Marsha MoxleyRN, BSN, MA, CPHQVice President Clinical Quality

Using Flowcharting to Improve

Inefficiencies

Using Flowcharting to Improve

Inefficiencies1:30 to 2:45 p.m. Friday, February 18, 2011

Learning Objectives

› Identify three most common shapes used to develop flowchart

› List three different types of flowcharts

› Describe reason for utilizing flowcharting to understand basic concept of process management

BY END OF SESSION, PARTICIPANTS WILL BE ABLE TO:

When Should You Use Flowcharting?

› To gain knowledge and understanding of how actual system works vs. ideal system

› To identify redundant steps in system to improve performance

› To reduce variation and eliminate waste to improve quality and cost of care delivery

Purpose of Flowchart

Flowcharts are utilized to examine relation and sequence of steps; to identify

redundancy, unnecessary complexity, inefficiencies and to create common

understanding of flow of system

A flowchart is a picture of the steps(processes) within a system.

Most errors are a result from faulty systems rather than human error,

e.g., poorly designed processes that put people in situations where errors are

more likely to be made. Those people are, in essence, “set up” to make errors for which they are not truly responsible.

NATIONAL PATIENT SAFETY FOUNDATION’S (NPSF)

PHILOSOPHY

Flowchart: Snapshot of Your Business Process

› You can tell a lot about complexity (and often over-complexity) of many business processes just by looking at an “as is” flow chart of them … without even reading text in symbols

Flowchart: Snapshot of Your Business Process

› You can easily see:

– Flow of information and materials

– Branches in process

– Opportunities for infinite loops

– Number of process steps

– Inter-departmental operations … and more

What is Difference BetweenProcess and System?

Process Series of actions that leadtoward particular result

System Regularly interacting or inter-dependent group of items forming unified whole; methodical in procedural of plan

— Webster’s New Collegiate Dictionary

Why Use a Flowchart?

In process improvement, flowcharts are often used to clarify:

How process/system is currently being performed

1

To design how system should be performed

2

Why Use a Flowchart?

To assist in standardization of systems as graphical format for policy and procedures in organization

3

To assist training to visually lay out how policy and procedures should be performed by employees

4

Flowcharting Symbols

OVAL

Represents START or STOP of process/system;

ovals are “boundaries”

RECTANGLE

Represents ACTIVITY

step(s)of

process/system

DIAMOND

Represents DECISION

points; form question; each decision should have

yes or no path

Flowcharting Symbols

SMALLCIRCLE

Represents a CONNECTION

in process flow; more

than 1 columnor more than

1 page

Represents step where

there isWAITING or STORAGE

occurs(admission/discharge)

Represents step where

product (or patient)

is inTRANSPORT

(To therapy/dialysis)

ARROWTRIANGLE

If you don’t involve the user…

you will develop the wrong system.

— Brian Joiner

Steps to Develop Flowchart

Decide on system to flowchart

1

Define beginning and endingsteps of system

2

These are known asprocess/system boundaries

TIPTIP

Steps to Develop Flowchart

When developing flowchart, steps can be written on sticky notes so

that actions can be reordered easily

TIPTIP

Describe beginning of systemwith an

3

OVAL

Steps to Develop Flowchart

Ask What happens next?

Each subsequent process step will be in a

4

RECTANGLE

Steps to Develop Flowchart

When decision step occurs, use a for questions

Write yes or no and developpath for each

5

DIAMOND

Ensure each decision loop reenters system or is pursued to conclusion

TIPTIP

Steps to Develop Flowchart

Sometimes, due to branching at decision points, system may have more than one ending boundary —

especially if complex “super” system

TIPTIP

Describe ending stepin an

6

OVAL

Things are the way they are …

simply because they got that way.

It’s always been done that way …

Examples ofVarious Types of

Flowcharts

Examples ofVarious Types of

Flowcharts

Common Namesfor Flowcharts

› Process flowchart

› Process map

› Process chart

› Business process model

› Process model

› Process flow diagram

› Workflow diagram

› Top down flowchart

Top Down Flowchart

1.1 Assessif eligible to apply

1.2 Review AHCA application

1.3 Attend workshop

1.4 Etc.

Step 1: Plan to write

AHCAapplication

2.1 Copy of application to team

2.2 Assign sections for content experts

2.3 Set completion deadlines2.4 Review data,

decide improvements2.5 Assign graphs;

review options2.6 Assign 1 writer2.7 Etc.

