To respond to the needs of a changing environment, where customers ask each supplier, and their competitors, for new solutions with characteristics derived from technological innovations; it is necessary to change the operating methods in companies, that is, their processes. It is no longer thought that processes can be designed with an ideal structure, which remains unchanged over the years.
On the contrary, these processes are constantly subject to revisions, since like any process, they can be improved. There is always some detail, some sequence, that increases its performance in aspects such as productivity of operations or reduction of defects.
As a basis for improvement, the use of process maps is extended, allowing the visualization and appreciation of the interrelationships between processes, threads and activities to perfect the results that customers want. A widely used approach to process mapping is the As-Is diagram (as is) that allows for greater visibility and understanding.
Health institutions also strive to incorporate this and other management tools and models from the industrial world and try to generalize the review of processes as a systematic, routine practice and an integral part of medical culture.
The present work provides an example on the construction of As-Is diagrams and the documentation that complement them in a key process of a Hospital of the territory, a hospital institution that is in a process of Hospital Improvement. The information obtained from the diagrams allows the value analysis of each of the activities that make up the process, for subsequent improvement.
Introduction
To achieve easy visualization of processes and sub-processes, companies today use the representation of processes from diagrams that allow preliminary information on their breadth, timing and activities.
The graphic representation facilitates the analysis, and the decomposition of the processes into activities; as well as the distinction between those that provide added value from those that do not, that is, they do not directly provide anything to interest groups or the desired result.
Within this context, the process maps are the basis for better management and focus on meeting customer expectations to the maximum, managing the activities and tasks of the processes, eliminating those that do not add value (…) and seeking to incorporate opportunities for improvement ”.
Even though the ISO standards do not explicitly exist, the requirement to specifically develop a process map, has become a generalized practice by certified companies or in the process of certification that, according to the provisions of the general requirements of section 4.1 of ISO 9001: 00, establishes that the organization must identify the processes necessary for the quality management system and its application through the organization and determination of the sequence and interaction of these processes.
In short, the maps that represent processes are very useful for:
Know how the work is carried out.
Analyze the process steps to reduce the cycle time or increase quality.
Use the current process as a starting point to carry out process improvement projects.
Orient new employees.
Develop alternative ways of doing work at critical moments.
Evaluate, establish or strengthen the indicators or measures of results.
As Is diagrams. Their usefulness for process improvement
There are different process maps, depending on their attributes and objectives. Among these various representation techniques are As-Is diagrams that are used to record how the current process actually operates, through the graphic representation of the workflow or information, which provides better visibility and allows the analysis of each activity..
According to Trischler (1998), in order to increase the competitiveness of companies, two fundamental approaches are currently being carried out: the process-based management approach and the elimination of waste derived from said processes when they do not contribute value added.
This analysis of the added value in the processes is carried out by decomposing into steps or stages, which are represented from the so-called As-Is diagrams (as is) and, subsequently, a study is carried out at each stage where They locate the activities that do not provide added value to consider their possible elimination or improvement.
As Is diagrams have gained popularity in today's business world for their ability to detail the activities that occur in a process, and are practically a requirement in most methods for process improvement.
In the health activity, the use of As Is maps and diagrams has also been incorporated, verifying that Process Management can be a working instrument of successful and beneficial application to improve healthcare activity, because it allows to identify, understand and stabilize the processes, from detecting opportunities for improvement; This is achieved by analyzing the activities and their contribution of value.
Experiences in this field are increasing, especially in European countries where the applicability of Process Management and its possibility of guiding healthcare organizations to the client is recognized.
In Cuba, the need for the treatment of processes to reach an improvement in their operation is becoming increasingly evident. One of the sectors that has benefited the most in this regard has been Tourism, where a group of investigations has been carried out aimed at managing and improving hotel organizations based on the identification, selection and analysis of processes and their added value, assisted by the use of process maps and As-Is diagrams.
Within the service sector, the hospital activity seeks changes in its management, since the need to rationally use resources as a concessionality of increasingly efficient processes is evident.
That is why the National Health System (SNS) decides to reinforce the management improvement program and the accreditation program, eliminate surgical waiting lists, decrease hospital stay, reduce, at least by 10%, hospital beds that are idle., increase income in foreign currency for different concepts, and increase the satisfaction of the population with the health system.
Consequently, in 2001 the claims to increase the efficiency and quality of services increase and, likewise, to guarantee the sustainability of the system.
Within this context, and facing the new business practices that are combined in the national framework (such is the case of Business Improvement), the hospital activity seeks new models adapted to its characteristics to achieve a contribution to the improvement of the organization.
Hospital Improvement is a management model that aims to ensure that hospital services are excellent, that is, that they have high quality, acceptable costs, and are oriented to satisfy the needs of clients.
