DDHA 8203 Week 2 Process Map Example

The Written Procedure and the Chair Turn That Actually Runs: A Two-Path Process Map of One Infusion Suite, With Six Points Where the Paths Part

Student Name

Walden University

DDHA 8203: Advanced Healthcare Operations Management

Instructor Name

Month Day, Year

The Written Procedure and the Chair Turn That Actually Runs: A Two-Path Process Map of One Infusion Suite, With Six Points Where the Paths Part

Purpose and Scope of the Map

This map follows one unit of work in a composite outpatient infusion suite, the twelve-chair center at a community cancer program I will call Larkspur Oncology. The unit of work is a single chair turn, which begins when a patient is seated and ends when the chair is clean and released for the next booking. I chose the chair turn instead of the patient's whole day because the chair is what the suite schedules, sells and runs short of, and because every delay in the suite eventually appears as a chair that is occupied without anything happening in it.

The map draws two paths together. The documented path comes from the suite's written procedure for standard infusions, revised eighteen months ago. The observed path comes from watching the suite on three weekday mornings, from 7:30 to 12:30, during which I followed 42 chair turns from seating to release. Trebble et al. (2010) recommend that a map of a patient journey be built by walking the process and talking to the people who do the work, rather than by drafting it from documents, and that advice shaped the method. The written procedure was used only as the comparison line.

How the Map Was Built

I recorded each turn on a timing sheet with eleven columns, one for each event the written procedure names, and a free-text column for anything that happened outside those events. Times were taken from the wall clock to the nearest minute. Where a step did not occur in the documented order, I wrote down the order in which it actually occurred. After each morning I showed the sheets to the charge nurse, who corrected two entries on the first day and none afterward. Antonacci et al. (2018), reviewing process mapping in quality improvement projects, found that published maps often gave little account of how the information behind them was collected, which makes them hard to trust. For that reason the sheet, the window and the corrections are reported here with the map rather than left out.

Two rules governed what went into the notes. First, what I watched and what staff told me were kept in separate clauses, so a reader can tell a measurement from an explanation. Second, waiting was recorded as a stretch of time with no step attached, instead of being folded into the step that followed it. A map that shows only activity describes a service no patient has experienced, and the purpose of this exercise was to find the intervals in which nothing was happening to the patient or the chair.

The Two Paths

Table 1

Documented and Observed Path for One Chair Turn (Median of 42 Turns)

In the drawing that accompanies the sheet, the documented path is the lighter line and the observed path the heavier one; waiting appears as lengths of line, so the stretch between seating and drug arrival is the longest single segment on the page.

The Six Divergences

The two paths travel together for the first ten minutes and part at the third step. At divergence 1, laboratory results that the procedure assumes are already on file were missing for 15 of the 42 turns, so the nurse drew blood at the chair and the patient waited for the result before treatment could be approved. Staff said that many patients find a separate laboratory visit the day before hard to arrange, especially those who travel more than an hour; I recorded this as a reported reason, not a finding.

Divergence 2 is the largest. The procedure says pharmacy begins mixing when the patient checks in. In practice, pharmacy waited for the nurse's ready-to-treat call, and the median time from seating to the drug's arrival at the chair was 61 minutes against a documented 25. The pharmacist on duty said the change began after several expensive doses were mixed for patients who were later held for low counts, and the drug was wasted. That explanation is plausible and also unverified by me, so it appears in the note as what staff said.

Divergence 3 sits at the second-nurse verification. The procedure assumes another nurse is available at the chair when the drug arrives. On the mornings observed, the median wait for a free nurse was six minutes, with the longest waits at 9:30, when four chairs reached this step within a quarter of an hour.

Divergence 4 concerns premedication timing. The procedure calls for premedication thirty minutes before the infusion starts. Because the drug's arrival time was unpredictable, nurses gave premedication when it came up from pharmacy, often within ten minutes of the start. The map records this as a timing divergence and makes no clinical judgment about it, which belongs to the pharmacy and therapeutics committee rather than to an operations analysis.

Divergence 5 is an addition to the procedure rather than a delay inside it. Thirty minutes of observation after the infusion is required only after a first dose. Some nurses applied it to repeat-dose patients as well, 19 of the 30 repeat-dose turns I watched. Staff said this followed a reaction in a repeat-dose patient the previous winter. Whatever its merit, it adds half an hour of chair time to most turns, and it is not written anywhere.

Divergence 6 is at the end. The procedure says environmental services cleans the chair on a page. In practice the page went out when the nurse remembered to send it, and a used chair sat for a median of 14 minutes before anyone cleaned it.

What the Map Shows When Read as a Whole

Read together, the divergences show a suite whose chairs are occupied far longer than they are in use. Of the median chair turn I observed, the patient spent roughly an hour and a half waiting for laboratory results, for the drug, for a nurse or for the observation period to end, and the chair spent another quarter hour used but not ready. None of these waits appears in the written procedure, so a manager who planned capacity from the procedure would conclude that the suite has more chair time than it does.

The map also shows that several divergences are linked. Divergence 2 exists partly because of divergence 1: pharmacy will not mix early because it cannot be sure the patient will be treated, and it cannot be sure because results are missing. Kim et al. (2006), describing the application of production principles in a hospital, emphasize seeing the whole flow of a service rather than optimizing departments one at a time. In this suite, a fix to pharmacy alone would likely fail, because the information pharmacy needs arrives late for reasons outside pharmacy.

Limits of the Map

Three mornings and 42 turns are a small sample, and afternoons, when the suite runs longer infusions, may look different. One observer, who was also visible to staff, may have changed behavior during the window. The timing sheet relies on a wall clock and on my own attention, and short events may have been missed. These limits do not change the direction of the findings but do make the medians approximate, and the map states them in its legend so that the next reader does not treat them as precise.

Conclusion

The documented path describes a chair turn of about two hours for a standard infusion. The observed path describes one closer to three and a half hours, and the difference sits almost entirely in six places where the work leaves its written procedure. The two most consequential divergences, laboratory results drawn at the chair and pharmacy mixing on the nurse's call, are linked and should be addressed together. The next step is to share the map with the nurses and pharmacists whose work it records, invite them to correct it, and then decide which of the six divergences the suite intends to remove and which it intends to write into the procedure.

References

Antonacci, G., Reed, J. E., Lennox, L., & Barlow, J. (2018). The use of process mapping in healthcare quality improvement projects. Health Services Management Research, 31(2), 74-84. https://doi.org/10.1177/0951484818770411

Kim, C. S., Spahlinger, D. A., Kin, J. M., & Billi, J. E. (2006). Lean health care: What can hospitals learn from a world-class automaker? Journal of Hospital Medicine, 1(3), 191-199. https://doi.org/10.1002/jhm.68

Trebble, T. M., Hansi, N., Hydes, T., Smith, M. A., & Baker, M. (2010). Process mapping the patient journey: An introduction. BMJ, 341, Article c4078. https://doi.org/10.1136/bmj.c4078