Process Flow Mapping

A Critical QI Tool

Achieving your quality improvement goals will almost certainly require that substantial changes be made to whichever process you target. Although you may think that you understand the gaps between your current process and the best practice, formally mapping the process will likely reveal gaps that would otherwise be overlooked. It will also provide your team with a better understanding of the process in general. Process mapping is really nothing more than writing down everything that happens in a given process. The Web sites of the Institute for Healthcare Improvement(IHI) (http://www.IHI.org) and the American Society for Quality (http://www.asq.org/quality-progress/2003/01/problem-solving/a-simple-process-map.html; accessed June 30, 2009) provide more in-depth information about process mapping. Often, the major steps of the process are defined first, and then each step is analyzed in detail. In some case, the major steps in a process can be accurately defined by a single individual (such as the team leader). However, usually, no individual is able to complete a detailed analysis of all the steps. This highlights the importance of the multidisciplinary team in completing this exercise.

Once the process is mapped, the gaps between the current process and the best practice will become apparent. The members of the team with the most detailed understanding of the best practice will be able to recognize the gaps and highlight them for the team. The assessment questions, presented earlier in this section, can also help team members recognize the gaps.

Ideally, this process will leave the team with a list of gaps that need to be addressed in order to achieve the team’s goals, and this list will be used to create interventions.

Diabetic Foot Infection Process Mapping

Team members should build consensus around the optimal care delivery process for the population studied. This may be based on available evidence, expert opinion, or local standards of care. Some degree of manual chart abstraction will need to occur in order to establish the care delivery process “gap.” Establish high-level process measures and avoid granularity. Nodes in the process map may serve as discrete outcomes measures when tracking the performance of your intervention.

Download the DFI Inpatient Care Path

Build process maps to better define the steps for each failure mode. Fish diagrams are a useful tool to help drill down process flaws:

Download the BKA due to DFI Fish Diagram

Some considerations and decision points (these may vary between institutions):

1. Who is responsible for tissue debridement? Some institutions use general surgery services, whereas others rely on vascular surgery, plastic surgery, or even a combination according to ulcer location and depth.
2. Do the surgical services involved with debridement have their own protocols?
3. Who will provide amputation services?
4. Blood glucose management — are pathways in place regarding a diabetes management team, endocrine consultation, or glycemic protocols?
5. Are ancillary diabetes services available? These may include patient education, nutritionists, and/or social workers.
6. What wound care services exist at the institution or nearby?
7. What is the rate of resistant organisms, especially MRSA, in your institution? What are the procedures for surveillance, isolation, and empiric antibiotics?