Stresses that, for an organization to develop, it is necessary that its services are competitive, and that this requires not only the increase in quality and timely customer service, but also the optimization of the use of resources and reducing costs, so it is essential to study the processes or activities that allow the optimal use of material resources and human capital, while increasing their result.
Case: Hospital Diagnostic Means process
As a contribution to this improvement process, the Hospital under study carries out the application of a process management and improvement procedure that begins with the identification of processes, their classification and determination of those key to the organization, to start the improvement on them and then extend it to the rest.
The processes identified as key were: Quality Management, Hospitalization and Diagnostic Means.
The hospitalization process is the heart of the hospital, and is considered the one with the greatest impact on the strategic objectives of the organization and, of course, on clients. As Quality Management, as it is considered a process of great relationship with the rest of the processes, it has a major impact on customers. Diagnostic Means is also vital because other processes depend on its activity, mainly Hospitalization; its operation has been somewhat unstable, so it was evaluated as critical. The treatment carried out in the Diagnostic Means process is explained below.
Once this process was selected, the work team was set up consisting of the specialists, who carry out the different activities, and the department heads.
For the description of the process under study, the process sheet was prepared (Figure 1), where information such as: related sub-processes, limits, interest groups, related activities, indicators, etc. was included.
After the preparation of a general file for the process, the main sub-processes were determined and, in the same way, a file was prepared for each sub-process. In this case, the main threads were: Pathology, Clinical Laboratory and Hemotherapy, Microbiology and Imaginology.
| Responsible: Head of the Diagnostic Media Department | Process Type: Operational |
| Purpose of the Process: To guarantee the completion of the complementary examinations that the patient needs with the required quality. | |
| Objective: To guarantee the organization of x-rays, clinical laboratory analysis, biopsies, necropsies, blood draws and transfusions in a suitable time, both for hospitalized patients, as well as for patients from outpatient consultations or on-call staff. Ensuring quality and control. | |
| Suppliers: Medical supplies, central sterilization, energy carriers, air conditioning, Department of general services, national laboratories, national and provincial electromedicine. | |
| Clients: Patients coming from hospitalization, outpatient consultation, urgent and emergency care. | |
| Inputs: Order, sample, reagents, patients, laboratory technicians. | |
| Outputs: Reports and orders with results. | |
| Stakeholders: employees, suppliers, medical students and middle technicians. | |
| Contents Start of the Process: Receive the patient and / or the order by the secretary. | |
| End of the process: Statistically process the results. | |
| Threads: biopsy, necropsy, cytology, x-rays, ultrasound, microbiology, clinical laboratory, hemotherapy. | |
| Activities included: Receive the analysis order, take the sample and receive it, analyze the sample, record the results on record and in the order, send the order to file, statistically process the results, transfuse the patient. | |
| Indicators: Average time for diagnosis.
Lost results index. Pathological clinical correlation index. Positivity index. |
|
| Related processes: Hospitalization, External consultation, Urgent and emergency care, Human capital management, Quality management, Knowledge management. | |
| Related activity: Provision of fresh pieces and clinical-pathological activities, quality control and analysis. |
Related activity: Provision of fresh pieces and clinical-pathological activities, quality control and analysis.
Figure 1. Process tab: Diagnostic means
Preparation of As-Is diagrams (as is)
The process diagram "as is" is the image that best represents the process through its stages, and therefore represents the basis for its documentation and analysis.
Trishler's proposal was taken as the basis for defining the activities.
To begin with, the verb in the infinitive is used to facilitate the work when preparing the dictionary of activities. Then the object of the action is placed and finally the resource, that is, who performs the action (subject).
To make the As Is diagrams, the work team with the task performers relate all the activities carried out in the process in question, this procedure requires the cooperation of all those who in one way or another are involved with it and Each diagram should undergo a thorough review to ensure that the actions depicted are the ones actually carried out.
In this way, the As-Is diagrams of the Diagnostic Means process and its threads are formed. These diagrams allow the analysis of each of the activities to detect opportunities for improvement. The example (Figure 2) shows the diagram of the Biopsy thread:
Figure 2. As-Is Diagram of the Diagnostic Means Process, Biopsy subprocess
From the elaboration of these diagrams, the value analysis was carried out based on the following elements: strategic objectives of the organization related to the process, interest groups, quality characteristics defined by the patient, and moment of truth These elements and the value contribution by activities are listed in Table 1.
