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Use of Process Mapping During Outbreak Response Practice BMJ Glob Health: first published as 10.1136/bmjgh-2020-003901 on 8 October 2020. Downloaded from Systems thinking for health emergencies: use of process mapping during outbreak response 1,2 1 1 1 Kara N Durski , Dhamari Naidoo, Shalini Singaravelu, Anita A Shah, Mamadou Harouna Djingarey,3 Pierre Formenty,1 Chikwe Ihekweazu,4 James Banjura,5 Benoit Kebela,6 Adesola Yinka- Ogunleye,4 Ibrahima- Soce Fall,3 Womi Eteng,4 Mohamed Vandi,5 Charles Keimbe,5 Anwar Abubakar,4 Abulazeez Mohammed,7 Desmond E Williams,8 Margaret Lamunu,9 Sylvie Briand,1 Jean Claude Changa Changa,10 Etienne Minkoulou,3 Dan Jernigan,8 Demba Lubambo,3 Asheena Khalakdina,1 Ibrahim Mamadu,11 3 12 5 1 Ambrose Talisuna , Albert Mbule Kadiobo, Amara Jambai, Bruce Aylward, Michael Osterholm2 To cite: Durski KN, Naidoo D, ABSTRACT Summary box Singaravelu S, et al. Process mapping is a systems thinking approach used Systems thinking for health to understand, analyse and optimise processes within ► There is little to no published research on process emergencies: use of process complex systems. We aim to demonstrate how this mapping during outbreak mapping being conducted during health emergen- methodology can be applied during disease outbreaks response. BMJ Global Health cies to improve the current outbreak response. to strengthen response and health systems. Process 2020;5:e003901. doi:10.1136/ ► Our research shows that despite the chaos and mapping exercises were conducted during three unique bmjgh-2020-003901 complexities associated with emerging pathogen emerging disease outbreak contexts with different: mode outbreaks, process mapping can address immediate of transmission, size, and health system infrastructure. Handling editor Seye Abimbola response priorities while simultaneously strengthen- System functioning improved considerably in each country. ing components of a health system. ► Additional material is In Sierra Leone, laboratory testing was accelerated from ► This methodology could be applied to any country published online only. To view 6 days to within 24 hours. In the Democratic Republic of please visit the journal online that has an outbreak, including COVID-19 cases. Congo, time to suspected case notification reduced from (http:// dx. doi. org/ 10. 1136/ ► There is an acute need in the global health commu- 7 to 3 days. In Nigeria, key data reached the national bmjgh- 2020- 003901). nity to respond to disease outbreaks in a way that http://gh.bmj.com/ level in 48 hours instead of 5 days. Our research shows effectively uses limited resources. that despite the chaos and complexities associated with ► This is a user- friendly and low- cost methodology emerging pathogen outbreaks, the implementation of Received 6 September 2020 that can be implemented during any time point of an Revised 11 September 2020 a process mapping exercise can address immediate outbreak, including during preparedness and readi- Accepted 13 September 2020 response priorities while simultaneously strengthening ness activities. components of a health system. ► Future operational and implementation research fo- cussed on using process mapping and other applied on October 8, 2020 by guest. Protected copyright. system methodologies during outbreaks should be conducted. INTRODUCTION Process mapping is a systems thinking approach used to understand, analyse, and been applied in the health systems and optimise processes within complex systems.1 healthcare field. It has been used to ensure Process maps were first introduced in the optimisation of civil registration and vital early 1920s;2 however, it was not until the statistics systems and in various healthcare © Author(s) (or their 1980s that frameworks and methodologies quality improvement projects, from mapping employer(s)) 2020. Re- use permitted under CC BY-NC. No which brought together various disciplines the patient journey in a healthcare facility to commercial re-use. See rights such as architecture, design and engineering redesigning procedures to increase efficiency and permissions. Published by were developed. This participatory method- in the USA and UK.1 4–6 It was used in South BMJ. ology promotes collective thinking, facilitates Africa to understand how the use of point of For numbered affiliations see communication among stakeholders and care tests for sexually transmitted infections, end of article. provides visualisation of challenges.3 tuberculosis and HIV impacted care at large 7 Correspondence to To date, process mapping during outbreaks urban public healthcare clinics. Additionally, Kara N Durski; durskik@ who. int has not been documented, although it has process mapping has been used to improve Durski KN, et al. BMJ Global Health 2020;5:e003901. doi:10.1136/bmjgh-2020-003901 