NIHR King's Patient Safety and Service Quality Research Centre, King's College London, Strand Bridge House, 138-142 Strand, London WC2R 1HH, UK.
BMC Health Serv Res. 2010 Jan 7;10:7. doi: 10.1186/1472-6963-10-7.
Many quality and safety improvement methods in healthcare rely on a complete and accurate map of the process. Process mapping in healthcare is often achieved using a sequential flow diagram, but there is little guidance available in the literature about the most effective type of process map to use. Moreover there is evidence that the organisation of information in an external representation affects reasoning and decision making. This exploratory study examined whether the type of process map - sequential or hierarchical - affects healthcare practitioners' judgments.
A sequential and a hierarchical process map of a community-based anti coagulation clinic were produced based on data obtained from interviews, talk-throughs, attendance at a training session and examination of protocols and policies. Clinic practitioners were asked to specify the parts of the process that they judged to contain quality and safety concerns. The process maps were then shown to them in counter-balanced order and they were asked to circle on the diagrams the parts of the process where they had the greatest quality and safety concerns. A structured interview was then conducted, in which they were asked about various aspects of the diagrams.
Quality and safety concerns cited by practitioners differed depending on whether they were or were not looking at a process map, and whether they were looking at a sequential diagram or a hierarchical diagram. More concerns were identified using the hierarchical diagram compared with the sequential diagram and more concerns were identified in relation to clinical work than administrative work. Participants' preference for the sequential or hierarchical diagram depended on the context in which they would be using it. The difficulties of determining the boundaries for the analysis and the granularity required were highlighted.
The results indicated that the layout of a process map does influence perceptions of quality and safety problems in a process. In quality improvement work it is important to carefully consider the type of process map to be used and to consider using more than one map to ensure that different aspects of the process are captured.
许多医疗保健质量和安全改进方法依赖于对过程的完整和准确描述。医疗保健中的流程映射通常使用顺序流程图来实现，但文献中几乎没有关于使用最有效类型的流程映射的指导。此外，有证据表明，外部表示中的信息组织会影响推理和决策。这项探索性研究考察了流程映射的类型（顺序或层次）是否会影响医疗保健从业者的判断。
基于从访谈、对话、参加培训课程以及检查协议和政策中获得的数据，生成了社区抗凝诊所的顺序和层次流程映射。要求诊所从业者指定他们认为包含质量和安全问题的流程部分。然后以平衡的方式向他们展示流程映射，并要求他们在图表上圈出他们认为质量和安全问题最大的流程部分。然后进行了结构化访谈，询问他们有关图表各个方面的问题。
从业者提出的质量和安全问题取决于他们是否正在查看流程映射，以及他们是在查看顺序图还是层次图。与顺序图相比，使用层次图可以识别出更多的问题，并且与行政工作相比，临床工作中会识别出更多的问题。参与者对顺序图或层次图的偏好取决于他们将在何种上下文中使用它。还强调了确定分析边界和所需粒度的困难。
结果表明，流程映射的布局确实会影响对流程中质量和安全问题的看法。在质量改进工作中，重要的是仔细考虑要使用的流程映射类型，并考虑使用多个映射以确保捕获流程的不同方面。
