Process mapping in healthcare

A simple process map is depiction of sequence of information and material flow involving business entities (actors) using a standard set of symbols (BPMN/ADONIS) [1]. In 1921, Frank Gilberth introduced the first structured method for documenting process flows. Enhanced process mapping depicts functional units and roles using swim lanes. They start with level zero and progressively increase showing higher level of granularity. Although not exhaustive, the paper briefly describes the objectives, types, and best practices in process mapping.
Objectives of process maps
Process maps are fundamental to information capture. It is the building block of any new or improvement project.
 Even though not always entire objective, a process map reproduces pre-existing reality. It allows us to contrast actual flow to the ideal flow.
 They help getting past organizational silos [2].
 We may employ process maps in a variety of scenarios like B2B (between organizations as in case of revenue cycle management), B2C (hospital patient interaction like outpatient and inpatient procedures), and B2E (employee to hospital interaction).
 Discover complexity, redundancy, and blocks in the process, help to revaluate underlying assumption and predispositions
 Identify location where there is a need to collect additional data and investigate [3].
Different types of process map
Process map comes in several flavors each highlight a different aspect and intended for a different audience.
 High-level process flow shows core process within the organization. It shows the interaction between entities. Low-level process flow shows decision gates and loops
 Cross-functional maps that use swim lanes, which allow the slotting of the activities among department or roles indicating the organizational structure and complexity involved.
 Value stream maps that capture wait times, and additional attributes like inventory, throughput, and flow time.
 SIPOC diagram which shows the high-level visual between suppliers, inputs, process, outcomes, and customers (refer to appendix).
There may be other variations of process maps, either tailored or derived to meet specific circumstances
Best Practices
 Articulate the problem clearly and specifically using information available.
 Involve the stakeholder group to participate in the modeling process
 Determine the boundary or scope of the process to facilitate data collection and retain focus.
 Determine and sequence the steps identifying the start and the end-points and the customer.
 Start with high level and drill down progressively. Maintain consistency at each level.
 Test for completeness of the map at each level.
 The mapping exercise must be led by a facilitator who
 Must have a neutral stand
 Must set ground rules of engagement
 Will create an environment for brain storming
 Keep the exercise on track by parking contentious issues, keep focus on “value to the customer”

Conclusion
Process mapping spans across the “Define” and “Measure” phase of DMAIC framework of 6-Sigma and discovery of the “hidden plant” used in Lean. Define-Measure-Analyze-Improve-Control (DMAIC) is a framework for 6-Sigma implementation. The Define phase identifies the opportunity set for improvement and Measure phase quantifies the current state in terms of contextually relevant indicators. Hidden Plant is a lean construct denoting the unreported rework and scrap that goes into the outcome of a process.
Patient focused Integrated Care Pathways (ICP) is a good derivative of process map. They act templates to deliver care fostering evidence based medical practice. The ICP is not rigid but allows the variation in the clinical intervention depending on unique needs of the patient. The ICP serves as a reminder to document the variations in care from published guidelines. This in turn supports management of clinical risks and modification of the contents of the ICP.
Process mapping lays the foundation of any problem solving assignment. It also is an excellent tool to capture and transmit best practices in the organization and in the industry. Sophisticated information systems integrate process maps with packaged application making configuration and customization simpler and easy to maintain. Lean Six Sigma uses this methodology extensively to evaluate as-is state and create to-be state. It allows easy visualization of check- points to measure, monitor, and sustain activities in the process.

References
[1] eBusiness in Healthcare From eProcurement to Supply Chain Management Series: Health Informatics Hübner, Ursula; Elmhorst, Marc A. (Eds.)
[2] What’s in a care pathway? Towards a cultural cartography of the new NHS Ruth Pinder,Roland Petchey,Sara Shaw,Yvonne Carter. Sociology of Health & Illness Vol. 27 No. 6 2005 ISSN 0141–9889, pp. 759–779
[3] The Premier Healthcare Alliance. http://www.premierinc.com/about/mission/social-responsibility/cares/process-maps.pdf
[4] What is an integrated care pathway? Sue Middleton, Jane Barnett, David Reeves. Hayward Medical Communications. www.evidence-based-medicine.co.uk
[5] A toolkit for Redesign of healthcare. AHRQ. http://www.ahrq.gov/qual/toolkit/tkformf.htm
[6] http://facultyweb.berry.edu/jgrout/processmapping/Swim_Lane/swim_lane.html
[7] http://www.hfma.org/Templates/InteriorMaster.aspx?id=21198

