2019 HSR&D/QUERI National Conference

4118 — Process mapping as a tool to inform design and implementation of care coordination interventions in the VA

Lead/Presenter: Marina McCreight,  COIN - Seattle/Denver
All Authors: McCreight MS (COIN-Seattle/Denver), Kelley LR (COIN - Seattle/Denver), Ayele R (COIN - Seattle/Denver) Leonard CA (COIN - Seattle/Denver) Gilmartin HM (COIN - Seattle/Denver) Battaglia CT (COIN - Seattle/Denver)

Process mapping is a component of Lean Six Sigma (LSS) process improvement approach and offers a method to assess current processes in complex systems, identify process gaps and inefficiencies, and facilitate process improvement. Two programs aimed to improve care coordination were funded for expansion in the Veterans Health Administration (VA): Community Hospital Transitions program (CHTP) to facilitate care coordination between VA primary care (PC) teams and community hospitals; and Rural Transitions Nurse program (TNP), to facilitate care coordination for rural Veterans between urban VA Medical Centers (VAMC) and rural PC clinics. Our objective was to test process mapping as a tool to assess pre-implementation care coordination processes, engage staff, and determine how to best design and implement health interventions.

We conducted observational qualitative study guided by Lean Six Sigma approach. Process data were collected through interviews, direct observations, and group sessions with front-line clinical and administrative staff from VAMCs, rural PC teams, community hospitals, and Veterans. Team-based iterative and reflexive analyses of the qualitative data was conducted, and process maps were designed using Microsoft Visio.

We conducted 6 site visits with over 23 hours of observations, 102 key informant interviews, and 13 group sessions; collected data was integrated to create eleven process maps. In CHTP we identified delayed notification of a Veteran hospitalization in a community hospital and delayed receipt of medical records as inefficiencies; we included these in the design of the CHTP intervention components. In TNP we identified potential role duplication and provided recommendations to the sites for the intervention tailoring and initial roll-out.

Process mapping provided insights about the processes for the design and implementation of care coordination interventions. The process mapping activities were useful in engaging the local staff and simultaneously guided design and adaptations of the interventions to meet local needs. Our approach - combining multiple data sources while adapting Lean Six Sigma principles into practical use - may be generalizable to other care coordination programs.

Process mapping can be a valuable and practical approach to accurately assess site processes before implementation of care coordination programs in complex systems.