In this lecture, you will learn about another tool that is frequently used in quality improvement initiatives, process mapping. Process mapping provides a structured means of understanding what is happening in a particular part of a healthcare system. When working in complex systems, this can be very important. It can both help us to understand what is actually happening and support decision-making around what changes need to be made to improve a system. Before I introduce process mapping, let's take a look at what we mean by the terms 'system and complex system'. W Edwards Deming gave the following definition: "A system is a network of interdependent components that work together to try to accomplish the aim of the system." In the case of health systems, the components include; organizations, departments, teams, and individuals. The aim, according to the World Health Organization, is to promote, restore or maintain health of the population. Unlike say a computer system, health systems are focused on people and people have agency. They are autonomous, opinionated, and modify their behavior in an effort to improve outcomes relative to their own perspectives and objectives. The different organizations, teams, and resources in a healthcare system affect each other, they are interconnected. Healthcare systems are dynamic, they're constantly changing in both planned and unplanned ways. These characteristics are what define a complex system. Such systems often behave in unpredictable ways so that we cannot predict the outcome of an intervention fully in advance. Seeming the obvious solutions can have minimal impact on outcomes, while small changes can have large unanticipated consequences. We can think of healthcare systems as operating across multiple different levels. The macro-level comprises national health systems, acknowledging international influences, policy, regulation and government. The MESO level encompasses regional and organizational bodies, including, for example, hospitals, primary care networks, and community services. The micro-level comprises the interactions of individuals, often within a team or a specific service. For example, a GP practice or a hospital ward would be examples of micro-systems. A process is defined to be a series of actions or steps towards achieving a particular end. In common with many quality improvement efforts, both the Michigan Keystone and the Maya Health Alliance Obstetric Care Navigation initiatives attempt to improve the process of care. In quality improvement, processes are important because most healthcare failures happen due to problems with systems and processes, rather than individual human error. It is important to recognize that in complex systems, processes frequently do not behave as intended. People do what they think is best in their situation. In a micro-system, one or many processes of care take place as patients, members of the public and healthcare workers together act to deliver health outcomes. Whilst a detailed understanding of the processes of care at even an organizational level would be infeasibly complex, at a micro-system level, this understanding is often possible and necessary to make improvements. This is where process mapping comes in. A process map is a visual representation of a healthcare process showing the start and end points of the process, the activities that are undertaken as part of the process and any branch points where the process splits. Successive activities and branch points are joined by arrows, showing the order in which they occur. Often, no single person knows every detail of a healthcare process. Process mapping is a good way to capture valuable insights from multiple different perspectives and to engage stakeholders. Getting a good understanding of key processes before designing and implementing improvement interventions can help to avoid problems stemming from incorrect assumptions about how a process is functioning. In focusing on this topic, you have seen how even in complex systems, we can capture and understand what is happening at the micro level using process mapping. In the connected video, the Imperial College Healthcare Trust Quality Improvement Team will take you through an example of using process mapping in practice as part of a quality improvement initiative.
