Process Mapping Exercise Research Articles

Centering the role of community health workers in social risk screening, referral, and follow-up within the primary care setting

BackgroundCommunity health workers (CHWs) remain an underutilized resource in social risk diagnostics in the primary care setting. This process evaluation study seeks to assess the role of CHWs in social risk screening, referral, and follow-up through process mapping to identify barriers to the process for future quality improvement efforts.MethodsResearchers at the Arizona Prevention Research Center (AzPRC) engaged with two Federally Qualified Health Centers (FQHCs) in two of Arizona’s major urban areas to evaluate their internal processes for social risk screening and intervention. The Consolidated Framework for Implementation Research (CFIR) was used to direct a process mapping exercise to visually describe the workflow, gaps, and barriers to identifying and addressing social risk.ResultsThe process unveiled key areas for health system improvements in the community setting, the organizational setting, and in the implementation of social risk screening, referral, and follow-up. Further, process maps highlight the potential resources needed for effective CHW integration to address social risk in the primary care setting.ConclusionsOur findings demonstrate the importance of organizational tools, such as process mapping, to assist primary care settings in evaluating internal processes for quality improvement in addressing social risk and in effectively integrating the CHW workforce. Subsequent research will evaluate rates of social risk screening, referral, and follow-up within all of Arizona’s FQHCs and propose models for CHW integration to address social risk in primary care and strengthen social risk screening reach and effectiveness.

Mapping the processes and information flows of a prehospital emergency care system in Rwanda: a process mapping exercise

ObjectiveA vital component of a prehospital emergency care system is getting an injured patient to the right hospital at the right time. Process and information flow mapping are recognised methods...

The symptom to assessment pathway for suspected chronic limb-threatening ischaemia (CLTI) affects quality of care: a process mapping exercise

BackgroundDelays in the pathway from first symptom to treatment of chronic limb-threatening ischaemia (CLTI) are associated with worse mortality and limb loss outcomes. This study examined the processes used by...

Patients' Experiences of a Sarcoma Diagnosis: A Process Mapping Exercise of Diagnostic Pathways.

To describe patients' experiences of pre-diagnostic signs/symptoms and pathways to diagnosis, including where help was sought, and the processes involved. Mixed methods involving quantitative, qualitative and inductive thematic analyses using novel process mapping of patient journey data, as reported by the patients. We examined the time from symptom onset to first professional presentation (patient interval, PI), first consultation to diagnostic biopsy, first consultation to diagnosis (diagnostic interval) and first presentation to diagnosis (total interval). A total of 87 interviews were conducted over 5 months in 2017. Of these, 78 (40 males/38 females) were included. The sarcoma subtypes were bone (n = 21), soft tissue (n = 41), head and neck (n = 9) and gastro-intestinal (GIST; n = 7). Age at diagnosis was 13-24 (n = 7), 25-39 (n = 23), 40-64 (n = 34) and 65+ (n = 14) years. The median PI was 13 days (1-4971) and similar between sarcoma subtypes, with the exception of GIST (mPI = 2 days, (1-60). The longest mPI (31 days, range 4-762) was for those aged 13-24 years. The median diagnostic interval was 87.5 (range 0-5474 days). A total of 21 patients were misdiagnosed prior to diagnosis and symptoms were commonly attributed to lifestyle factors. Prolonged times to diagnosis were experienced by the majority of patients in our sample. Further research into the evolution of pre-diagnostic sarcoma symptoms is required to inform awareness interventions.

Process mapping of hip fracture orthogeriatric care: Experience from a tertiary hospital in Malaysia

Background: Early surgical repair and mobilization postoperatively is associated with improved outcomes for older people with hip fractures. A process mapping exercise was performed to identify the delivery of this aspect of care in a tertiary center. Methods: Analysis was done on electronic health record data of those ≥65 years who had surgery over a 3-month period. Barriers to surgery within 48 h of admission, and mobilized within the day after surgery were identified. Results: Fourty-two patients had surgery where the majority were female, had an average age of 78 years, frail, and multimorbid. 10/42 (23.8%) and 9/42 (21.4%) patients were operated on and mobilized early. Eighteen (42.9%) patients had pre-operative cardiology assessment and 19 patients (45.2%) had pre-operative echocardiogram. None led to a change in the surgical management plan. Other reasons for the delay to early surgery included the need for further medical optimization, financial constraints, blood transfusion, and being on antiplatelet/anticoagulant. Barriers to early mobilization postoperatively were lack of weekend service, delayed referral to therapists, pain, hypotension, anemia, and delirium. Conclusions: Streamlining referrals, agreed clinical pathways, consolidating multidisciplinary involvement, and continuous audit would address the barriers identified in delivering early surgical repair and mobilization post-operatively.

