CPOM Module 10, Section 2: Process Mapping and Value Stream Analysis
MODULE 10: OPERATIONAL PROCESS IMPROVEMENT

Section 2: Process Mapping and Value Stream Analysis

You cannot improve a process you do not understand. Learn the techniques of process mapping and value stream mapping to make your current state visible, identify bottlenecks, and distinguish value-added steps from wasteful ones.

SECTION 10.2

Process Mapping and Value Stream Analysis

Making Your Pharmacy’s Work Visible.

10.2.1 The “Why”: The Danger of the “Mental” Process Map

Ask five different people in your pharmacy to describe the process for filling a new prescription, and you will get five different answers. The technician at drop-off sees a series of data entry screens. The filling technician sees a sequence of scanning barcodes and counting pills. The pharmacist sees a checklist of clinical verifications. The patient at the counter simply sees a long, opaque period of waiting. Each person holds a “mental map” of the process, but it is incomplete, biased toward their own tasks, and largely blind to the handoffs, delays, and rework loops that happen outside their immediate view. This is the single biggest barrier to effective process improvement.

Relying on these mental maps is like trying to fix a city’s traffic problem by only talking to taxi drivers. You’ll hear about specific intersections that are bad, but you’ll have no understanding of the overall traffic flow, the timing of the signal lights, the impact of a downtown event, or the bottlenecks on the freeway ramps. To solve the problem, you need a single, shared, objective view of the entire system. You need a city-wide traffic map.

Process mapping and value stream analysis are the tools you use to create that map for your pharmacy. The act of mapping is a powerful intervention in itself. It forces a team to come to a shared understanding of how work is actually done, not how it’s supposed to be done in the policy and procedure manual. It externalizes the collective knowledge of the team into a visual format that can be discussed, debated, and analyzed. This visual representation immediately exposes the hidden complexities, the nonsensical workarounds, and the glaring opportunities for improvement that were invisible when they only existed in individual, mental maps. Before you can make a process better, faster, or safer, you must first make it visible. This section will provide you with the master skills to do just that.

Retail Pharmacist Analogy: Solving a “Mystery” Co-pay Problem

A patient comes to your counter to pick up their maintenance medication and is shocked that the co-pay, which is usually $20, is now $150. This is the problem. Your “firefighting” instinct is to immediately start trying to solve it for this one patient. You look at the claim details. You see it processed, but the co-pay is high. You might guess it’s a deductible issue and spend ten minutes explaining how deductibles work. The patient is confused and upset. This is trying to fix the problem using an incomplete mental map.

The “fire marshal” or process improvement approach is to first map the process of how a co-pay is determined. You grab a whiteboard and start flowcharting. The process starts with the pharmacy software sending a claim. The claim goes to a switch, then to the Pharmacy Benefit Manager (PBM). The PBM’s system then runs a series of checks.

  • Decision 1: Is the patient eligible? (Yes/No)
  • Decision 2: Is the drug on formulary? (Yes/No)
  • Decision 3: Is a Prior Authorization required? (Yes/No)
  • Decision 4: Has the patient met their annual deductible? (Yes/No)
After the deductible check, another series of steps occurs:
  • Process: Apply the drug’s tier-level cost-sharing. Is it a Tier 1 (generic, low co-pay) or a Tier 4 (specialty, high co-insurance)?
  • Decision 5: Is the patient in the Medicare Part D Coverage Gap (“Donut Hole”)? (Yes/No)
Finally, the system calculates the final co-pay and sends the response back to your pharmacy.

By mapping this out, you immediately see that a “high co-pay” is not a single problem; it’s a symptom that can result from failing at several different steps in the process. The map gives you a diagnostic tool. Now, when the patient presents the problem, you don’t just guess. You walk through the map: “Okay, let’s figure this out. The claim paid, so we know you’re eligible and the drug is on formulary. That means the issue is likely in the cost-sharing part of the process. Let’s check your deductible status first. Ah, it looks like your plan’s deductible reset on January 1st, and this is your first expensive fill of the year. You’re paying the full cost until your $500 deductible is met.”

The process map transformed a frustrating mystery into a solvable problem. It provided a structured way to think and communicate, allowing you to pinpoint the exact root cause and provide a clear, confident explanation to the patient. This is the power of making the invisible process of claim adjudication visible.

