Transcript Using Flowcharting to Improve Inefficiencies

Using Flowcharting
to Improve
Inefficiencies
1:30 to 2:45 p.m. Friday, February 18, 2011
Marsha Moxley
RN, BSN, MA, CPHQ
Vice President Clinical Quality
Learning Objectives
BY END OF SESSION, PARTICIPANTS WILL BE ABLE TO:
› 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
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
A flowchart is a picture of the steps
(processes) within a system.
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
NATIONAL PATIENT SAFETY
FOUNDATION’S (NPSF)
PHILOSOPHY
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.
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 Between
Process and System?
Process
Series of actions that lead
toward particular result
System
Regularly interacting or interdependent 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:
1
How process/system is
currently being performed
2
To design how system
should be performed
Why Use a Flowchart?
3
To assist in standardization
of systems as graphical
format for policy and
procedures in organization
4
To assist training to visually
lay out how policy and
procedures should be
performed by employees
Flowcharting Symbols
OVAL
RECTANGLE
DIAMOND
Represents
START or
STOP of
process/
system;
ovals are
“boundaries”
Represents
ACTIVITY
step(s)
of
process/
system
Represents
DECISION
points;
form question;
each decision
should have
yes or no path
Flowcharting Symbols
SMALL
CIRCLE
Represents a
CONNECTION
in process
flow; more
than 1 column
or more than
1 page
TRIANGLE
ARROW
Represents
step where
there is
WAITING or
STORAGE
occurs
Represents
step where
product
(or patient)
is in
TRANSPORT
(admission/discharge)
(To therapy/dialysis)
If you don’t involve the user…
you will
develop
the
wrong
system.
— Brian Joiner
Steps to Develop Flowchart
1
Decide on system
to flowchart
2
Define beginning and ending
steps of system
TIP
These are known as
process/system boundaries
Steps to Develop Flowchart
3
Describe beginning of system
with an
OVAL
TIP
When developing flowchart, steps
can be written on sticky notes so
that actions can be reordered easily
Steps to Develop Flowchart
4
Ask What happens next?
Each subsequent process
step will be in a
RECTANGLE
Steps to Develop Flowchart
5
When decision step occurs,
use a
for questions
DIAMOND
Write yes or no and develop
path for each
TIP
Ensure each decision loop reenters
system or is pursued to conclusion
Steps to Develop Flowchart
6
Describe ending step
in an
OVAL
TIP
Sometimes, due to branching at
decision points, system may have
more than one ending boundary —
especially if complex “super” system
Things are the way they are …
simply
because
they got
that way.
It’s always
been done
that way …
Examples of
Various
Types of
Flowcharts
Common Names
for Flowcharts
›
›
›
›
›
›
›
›
Process flowchart
Process map
Process chart
Business process model
Process model
Process flow diagram
Workflow diagram
Top down flowchart
Top Down Flowchart
Step 1:
Plan to write
AHCA
application
1.1 Assess
if eligible
to apply
1.2 Review
AHCA
application
1.3 Attend
workshop
1.4 Etc.
Step 2:
Organize/
Assign roles;
set deadlines
2.1 Copy of application
to team
2.2 Assign sections
for content experts
2.3 Set completion deadlines
2.4 Review data,
decide improvements
2.5 Assign graphs;
review options
2.6 Assign 1 writer
2.7 Etc.
Step 3:
Submit
the darn
thing
3.1 Get final clean
copy from writer
3.2 Credit card
approval
3.3 Submit online
3.4 Go out
and celebrate!
Workflow Diagram
BEFORE
Workflow Diagram
AFTER
Process Map
Alarm
goes
off
A
Go back
to sleep
Can I
hit snooze
button?
Blow dry hair
Decide what to wear
Get out of bed,
turn off alarm
Any
special
meeting?
Let dog out
Take shower
Start coffee
Get dressed,
put on jewelry
Turn on TV,
listen to news
Apply makeup
A
1
Change would be easy …
if it
weren’t
for
all the
people.
Process Chart
Business Process Model
Process: Hospital Key Patient Processes
Admitting
Management
Physicians/Nurses
Accounting
Schedule patients
Register patients
Receive patients
Manage patient
medical info
Assure quality
Care for patients
Release patients
Generate
billing records
Collect
payments
RISK IDENTIFICATION/PREVENTION
New Admission/Re-admission
Complete 24 hr. Admission Assessment
YES
1. Skin assessment to be 1st section completed
2. Compare assessment findings to risk factors on IPOC.
Assess change in risk status by weekly skin
assessments, change of condition, etc.
Is pressure ulcer present?
YES
NO
1. Discuss risks with resident
and family/Risk brochures
2. Implement immediate
interventions.
3. Develop individualized
care plan.
NO
*See change of condition criteria below
Pressure Ulcer Flow Diagram
Pressure ulcer identified from admission skin
assessment/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
TREATMENT: ACTIONS/STEPS
Initiate IPOC – BE565 and place individual resident
interventions and mark problems/risk factors
Notify physician and document notification
Notify family and document notification
Print new treatment order and place on Treatment
Administration Record (TAR)
Notify:
• Dietary
• Activities
• Social Services
*Change of condition criteria — May include following:
•
•
•
•
•
•
Bed mobility problem
Bedfast
Bowel incontinence
Previous ulcer
Skin desensitized to pain or pressure
Daily restraint
Input MD order/treatment into Vista Keane system
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.
Flowchart
for
Problem
Resolution
YES
NO
Is It Working?
Don’t Mess With It!
YES
Did You Mess
With It?
YOU IDIOT!
NO
Anyone Else
Knows?
NO
Hide It
YES
You’re SCREWED!
NO
Can You Blame
Someone Else?
YES
NO PROBLEM!
YES
Will It Blow Up
In Your Hands?
NO
Look The Other Way
Let’s give it a try!
What
Did
You
Learn?
Developing
Flowchart 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 validate
flowchart is accurate vs. ideal
Common Questions
for 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
Flowchart
a falls
system
Decide
who will
debrief
to all
Have
some
fun!
Flowcharting
Software
› 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
THANK YOU!
Questions?
Marsha Moxley
RN, BSN, MA, CPHQ
Vice President Clinical Quality