DEWITT ARMY HOSPITAL Fort Belvoir, VA. OUTLINE Definition of Process Mapping Parts of Process Mapping Steps of Process Mapping Tools for Process Mapping.

DEWITT ARMY HOSPITALFort Belvoir, VA

OUTLINE

• Definition of Process Mapping• Parts of Process Mapping• Steps of Process Mapping• Tools for Process Mapping• Final Checking of Process Mapping• Examples of Process Mapping• How Process Mapping fits into the QSEs• Common Mistakes in Process Mapping

Process Mapping

• Is a graphical representation from start to finish.

• Flow chart

Oval: Show the input to start the process

Box or Rectangle: Show a task or activity performed in the process

Diamond: Shows where a Yes/No question is asked

or a decision is required

Usually only one arrow out of an activity box. If more than one arrow, you may need a

decision diamond.

Oval: Show the output at the end of the process

YesNo

Arrows show direction or the flow of the process

Make sure every feedback loop is closed, Every path takes you either back or forward to another step

TEMPLATE

Flow Chart

Tools for Process Mapping

• Pen and paper• Post-It notes

• Software: PowerPoint, Visio, etc.

Quality System Essentials

Organization

QUALITY SYSTEM ESSENTIAL Organization

DCCS

Chief, Pathology

DeWitt Army Community HospitalDepartment of Pathology

Soldiers

MLT Phase II

Safety

Anatomical Pathology

Clinical

Pathology

Client

Services

DecentralizedLabs

Histology

Chemistry

Blood Bank

Microbiology

Hematology

Central Processing

Phlebotomy

Shipping

POCT

Rader

Woodbridge

Fairfax

Lab Manager

NCOIC

Quality Management

Administrative Support

Organizational Chart6/28/2007

Assistant Lab Manager

Quality System Essentials

Safety

GS CivilianDA 4106,

FM 879, DD 689 CA-1 & CA-17* *when applicable

Report to ER for emergent care

ATTENDING MD

Report to your respective Contract

Representative Office or Primary Provider for follow- up care

Report to Occupational Health within 72 hours of injury for follow-up care,

(bring SF 558)CA-1 should be submitted to Safety Manager within 5 workdays of the injury

SF 558 or progress notes. Give to injured employee

Consent FORMS for HIV on both source & injured employee

Order & draw lab tests STAT:“NEEDLE SOURCE” (order set name)Tubes: 1 red, 1 purple, & 1 HIV Tests: Rapid HIV-1; HIV; Hepatitis B Surface AG; Hepatitis C Antibody“NEEDLE EMPLOYEE”(order set name) Tubes: 2 red, 1 purple, & 1 HIVTests: HIV, Hepatitis B Surface Antibody, Hepatitis C Antibody; CBC, CMP, HCG (female childbearing age)

Decide on Tetanus shot If necessary, consult Community Health

Nurse for psychological assistance

Phone #s: ER (805-0518); Occ Health (805-0443); Infection Control (805-0044); Safety Manager (805-0157); Patient Safety (805-8048);CPAC (703-704-2743)

Report to ER for emergent care

Decide on PEP (post exposure prophylaxis) therapy

• If YES, contact WRAMC Infectious Disease for follow up 202-782-1663

APPLY FIRST AID !!!OR REPORT TO ER IMMEDIATELY

MilitaryDA 4106DD 689FM 879

Patient, Contract , Student, Volunteer,

VisitorDA 4106

SUPERVISOR

• Ensure paperwork is properly filled out• Forward Paperwork to designated area. REFER TO BACK PAGE.•Report event to Infection Control

Report to ER for emergent care

UPDATED 11-23-2004

NEEDLESTICKOr other blood borne pathogen exposure

NOTIFY SUPERVISORSupervisor/ employee complete the assigned forms

What is the status of the employee?

END

ACCIDENT/INJURY REPORTING

GS/WG CivilianDA 4106,

FM 879, DD 689 CA-1 & CA-17*

*when applicable

Report to ETR for emergent care and

OH for first aid (DD 689 required)

Report to your respective Contract

Representative Office or Primary Provider for follow- up care

Report to Occupational Health within 72 hours of injury for follow-up care and

bring DD 689 and ETR Report (SF558) if seen at DACH ETR. For GS/WG

civilians, medical documentation is required.