10.2.2 Process Mapping (Flowcharting): The Blueprint of Your Workflow

A process map, or flowchart, is the most fundamental tool in your improvement toolkit. It is a simple, graphical representation of the sequence of steps, decisions, and handoffs that make up a process. Its power lies in its simplicity and its ability to create a shared understanding among a team. Before diving into creating one, it’s essential to master the basic, universal language of flowcharting.

Masterclass Table: The Basic Language of Flowcharts
Symbol Name Function Pharmacy Example
○ Oval
 Terminator Represents the start and end points of a process. Every map must have a clear beginning and end. “Patient Arrives at Drop-off” (Start) or “Prescription Dispensed to Patient” (End).
▭ Rectangle
 Process Represents a single step, task, or activity being performed. This is the most common symbol. “Enter prescription into computer,” “Count and package medication,” “Pharmacist verifies order.”
◇ Diamond
 Decision Represents a point where a question is asked, and the flow branches based on the answer (e.g., Yes/No, True/False). “Is medication in stock?,” “Does prescription require clarification?,” “Is prior authorization required?”
→ Arrow
 Flowline Connects the symbols and indicates the direction of flow through the process. Connects “Enter prescription” to “Scan product NDC.”
⬟ Parallelogram
 Data (Input/Output) Represents inputs to or outputs from the process, such as data or materials. “Receive e-prescription,” “Print prescription label,” “Generate report.”
D Delay
 Delay Represents a period of waiting where no work is being done. Critical for identifying bottlenecks. “Wait for pharmacist check,” “Wait for insurance response,” “Wait for patient pickup.”
Beyond the Basics: The Power of the Swimlane (Cross-Functional) Diagram

A simple flowchart is good, but for most pharmacy processes, it’s not good enough. Pharmacy work is a team sport, involving a complex series of handoffs between different people and departments. The swimlane diagram is the single most valuable tool for visualizing this complexity. It’s a flowchart that is organized into lanes, with each lane representing a person, role, or department. By mapping the process steps within their respective lanes, you can instantly see every time the process crosses from one lane to another. These “lane crossings” are the handoffs, and they are frequently the points where delay, miscommunication, and error occur.

Why Swimlanes are Essential for Pharmacy

Imagine mapping the process for an inpatient medication order. A simple flowchart would just show a list of steps. A swimlane diagram reveals the true story:

  • Lane 1: Prescriber -> Enters order into EHR.
    (Handoff to Pharmacy)
  • Lane 2: Pharmacist -> Verifies order for clinical appropriateness.
    (Handoff to Technician)
  • Lane 3: Technician -> Fills dose from Automated Dispensing Cabinet (ADC).
    (Handoff to Nursing)
  • Lane 4: Nurse -> Retrieves dose from ADC and administers to patient.

This map immediately highlights the three critical handoffs. If there’s a delay, the swimlane map forces you to ask: Is the problem the pharmacist’s verification time, or is it the time the order sits in a queue *between* the prescriber and the pharmacist? Is the nurse not getting the medication because the technician is slow, or because there was a communication breakdown *between* the technician and the nurse? Swimlanes expose these systemic issues.

How to Create a Process Map: A Step-by-Step Guide
  1. Assemble the Right Team. You cannot map a process from your office. You must involve the people who actually do the work every day. For an outpatient prescription workflow, this includes at least one intake technician, one filling technician, and one pharmacist. Do not just include the superstars; include the average performers and even the ones who seem to struggle, as they often have the best insights into what’s broken.
  2. Define the Scope. A process map must have a clear start and end point. If you don’t define the boundaries, the map will sprawl uncontrollably. For example, is the start of the filling process “prescription dropped off” or “prescription data entry complete”? Is the end “patient picks up medication” or “pharmacist bags the prescription”? Be explicit.
  3. Gather Your Tools. The best mapping sessions are low-tech. You need a large whiteboard or wall space, a pack of large sticky notes in multiple colors, and plenty of markers. The sticky notes are crucial because they allow the team to easily move, add, and remove steps as they build the map.
  4. Walk Through the Process Step-by-Step. Start at the defined beginning. Ask the team, “What is the very first thing that happens?” Write it on a sticky note and put it on the board. Then ask, “What happens next?” Continue this, one step at a time. Use different colored notes for different roles if you are building a swimlane map.
  5. Capture Reality, Not Fantasy. This is the most important rule. You must map what actually happens, not what the policy says should happen. Encourage honesty about workarounds, shortcuts, and common problems. If the official process is to scan every bottle, but in reality, technicians often type the NDC because the scanner is broken, the map must show “Type NDC.” The map is a tool for diagnosis, and it must reflect the true condition of the patient.
  6. Identify Decision Points and Rework Loops. Pay close attention to any “if/then” statements. These are your decision diamonds. “Is the drug in stock?” If no, what happens? This often reveals a “rework loop”—a series of steps to order the drug that takes the process off the main path and then brings it back later. These loops are major sources of delay and variation.
  7. Photograph and Digitize. Once the team agrees that the map on the wall accurately represents the current state, take several high-resolution photos of it. Then, use simple software (like Microsoft Visio, PowerPoint, or free online tools like diagrams.net) to create a clean, digitized version that can be shared and used for analysis.