Development of a workflow process mapping protocol to inform the implementation of regional patient navigation programs in breast oncology.

Implementing city-wide patient navigation processes that support patients across the continuum of cancer care is impeded by a lack of standardized tools to integrate workflows and reduce gaps in care. The authors present an actionable workflow process mapping protocol for navigation process planning and improvement based on methods developed for the Translating Research Into Practice study. Key stakeholders at each study site were identified through existing community partnerships, and data on each site's navigation processes were collected using mixed methods through a series of team meetings. The authors used Health Quality Ontario's Quality Improvement Guide, service design principles, and key stakeholder input to map the collected data onto a template structured according to the case-management model. Data collection and process mapping exercises resulted in a 10-step protocol that includes: 1) workflow mapping procedures to guide data collection on the series of activities performed by health care personnel that comprise a patient's navigation experience, 2) a site survey to assess program characteristics, 3) a semistructured interview guide to assess care coordination workflows, 4) a site-level swim lane workflow process mapping template, and 5) a regional high-level process mapping template to aggregate data from multiple site-level process maps. This iterative, participatory approach to data collection and process mapping can be used by improvement teams to streamline care coordination, ultimately improving the design and delivery of an evidence-based navigation model that spans multiple treatment modalities and multiple health systems in a metropolitan area. This protocol is presented as an actionable toolkit so the work may be replicated to support other quality-improvement initiatives and efforts to design truly patient-centered breast cancer treatment experiences. Evidence-based patient navigation in breast cancer care requires the integration of services through each phase of cancer treatment. The Translating Research Into Practice study aims to implement patient navigation for patients with breast cancer who are at risk for delays and are seeking care across 6 health systems in Boston, Massachusetts. The authors designed a 10-step protocol outlining procedures and tools that support a systematic assessment for health systems that want to implement breast cancer patient navigation services for patients who are at risk for treatment delays.

Understanding vocational rehabilitation service access among adolescents and young adults in foster care

ABSTRACT Using mixed methods, this study examined vocational rehabilitation (VR) access for foster youth with disabilities through child welfare agencies in Illinois. First, one agency completed a process mapping exercise to document VR referral practices. Second, agencies (N = 26) across the state completed surveys about knowledge and use of VR. Only 50% of agencies assessed employment needs at intake, and although 71% of agencies were familiar with the Division of Rehabilitation Services (DRS)-funded VR, only 39% made referrals. Increased collaboration across child welfare agencies and DRS is needed to ensure vulnerable youth are effectively connected to disability-specific employment services supporting economic stability into adulthood.

683 UNDERSTANDING HOW DISCHARGE SERVICES FOR OLDER PATIENTS CAN BRIDGE THE GAP BETWEEN HOSPITAL, COMMUNITY AND SOCIAL CARE

Abstract Introduction UK policy recommends that discharge support is provided by hospital, community and social care staff. However, there is a lack of understanding regarding how these multiagency hospital discharge services work in practice, how they can be sustained and what service stakeholder experiences of them are. This research aimed to understand how integrated discharge services work and the views and experiences of stakeholders. Method A qualitative case study of a supported integrated hospital discharge service (SIHDS) for older people was undertaken, which involved interviews with service staff (hospital, community and social care), patients and carers. Staff, patients and carers were interviewed on their experiences of SIHDS. Staff also took part in a process mapping exercise to understand how the service works. Interviews were analysed using thematic analysis. Ethical approval was obtained for this research. Results A variety of staff (n = 14) and patients aged over 60 years (n = 11) and their informal carers/family members (n = 4) were interviewed. Three main staff themes emerged from the findings: 1. Preparedness for discharge and impact of discharge service; 2. Integration and impact on patient pathway and 3. Organisational aspects. The three main patient/carer themes were: 1. Support for patients; 2. Patient Outcomes and 3. Information exchange. The findings demonstrated that: SIHDS was seen as important to allow patients to be discharged home in a timely and safe manner; that communication is important at all levels of a SIHDS and SIHDS need to continuously evolve to provide patient centred care. Conclusion The findings from this qualitative case study allow the complexities involved in SIHDS to be understood from the experiences and perspectives of multiagency staff, patients and carers. It shows SIHDS are complex, but useful to overcome gaps between services. However, to effectively sustain a patient centred service it is important to regularly review and develop SIHDS.

