Tackle Waste, Inefficiency and Variation in Healthcare Using the Spaghetti Map

For the next several months, I will be writing about some simple yet very effective Lean Six Sigma tools to tackle waste, inefficiency and variation in healthcare. In this column we will look at the Lean Six Sigma tool, the spaghetti map (also referred to as the spaghetti chart or the spaghetti diagram).

The spaghetti map is a simple Lean Six Sigma visual tool that provides a powerful overview of a process. It helps in mapping the flow of people and material, delivering care or service in an organization. The pathways taken by people working in the process and the use of supplies when drawn on a paper often resembles cooked spaghetti, hence the name. The spaghetti map helps in quantifying the distances traveled, in addition to helping to surface the bottlenecks, poor layout, workarounds and inefficiencies in the process.

Building a Spaghetti Map

The first step to building a spaghetti map is to define the objective for the mapping. Are you using the spaghetti map to understand how staff delivers care, or to see the pathway of patient flow in the area or to understand the flow of a product (e.g. blood glucose meter) in the work area? Once the goal is defined and agreed to by the team, the second step is to draw the layout of the area that is being studied (scope) for the mapping exercise. Third, observe the delivery of service or care and draw a line from point 1 to point 2 and then to point 3, etc. Continue the observation from the time a person or product enters the area defined to be in-scope (step 2) until the person or product exits the area under study. You could use different colored pencils or pens for different people delivering care.

To be successful with the spaghetti map, use the following helpful guidelines:

1. Communicate ahead of time with the groups that are being observed. (The emphasis should be on the process improvement, and make it clear to the staff working in the process that they are not being monitored.)
2. Keep track of the time, distance traveled and any interruptions noted. (For example, the staff has to find supplies, need to attend a page.)
3. Recruit volunteers from the area to help with the data collection/mapping.
4. Keep track of other activities or context.

Once the spaghetti map is drawn, look for the wastes in the process. Some of the wastes to surface include unnecessary motion (to retrieve supplies, materials, documents, etc.), non-value added transportation, defects in the process, waiting and excessive inventory.

Next, present the findings to the team and quantify the effort to complete the process being studied (e.g. distance traveled to get supplies, number of interruptions noted while providing service, defect percent, etc.). The visual spaghetti map, in addition to the qualitative and quantitative data, helps the team to clearly see the "waste and inefficiencies" in the current process. The team then brainstorms how to best deliver care or service in the most efficient manner.

Once the team agrees on the changes to the existing process, pilot the changes to the layout and/or process and repeat the spaghetti mapping exercise for the new process. The new spaghetti map along with the qualitative and quantitative data helps in articulating the impact of the changes to the layout and/or process.

Mayo Clinic Examples of Using the Spaghetti Map

Hand hygiene compliance among healthcare workers continues to be a problem. To fully understand the reasons for the low compliance, we used a spaghetti map to see the workflow. In the patient care floor we observed that the layout to perform hand hygiene was not ideal. For example, the healthcare provider had to take a few steps to find the trash can, take a few more steps to get the alcohol rub and a couple more steps to get to the gloves and then go back to the patient. The spaghetti map quickly brought attention to the layout problem. The team brainstormed on ideas and agreed to pilot to bring the alcohol rub, gloves and trash can close to the point of care, thus eliminating the layout barrier. (Click on image to enlarge.)



In another example, the glucometer used for the 8 bed unit was tucked away in the supplies room, to keep it plugged in when not used (the electric outlet was in the back corner of the room). This led to about 20 additional steps for the provider to get to the glucometer. The spaghetti map highlighted the excessive motion. The staff working in the process with this information was successful in challenging the assumption that the glucometer was in the right place (the distance travelled and the number of times the glucometer was used provided the empowering data). They moved the glucometer closer to the staff workstation and brought the supplies next to the glucometer, thus getting it closer to the point of care.

In these examples, one could see that the simple spaghetti map helped the staff to think differently, challenge the status quo and make changes that improved their work flow and made it efficient.