History of healthcare quality

History of Healthcare Quality
The earliest notions of quality traces back to that of the “quality of life” elucidated in the Vedas. Subsequently, “quality of living” became the norm of a materialistically motivated society. Product and service quality are offshoots of this paradigm. However, in this brief paper we will focus on the history and evolution of quality in the recent past.
History of quality is probably as old as medical care itself.
Voluntary programs
 Explicit and systematic use of death rates as a quality indicator by Florence Nightingale in mid 1800s marks the emergence of the quality assurance in healthcare.
 The Flexner report in the early 1910[1] on the quality of medical education in the US was the first wake up call for reforming quality of medical education.
 In 1915s, Ernest Codman gave the idea of outcome oriented medical audit which led to the establishment of the Hospital Standardization Program of the American College of Surgeons in 1918s[2].
 Avedis Donabedian inspired by Codman conceived the Structure-Process-Outcome theory[3]. According to him, quality is a product of two factors. One is the science and technology of providing care and the second the application of first factor in practice. He proposed that the components of quality in healthcare consisted of efficacy, effectiveness, optimality, legitimacy, equity, and acceptability[4].
 In 1950-60s, JCO adopted Donabedian’s theory and created quality assessment and improvement framework based on physical and staffing characteristics of caring for patients, the method of delivery, and the results of care. Over the years, JCO’s mission grew to embrace most healthcare settings[4].
Government regulatory programs
 State licensing programs prevailed in 1800s.
 In 1906, the FDA (Food and Drug Administration) undertook the national regulation of medication.
 In 1935, the Social Security Act set the standards for maternal and child health.
 In 1965 Medicare was institutionalized mandating principles central to hospital operations, staff credentialing, round the clock nursing care, and utilization review.
 In 1980s, Healthcare Quality Improvement Initiative allowed professional standards review organizations to apply patient care algorithm to claims history and data set to screen cases and describe how well the care conforms to established guidelines[5].
 On March 23, 2010, President Barack Obama signed The Patient Protection and Affordable Care Act into law. One week later, he signed The Health Care and Education Reconciliation Act of 2010, which made numerous changes to PPACA. This is likely to bring forth into play new patient care model, continuum of care, new AHRQ programs, metrics based reporting and a data driven national quality strategy.
Applying evidence to health delivery
Institute of Medicine defines quality in healthcare service as being safe, effective, patient centered, timely, efficient, and equitable[6]. There is a lag between discovery of efficacious forms of treatment and its incorporation into routine patient care[7]. In the recent past several private public partnerships like the Cochrane Collaboration and evidence based practice centers supported by AHRQ have emerged providing excellent models for quality care. Evidence based practice was started by Archie Cochrane in 1950s. It became apparent that it was not effective to train and encourage clinicians to independently find and apply best clinical practices. Quantitative systematic reviews began to appeal to the physician’s scientific outlook over qualitative “suggestions.” This eventually paved the way for healthcare to embrace the six sigma and lean frameworks.
Since 1980s there has been a steady transition from a needs based to an efficient profit making industry by adopting quality concepts like TQM, quality trilogy, and zero defects. Deming, Juran, and Crosby were the three quality gurus whose expansive work in the field of quality brought radical changes in other industries especially automotive. During 1980s, the John Hartford Foundation and Harvard Community Health Plan sponsor the national demonstration project on quality improvement in healthcare to determine if industrial TQM applies to healthcare[8].
Conclusion
We see that astute individuals, federal regulations, and other industrial best practices have shaped the quality in healthcare. Everyone understands the notions of superior quality. The challenge has been to have create mass momentum to make sure quality is not a matter of adherence but rather a thing of constant engagement.
 
References
[1] The Flexner Report at the Century Mark. A Wake-Up Call for Reforming Medical Education. Mike Mitka JAMA. 2010; 303(15):1465-1466
[2] Evaluation of the care of patients Codman Revisited. John D. Porterfield, M.D. Director, Joint Commission on Accreditation of Hospitals. Vol. 52, No. 1, January 1976
[3] The evolution of quality in the US health care industry: an old wine in a new bottle. Patrick Asubonteng, Karl J. McCleary and George Munchus University of Alabama, Birmingham, Alabama, USA
[4] An introduction to quality assurance in health care. Avedis Donabedian, Rashid Bashshur
[5] Luce JM, Bindman AB, Lee PR: A brief history of health care quality assessment and improvement in the United States. West J Med 1994; 160:263-268
[6] Crossing the Quality Chasm: A New Health System for the 21st Century (2001)
Institute of Medicine (IOM)
[7] Balas E, Boren S. Managing clinical knowledge for health care improvement. In: Bemmel J, McCray AT (eds). Section 1: health and clinical management. In Yearbook of Medical Informatics: Patient Centered Systems. Stuttgart, Germany: Schattauer Verlagsgesellschaft; 2000:65-70
[8] Quality in health care: theory, application, and evolution. Edition: 3 - 1995 Nancy O. Graham