1 BMJ Global Health BMJ Glob Health: first published as 10.1136/bmjgh-2020-003901 on 8 October 2020. Downloaded from collaboration at the human-animal interface across leadership, facilitation and coordination skills led the a variety of sectors through the One Health Systems exercise and an additional one to two people (depending Mapping and Analysis Resource Toolkit (OH- SMART).8 on the country and context) helped conduct the inter- Process mapping visually clarifies stakeholders’ relation- views. ships and identifies bottlenecks, inefficiencies and design flaws that limit system performance.3 It can therefore be Preparation a useful tool for effective outbreak response when health In step one, which took a few hours, big- picture opera- systems become overloaded and basic health services tional challenges were identified with Senior Leadership cannot be maintained, allowing existing processes to and the Incident manager. Engagement and buy- in from be streamlined and strengthened instead of creating senior leadership within the Ministry of Health (MoH) new ones. Mapping processes allows interactions, gaps or National Disease Control units is essential. Then the and redundancies within the health system to be identi- goals and objectives for each process mapping exercise fied, captures complexities effectively and brings people were defined according to challenges of each outbreak. together to share a common view of the system which are Indicators were identified to measure the effectiveness useful for developing solutions that can improve acute of the process re- design. The indicators collected varied challenges as well as the long-term functionality of a according to the process being mapped and the oper- health system.3 This methodology can support countries ational context in which the outbreak was occurring. to leverage the incoming resources during response and Organisations, partners and stakeholders who were recovery efforts, thus facilitating short- term and long- impacted by or involved with the process were also iden- term health system strengthening. The flexibility of the tified. methodology lends itself to being implemented in low- Conduct interviews income, middle- income and high- income countries alike Next, individual interviews lasting up to 1 hour were and may be useful to address many of the operational conducted with all persons identified during step 1. complexities of the COVID-19 pandemic. Stakeholders were encouraged to provide honest and Process mapping exercises, which have proven to be constructive opinions during the discussions. Interviews an effective tool at optimising processes in other disci- focussed on obtaining specific knowledge regarding plines, can be a useful tool to assist with specific chal- the step- by- step process related to the main operational lenges during outbreak response. We aim to demonstrate challenge being mapped including obtaining an under- how this methodology can be applied during any phase standing of their specific responsibilities and roles, the of a disease outbreak response so that processes can be roles and responsibilities of their colleagues, challenges streamlined to improve the current outbreak response as that they encounter within the health system, barriers that well as the long- term challenges in the information, clin- prevent the health system from operating at an optimal ical and laboratory systems. level, barriers that prevent the current response from operating at an optimum level, specific pain points (ie, http://gh.bmj.com/ CONDUCTING PROCESS MAPPING EXERCISES challenges) in the current process, and general system- Process mapping exercises were conducted during three atic challenges that impact the process. If stakeholders unique disease outbreak contexts in Sierra Leone, the not initially identified during step 1 were mentioned as Democratic Republic of Congo (DRC) and Nigeria instrumental to the process, they were also contacted and between 2014 and 2017. Each mapping exercise followed interviewed. the same four- step methodology but had a unique focus on October 8, 2020 by guest. Protected copyright. based on the specificities of the disease outbreak, country Map and analyse context and health system. All addressed a challenge Next, each step in the process, as documented during the related to the health system either not functioning at an interviews, was drawn out and visually mapped with pen optimal level or being overwhelmed by the outbreak, or and paper. Prior to the group re- design session, this was both. The process mapping methodology we used was put into an electronic format to improve legibility for all adapted from the operations management discipline9 10 stakeholders. and Savigny et al’s ‘Applied Systems Thinking for Health Validate
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