Posted by: ayrshirehealth | May 28, 2014

We are not a process! by @stewartcard

The patient journey

Process mapping in the NHS can be difficult. I have often heard that “we are not a process” nor do “we work in one”. It would seem that we are often reluctant to view and name a patient journey or indeed pathway as such; possibly avoiding direct comparison with the cash and efficiency focussed production lines of other complex ‘private’ businesses. Process line Although when we review the definition of process, we take an input and by utilising people, equipment, materials, procedures and expertise we change or more importantly improve the outcome.

It seems that process is exactly what we do have in great numbers in our NHS.

We certainly have the ability to identify key performance indicators in the patient journey, but we need to use that detail to better understand the bottlenecks, time-traps and all key causes of variation within our hospitals. We really need to understand the journey of the individual central to our purpose, the patient.

A pathway to understanding

screen-capture-18When we finally admit that we have a process or a pathway then we should be able to easily define and assess the layout, points of input and nature of flow, measure the performance at key stages, analyse to identify abnormal or unwanted conditions, implement corrective actions and further ensure that we control the process rather than allowing it to control us.

After all our clinical colleagues routinely measure, display, provide feedback and act upon variation in the vital signs of their patients, such as temperature, blood pressure, heart rate and oxygen saturation.screen-capture-21

However, lack of process identity remains and we therefore don’t feel the need to review variation within and miss out on the vital signs of the patient pathway and ultimately patient flow.

From the emergency department front door to effective patient discharge, each of the journey stages in-between can advise us of the consistency, reliability, capability and acceptability of our processes. We need to reconsider the usefulness of age old review measures such as average length of stay, which can often paint a reasonable picture but ignore any skew in the length of the journey and allow extremely long episodes to go almost unnoticed. We should consider comparing the average with the median length of stay and assess for consistency in all patients’ lengths of stay, whilst fully understanding the detail behind the extremes too. Are these extreme episodes down to one-off special causes or more worryingly are they expected and repeatable events?

There’s a mountain of improvement data

Analysis could be carried out by specialty, pathway and condition allowing us to define the real causes of delays and variation such as blocked discharge, delay in diagnostic examination or review, onward referral, delayed clinical assessment, pharmacy issues and social constraints.Flow

We would soon unearth the key problems within our processes and be able to focus our efforts on corrective action where most needed.

There is a mountain of improvement data waiting to be converted into useful information for understanding and improvement. There are many unknown unknowns in our service.

So that’s all fine I hear you say, we’ll simply deconstruct our processes and identify key measurements, we’ll promptly analyse and identify actions, quickly implement them and maintain control as we carry on being nurses, surgeons, physicians and other clinical and support specialists……….how?

Aye, therein lies the rub…..

It is a new method of support that’s required as it’s almost impossible to review a process that you work ‘in’ without allowing time to work ‘on’ it. This may be the future of service development and improvement within our and other healthcare systems. Where we design and develop the processes and pathways with acceptable limits, known inputs and desired outputs and measure with a desire to control and constantly improve. We need to be able to identify the key performance indicators rather than give and receive anecdotal tales of repeated failure and overblown success, after all “data is not the plural of anecdote”, as far as we know.

Clinical and support colleagues have always needed accurate evidenced based information to drive quality decision making and provide high quality, effective person centred care. We now need to extract meaningful data from our often complex and numerous processes and allow a new breed of analyst to supply the process improvement information that will allow us to complement the clinical care by providing a high quality, effective, repeatable, evidence based person centred journey.

This week’s blog was by @stewartcard (Stewart Cardwell), Assistant General Manager, Children & Diagnostics Services, Ayrshire and Arran



  1. thanks stuart really interesting. The evidence is there and we must learn to use it for improvement. well done

  2. Agreed totally. As the current Patient Opinion Coordinator for Ayrshire and Arran I think we can gain help from this forum too. The patient / public experience and perception of their experience throughout their ‘journey’ can be an additional source of help to inform the process.

    Eveything you say is right but people fuel and run the process and for some, we need a culture change away from ‘that is the way it is, we are very busy you know’. which I heard when I was enquiring about an issue recently.

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