Understanding and Using Pathway Mapping for Healthcare Service Redesign

Why this topic matters

Clinical pathways are the sequences of events that patients experience during a particular episode of care, from initial referral through to discharge or follow-up. Within the NHS, these pathways can become complex and fragmented over time due to historical developments, departmental silos, and changing demands. Issues such as bottlenecks, redundant steps, unnecessary delays, and poor communication often manifest as inefficient patient flow, increased waiting times, and suboptimal patient and staff experiences.

Pathway mapping provides a structured approach to analyse these complexities. By clearly illustrating the journey, it enables teams to identify 'waste' (e.g., waiting, defects, non-value-adding steps) and 'value' from the patient's perspective. It fosters a shared understanding amongst multidisciplinary teams, facilitating collaborative problem-solving and evidence-based decision-making for service redesign. NICE guidance, for example, frequently outlines recommended care pathways, and local pathway mapping helps ensure adherence and identify deviations that could impact patient outcomes or resource utilisation.

Practical explanation

Pathway mapping is a visual representation of all the steps a patient takes and all the interactions they have within a specific healthcare service or condition. It often involves documenting:

• Key stakeholders: Who is involved at each stage (e.g., patient, GP, nurse, consultant, allied health professionals, administrative staff).
• Actions/steps: What happens at each point (e.g., referral, assessment, investigation, treatment, discharge).
• Decision points: Where choices are made that can alter the patient's journey.
• Waiting times/delays: Gaps between steps.
• Information flow: How information is shared (or not shared) between different points.
• Resources used: equipment, facilities, staff time.

There are generally two main types of pathway maps created during a redesign project:

1. 'As-is' Pathway Map: This depicts the current state of the service – how it actually functions, not how it's supposed to function. This is crucial for understanding real-world challenges.
2. 'To-be' Pathway Map: This illustrates the future, ideal state of the service after redesign – how it should function to achieve desired improvements.

The process of mapping involves more than just drawing a diagram; it's a team exercise in observation, data collection, and critical analysis. Tools can range from simple pen and paper or whiteboards to specialised software. Common visual elements include swimlanes (to separate activities by responsible team/role), process symbols (like rectangles for steps, diamonds for decisions), and arrows to show flow.

Common pitfalls

While highly beneficial, several common pitfalls can hinder the effectiveness of pathway mapping efforts:

• Not involving the right people: Exclusion of key stakeholders (especially patients, front-line staff, and administrative teams) can lead to an inaccurate 'as-is' map or a 'to-be' map that lacks buy-in or is impractical to implement. Patients offer invaluable insights into their experience of the pathway.
• Mapping the 'should-be' instead of the 'is-is': Teams often document the ideal process rather than the messy reality. It is essential to observe and speak to staff/patients to understand how things actually work.
• Lack of clear scope: Trying to map too broad a pathway can make the exercise unwieldy and overwhelming. Define clear start and end points for the pathway being mapped.
• Spending too long mapping: The goal is understanding and improvement, not perfect documentation. Over-analysing or endlessly refining the map can delay redesign efforts.
• Treating the map as the end goal: The map is a tool for diagnosis and design, not the solution itself. The real work begins after mapping, with analysing findings and implementing changes.
• Ignoring data: Relying solely on anecdotal evidence without incorporating existing data (e.g., waiting times, patient feedback, clinical outcomes) can lead to misinterpretations or missed opportunities.
• Lack of follow-through: Without a clear plan for implementing the 'to-be' pathway and monitoring its effectiveness, the mapping exercise can become a sterile academic activity.

Step-by-step approach for effective pathway mapping

Here’s a structured approach to guide your team through the pathway mapping process:

1. Define the Scope and Objectives

• Identify the specific pathway: What patient journey are you interested in? (e.g., 'Suspected Heart Failure Pathway,' 'Elective Hip Replacement Journey,' 'Emergency Department Flow for Minor Injuries').
• Define start and end points: Be precise. For example, 'from GP referral received by trust' to 'patient discharged from follow-up clinic'.
• Establish clear objectives for the redesign: What problems are you trying to solve? (e.g., reduce waiting times by 20%, improve patient satisfaction scores, streamline discharge process).
• Form your multidisciplinary team: Include clinical staff, administrative staff, managers, patients/service users, and QI specialists.

2. Gather Information for the 'As-Is' Map

• Walk the pathway: Observe actual patient journeys. Shadow staff. This is often called a 'Gemba walk' in Lean methodology.
• Interview stakeholders: Conduct interviews with a range of staff and patients. Ask open-ended questions like 'What happens next?', 'What are the main delays?', 'What frustrates you most?'.
• Collect data: Review existing data on patient numbers, waiting times, bed occupancy, complication rates, staff workload, and patient feedback.
• Document all steps: Capture even informal steps or 'workarounds' that staff use.

3. Create the 'As-Is' Pathway Map

• Visualise the pathway: Use a large whiteboard, flip charts, or digital software. Common elements include:
  • Swimlanes: Allocate a lane to each key role or department involved (e.g., Patient, GP, ED Nurse, ED Doctor, Radiology, Ward Staff).
  • Shapes: Use standard flowchart symbols (rectangles for steps, diamonds for decisions, ovals for start/end).
  • Arrows: Show the direction of flow.
  • Detailed descriptions: Label each step clearly.
• Add time and resource data: Estimate durations for each step and waiting times between steps. Note resources consumed.
• Validate: Present the 'as-is' map back to the wider team and relevant front-line staff for accuracy and completeness. Ensure it reflects reality.

