involved patient scheduling, as no system was in place to schedule future patients, except for “new” versus “follow-up.” This led to several new patients being booked consecutively, which perpetuated the first two concerns. For example, scheduling a cancer discussion within a 15-minute follow-up visit often led to longer wait times for subsequent patients, as discussions often exceeded the allotted time. Also, scheduling new patients as the day’s first two patients often increased wait times for subsequent patients because of paperwork.
A current-state process flow map effectively identifies quality-improvement targets. The next step after constructing a map is to study key areas to quantify the severity of the issue. Then, a decision can be made about correction, based on work-to-benefit ratios.
The consent issue identified in the surgery map was further studied and found to occur in 1.5 percent of cases with potentially disastrous results. A “stop-go” protocol was instituted in the preoperative area to address this issue. After implementation, the error rate dropped to zero over the next 500 cases.15 The materials issue in the operating room also was studied further. Stockouts, excessive inventory and expedited shipping were examined, and implementation of a system for timed delivery of materials was developed — a Kanban card system, in which inventory is replenished from a central location as it is consumed.16 This system resulted in improved inventory management — stockouts dropped to zero, expired inventory decreased, and expedited shipping decreased by 20 percent.16
With the ED map, further study of the materials issue found a nurse leaving the ED for 10 minutes every hour waiting for or getting supplies. After implementation of a timed-delivery Kanban card system, this dropped to zero minutes each hour; nurses rarely had to fetch materials. This allowed them more time to spend with the patient and led to decreased ED throughput times.13 Analysis of the process from decision to discharge from the ED yielded batching of lower-acuity patient orders and prescriptions, thus causing delays and bottlenecks in the ED patient flow. Correction led to decreased decision-to-departure times (see Figure 3).
The ambulatory care map was studied further and developed into a value stream map. This type of map includes more detail than the current-state map and requires more study of the process to quantify certain metrics.7,9 The value stream map helps provide guidance on the significance of an issue found in the current-state map (see Figure 4).7 In this example, the process was observed and times as well as reasons for delays were documented. This yielded excessive wait times for not only the patient but also the physician when new-patient paperwork, scheduling issues or waiting on patient records created inefficiencies in the system.6,7 Once corrected, the practice regained up to three hours a day, which produced less waiting time and less overtime for the practice.7
Value stream maps have been discussed and highlighted in other quality-improvement projects in health care as well. Studies effectively have used current-state value stream mapping to analyze the surgical process, identifying problems in patient flow — allowing corrective actions to make improvements in on-time starts, cases after 5 p.m., and overtime leading to increases in financial margins.5 Other studies have used current-state and value stream maps to identify problems with pathological specimen collection and transport — enabling targeted projects for improvement based on objective data, leading to substantial decreases in rejected specimens. The maps provided the data needed to guide project direction.17 Further studies have used current-state and subsequent value stream maps to study pediatric MRIs with general anesthesia — permitting identification of scheduling problems and process inefficiencies that were targeted with subsequent interventions.18
Current-state maps are not only an appropriate first step in quality-improvement project initiation, but also are suitable for teaching residents. In fact, these maps are effectively described, along with the seven types of waste, in the quality in-training initiative from the American College of Surgeons. This guide for residents appropriately describes Lean processes as quality-improvement tools and lays out examples of using value state maps to identify waste.14 Current-state maps are an appropriate teaching tool for quality-improvement education as well.
Limitations to this descriptive study exist. The team leader had significant Lean experience, and this luxury might not be available at every institution. Also, these projects were carried out in a smaller institution. However, Lean projects have been carried out in larger institutions and have been found to improve flow, fiscal responsibility and efficiency.1-3
The current-state process flow map is an appropriate tool for quality-improvement initiation. It allows for identification of potential targets for improvement projects. These areas then can be studied further to quantify the issue and assess the work-to-benefit ratios before to starting a Plan-Do-Study-Act project.
Andrew M. Harris, MD, is the endourology/robotics fellow and a clinical instructor at the University of Kentucky Medical Center.
- Park KW, Dickerson C. Can efficient supply management in the operating room save millions? Curr Opin Anaesthesiol. 2009;22(2):242-248.
- Going Lean in Healthcare. Institute for Healthcare Improvement. 2005;Cambridge, MA(IHI Innovations Series White Paper).
- Collar RM, Shuman AG, Feiner S, et al. Lean management in academic surgery. J Am Coll Surg. 2012;214(6):928-936.
- Womack JP, Jones DT. Lean thinking : banish waste and create wealth in your corporation. 1st Free Press ed. New York: Free Press; 2003.
- Cima RR, Brown MJ, Hebl JR, et al. Use of lean and six sigma methodology to improve operating room efficiency in a high-volume tertiary-care academic medical center. J Am Coll Surg. 2011;213(1):83-92; discussion 93-84.
- Harris C, Harris AM, Harris R. The Blessings of a Level Schedule. Industrial Management. 2015;57(6).
- Harris C, Harris AM. Using Lean Manufacturing to Improve Patient Care in a Rural Urological Practice. Physician Leadersh J. 2015;2(6):18-20.
- Harris C, Harris R. Lean connections : making information flow efficiently and effectively. Boca Raton: CRC Press; 2008.
- Harris R, Harris C, Wilson E. Making materials flow: a lean material-handling guide for operations, production-control, and engineering professionals. Brookline, MA: Lean Enterprise Institute; 2003.
- Jones D MA. Lean Thinking for the NHS. NHS Confederation. 2006.
- Kasivisvanathan R, Chekairi A. The productive operating theatre and lean thinking systems. J Perioper Pract. 2014;24(11):245-248.
- Leslie M, Hagood C, Royer A, Reece CP, Jr., Maloney S. Using lean methods to improve OR turnover times. AORN J. 2006;84(5):849-855.
- Harris AM. Boosting Efficiency with a Kanban Plan. Physician Leadersh J. March/April 2018.
- Surgeons ACo. Practical QI: The Basics of Quality Improvement. The Quality In-Training Initiative: An ACS NSQIP Collaborative 2017.
- Harris AM, Harris C. Using a STOP/GO protocol in the Preoperative Area to Increase Patient Safety. J Perioper Pract. 2016;26(10):229-231.
- Harris AM. Increasing Operating Room Materials Efficiency Through Use of a Timed Delivery Kanban Card System Increases Patient Safety and Fiscal Responsibility. Submitted. 2017.
- Hung SH, Wang PC, Lin HC, Chen HY, Su CT. Integration of Value Stream Map and Healthcare Failure Mode and Effect Analysis into Six Sigma Methodology to Improve Process of Surgical Specimen Handling. J Healthc Eng. 2015;6(3):377-398.
- Lee E, Grooms R, Mamidala S, Nagy P. Six easy steps on how to create a lean sigma value stream map for a multidisciplinary clinical operation. J Am Coll Radiol. 2014;11(12 Pt A):1144-1149.