Implementing Telecare
Redesign operational processes

A ‘process map’ shows clearly the activities and linkages between tasks that people perform to deliver a service. As telecare is introduced this is bound to change the way people perform certain tasks, and unless all the steps in this new process are defined and communicated there will be delay, confusion and waste.

Redesigning processes helps to:

• Ensure that all the steps required to deliver a new service are identified, and their relationships with other processes made clear
• Enable clear basis for discussions with managers in other units about the connections between activities
• Provides a way of looking critically at processes, to see how they can be designed to work more efficiently and smoothly
• Ensure that all staff, especially those in different departments, follow common procedures in delivering a service
• Improve the service provided to users and carers
• Identify what changes in service provision are necessary to offset costs through the use of telecare e.g. sleepover replacement; home care hours; etc. This is essential otherwise telecare will add to the cost of service provision rather than deliver efficiencies in it.

Process re-design guidelines

A process is simply a chain of all the tasks from the start to the end of a service delivery. One process will usually affect others, so these links also need to be identified and specified so that connections are smooth.

A process should be as short as possible (less time) and as narrow as possible (fewer people). In a poor process most of the time is taken up waiting for the next process to start – a sure sign that it involves too many people. It should also be complete, in the sense that it includes earlier and later processes – i.e. it should be “end to end”.

Monitoring is only part of the new activity – the complete process map should also include the processes for deciding on eligibility, referral, assessment of need, installation, response, monitoring and review (of service and the outcomes for users and carers), and possibly others. A complete walk-through of the proposed new process pathway should then take place with the Project Group or other key staff as appropriate to spot any ‘glitches’.

Telecare processes also need to fit other processes such as those for community care assessment, supported housing allocations, management of long term conditions, home safety and service delivery (including potentially children’s services) generally. So consideration has to be given to possible impacts and links within the process plan, and consultation undertaken.

A quick guide to process mapping (courtesy of CSIP)

Process mapping is a technique that is used to help teams to understand how whole services work in order to identify where to start making improvements that will have the biggest impact for people who use their services.

It focuses on mapping a person’s journey through the system, identifying the exact steps that are taken, problems that arise, and the time taken to complete each step as well as the duration of each step. You may wish to document the feelings of the person that uses the system at each step. This will enable the team to see the system through the eyes of the people that use them.

Why is it used?

This technique enables teams to clearly identity and understand how the whole system works. It identifies gaps and overlaps in services, problems to tackle, and ways of making improvements, defining the service improvement work to be undertaken. It enables good practice to be identified. It provides a view of the whole system supporting a holistic view rather than reacting to problems as they arise.

Most importantly, it focuses on the person that uses the services, ensuring that the improvements that are made will benefit the people that use them, not ones that will be perceived to be of benefit.

When to use it?

The process mapping exercise should be used at the start of service improvement projects. It is also a tool that is often used alongside the ‘Model for Improvement’ and the Plan, Do, Study, Act cycle.

Who to use it with?

It should be used with ideally teams of five or more and representatives of everyone involved in services including the person that uses the services, the people that support them, service staff and service managers.

How to use it?

A process-mapping event should be run in order to carry out the exercise effectively.

Before the event

1. Identify the group of people that would most benefit by the redesign, considering groups: a.who have common characteristics. b.who appear in a relatively high volume. c.whose appearance is highly predictable. d.whose care could be standardised based on good evidence. e.whose care could be relatively fast if all the waits and delays in the system were taken out. f.whose care could be mainly pre-scheduled
2. Define the objectives, scope and focus of the process mapping session.
3. Meet with clinical, managerial and service leaders beforehand.
4. Identify the staff groups that are involved in the relevant stage of the process, inviting 15-25 representatives to map the journey, including people that use the services and the people that support them. 
5. .Obtain an independent facilitator if possible, to allow everyone in the team to participate fully in the exercise, also allowing for someone outside of the team to ask the more challenging questions without fear of breaking down relationships.
6. Ensure that you purchase the necessary resources: roll of brown paper, post it notes, pens and sticky tape.

At the event

Agree some ground rules with the group in order to encourage everyone to participate fully such as:

• Things are confidential if people ask them to be
• Everyone’s contribution is important
• Be prepared to take some risks
• Listen to what others have to say
• Nothing anyone says is ‘stupid’
• We’re not here to blame
• Focus on ‘doing’ and making things better for people that use services
• Share responsibility
• Think creatively and positively

When mapping the journey:

1. Define and agree the group of people to be mapped
2. Decide on the level e.g. you may do a high level map, then a medium level
3. Define and agree the scope (first and last step of the process)
4. Identify all staff groups involved within the scope of this part of the process
5. Map that stage of the person’s journey through the system/service, identifying the steps, the problems and possible solutions on the post it notes. You may find it useful to use colour-coded post it notes or different shaped post it notes for the steps, problems and solutions– ensuring that you only write one item per post-it-note. You may want to either write all the steps first, then all the problems, and then the solutions or you may want to write one step, and the problems and solutions at that step, before moving on to the next step.
6. Record what happens 80% of the time
7. Add ‘guestimates’ of time for each step and between each step.

After mapping the journey

The project team should then analyse the process map, considering:

• How many steps are there?
• How many handoffs?
• What is the approximate time of or between each step? 
• Where are possible delays and why?
• How many steps do not “add value” for the people that use the services?
• Where are the problems for the people that use the services and staff?

This analysis should develop everyone’s understanding of the system, where the problems are, and where improvements should be made.

Examples of process maps done before and after service redesign are included on the following pages (Tool 18). The maps are of Sutton Community Adult Mental Health Services (CAMHS), however, the process mapping approach would be the similar for mapping telecare services.

Most telecare partnerships have developed new operational processes for elements of telecare service delivery including referrals, assessment, installations, call monitoring and response. Examples of polices, procedures and operational tools can be found on the JIT website – see box below.