4. Analyse the 'As-Is' Map

• Identify pain points: Where are the delays, bottlenecks, repeated steps, communication breakdowns, or areas of high cost/resource use?
• Look for non-value-adding activities: Which steps do not directly contribute to the patient's care or experience?
• Root cause analysis: For each issue identified, explore its underlying causes (e.g., using a '5 Whys' technique).
• Quantify impact: Estimate the impact of identified issues on time, cost, patient safety, and experience.

5. Design the 'To-Be' Pathway Map

• Brainstorm solutions: Based on the analysis, collaboratively generate ideas for improvement. Think creatively about how to eliminate waste, streamline processes, improve communication, and better utilise resources.
• Develop the 'to-be' pathway: Create a new map reflecting the proposed improvements. This might involve removing steps, reordering activities, changing decision points, or introducing new technologies/roles.
• Consider best practice/evidence: Integrate national guidance (e.g., NICE) and examples of successful pathways from other trusts or regions.
• Test and refine: Simulate the 'to-be' pathway mentally or through small-scale pilots (e.g., 'dry runs' or 'table-top exercises') to identify unforeseen issues.

6. Implementation and Evaluation

• Develop an implementation plan: Outline who will do what, by when, and with what resources. This should align with your project objectives.
• Communicate changes: Ensure all affected staff are aware of and trained on the new pathway.
• Monitor and evaluate: Collect data on the new pathway's performance against your objectives. This could include patient flow metrics, waiting times, patient satisfaction, and clinical outcomes.
• Sustain improvements: Embed the new pathway into standard operating procedures and regularly review its effectiveness, making further refinements as needed.

Example in clinical practice: Reducing ED wait times for frail older patients

A large NHS Trust's Emergency Department (ED) identified persistently long waiting times for frail older patients, leading to increased pressure on staff, potential patient deconditioning, and delayed access to specialist geriatric assessment.

1. Scope & Objectives: Map the 'Acute Frailty Pathway' from ED arrival to either discharge or admission to a specialist ward, with the objective of reducing median time to specialist assessment by 30% and improving patient experience scores.

2. Information Gathering: The team (ED consultants, nurses, geriatricians, OTs, physios, social workers, and ED reception staff) conducted 'walk-throughs' and shadowed patients. They interviewed staff and collected data on patient journeys, delays, and decision points. They found frail patients often experienced multiple assessments, long waits for imaging, and delays in social care input.

3. 'As-Is' Map: The team collaboratively mapped the complex 'as-is' pathway, using swimlanes for ED Triage, ED Physician, Geriatrician, ED Nurse, Imaging, and Social Services. The map clearly showed where frail patients often spent hours awaiting specific input, e.g., waiting for a geriatrician review whilst occupying an ED bed, or waiting for a social work assessment.

4. Analysis: Key issues identified included:

• Lack of a dedicated frailty screening tool at triage, leading to delayed identification.
• No co-located 'Frailty Assessment Unit' (FAU) to rapidly assess and treat frail patients outside the main ED.
• Intermittent availability of geriatrician input, requiring patients to wait or be reviewed by general ED doctors first.
• Fragmented communication between ED, geriatric team, and social care.

5. 'To-Be' Map: The team designed a 'to-be' pathway featuring:

• Introduction of a validated frailty screening tool at ED triage.
• Rapid referral to a newly created, co-located FAU staffed by a multidisciplinary team (geriatrician, specialist nurse, OT, physio, social worker) available during peak hours.
• Enhanced communication protocols with direct phone lines/referral systems between ED and the FAU team.
• Clear criteria for direct discharge from FAU or admission to an acute frailty ward.

6. Implementation & Evaluation: The Trust secured funding for the FAU. Staff were trained, and the new pathway was piloted. Monitoring data showed a significant reduction in ED length of stay for frail patients and a marked decrease in time to specialist assessment. Patient satisfaction scores improved, and there was early indication of reduced hospital admissions for some patients.

This example illustrates how visually understanding the current state allowed the team to pinpoint inefficiencies and design a more integrated, patient-centred service.

How Lazomis can help

Lazomis offers tools that can support various stages of your pathway mapping and service redesign journey.

• Visual project management: Use Lazomis's project setup and task management features to plan and organise your mapping activities. Assign tasks for data collection, interviewing, and map creation to your multidisciplinary team, ensuring accountability.
• Document repository: Securely store all your 'as-is' and 'to-be' pathway maps, interview notes, data analysis, and supporting documents in one centralised location, making them easily accessible to all team members.
• Built-in templates: Access templates that can guide your qualitative data collection and analysis, helping you structure your observations and stakeholder interviews effectively.
• Progress tracking and reporting: Monitor the progress of your redesign project, track key metrics related to the 'to-be' pathway implementation, and generate reports for stakeholders on the impact of your service improvements.

This resource supports, but does not replace, clinical judgement. Local policy, formulary and specialist advice should be followed.

Key takeaways

• Pathway mapping visually represents complex patient journeys to identify inefficiencies.
• Creating 'as-is' and 'to-be' maps is crucial for understanding current state and designing future improvements.
• Involve multidisciplinary teams, including patients, for accurate and effective mapping.
• Focus on gathering real-world data and observing actual processes, not just ideal ones.
• The map is a diagnostic tool; true value comes from analysing findings and implementing redesign.
• Regular evaluation and iteration are essential for sustaining service improvements.