For a total of 14 possibilities of relationships, if they are all strong and are evaluated from 5 points on the scale of 1 to 5, the total per activity will be 70 (maximum possible score), if all are average, a total of 42 will be obtained (average score) and if they are all weak, a total of 14 would be obtained (low score), so the following ranges of added value are established:
- 0. does not add value1-14. Weak value added (VAD) 15-42. Average added value (VAM) 43-70. Strong added value (VAF)
| Activities | goals | Groups of
interest |
Charac teristics quality | Real moments | Total | ||||||||||
| one | two | 3 | one | two | 3 | 4 | 5 | one | two | 3 | 4 | 5 | |||
| To receive | one | one | one | 5 | 8 | ||||||||||
| Guide | 3 | 3 | 3 | one | 5 | fifteen | |||||||||
| Enroll | one | one | one | 5 | 8 | ||||||||||
| Give | one | one | one | 3 | one | 5 | 5 | 17 | |||||||
| Perform | 5 | 5 | 5 | 5 | 3 | 5 | 3 | 5 | 5 | 5 | 3 | 5 | 54 | ||
| Bring | one | one | 3 | 5 | |||||||||||
| Portray | 3 | 3 | 3 | 3 | 3 | one | one | 3 | 3 | 2. 3 | |||||
| Process | 3 | 3 | 6 | ||||||||||||
| Deliver | one | one | 5 | 5 | 5 | 16 | |||||||||
| To show | 3 | 3 | one | 5 | 3 | fifteen | |||||||||
| Fire | one | one | 5 | 7 | |||||||||||
| Dry off | 3 | 3 | 3 | 3 | one | one | 3 | 5 | 5 | one | 3 | 31 | |||
| Order | one | one | one | one | one | one | one | one | one | 3 | 12 | ||||
| Make | 3 | 3 | 3 | 3 | 3 | fifteen | |||||||||
| To diagnose | 5 | 5 | 5 | 5 | one | 5 | 3 | 3 | 5 | 5 | 3 | 5 | fifty | ||
| check | one | one | 3 | 5 | |||||||||||
| Control | one | one | one | one | one | one | one | one | one | 9 | |||||
| file | one | one | two |
Table 1 summarizes the activities that add value in the different ranges, according to the variables evaluated. Table 1. Analysis of the added value for the Diagnostic Means process.
| Strategic objectives | Quality features | Interest groups | Activities that add value (%) |
|
1. Quick attention and results.2. Good technician (right-handed, skillful, experienced, etc.)
3. Good deal. 4. Hygiene and comfort of the facilities. 5. Reliable results. |
1. Patients and relatives.2. Employees
3.Suppliers. 4.Medical students 5. Average technicians. |
50% weak value, 39% average value.
11% strong value. |
Table 2. Contribution of value of activities of the Diagnostic Means process
This analysis denotes the existence of a considerable percentage of activities that contribute little value, compared to those of high value. That is why the improvement must be aimed at eliminating or reducing the effect of the former, through the optimization of the resources they consume; but also enhance the effect of those that provide medium and high values.
In the specific case: the activities to process and archive, with a low added value, cannot be eliminated, but can be optimized in time and cost; One way could be the introduction of a computerized data storage system. Likewise, the closing activity (the medical records of the deceased) cannot be stopped for obvious reasons of organization and control, but it will be necessary to do it in the shortest possible time. In the same way, it can be done in the cases of: verifying, registering, carrying or enabling.
Likewise, it is important to optimize activities such as: capturing, diagnosing, drying, observing, identifying, and other activities necessary for the result of the analysis. For this, the use of both human resources (that the staff is up to the activity they carry out) and materials (managing the necessary materials to achieve the execution of the activities with greater efficiency and effectiveness), destined for the realization, can be promoted. of homework.
This analysis generated several potential solutions: introduction of inspection and control points as close as possible to the activities where errors are made, to detect deviations in advance and take corrective actions, assigning personnel to those activities that have exhibited difficulties due to personnel deficits. specialized or setting indicators in different processes.
Conclusions
The representation and description of the processes, from the use of As-Is diagrams, accompanied by information and documentation, collected in the process sheets, is the prelude to improvement in design and operation.
By decomposing the processes, in their activities and stages, the activities that do not add value can be located to consider their possible elimination or improvement, as well as detect failures, errors, waste and other deviations that lead to the optimization of those that contribute.
In this context, the Cuban hospital activity seeks the incorporation of this and other tools, adapted to their characteristics and conditions, to contribute to the improvement of the organization.
Bibliography
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Available at:
Mora Martínez et al., (2002), SESCAM (2002), Website: http://www.jormazabal.com/Procesos/Guia/Introduccion.pdf
Marrero Latorre (2003), Pérez García (2003), Alés Fundora (2003), Curbelo Dévora (2004)
For further study, consult the works of Ramos Alfonso (2005) and Parejo Cárdenas (2005)
The strategic objectives were defined in the Strategic Planning exercise (Improvement File, 2005). The groups of interest were determined from the Trishler reference (1998) and with the particularization in the hospital activity studied. To define the quality characteristics, patient / client interviews were conducted and passive methods were also used. Meanwhile, the moments of truth are the moments in which the client comes into direct contact with the system that offers the service. These elements are discussed in Ramos Alfonso (2005).
In this case, an analysis of the competencies for each process could be carried out, so that the personnel dedicated to the activity in question respond to the demands and requirements necessary to achieve the desired results. See Parra Ferié (2005)