Systems thinking for health emergencies: use of process mapping during outbreak response

Process mapping is a systems thinking approach used to understand, analyse and optimise processes within complex systems. We aim to demonstrate how this methodology can be applied during disease outbreaks...

Clean Cut (adaptive, multimodal surgical infection prevention programme) for low-resource settings: a prospective quality improvement study.

Clean Cut is an adaptive, multimodal programme to identify improvement opportunities and safety changes in surgery by enhancing outcomes surveillance, closing gaps in surgical infection prevention standards, and strengthening underlying processes of care. Surgical-site infections (SSIs) are common in low-income countries, so this study assessed a simple intervention to improve perioperative infection prevention practices in one. Clean Cut was implemented in five hospitals in Ethiopia from August 2016 to October 2018. Compliance data were collected from the operating room focused on six key perioperative infection prevention standards. Process-mapping exercises were employed to understand barriers to compliance and identify locally driven improvement opportunities. Thirty-day outcomes were recorded on patients for whom intraoperative compliance information had been collected. Compliance data were collected from 2213 operations (374 at baseline and 1839 following process improvements) in 2202 patients. Follow-up was completed in 2159 patients (98·0 per cent). At baseline, perioperative teams complied with a mean of only 2·9 of the six critical perioperative infection prevention standards; following process improvement changes, compliance rose to a mean of 4·5 (P < 0·001). The relative risk of surgical infections after Clean Cut implementation was 0·65 (95 per cent c.i. 0·43 to 0·99; P=0·043). Improved compliance with standards reduced the risk of postoperative infection by 46 per cent (relative risk 0·54, 95 per cent c.i. 0·30 to 0·97, for adherence score 3-6 versus 0-2; P =0·038). The Clean Cut programme improved infection prevention standards to reduce SSI without infrastructure expenses or resource investments.

Developing an Easily Applicable Quality Improvement Process to Optimize and Improve Discrete Workflows; Methods for Iterative Change and Successful Scale

<h3>Introduction</h3> We sought to develop a quality improvement method for workflow and resource optimization that is easy to implement, engages multidisciplinary staff, and can be taught and applied across improvement initiatives. Very busy staff, often lacking baseline knowledge of quality improvement methods, needed an easily applicable method to evaluate and implement change with the goal of streamlining workflows. We applied this method to a discrete problem in our inpatient hospital. <h3>Methods</h3> To test this process, we chose a project that sought to reduce delays in inpatient hospital discharge due to delayed discharge teaching for patients receiving autologous stem cell transplant. This intervention assessed the impact on discharge time when teaching was moved from discharge day to a scheduled appointment 2-3 days prior to discharge. A project team including multi-disciplinary leaders and stakeholders defined problematic elements of the workflow. A process mapping exercise identified problem areas in the current state. Success metrics were defined that reflected the goals of the project. Staff, patients, and caregivers were informed of changes using printed educational materials, project team attendance at nursing meetings, and phone calls. Process mapping was completed for the new workflow (Fig 1). Stakeholders provided feedback on a continuous basis. <h3>Pilot approach</h3> The project team evaluated the streamlined workflows and educational materials using a pilot approach where the new operating system was implemented in one small part of the organization to start (a single inpatient unit). The pilot received focused attention and resources from the project team to test, refine, and perfect operations. After the new process was running smoothly on the pilot unit, it was then scaled to three additional inpatient units. Using this approach allowed the project team to gain buy-in from frontline staff and generate momentum that resulted in successful change on a small scale before rolling the process out to other units of the inpatient hospital. Control measures are underway to monitor the process and collect and measure outcomes against established metrics. <h3>Findings</h3> Using this method led to iterative process improvement by implementing discrete changes to a workflow that impacts clinicians, staff, patients, and caregivers. By involving various stakeholders in the process and creating a framework by which changes to a workflow could be evaluated and disseminated, we measured a significant reduction in discharge delays for patients. This method of implementing iterative quality improvement for discrete segments of processes could be more generally utilized in the setting of a large academic medical center. We plan to apply this process to other opportunity areas in our program.

Utilizing Lean Methodology to Optimize Operating Room Efficiency: A Multidisciplinary Process Mapping Exercise.

Utilizing Lean Methodology to Optimize Operating Room Efficiency: A Multidisciplinary Process Mapping Exercise.