10.2.3 Value Stream Mapping (VSM): Adding the Dimensions of Time and Value

A process map tells you what you do. A Value Stream Map (VSM) tells you how well you do it. VSM is a Lean tool that builds upon a standard process map by incorporating data, specifically time and an assessment of value at each step. It is one of the most powerful diagnostic tools available because it shifts the focus from just looking at the steps to looking at the flow and, most importantly, the delays between the steps.

The core activity of VSM is to categorize every single step in your process map into one of three categories from the customer’s (patient’s) perspective:

  1. Value-Added (VA): Any activity that physically transforms the product or service in a way the patient is willing to pay for. These are the essential steps that directly contribute to the therapeutic outcome. In pharmacy, these are surprisingly few. Examples include: compounding an IV, counseling a patient, or applying a label to a vial.
  2. Non-Value-Added but Necessary (NVAN): Activities that create no direct value for the patient but are required by law, regulation, or the limitations of current technology. Our goal is to minimize or simplify these steps, but we often cannot eliminate them completely. Examples include: pharmacist clinical verification, documenting a clarification in the computer, or submitting a claim to insurance. The patient doesn’t want to pay for these, but they must be done.
  3. Non-Value-Added (NVA) / Waste: Any activity that consumes resources but adds no value and is not necessary. This is pure waste. These are the activities we want to ruthlessly eliminate. The 8 Wastes of DOWNTIME (Waiting, Defects, Motion, etc.) fall squarely into this category.
The Metrics That Matter: Lead Time, Process Time, and Cycle Efficiency

The next step in VSM is to collect time data for every step and delay in your process. This allows you to calculate three crucial metrics:

  • Process Time (PT) (also called “Touch Time”): This is the sum of the time for all the Value-Added steps. It is the amount of time someone is actually “touching” or working on the prescription.
  • Lead Time (LT): This is the total elapsed time from the start of the process to the end. It is what the patient or customer experiences. It includes not only the Process Time but all the waiting and delays in between.
  • Process Cycle Efficiency (PCE): This is the single most sobering metric in process improvement. It is the ratio of the value-added time to the total time. $$ PCE = \frac{\sum Process Time}{\sum Lead Time} \times 100% $$
The Harsh Reality of Process Cycle Efficiency

Prepare to be shocked. In most service industries, including healthcare and pharmacy, the Process Cycle Efficiency is abysmal. It is very common to find that the PCE is less than 10%, and often less than 1%. This means that for a prescription that takes 60 minutes to get to a patient (Lead Time), the total amount of “hands-on” value-added work (Process Time) might only be 3-6 minutes. The other 54-57 minutes—the vast majority of the time—is pure waste, primarily the waste of Waiting.

This discovery is the “aha!” moment of Value Stream Mapping. It proves that the best way to dramatically improve speed and efficiency is not to get people to work faster at the value-added steps (e.g., counting pills 10% faster). The biggest opportunity by far is to attack and eliminate the massive blocks of waiting time that exist between the steps.

10.2.4 Masterclass Case Study: Value Stream Map of a STAT Inpatient IV Dose

Let’s apply these concepts to a critical hospital pharmacy workflow: preparing a STAT first dose of an antibiotic for a patient in the ICU. The team has mapped the process and collected baseline data by observing 20 recent orders. The goal is to understand the current state, calculate the PCE, and identify the biggest opportunities for improvement.