DD 689 – Individual Sick Slip Form –Supervisor will give a signed form to injured employee to seek medical attention at ETR or Occupational Health

DA4106 – Quality Assurance/Risk Management Form – On duty injuries must be reported to Patient Safety

MEDDAC FM 879 – DeWitt Army Hospital Supervisor Mishap Report –Required to be submitted to Safety Management Office within 5 days of injury/accident. DA 285-A-B-R may be substituted to report POV incidents for military.

CA1 – Federal Employee’s Notice of Traumatic Injury and Claim for Continuation of Pay/Compensation – Supervisors are required to fill out form and bring it to Safety Management Office to be submitted to Department of Labor. Form is required to be submitted within 3 days of injury/accident.

CA17 – Duty Status Report – Supervisor will fill out column A of form and give to injured employee if limited duty is applicable. Employee will provide form to provider and return to supervisor.

Phone #s: Safety Manager (805-0157); Occupational Health (805-0443); Infection Control (805-0044); Patient Safety (805-8048);CPAC (703-704-2743)

Report to ETR for emergent care

FIRST AID FIRST!!!IF UNCLEAR, REPORT TO ER IMMEDIATELY

MilitaryDA 4106DD 689FM 879

(Both On and Off Duty accidents

must be reported)

Contract , Student, Volunteer, Visitor

DA 4106

SUPERVISOR

• Ensure paperwork is properly filled out• Forward Paperwork to designated area. REFER TO BACK PAGE.•Report event to Safety Management Office at 703-805-0157

Report to ETR for emergent care and

OH for first aid (DD 689 required)

UPDATED 02-04-2005

NOTIFY SUPERVISORSupervisor/ employee complete the assigned forms

What is the status of the employee?

END

DA 4106

(Incident Report)

FM 879 (Dewitt Army Community

Hospital Supervisor’s Mishap Report)

DD 689 (Individual Sick

Slip)

CA-1 (Federal Employee’s Notice

of Traumatic Injury and Claim for Continuation of

Pay/Compensation)

CA-17 (Duty Status Report)

SF 558 (Emergency Care and

Treatment- Dewitt ACH)

SAFETY MANAGER

COPY ORIGINAL COPY COPY(Electronically

submitted)

COPY COPY

OCCUP HEALTH

COPY COPY COPY COPY

PATIENT SAFETY

ORIGINAL

*CPAC

(Civilian only)

ORIGINAL ORIGINAL ORIGINAL COPY

EMPLOYEE FILE

COPY COPY COPY COPY COPY

LAB PI COPY COPY COPY COPY COPY COPY

# OF COPIES 2 2 4 4 4 5

Quality System Essentials

Occurrence Management

*** START***Confirmed

CRITICAL VALUE

NOTIFICATION / DOCUMENTATION CRITICAL VALUES

Inpatient (Wards )

CALL MOD ( after minimum of 2 attempts )

Outpatient, ER and Outlying Clinics

(Fairfax+ Woodbridge)

Patient’s location?

Document in CHCS

*** END ***

Ask for :

1st: ORDERING PROVIDER2nd: RN in charge of patient or charge nurse

Successful Reporting ?

Successful Reporting?

Normal duty hour? (Refer to Clinic hours)

Normal duty hr: -Inform supervisor, lab manager, QI, or pathologist

Off duty hr:-Call pathologist-on call

Call clinic and ask for

ORDERING PROVIDER

Page ORDERING PROVIDER

YES

NO

YES

NO

YES NO

HOW TO DOCUMENT IN CHCS: (Example)“Critical read back by Dr. Jane Doe, ER, 7/06/06@0800 GHY”Note: Have Health Care Provider read back critical lab results with patient’s name

QSE:

Purchasing and Inventory

&

Process Control

QUALITY SYSTEM ESSENTIALSPURCHASING AND INVENTORY

REQUEST FOR CRITICAL EQUIPMENT/SUPPLIER/SERVICES

DOCUMENT QUALIFIERS REQUIREMENTS (REFER TO PROCESS VALIDATION FORM)

Meets requirements?NO

YES

1. Request for 3953 (Purchase request and commitment)2. Accounted by property book (check annually)3. Med Maint will do functional, preventive checks4. Provide ER 24-7

1. Received by authorized or designated personnel (supply officer)2. If high priority, will notify telephonically

Deliver to the section

SECTION CHECKS/

DOCUMENTS:-supplies: lot #, expiration dates, temperature, qc-equipment: calibration, scheduled qc

CHECKS WITHIN ACCEPTABLE LIMITS?