1187 Utilizing Lean Methodology to Optimize Operating Room Efficiency: A Multidisciplinary Process-Mapping Exercise

Study Objective Optimizing surgical capacity while maintaining high quality patient care is an ongoing challenge in the operating room, particularly for complex procedures requiring significant resources, such as robotic hysterectomy. Process Mapping is a Quality Improvement (QI) strategy which can identify common barriers to surgical efficiency and quality of care by dividing a process into its individual components and analyzing each step separately. Our aim was to design an ideal-state intraoperative pathway for robotic hysterectomy in order to improve operating room efficiency and minimize case cancellation. Design Surgical care team members were invited to a meeting where process steps were evaluated and suggestions for improvements were identified. Various QI/LEAN methodologies were utilized including affinity diagrams with multi-voting, parallel processing strategies and checklist development. Setting Canadian tertiary-care academic hospital Patients or Participants A “current-state” process map for robotic hysterectomy was developed with input from the intraoperative care team consisting of gynecologists, anesthesiologists and nursing staff Interventions Output from the exercise included the design of a “future-state/ideal-state” process map incorporating proposed multidisciplinary strategies for improved efficiency and plans for subsequent implementation. Measurements and Main Results In the 5 months following introduction of the ideal-state process map, mean surgical case time for robotic hysterectomy decreased by 28 mins (11%) and case cancellation rate decreased by 70%. Mean case time, case cancellation rates and the acceptability of proposed interventions will be analyzed in a recurring fashion as part of a Plan-Do-Study-Act (PDSA) cycle. Conclusion A multi-disciplinary approach to improving operating room efficiency allowed for sharing of responsibility and improved communication between team members. Engagement of all stakeholders is fundamental to ensuring accurate analysis of current process flow and successful deployment of QI strategies. This process mapping exercise can be easily applied to other surgical procedures and expanded for use in surgical teaching and education.

Collaborative approach to reducing cardiac arrests in an acute medical unit.

Cardiac arrests are often preceded by a period of physiological deterioration. Preventing potentially avoidable cardiac arrests therefore depends on reliable recognition of, and response to, those deteriorations. Our hospital’s acute medical unit had one of the highest rates of cardiac arrest in our organisation at baseline. The aim was to reduce our unit’s cardiac arrest rate by over 50%. Pareto chart analysis identified unreliable processes in the recognition and response to deteriorating patients. Process mapping exercises were performed, then the model for improvement and rapid cycle tests of change were used to develop standardised processes for clinical observations, recognising deteriorating patients and responding to hypoxia. Multidisciplinary learning from what went well, incorporating resilience engineering principles, helped to identify good practice and then test ways of making good practice happen more reliably. Learning from success also addressed some of the psychological barriers to change by encouraging pride in work and a positive focus within our unit. The cardiac arrest rate reduced from 4.3/1000 (October 2014 to February 2016) to 1.1/1000 (March 2016 to end of 2016), associated with improved reliability of the following process measures: reliability of clinical observations, documentation of target oxygen saturations, identification of hypoxia and completion of structured response to hypoxia. This study is an example of a multidisciplinary team engaging in quality improvement, identifying their own local problems and testing their solutions scientifically. Learning from what went well had a positive impact on the project, and the team plans to spread the successful interventions across the organisation.

Creating an integrated tracheostomy care pathway for patients in an Irish regional hospital setting - the feasibility and effectiveness of a dedicated tracheostomy team

