EXAMPLE: ANALYSING VULNERABLE PROCESSES IN NEW ORTHOPAEDIC PATIENT (NOP) TREATMENT

Process maps are used in hospitals to describe various processes in place, identify resources required and potential blockages. Although this artefact was useful in mapping out the activities, it was incomplete in several places; hence our fieldwork reports based on our ethnographic observations were most valuable for filling in the missing information.

The category of ‘New Orthopaedic Patient’ (NOP) includes all new orthopaedic cases referred to the hospital via a letter from the patient’s GP. The process map for the NOP patients covers the following stages in referral and treatment:

• GP referral letter received in Data Management Section;

• patients details registered on Patient Administration System (PAS)

• appointments prioritised and booked via consultant’s secretary

• attendance at consultant clinic at pre-arranged time

• necessary tests e.g. X-ray

• arrangements for follow-up appointments.

We will now look at some of above stages and identify ‘essential’ activities, key personnel involved and potential weaknesses in the processes. We will ask specific questions which will enable us to assess where things can go wrong and highlight processes that are vulnerable to failure. We will also look at the role that placeholders play as a means of recovery in case of failures, thus facilitating process completion. Although we were not explicitly looking for the 4Rs patterns (Request, Receipt Response, Response), we did see them emerge; hence we have kept them in the activity mapping diagrams.

Scenario 1: GP referral letter processed by Data Management Section

The GP’s referral letter for a new patient first reaches the Data Management section of the hospital where it gets processed as shown by the activities in figure 1.

Figure 1: activity mapping showing processes in Data Management Section

The potential failures that may arise in the above scenario are:

Between the Request and the Receipt of an activity (1) we may question the reliability of the messaging system, especially when person is not physically involved in the delivery process. So for example, is the communication medium timely, how long would it take for the letter to reach to the right destination, etc? Given that the communication medium in use here is the postal system we will assume that is reliable.

Moving on the next activity (2) where the clerical staff enters the patient’s record on the Patient Administration System (PAS), we can ask: what happens if for some reason this record does not get entered on PAS? Will it get noticed internally, i.e. is there a placeholder somewhere, for instance a tick box on the letter after entering the record which may be picked up at some stage? Or is the record on PAS itself acting as the placeholder? If that is the case, then what happens when PAS stops working? Otherwise, if there is no further interaction with PAS, does the patient information get recorded anywhere else?

After sorting the referral letters as either routine or an urgent (3), there is the danger that the letter may be placed in the wrong wallet. Although this is more of a functional failure we can ask: when does this get noticed?

Despite the above potential failure points, most of the processes in this scenario are relatively secure because the referral letter is acting as an important physical placeholder. A failure in the Data Management Section may block the whole process, but the activities are merely passing through that department, so any error is likely to be picked up at some stage. We can look for additional placeholders somewhere else, in this case PAS could also send out notifications which allow recovery in case of failures.

Scenario 2: Referral letter given to consultant for assessment via secretary.

This scenario will run through the processes that take place when referral letters from the Data Management Section reaches the consultant’s office (see figure 2).

As the process maps do not specify who actually distributes the referral letters to the consultant’s secretary (5), we will assume it is either the ‘porter’ or the ‘clerical staff’. Furthermore, in order to formulate the 4Rs pattern, we have created the ‘Receipt’ activity ‘consultant secretary receives referral letters’ and in so doing, we have created a physical placeholder, namely the referral letter which the secretary may perhaps keep on her desk.

At (6) there is a branching in the activities which denotes information requirements; therefore different things should happen depending on whether the consultant is available or not. However, the activity mapping diagram clearly shows that there are no processes specified when the consultant is unavailable. So we can question who is responsible for making the decision regarding the course of action to follow when the consultant is not available - how reliable is the decision taken, how reliable is the information and where does the information come from?

Figure 2 activity mapping showing assessment processes by Consultant’s office

We can also question: who keeps the placeholder - the consultant or the secretary? If the placeholder stays solely with the consultant, then recovery may be difficult, when for example, the consultant is ill. Similarly, recovery may be difficult if the placeholder stays only with the secretary. But if it is more a case of the secretary waiting until the consultant is in the office to discuss referrals then it will be easier to recover when failures occur.

Concluding remarks

The above scenarios show how activity mapping can clearly represent activities at different stages, identify key personnel and processes. We can analyse the processes by asking specific questions about them in order to assess potential weaknesses and possible recovery.

There are three main types of failures that can arise: (a) functional failure, when we do the wrong thing, (b) temporal failure, when we have missed doing things as a result of being interrupted and (c) sequencing failure, when there is a wrong order of activities.

Activity mapping can assist us in uncovering three levels of failures:

(a) We can look at each individual’s role and question the consequences when things are done incorrectly. For instance, if an activity is merely passing through various individuals and eventually returns back to the original person, any failure that arises will be easily noticeable and recovery will be fairly straightforward.

(b) We can look at how the activities are modelled as a whole and ask if there are points of recovery, i.e. presence of placeholders, in case of failures.

(c) Finally, we can assess the effects of interference outside the activity, i.e. question how well do the activities fit with the external world, whether placeholders are unique or do they interfere with other placeholders.