We define workflows as the individual processes (e.g., office visits, refills, scheduling) that collectively get the job done and create value for patients. The process of workflow mapping can help you and your staff visualize the sequence of steps involved in each workflow function. Mapping is valuable for a number of reasons, including evaluating whether a process can be optimized to decrease non-value added time spent doing routine office functions and clinical activities.  Metrics, such as the time it takes to complete a given process, will help you assign values to compare effectiveness. In addition, mapping can also identify opportunities to reduce unnecessary variation in how work is completed, for example, relying on so many different types of patient visits that scheduling and rescheduling take far more time than necessary with little added value.

Mapping Tools

A variety of tools can be used for mapping, including flow charts, spaghetti diagrams, and value stream mapping. Originally developed for information technology projects, flow charts utilize shapes (e.g., rectangles, diamonds, arrows) to identify the sequence of all activities for a given process. Spaghetti diagrams use free-form lines to visualize movement and activities of individuals (e.g., provider, patient) as well as objects (e.g., flow sheet). A simple hand or computer-generated drawing can be used.

So-called lean management strategies utilize value stream mapping to compare current state against ideal workflows. While similar to flow charting, value stream mapping can also be used as a foundation for fixing broken processes. Value stream mapping is easy and requires minimal training. Using value stream mapping and spaghetti diagrams in the process of renovating their office, one group found physicians were traveling up to 48 steps multiple times each day to reach exam rooms from their offices. After lengthy discussions over a number of months, providers decided to move into a common area surrounded by exam rooms. The result? Better access to staff and less messaging. The group also enjoyed more collegial discussions about treatment strategies.  This is not to say moving office space and making radical shifts are the only ways that value stream mapping can be useful.  Start small and see if you and your team can identify a change that would reduce unnecessary actions or activities.  To get started, consider asking everyone in your office to submit a list of the top three workflow processes they find cumbersome, and a brief explanation of why.  If you see an item that's mentioned on more than one list, consider inviting each person involved in that process to participate in a value stream mapping exercise during lunch or after a staff meeting.

Lean thinking has enabled Toyota and others to significantly improve manufacturing workflows and reduce errors. The concepts are being utilized increasingly in health care to improve efficiency and access to care, including offering patients same-day appointments. Central to the lean concept is identifying and eliminating steps that don't add value (e.g., interruptions, waiting) so that value (care) flows continuously throughout a process.

Primary processes are those that serve external customers (patients); internal processes serve internal customers (staff and physicians, for example). Processes that create value are those for which an external customer would be willing to pay a fee. A perfect process: 1) creates value for those experiencing it; 2) is easy to manage; and 3) is satisfying for staff to perform.[1] 

Where to Start

Using index cards or Post-it notes, identify each step for a given process in the sequence that it occurs. Getting your staff to complete this activity builds teamwork and ensures that every step is noted. It can also help to physically walk through each step in a process. To create a value stream map, line up activities from left to right - be sure to jot the amount of time it takes to complete each step of the activity.

One practice used value stream mapping to help them visualize potential changes they could consider as they tried to improve the patient-centeredness focus of their practice. Figure 1 shows a current state value stream map of activities completed during a typical office visit. Time spent on each activity is noted in parentheses with totals at the top of each column. The site identified 16 patient activities during an office visit. In addition, 24 of the 69.5 minutes of patient time on site was spent waiting, clearly an activity that does not add value. Figure 2 is a spaghetti diagram of their current state value stream.

What do patients value during an office visit? An article in Family Medicine indicates patients are most satisfied with visits in which they "talk about their specific treatment, are examined, and receive health education. There is a negative relationship with time spent on history taking."[2]  Replacing some of the time (six minutes) spent taking a patient's history (items 6 and 9 in Figure 1) with time discussing their needs could result in increased patient satisfaction.

After each step is mapped, briefly note problems related to it in a separate process box. Figure 3 shows a process box for an office visit check-in. A practice used this opportunity to identify the average time to complete a process and so-called lead time (i.e., the total time to complete a step, including wait times). Once common problems are identified and visually sequenced, priorities can be set on when and how to solve them.  Problems with check-in at this site included provider complaints regarding waits and Internet connection downtime. In addition, registration forms weren't well designed; the form included three different demographic data requests.

Perfect state value stream maps answer this question: what needs to change in the next 12-18 months for this process to be perfect based on delivering value to a customer?  The perfect state value stream map (Figure 4) and spaghetti diagram (Figure 5) show reductions in the steps taken to complete a visit (from 16 steps to nine steps). The practice set a goal of reducing non-value added wait time from 45 minutes or more. They identified several ways to accomplish this: 1) helping patients make online appointments; 2) take vital signs and check patient out in the exam room to reduce travel time; and 3) have patients check-in and provide history information at electronic kiosks to free-up staff time and allow the provider to focus on other patient information during the visit, such as discussing treatment options.

While some may contend patients would not value completing visit activities usually done by staff, the opposite is likely the case. Winning the Service Game by Schneider and Bowen describes how consumer involvement in service delivery can actually enhance satisfaction. "Perhaps the thought of making customers serve themselves seems out of step with these times in which businesses are constantly chided to pamper and delight their customers. Yet customers can obtain delight from serving themselves if it provides them with a greater sense of control over the service production process."[3]

Improved processes that have an "owner" who takes responsibility for knowing and monitoring it are more likely to be sustained over time. An owner should be someone who has familiarity with a process in the course of his or her daily work.  

Keep in mind the examples in this article may not represent the changes that would work in your office. The important part of this exercise is to bring your staff together to discuss changes that everyone agrees would add value and increase the satisfaction of office staff and your patients' experience. Work flow mapping provides a practical way to visualize processes and guide desired change. But no mapping and subsequent process improvement is sustainable if physicians and staff don't believe in it. Make sure there's enough motivation and buy-in from those who will need to make the change happen. Finally, be sure site leadership is committed to take needed action for as long as it takes so an improved set of results can be achieved.

Suzanne Houck serves as President of Houck & Associates Inc., a leader in ambulatory care redesign consulting and training. Sue is the author of What Works: Effective Tools & Case Studies to Improve Clinical Office Practice, the first comprehensive book on ambulatory care redesign. She also has experience as an ambulatory care manager and nurse practitioner throughout the United States and Africa.

DISCLAIMER

The articles provided in Practice Management News are general.  They do not constitute legal, practice management or coding advice in any particular factual situation or create an attorney-client relationship.  Consult your attorney or other professional for advice in your particular situation.

[1] Getting Lean in Health Care Edited by Diane Miller, Institute for Healthcare Improvement, Innovation Series, 2005. p.5.

[2] Robbins, J.A., Bertakis, K.D., Helms, L.J., Azri, R., Callahan, E.J., Creten, D.A. (1993, January).The influence of physician practice behaviors on patient satisfaction. Family Medicine, 25(1):17-20.

[3] Schneider, B., & Bowen, D. (1995). Winning the Service Game. Boston, MA: Harvard Business School Press.