Step 2:Organize/

Assign roles;set deadlines

3.1 Get final clean copy from writer

3.2 Credit card approval

3.3 Submit online

3.4 Go out and celebrate!

Step 3:Submit

the darnthing

Workflow DiagramBEFORE

Workflow DiagramAFTER

Get dressed,put on jewelry

Apply makeup

1

Process Map

Go backto sleep

Alarmgoesoff

Can Ihit snooze

button?

Start coffee

Let dog out

Get out of bed,turn off alarm

A

Take shower

Turn on TV,listen to news

A

Blow dry hair

Decide what to wear

Anyspecial

meeting?

Change would be easy …

if it weren’t for all the people.

Process Chart

Business Process Model

Process: Hospital Key Patient ProcessesAdmitting Management Physicians/Nurses Accounting

Manage patientmedical info

Assure quality

Register patients

Receive patients

Schedule patients

Collectpayments

Generatebilling records

Care for patients

Release patients

NO

1. Discuss risks with residentand family/Risk brochures

2. Implement immediateinterventions.

3. Develop individualized care plan.

RISK IDENTIFICATION/PREVENTIONNew Admission/Re-admission

Complete 24 hr. Admission Assessment1. Skin assessment to be 1st section completed2. Compare assessment findings to risk factors on IPOC.

YES

Assess change in risk status by weekly skin assessments, change of condition, etc.

*See change of condition criteria below

NO

Is pressure ulcer present?

YES

Pressure Ulcer Flow Diagram

Pressure ulcer identified from admission skinassessment/weekly skin assessment/observation

Implement resident specific interventions immediately:• Specialty mattress/pressure reduction mattress on bed• Pressure reduction cushion in wheelchair• Treatment as ordered• Individualized repositioning*See Pressure Ulcer Guideline and IPOC

PLAN OF CARE/COMMUNICATION

Initiate IPOC – BE565 and place individual resident interventions and mark problems/risk factors

Notify family and document notification

Notify: • Dietary• Activities• Social Services

Notify physician and document notification

Input MD order/treatment into Vista Keane system

Print new treatment order and place on Treatment Administration Record (TAR)

Initiate BE598C – Pressure Ulcer Report and document initial assessment of pressure area including:• Location and staging• Size (length x width/depth) presence and location of

undermining and tunneling• Edudate/if present” type, color, odor, and approximate amounts• Pain/if present: nature and frequency• Wound bed: color & type of tissue/character including/character

including evidence of healing (granulation) or necrosis (slough and eschar)

• Description of would edges and surrounding tissue

Reassess, re-evalute and revise interventions when progress is not noted within 14 days.

*Change of condition criteria — May include following:

• Bed mobility problem• Bedfast• Bowel incontinence• Previous ulcer• Skin desensitized to pain or pressure• Daily restraint

TREATMENT: ACTIONS/STEPS

Flowchartfor

ProblemResolution

Flowchartfor

ProblemResolution

Don’t Mess With It!

YES NO

YES

YOU IDIOT!

NO

Will It Blow UpIn Your Hands?

NO

Look The Other Way

Anyone ElseKnows?

You’re SCREWED!YESYES

NO

Hide ItCan You Blame Someone Else?

NO

NO PROBLEM!

YES

Is It Working?

Did You Mess With It?

Let’s give it a try!

WhatDidYou

Learn?

WhatDidYou

Learn?

DevelopingFlowchart Tips

› Use sticky notes and sharpies/markers (visible)

› Doesn’t have to be in meeting room– Go to nursing station

– Put each process on sticky note

› Use flipchart paper (easily switch steps)

› Ask those that work in system to validateflowchart is accurate vs. ideal

Common Questionsfor User of System

› What do you do first?

› What happens next?

› Is it always that way?

› Does it always work this way?

› Do you sometimes do something else?

› Do you ever experience problems because of lack of training, supplies or equipment?

Case Study

Group Exercise

Flowcharta falls system

Decidewho willdebriefto all

Havesomefun!

FlowchartingSoftware

› Microsoft Word, PowerPoint, Excel (draw function)

› www.smart.draw.com

› www.breezetree.com

› www.edrawsoft.com

› www.springcape.com

› Google flowcharting …you will be amazed!

References

› www.smart.draw.com

› www.breezetree.com

› Webster’s New Collegiate Dictionary

› The Team Handbook, Joiner, 5th Ed., 2001

› Root Cause Analysis: Simplified Tools and Techniques, Bjorn Anderson, Tom Lagerhaug, Milwaukee, WS, ASQ Quality Press, 2000

Marsha MoxleyRN, BSN, MA, CPHQVice President Clinical Quality

Questions?Questions?

THANK YOU!THANK YOU!