The use of PM within healthcare improvement projects helps to support understanding of complex healthcare systems and adaptation of improvement interventions to their local context. We reviewed methodological guidance on PM, peer-reviewed empirical literature, and developed a conceptual framework to guide effective implementation, assessment, and reporting of PM in healthcare. We assessed adherence of 105 empirical studies to quality criteria outlined in the conceptual framework. Comparison of methodological guidelines and empirical literature helped to identify common features characterizing the use of PM across the selected studies. We also identified reported context of use and benefits of using PM in improvement work.
To our knowledge, this is the first systematic literature review exploring the use of PM in healthcare improvement projects. The review demonstrates that PM is used in projects to improve the quality and safety in a wide range of healthcare settings. These projects focus on different QI tools and approaches, and use PM either as a standalone methodology or as a support for other QI methods.
Using the conceptual framework, we found inconsistencies in reporting and in adherence to PM quality criteria. None of the studies adhered to all the criteria and only 7% studies adhered to 8/10 or 9/10 criteria. Assessment of adherence was, however, challenging due to variation in reporting of PM exercises across studies. This is attributable both to the diversity of the contexts for using PM and lack of standardized reporting requirements. Analysis of the reviewed studies suggests that poor adherence with quality criteria reflects not just problems in the reporting of PM, but also the conduct of the method.
Although for most reviewed studies, views of different stakeholders were gathered, only 15% reported the involvement of patients. Moreover, less than half (45%) clearly reported that process maps were generated through multi-professional meetings. This suggests that some benefits of PM may not have been realized in these studies, as failure to engage all stakeholders is unlikely to produce realistic process maps or support successful patient-centred QI initiatives. If PM is conducted without appropriate stakeholder participation, some of the benefits derived from the social interactions, such as empathy between professional groups and agreement for shared solutions, are inhibited.[12] Two of the studies identified in the systematic review reported that the limited involvement of clinical staff was related to the difficultly of relieving them from their daily job,[96, 114] but reasons for poor patient involvement should be further investigated.[24]
Only 14 of the reviewed studies report training in PM techniques as part of the project. Limited training in PM techniques may explain the lack of discussion or consideration of the process modelling language used to draw the process map in the reviewed studies. This finding confirms previous research stating that most projects in healthcare only use flowchart diagrams, regardless the variety of process modelling techniques and tools available.[123] The choice of modelling language used is important in describing and understanding systems analysed with PM and overlooking these aspects can impact its effective use.[124] Furthermore, training project teams in QI is important not only to improve participants’ technical skills, but also to enhance their engagement in the project.[97, 125] We advocate further research on how to make advanced modelling techniques and tools accessible to healthcare professionals, as well as how this enhanced knowledge affects the success and impact of PM.
Some studies reported that they had to balance the rigorous use of the PM method with resource and time constraints they had to face in practice.[64, 87, 97, 110, 114, 126] Despite reviewed studies demonstrating overall poor adherence to the identified PM quality criteria, they describe a number of benefits derived from its use in healthcare improvement projects, demonstrating the key role played by PM in addressing the challenge of designing and implementing change in complex systems. Using PM in improvement work helps to achieve the strategic principles identified by the Successful Healthcare Improvement from Translating Evidence in Complex Systems (SHIFT-evidence) framework (act scientifically and pragmatically, embrace complexity, engage and empower).[53] The capacity of PM to bring together diverse stakeholder perspectives and provide a visual representation of the system is key to address the complexity which characterizes healthcare processes. Within QI projects PM helped to provide a shared understanding of the reality of complex systems and facilitated dialogue between team members. This increased engagement of project participants and eased their agreement on common solutions to problems, thus supporting two levers recognized as important for successful improvement in complex systems: knowledge co-production and the definition of shared goals across stakeholders.[127, 128]
The use of PM as a monitoring and evaluation tool [9, 31, 70, 117, 129–131] appeared to be out of scope of application by many QI teams. Most of the articles we reviewed focus on use of PM to better understand systems only at the early stages of an improvement initiative or to visualize and disseminate process maps as the “output” of the project. Only 42% of the reviewed studies describe actions undertaken following the PM exercise, suggesting there is still more to know on how PM influences action and impact in overall improvement efforts.
Findings from this literature review show there is still much room for improvement in the use and reporting of PM as a QI method. Limited adherence to recommended practice for PM is a finding consistent with the assessment of fidelity reported for other QI methods.[47, 132]
We unpacked the black box of PM as a QI method and outlined quality criteria to guide its systematic use and reporting. Improving the quality of reporting of PM exercises would enhance transparency, encourage appropriate use of PM in practice, and support the definition of a common language to describe the process of PM.[24] We encourage practitioners and researchers to use and test the validity of our conceptual framework when implementing or reporting PM. We also suggest further development of reporting guidelines for PM exercises and their use as a starting point in the design of prospective studies exploring the effectiveness of the method. Our findings show that improvements in reporting are required not only to systematically describe the “process” of PM but also for representation of the process map, as we found that many articles report only a partial or sample representation of the process map developed. Online versions of published articles or online supplements [64, 84, 98, 104, 125, 133–137] could provide more detailed process maps as these are often difficult to display in printed versions of journals.
Previous studies also demonstrated that successful implementation of QI initiatives depends not only on the conformance to methodological guidelines, but is greatly influenced by contextual factors (leadership, organizational culture, etc.).[16, 138–140] Our study has not taken into account the influence of context on PM exercises, because these factors cannot be assessed by analysis of the literature. We partially addressed this issue, published elsewhere, by conducting an empirical study investigating benefits and success factors of PM in a sample of QI projects.[12] Further empirical research is needed to test whether our findings hold in QI projects developed by teams using different approaches to conduct the PM exercise, as identified in this literature review.
4.1 Limitations
There are some limitations due to the search process. The database search could have included other search terms such as “process model*”, “process design*” or “system design*”, but the authors agreed that the effort required to screen the resulting records was not justified by the purpose and boundaries of the present study.
A key limitation is due to the fact that the systematic review is based on PM exercises as described in the selected empirical literature and not on the analysis of actual practice. This implies that results might be affected by reporting bias and selection of studies, as well as publication bias. The content of publications heavily depends on what journals accept for publication and on the limited space allowed. Therefore, projects using specific approaches (e.g. TDABC, Lean or IS development) are less likely to present a detailed description of the PM process, compared to other process improvement projects. Successful projects are more likely to be published than studies reporting less successful interventions, which may be equally useful for knowledge generation. Bias could also arise because we only searched English-language papers. However, our objective was not to perform an exhaustive review of all the studies applying PM techniques in healthcare, nor to assess the effectiveness of PM, but to provide a representative overview of the use of PM as reported in empirical literature.
Another limitation is due to the fact that PM exercises were usually reported as a part of a wider project. Clearly distinguishing the component attributable to PM from that associated with the whole project was therefore not always straightforward. We addressed this limitation in the development of the data item sheet and the theoretical framework, as well as in the data collection and analysis phase. For example, we decided not to quantitatively assess the different roles involved in the PM exercise, because it was not always clear if and how all team members were involved in the PM exercise. Furthermore, we evaluated the actual implementation of the recommendations derived by the PM exercise, considering the improvement actions reported in respect of the whole project.
Finally, within the included studies we found three papers [120–122] which seemed to derive from the same project. We addressed this bias in the analysis and summary phase by discounting the patterns emerging from common characteristics of these three studies.