Current State Value Stream Map Data
Step Number Process Step Description Role Value Category Avg. Process Time (PT) Avg. Wait Time Before Step
1 Physician enters order in EHR Physician NVAN 2 min 0 min
2 Order waits in Pharmacist queue System NVA (Waste) 0 min 12 min
3 Pharmacist clinically verifies order Pharmacist NVAN 3 min 0 min
4 Label prints in IV room, waits for tech System NVA (Waste) 0 min 8 min
5 Technician gathers drug and supplies Technician NVAN 4 min 0 min
6 Technician compounds IV Technician Value-Added 5 min 0 min
7 Compounded IV waits for pharmacist check N/A NVA (Waste) 0 min 10 min
8 Pharmacist checks compounded product Pharmacist NVAN 2 min 0 min
9 Dose waits to be picked up for delivery N/A NVA (Waste) 0 min 5 min
10 Delivery to ICU Transport NVAN 6 min 0 min
11 Dose waits in bin for nurse N/A NVA (Waste) 0 min 7 min
12 Nurse retrieves and administers dose Nurse Value-Added 3 min 0 min
TOTALS 25 min 42 min
Analysis of the VSM Data

Now, let’s analyze these powerful findings:

  • Total Lead Time (LT): This is the total time the patient and nurse experience. It’s the sum of all Process Times and all Wait Times.
    $LT = 25 min (Process) + 42 min (Wait) = 67 minutes$
  • Total Value-Added Time (PT): This is the sum of only the truly value-added steps (Step 6 and Step 12).
    $PT = 5 min (Compounding) + 3 min (Administering) = 8 minutes$
  • Process Cycle Efficiency (PCE): Now we calculate the ratio of value-added time to total lead time.
    $PCE = (8 min / 67 min) times 100% = 11.9%$
The VSM’s Inescapable Conclusion

The data provides a crystal-clear diagnosis of the process’s health. For over an hour of total turnaround time, only 8 minutes were spent adding value. A staggering 42 minutes—or 63% of the total time—was pure, wasteful waiting. The biggest “rocks in the river” slowing down the flow are the 12 minutes waiting for pharmacist verification, the 8 minutes waiting for a technician to start, and the 10 minutes waiting for the final pharmacist check.

This analysis completely changes the conversation. The problem is not that the pharmacists or technicians are “slow” at their tasks. Even if they performed their work twice as fast, it would only save a few minutes. The true enemy is the queue time. The VSM gives you a data-driven mandate to focus your improvement efforts not on making people work harder, but on fixing the system to eliminate waiting.

10.2.5 From Map to Action: Designing the Future State

The Current State Map is a diagnosis, not a destination. Its purpose is to provide the insight needed to design a better process. The final step in this phase of an improvement project is to create a Future State Map. This is a new process map that visualizes what the workflow *could* look like after your improvements have been implemented. It’s your blueprint for change.

Using the insights from our STAT IV case study, the team might brainstorm a future state with the following changes:

  • Improvement 1 (Targets Wait Time #1): Implement a dedicated, color-coded, audible alert for STAT ICU orders that bypasses the standard verification queue and goes directly to the top of the pharmacist’s list. Projected Wait Time Savings: 10 minutes.
  • Improvement 2 (Targets Wait Time #2 & #3): Create a dedicated “STAT Technician” role for the busiest hours. When the STAT alert goes off, that technician immediately stops their batch work and handles the STAT order from start to finish, including compounding and handing off for the final check. Projected Wait Time Savings: 15 minutes.
  • Improvement 3 (Targets PT): Create a “STAT IV Kit” in the IV room that contains the most common antibiotics, diluents, and supplies, eliminating the need to search and gather. Projected Process Time Savings: 2 minutes.

The team can then create a new VSM table for the future state, calculating the projected new Lead Time and PCE. This future state map becomes the business case for the project. It allows you to go to leadership not with complaints, but with a data-backed proposal: “Our current process for STAT IVs takes an average of 67 minutes. We have designed a new workflow that we project will reduce this to under 40 minutes by targeting the three largest sources of delay. We would like to run a two-week pilot of this new process to validate our findings.”

This structured, visual, and data-driven approach is the heart of operational process improvement. It moves you away from opinions and anecdotes and into the world of objective analysis. By mastering the skills of process mapping and value stream analysis, you gain the ability to not only understand the complex systems you manage but also to redesign them for a future that is safer, more efficient, and relentlessly focused on delivering value to the patient.