Introduction: Temporary tracheostomy is increasingly used earlier in the management of the general critical care population. With rising numbers of temporary tracheostomies, more patient are being transferred from the Intensive Care Unit (ICU) to general wards, so the care pathway for inpatients has to be considered in both ICU and ward environments (Paul, 2010). International guidelines emphasise that the timely involvement of the multidisciplinary team (MDT) is essential for the good aftercare of patients with a tracheostomy (Global Tracheostomy Collaborative). A number of studies have documented the benefits of a dedicated or outreach tracheostomy MDT to support patient care and weaning from tracheostomy. Reduction in length of stay, time to decannulation, and incidence of adverse events have been reported. Impacts on quality of patient care have not been well documented (Garruba, Turner & Grieveson, 2009). In the Irish context, dedicated tracheostomy teams are less common in regional hospital settings. Little is known about their potential to improve patient outcomes. Objectives: The aim of this project was to: 1. Explore the feasibility of creating a dedicated tracheostomy team in an Irish regional hospital setting 2. Examine the potential for this team to improve outcomes and experience for patients with temporary tracheostomy in a regional hospital setting Method: With the support of a local quality improvement forum, a process mapping exercise was completed examining the journey for the patient with a temporary tracheostomy in a regional hospital setting. An audit of patient charts was completed, and outcomes at various stages of the patient journey were documented. Potential points for co-ordination of MDT care along the patient journey were identified, based on a comparison with international guidelines. A dedicated tracheostomy team was convened, based on need identified from audit findings, and staff resources available. The team consisted of Consultant Intensivist, Physiotherapy, Speech & Language Therapy, Intensive Care Nursing, and Respiratory Nursing. A once weekly MDT tracheostomy ward round was established. Repeat audit of patient charts was completed to evaluate the impact of above. Results: It is feasible to create and maintain a dedicated tracheostomy team in this regional hospital setting. Challenges were encountered, particularly in relation to availability of staff, but these can be addressed through planning and flexibility. The implementation of the team and ward rounds led to improvements in: - clarity of plan for weaning and decannulation - cuff management - time to assessment for basic communication support - time to assessment for speaking valve - time to swallow assessment Conclusion: A dedicated tracheostomy team can contribute to improvements in quality of care for the patient with temporary tracheostomy in a regional hospital setting. Due to the heterogenity of this clinical population, a larger sample size is required to explore its effectiveness, with regards to reducing length of hospital and ICU stay. Process mapping is a useful form of clinical audit. In this instance, multiple potential points for co-ordination of MDT care along the patient journey were identified, which could be addressed with further quality measures going forward.

Strategies for developing sustainable health research capacity in low and middle-income countries: a prospective, qualitative study investigating the barriers and enablers to locally led clinical trial conduct in Ethiopia, Cameroon and Sri Lanka

ObjectivesIn 2013, the WHO stated that unless low-income and middle-income countries (LMICs) become producers of research, health goals would be hard to achieve. Among the capacities required to build a...

Filling the empty hours

As a result of suggestions made by a number of patients about the ‘empty hours’ between 1pm and 4pm, a healthcare assistant and an occupational therapy (OT) student undertook a process mapping exercise and followed up by facilitating a trial three 30-minute ‘tea and chat’ sessions per week for a month. Overall, the sessions—which aimed to bring the patients together as a group—had positive social effects by reducing loneliness and enhancing friendship among the patients.

Process-Mapping Exercise (a)

Process-Mapping Exercise (a)

Nurse of the Year: Helen Dinham.

Helen implemented a service improvement project to bring surgical site infection incidence down to zero for patients who are operated on in Royal Gwent Hospital orthopaedic theatre. She also led a process mapping exercise to bring Credits 4 Cleaning compliance up to 100%, and achieved 100% patient and staff satisfaction with environment cleanliness and infection control standards. As a result of her work, improved practice has been rolled out across all theatres in Aneurin Bevan Health Board and 100% Credits 4 Cleaning compliance has been achieved in all 17 theatres of Royal Gwent Hospital

Barriers and enablers of locally led clinical trials in Ethiopia and Cameroon: a prospective, qualitative study

BackgroundClinical trials provide gold standard evidence for policy. Local investigator-initiated trials could generate highly relevant data for national governments of low-income and middle-income countries, but too few are done and information about how to facilitate them is scarce. We identified barriers and enablers to such trials in Ethiopia and Cameroon. MethodsOur multisite, prospective qualitative study—done in Ethiopia and Cameroon—consisted of in-depth interviews (n=22), focus group discussions (n=9), and process mapping exercises (n=7). Local health-researchers with varying trial experience, senior stakeholders, and regulators were recruited through snowball sampling (n=72). Approval was obtained from home, local, and national review boards and verbal or written consent was obtained from participants. We assessed data by thematic analysis. FindingsSystem and organisational barriers to trial conduct were similar between Ethiopia and Cameroon: low resources, weak regulatory and administrative systems, few learning opportunities, little human and material capacity, and few incentives for doing research. In Ethiopia, lack of awareness, confidence, and motivation to undertake trials were key individual barriers, but in Cameroon, environments that discourage personal initiative were more problematic. Learning opportunities and international collaboration were important enablers in both countries, but encouraging more active involvement of researchers at all stages of the trial process facilitated trial undertaking in Cameroon especially. InterpretationIn addition to context-specific issues, we have shown the existence of perennial organisational and system barriers in Africa. These findings indicate a common need to make system-wide changes and build receptive research environments for researchers in low-income and low-to-middle-income countries. FundingThe Global Health Network (Bill & Melinda Gates Foundation), Nuffield Department of Medicine Doctoral Prize Studentship.