NR 720 Week 2 Process Map Write-Up Example

Swimlane Map and Write-Up: Placement of a Central Line Through to the First Infusion in a Medical Intensive Care Unit, Crossing by Crossing

Student Name

College of Nursing, Chamberlain University

NR 720: Topics in Healthcare Systems Leadership I

Instructor Name

Month Day, Year

Swimlane Map and Write-Up: Placement of a Central Line Through to the First Infusion in a Medical Intensive Care Unit, Crossing by Crossing

Why Lanes

The process runs through five roles in two departments: the intensive care clinician who places the line, the bedside nurse, the order system, the radiology technologist and the radiologist. A flat list of steps would hide the moments when work passes from one role to another, and those moments are the subject of this course. Each role is therefore a lane, and every arrow that leaves a lane is a crossing that someone may or may not own (Antonacci et al., 2018).

The Map

Figure 1

Swimlane Map, Central Line Placement to First Use, Medical Intensive Care Unit

Note. Note. Built from interviews with four nurses, two advanced practice providers, one intensivist, two technologists and one radiologist, then checked against three observed placements.

Built From the People Doing It

The hospital's procedure document describes four steps: insert, order radiograph, provider reviews image and notifies nurse, use line. It was the first source, and it was wrong in two ways. It does not mention the order system's default priority, which every interviewed clinician knew about only once it was pointed out. And it says the provider notifies the nurse, which four of four nurses said rarely happens; nurses watch the results tab and ask. The map was therefore built from interviews and then tested by watching three placements, during which two steps appeared that no document records.

The Steps Nobody Wrote Down

Two unwritten steps carry much of the process. First, nurses check the results tab repeatedly, several times an hour, while the vasopressor runs peripherally; the work is real, unrecorded and unassigned. Second, some advanced practice providers look at the image themselves as soon as it appears and clear the line before the radiologist reads it, while others wait for the read. Which path a patient gets depends on who placed the line, not on any policy.

Walking the Crossings

Crossing 2, order to technologist, runs on a default. The order set marks the film routine, so it reaches the portable worklist alongside routine morning films. No one chose this; changing it requires a deliberate edit that busy clinicians rarely make.

Crossing 3, technologist to radiologist, is owned and works. Technologists take line films promptly once they see them.

Crossing 4, the reading queue, is owned by the radiologist but sorted by the priority set at crossing 2. A routine line film waits behind emergency department studies and urgent inpatient studies.

Crossing 5, result to bedside nurse, has no owner. The read appears in the record, but no procedure says who tells the nurse, so the nurse waits for a call that the clinician assumes is unnecessary.

What Each Department Would Draw

Asked to draw the process alone, each department produced a different and shorter map. Radiology's map began when an order arrived and ended when the report was posted; by that map, the process is fast and ends successfully. The intensive care unit's map began when the line was placed and ended with the infusion, but it treated the radiology portion as a single box labeled X-ray. Neither map included crossing 5, because each department assumed it belonged to the other. Drawing one map with both departments' lanes is what made the unowned crossing visible, and it is the reason the map was built jointly in a 40-minute meeting with a technologist, a radiologist, two nurses and an advanced practice provider in the room.

What the Interval Hides

The end-to-end figure, placement to first use, hides where the time sits. A single number of about two hours could come from a slow technologist, a long queue or a missed message, and each would need a different fix. The map shows that inside the lanes, work moves quickly; the waiting happens at crossings 2, 4 and 5. Time spent working on the film is a few minutes; time spent waiting for someone to pick it up is most of the interval (Graban, 2016).

How the Map Was Checked

The interview version of the map was tested against three placements watched from start to finish. In each, the observer noted the time and the lane of every action. All six steps appeared in all three placements, and the two unwritten steps appeared in all three as well: nurses checked the results tab between three and seven times while waiting, and in one placement the advanced practice provider cleared the line from the image before the radiologist's read. No step on the map was missing from the observations, and no observed action fell outside the map. Testing a map against practice in this way follows the work system view that the process actually performed, not the one written down, is what produces outcomes (Carayon et al., 2006).

What the Map Asks Next

The map tells the project what to time. Each crossing needs a start and an end that the record or an observer can capture: order time and priority for crossing 2, image time for crossing 3, read time for crossing 4 and the clearance note and first infusion for crossing 5. Crossing 5 is the hardest to time from the record, because the moment the nurse learns of clearance is not documented anywhere, so the following stage relies on watching placements to capture it.

The Edges of the Map

The map starts when the placing clinician finishes the line and ends when the nurse first infuses through it. It excludes lines placed in the operating room or emergency department, lines confirmed by ultrasound and the placement procedure itself. It describes weekday daytime practice; night practice, when one radiologist reads for the whole hospital, may differ and is not mapped here.

References

Antonacci, G., Reed, J. E., Lennox, L., & Barlow, J. (2018). The use of process mapping in healthcare quality improvement projects. Health Services Management Research, 31(2), 74-84. https://doi.org/10.1177/0951484818770411

Carayon, P., Schoofs Hundt, A., Karsh, B. T., Gurses, A. P., Alvarado, C. J., Smith, M., & Flatley Brennan, P. (2006). Work system design for patient safety: The SEIPS model. Quality and Safety in Health Care, 15(Suppl. 1), i50-i58. https://doi.org/10.1136/qshc.2005.015842

Graban, M. (2016). Lean hospitals: Improving quality, patient safety, and employee engagement (3rd ed.). CRC Press.