Application of process mapping to understand integration of high risk medicine care bundles within community pharmacy practice

Optimizing process flow diagrams to guide implementation of a colorectal cancer screening intervention in new settings

PURPOSE

The goal of this study was to assess acceptability of using process flow diagrams (or process maps) depicting a previously implemented evidence-based intervention (EBI) to inform the implementation of similar interventions in new settings.

METHODS

We developed three different versions of process maps, each visualizing the implementation of the same multicomponent colorectal cancer (CRC) screening EBI in community health centers but including varying levels of detail about how it was implemented. Interviews with community health professionals and practitioners at other sites not affiliated with this intervention were conducted. We assessed their preferences related to the map designs, their potential utility for guiding EBI implementation, and the feasibility of implementing a similar intervention in their local setting given the information available in the process maps.

RESULTS

Eleven community health representatives were interviewed. Participants were able to understand how the intervention was implemented and engage in discussions around the feasibility of implementing this type of complex intervention in their local system. Potential uses of the maps for supporting implementation included staff training, role delineation, monitoring and quality control, and adapting the components and implementation activities of the existing intervention.

CONCLUSION

Process maps can potentially support decision-making about the adoption, implementation, and adaptation of existing EBIs in new contexts. Given the complexities involved in deciding whether and how to implement EBIs, these diagrams serve as visual, easily understood tools to inform potential future adopters of the EBI about the activities, resources, and staffing needed for implementation.

Development of a workflow process mapping protocol to inform the implementation of regional patient navigation programs in breast oncology

BACKGROUND

Implementing city-wide patient navigation processes that support patients across the continuum of cancer care is impeded by a lack of standardized tools to integrate workflows and reduce gaps in care. The authors present an actionable workflow process mapping protocol for navigation process planning and improvement based on methods developed for the Translating Research Into Practice study.

METHODS

Key stakeholders at each study site were identified through existing community partnerships, and data on each site's navigation processes were collected using mixed methods through a series of team meetings. The authors used Health Quality Ontario's Quality Improvement Guide, service design principles, and key stakeholder input to map the collected data onto a template structured according to the case-management model.

RESULTS

Data collection and process mapping exercises resulted in a 10-step protocol that includes: 1) workflow mapping procedures to guide data collection on the series of activities performed by health care personnel that comprise a patient's navigation experience, 2) a site survey to assess program characteristics, 3) a semistructured interview guide to assess care coordination workflows, 4) a site-level swim lane workflow process mapping template, and 5) a regional high-level process mapping template to aggregate data from multiple site-level process maps.

CONCLUSIONS

This iterative, participatory approach to data collection and process mapping can be used by improvement teams to streamline care coordination, ultimately improving the design and delivery of an evidence-based navigation model that spans multiple treatment modalities and multiple health systems in a metropolitan area. This protocol is presented as an actionable toolkit so the work may be replicated to support other quality-improvement initiatives and efforts to design truly patient-centered breast cancer treatment experiences.

LAY SUMMARY

Evidence-based patient navigation in breast cancer care requires the integration of services through each phase of cancer treatment. The Translating Research Into Practice study aims to implement patient navigation for patients with breast cancer who are at risk for delays and are seeking care across 6 health systems in Boston, Massachusetts. The authors designed a 10-step protocol outlining procedures and tools that support a systematic assessment for health systems that want to implement breast cancer patient navigation services for patients who are at risk for treatment delays.

Process mapping in healthcare: a systematic review

INTRODUCTION

Process mapping (PM) supports better understanding of complex systems and adaptation of improvement interventions to their local context. However, there is little research on its use in healthcare. This study (i) proposes a conceptual framework outlining quality criteria to guide the effective implementation, evaluation and reporting of PM in healthcare; (ii) reviews published PM cases to identify context and quality of PM application, and the reported benefits of using PM in healthcare.

METHODS

We developed the conceptual framework by reviewing methodological guidance on PM and empirical literature on its use in healthcare improvement interventions. We conducted a systematic review of empirical literature using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) methodology. Inclusion criteria were: full text empirical study; describing the process through which PM has been applied in a healthcare setting; published in English. Databases searched are: Medline, Embase, HMIC-Health Management Information Consortium, CINAHL-Cumulative Index to Nursing and Allied Health Literature, Scopus. Two independent reviewers extracted and analysed data. Each manuscript underwent line by line coding. The conceptual framework was used to evaluate adherence of empirical studies to the identified PM quality criteria. Context in which PM is used and benefits of using PM were coded using an inductive thematic analysis approach.

RESULTS

The framework outlines quality criteria for each PM phase: (i) preparation, planning and process identification, (ii) data and information gathering, (iii) process map generation, (iv) analysis, (v) taking it forward. PM is used in a variety of settings and approaches to improvement. None of the reviewed studies (N = 105) met all ten quality criteria; 7% were compliant with 8/10 or 9/10 criteria. 45% of studies reported that PM was generated through multi-professional meetings and 15% reported patient involvement. Studies highlighted the value of PM in navigating the complexity characterising healthcare improvement interventions.

CONCLUSION

The full potential of PM is inhibited by variance in reporting and poor adherence to underpinning principles. Greater rigour in the application of the method is required. We encourage the use and further development of the proposed framework to support training, application and reporting of PM.

TRIAL REGISTRATION

Prospero ID: CRD42017082140.

A literature review of human factors and ergonomics within the pharmacy dispensing process

BACKGROUND

Within healthcare, Human Factors explores the fit between people and their working environment to improve safety, performance and wellbeing. The pharmacy setting is an area of particular interest considering the high-risk nature of the work activities in relation to dispensing errors. Internationally, the pharmacy setting is experiencing significant workforce changes, including the introduction of pharmacy technicians performing accuracy checks, and the adoption of novel technologies such as automated dispensing.

OBJECTIVE

A literature review was conducted to identify studies which have explored the pharmacy dispensing process from a Human Factors perspective.

METHODS

The databases Medline, EMBASE and PsycINFO were searched on the 27th of November 2018. All study designs were eligible for inclusion from community and hospital settings. Key study findings were extracted and reported using a descriptive narrative synthesis method.

RESULTS

Thirty-two studies were identified, with most published from 2010 onwards. The review identified that a myriad of aspects influence safety within the dispensing process; that the dispensing process is complex in nature and can be depicted in many different ways; and lastly, that deviations from intended practice appear commonplace. Most studies used two or more data collection sources, and various theories, models and frameworks were applied. Although the focus of all studies was within the wider domain of Human Factors, 14 studies did not explicitly refer to a Human Factors approach within the manuscript.

CONCLUSIONS

The complexity of the pharmacy dispensing setting suggests that adopting a Human Factors approach to explore this context is appropriate. Future Human Factors research should explore the implementation of new technology and services and focus on obtaining empirical evidence that adopting a Human Factors approach improves safety and/or efficiency within pharmacy practice. Clear guidance on how to apply the range of Human Factors approaches would help support such research and facilitate the development of sound theory.