Process mapping as a framework for performance improvement in emergency general surgery

Mapping Processes in the Emergency Department Using the Functional Resonance Analysis Method

Emergency departments (EDs) are dynamic, complex, and demanding environments. Introducing changes that lead to improvements in EDs can be challenging owing to the high staff turnover and mix, high patient volume with different needs, and being the front door to the hospital for the sickest patients. Quality improvement is a methodology applied routinely in EDs to instigate change to improve several outcomes such as waiting times, time to definitive treatment, and patient safety. Introducing the changes needed to transform the system in this way is seldom straightforward with the risk of "not seeing the forest for the trees" when attempting to change the system. In this article, we demonstrate how the functional resonance analysis method can be used to capture the experiences and perceptions of frontline staff to identify the key functions in the system (the trees), to understand the interactions and dependencies between them to make up the ED ecosystem ("the forest") and to support quality improvement planning, identifying priorities and patient safety risks.

Novel application of multi-facility process map analysis for rapid injury care health system assessment in Northern Malawi

OBJECTIVES

We used the process mapping method and Three Delays framework, to identify and visually represent the relationship between critical actions, decisions and barriers to access to care following injury in the Karonga health system, Northern Malawi.

DESIGN

Facilitated group process mapping workshops with summary process mapping synthesis.

SETTING

Process mapping workshops took place in 11 identified health system facilities (one per facility) providing injury care for a population in Karonga, Northern Malawi.

PARTICIPANTS

Fifty-four healthcare workers from various cadres took part.

RESULTS

An overall injury health system summary map was created using those categories of action, decision and barrier that were sometimes or frequently reported. This provided a visual summary of the process following injury within the health system. For Delay 1 (seeking care) four barriers were most commonly described (by 8 of 11 facilities) these were 'cultural norms', 'healthcare literacy', 'traditional healers' and 'police processes'. For Delay 2 (reaching care) the barrier most frequently described was 'transport'-a lack of timely affordable emergency transport (formal or informal) described by all 11 facilities. For Delay 3 (receiving quality care) the most commonly reported barrier was that of 'physical resources' (9 of 11 facilities).

CONCLUSIONS

We found our novel approach combining several process mapping exercises to produce a summary map to be highly suited to rapid health system assessment identifying barriers to injury care, within a Three Delays framework. We commend the approach to others wishing to conduct rapid health system assessments in similar contexts.

The Digital Divide: A Retrospective Survey of Digital Rectal Examinations during the Workup of Rectal Cancers

Background: Digital rectal examination (DRE) is considered an important part of the physical examination. However, it is unclear how many patients have a DRE performed at the primary care level in the work-up of rectal cancer, and if the absence of a DRE causes a delay to consultation with a specialist. Methods: A retrospective patient questionnaire was sent to 1000 consecutive patients with stage II or stage III rectal cancer. The questionnaire asked patients to recall if they had a DRE performed by their general practitioner (GP) when they first presented with symptoms or a positive FIT test. Demographic data, staging data, and time to consultation with a specialist were also collected. Results: A thousand surveys were mailed out, and a total of 262 patients responded. Of the respondents, 46.2% did not recall undergoing a digital rectal examination by their primary care provider. Women were less likely to undergo a DRE than men (28.6% vs. 44.3%, p = 0.019). While there was a trend towards longer times to specialist consultation in patients who did not undergo a DRE (27.0 vs. 12.2 weeks), this was not statistically significant (p = 0.121). Conclusion: A significant proportion of patients who are FIT positive or have symptomatic rectal bleeding do not recall having a DRE by their primary care provider. Barriers may include lack of comfort with performing DRE or lack of time. Clearer guidelines and more support for GP’s may increase uptake of DRE.

Process mapping in healthcare: a systematic review

INTRODUCTION

Process mapping (PM) supports better understanding of complex systems and adaptation of improvement interventions to their local context. However, there is little research on its use in healthcare. This study (i) proposes a conceptual framework outlining quality criteria to guide the effective implementation, evaluation and reporting of PM in healthcare; (ii) reviews published PM cases to identify context and quality of PM application, and the reported benefits of using PM in healthcare.

METHODS

We developed the conceptual framework by reviewing methodological guidance on PM and empirical literature on its use in healthcare improvement interventions. We conducted a systematic review of empirical literature using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) methodology. Inclusion criteria were: full text empirical study; describing the process through which PM has been applied in a healthcare setting; published in English. Databases searched are: Medline, Embase, HMIC-Health Management Information Consortium, CINAHL-Cumulative Index to Nursing and Allied Health Literature, Scopus. Two independent reviewers extracted and analysed data. Each manuscript underwent line by line coding. The conceptual framework was used to evaluate adherence of empirical studies to the identified PM quality criteria. Context in which PM is used and benefits of using PM were coded using an inductive thematic analysis approach.

RESULTS

The framework outlines quality criteria for each PM phase: (i) preparation, planning and process identification, (ii) data and information gathering, (iii) process map generation, (iv) analysis, (v) taking it forward. PM is used in a variety of settings and approaches to improvement. None of the reviewed studies (N = 105) met all ten quality criteria; 7% were compliant with 8/10 or 9/10 criteria. 45% of studies reported that PM was generated through multi-professional meetings and 15% reported patient involvement. Studies highlighted the value of PM in navigating the complexity characterising healthcare improvement interventions.