YES

READY FOR USE

NO

REMOVE FROM LIST

Page 1

PROCESS IN EVALUATING CRITICAL MATERIALS/ SERVICES

DMLSS (common use, not in contract)

CONTRACT (request for

3953, yearly)

CREDIT CARD (for emergency

request)

For equipment/services:

For supplies:

APPROVED BY LAB MANAGER

BACK TO MAINTENANCE

OR SUPPLY OFFICER

QSE: Process Improvement

Urine Collection Process in the Outpatient Phlebotomy Area

Log in CHCS

Print &Verify Labels

Patient Collect Sample

Patient Arrive

Met Requirements

?

Yes

Label samples

Patient turn in sample

Give instructions

to patient

Transport toShipping

dept

Ship to reference

lab?

Specimen transport to UA section

Start

YesNo

No

INPUT STEPS OUTPUT

(Adjustable, Specifications?) (Valuable, Measurable?)

BEGIN

END

Log inCHCS

Collect samples

Greet patient with a smile A

Phlebotomist Available

Patient Satisfaction Survey

V,M

Patient Waiting Time V,M

Verbal instruction “script” A

Instruction sheet A

Sterile cups with wipes (not expired)

Who will deliver ? A

Time to deliver (within 1hr) A

Back-up plan when busy A

Patient Identification V

Verification of the printed label

V

Eliminate mislabeled sample

V,M

Patient recall V,M

Repeat Testing

Delivered in a timely manner

V,M

Request for at least 2 IDs (DOB and name)

Labels ; printer

Labeled cups

INPUT PROCESS OUTPUT

(Adjustable, Specs?) (Valuable, Measurable?)

Patientarrive

Transportto lab

IMPROVE CUSTOMER SERVICE IN THE PHLEBOTOMY ROOM

VerifyLabels

Example of Measurable Output CUSTOMER SERVICE

( Patient Satisfaction Survey 2007)

Example of Measurable Output CUSTOMER SERVICE

COMPLAINTS

0

5

10

15

20

25

Access Policy Staff Behavior Quality of Care Misc

1st Q

2nd Q

3rd Q

4th Q

Percent Served <= 15 Minutes (Threshold: 90%)

60%

65%

70%

75%

80%

85%

90%

95%

100%

1 2 3 4 5 6 7 8 9 10 11 12

2006 2007

QUALITY SYSTEM ESSENTIALSASSESSMENTS

PHLEBOTOMY WAITING TIME

QUALITY SYSTEM ESSENTIALSASSESSMENTS

2007 PATIENT RECALL (Threshold: < 1%)

0

500

1000

1500

2000

2500

3000

3500

4000

4500

JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC

0.0%

0.2%

0.4%

0.6%

0.8%

1.0%

1.2%

1.4%

1.6%

1.8%

2.0%

# of patient seen % of pateint recalled

% Urine Contamination

0%

10%

20%

30%

40%

50%

previous current

25%

75%

male

female

16%

84%

male

female

peersYour lab

Example of Measurable OUTPUT

Steps of Process Mapping

• First identify the PROCESS

• Provide OUTPUT variables for each step before the INPUT variables

• OUTPUT : Valuable or measurable

• INPUT: Controllable and enter specifications – P and 5 M (People, Machine, Materials,

Method, Mother Nature, Measure)

Log inCHCS

Collect samples

Greet patient with a smile A

Phlebotomist Available

Patient Satisfaction Survey

V,M

Patient Waiting Time V,M

Verbal instruction “script” A

Instruction sheet A

Sterile cups with wipes (not expired)

Who will deliver ? A

Time to deliver (within 1hr) A

Back-up plan when busy A

Patient Identification V

Verification of the printed label

V

Eliminate mislabeled sample

V,M

Patient recall V,M

Repeat Testing

Delivered in a timely manner

V,M

Request for at least 2 IDs (DOB and name)

Labels ; printer

Labeled cups

INPUT PROCESS OUTPUT

(Adjustable, Specs?) (Valuable, Measurable?)

Patientarrive

Transportto lab

Improve Customer Service In The Phlebotomy Room

VerifyLabels

Finalizing the Process Mapping

• Review the process, by observing or asking the operator

• Are the operators following the process as charted?

• Do you have a consensus?

• Do you need to add or remove steps?

Process Mapping Mistakes•Map is too detailed, too much information and does not emphasize the importance.

Process Mapping Mistakes

• Process is not focused on your main goal i.e. create value for your customer (customer satisfaction)

• Map the process without showing how the results will be measured

QUESTIONS