CONCLUSION

The full potential of PM is inhibited by variance in reporting and poor adherence to underpinning principles. Greater rigour in the application of the method is required. We encourage the use and further development of the proposed framework to support training, application and reporting of PM.

TRIAL REGISTRATION

Prospero ID: CRD42017082140.

A Practical Guide to Performance Improvement: Data Collection and Analysis

This article discusses performance improvement (PI) data collection processes and the various tools that can be used to analyze and display data through the duration of a PI project. It describes the importance of data, how to determine the required amount of data, how to collect and analyze data, and in what format data should be presented. Personnel involved with PI projects may need to use various data collection methods and tools to ensure an effective project with a successful outcome. This article includes examples of how PI project team members can implement various data collection and analysis tools. After reviewing this article, the reader should have a better understanding of this part of the PI process.

Establishing a Geriatric Hip Fracture Program at a Level 1 Community Trauma Center

BACKGROUND

Traditional care of patients with geriatric hip fracture has been fragmented with patients admitted under various specialty services and to different units within a hospital. This produces inconsistent care and leads to varying outcomes that can be associated with increased length of stay, delays in time from admission to surgery, and higher readmission rates.

PURPOSE

The purpose of this article is to describe the process taken to establish a successful geriatric hip fracture program (GFP) and the initial results observed in a single institution after its implementation.

METHODS

All patients 60 years or older, with an osteoporotic hip fracture sustained from a low energy mechanism (defined as a fall from 3-ft height or less), were included in our program. Fracture patterns include femoral neck, intertrochanteric, pertrochanteric, and subtrochanteric femur fractures including displaced, nondisplaced, and periprosthetic fractures. Preprogram data included all patients admitted from January 1, 2012, through December 31, 2014; postprogram data were collected on patients admitted between May 1, 2016, and May 1, 2018.

RESULTS

Demographic characteristics of the populations were similar. After the GFP was implemented, the proportion of patients who were treated surgically within 24 and 48 hours increased. The average number of hours between admission and surgery significantly reduced from 35.2 to 23.2 hours. Overall length of stay was decreased by 1.8 days and readmission within 30 days of discharge was lower. Reasons for readmission were similar in both timeframes. The rate of inpatient death was similar in the two groups. Mortality within 30 days of surgery appeared somewhat higher in the post-GFP period.

CONCLUSION

Our program found that, with the utilization of a multidisciplinary approach, we could positively influence the care of patients with geriatric hip fracture through the implementation of evidence-based practice guidelines. In the first 2 years after initiation of the GFP, our institution saw a decrease in time from admission to surgery, length of stay, and blood transfusion requirements.

Variation in SBIRT delivery among acute care facilities

BACKGROUND

Screening, Brief Intervention, and Referral to Treatment (SBIRT) is an evidence-based process to recognize and intervene with people who use substances. Despite evidence to support the SBIRT effectiveness, this process is rarely used in acute care. To facilitate use of SBIRT in acute care, it is important to first understand the implementation processes.

PURPOSE

To describe SBIRT processes across 14 acute care facilities.

METHODS

A phone interview was conducted with site coordinators at 14 facilities to describe their SBIRT process and clinicians involved in each step.

FINDINGS

Seven different SBIRT processes were identified for people that use alcohol and/or drugs, and five different processes were identified for people that use tobacco. The function of SBIRT was consistent throughout facilities, but the form of implementation varied based on organizational context.

DISCUSSION

Future SBIRT dissemination efforts will need to first understand the local processes and clinicians involved within each facility to tailor implementation to local context.

Safety Culture and Perioperative Quality at the Volta River Authority Hospital in Akosombo, Ghana

BACKGROUND

The Volta River Authority Hospital (VRAH) is a district hospital associated with a large public works project in Akosombo, Ghana, that has developed a reputation for high-quality care. We hypothesized that this stems from a culture of safety and standardized processes typical of high-risk engineering environments. To investigate this, we evaluated staff and patient perceptions of safety and quality, as well as perioperative process variability.

MATERIALS AND METHODS

The Safety Attitudes Questionnaire (SAQ) and Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys were used to evaluate staff and patient perceptions of safety. Perioperative general surgery and obstetrical procedure observations generated process maps, which were analyzed for variability and waste.

RESULTS

Thirty-one SAQs were administered. 83% of workers held a positive perception of teamwork, and 77.4% held a positive perception of safety culture. Fifteen HCAHPS surveys of surgical inpatients showed a median hospital rating of 10 [IQR 8.5-10] on a ten-point scale. 90% gave maximal scores for pain management and 84.4% for nurse communication. Ten general surgery and obstetrical procedures were observed for which process map analysis was notable for no consistent waste steps and 100% adherence to the World Health Organization Safe Surgery Checklist.

CONCLUSIONS

Surveys suggest an institutional commitment to safety with strong teamwork culture and patient communication. Perioperative process mapping supports this culture, with low levels of variability and waste, and is useful for evaluating standardization of care. VRAH demonstrates the feasibility of delivering high standards of perioperative care in a low-resource setting.