This video is about process flowcharts.
Quality improvement focuses on improving processes and outcomes.
Through changing processes, we aim to make systems work better,
and ultimately to improve outcomes.
An important improvement tool is a flowchart,
also called a flow diagram or flow map.
It is essentially a picture that shows all key steps of a process
in sequential order.
Why should we map our process and create a flowchart?
Drawing a flowchart helps us define and standardise key steps of a process.
It allows us to have a deeper understanding of a process
and analyse the sequence of steps or actions that go into it.
We are then able to more easily and correct identify problems
in the flow of healthcare from the patient's perspective.
Mapping the flow of our work helps us highlight waste
and allows us to understand where inefficiencies lie.
This then leads us to the critical step of generating
and putting in place solutions to improve and streamline work processes,
which ultimately lead to improvements in outcomes.
Flowcharts are also a great communication tool
to help improvement teams develop a shared understanding
of how a process is performed.
Drawing a flowchart requires some basic materials,
some note cards or sticky notes, a large piece of paper,
and some marking pens.
Later on in this video, we will go over an example
of a flowchart of a typical patient's visit to a clinic.
But first, here is a five-step process for drawing a flowchart.
Step one, define the process to be mapped.
Write its title at the top of the large paper.
Step two, brainstorm the activities that take place in the process.
Sequence is not important at this point,
although thinking in sequence may help people remember all the steps.
Decide on the boundaries of your process.
Where or when does the process start?
Where or when does it end?
What level of detail should your flowchart include?
Do you want this to be a high-level flowchart
or do you want to get more granular?
Step three is to define as many key activities
as you can in the process.
Write down each activity on a card or a sticky note.
When all activities are included,
in step four, arrange the sticky notes in sequence
and draw arrows to show the flow of the process.
Step five, review the flowchart with others involved in the process
such as frontline clinicians, supervisors and patients
to see if they agree that the process is drawn accurately.
Edit the flowchart if needed.
Now that we have looked at the five key steps in drawing a flowchart,
let us move on to some common symbols used in drawing these charts.
Whether you choose to use these symbols or not
is up to you and your improvement team.
A rectangle shows one step in the process.
The step is written inside the box.
Usually, only one arrow leads out of the box.
An arrow shows the direction of flow
from one step or decision to another.
A diamond denotes decision points
between two or more parts in your flowchart.
The question is usually written in the diamond.
More than one arrow leads out of the diamond.
Each arrow shows the direction the process takes
for a given answer to the question.
Often the answers are yes and no or true and false.
This symbol that resembles the letter D
signifies a delay or waiting period
when no activity is performed.
A circle is a connector or link to another page
or another flowchart.
The same symbol on the other page or other flowchart
indicates that the flow continues there.
A parallelogram shows inputs or outputs
or receiving or sending any type of data.
Examples are receiving a lab report,
sending an order for a prescription medication to the pharmacy
or sending an email to a patient.
A document is represented as a rectangle with a wavy base.
Start and end symbols are represented
as ovals around the rectangles,
usually containing the words start or end.
Here are some tips for drawing process flowcharts.
Don't worry too much about drawing your flowchart
the right way or the wrong way.
The right way is a way that helps people
who are involved understand the process.
Make sure to identify all key people
involved with the process
and engage them in creating the flowchart.
This includes those who work in the process
or are affected by it,
such as clinicians, supervisors and patients.
Involve them by interviewing them before the session,
drawing the flowchart with them
or by showing them the developing flowchart
between work sessions and obtaining their feedback.
Drawing a flowchart needs to be a hands-on process
by frontline stakeholders.
Do not assign a technical expert to draw the flowchart.
People who actually perform the process should do it.
Sometimes it is best to start with a paper, pen and sticky notes.
Computer software is available for drawing flowcharts
and is quite handy for drawing a neat final diagram.
But for the messy initial stages of creating your flowchart,
using pen and paper is just fine.
Now let us look at an example of a process flowchart
that was drawn as part of an effort
to improve process turnaround time
at a pediatric outpatient clinic.
A high-level map of a typical patient's clinic visit
is drawn here.
We decided to colour code our steps
by whether they involve the front office,
the nurse or the physician.
Our process starts by the patient checking in
at the front desk.
At the front desk, the clerk enters the patient's information
into the electronic medical record or EMR system.
The nurse notes from the EMR that the patient has checked in,
gets the patient and her mother from the waiting room
and takes them to the vital signs station.
There the nurse records the patient's vital signs
and then walks with the family to the examination room.
Next, the medical trainee or resident sees in the EMR
that the patient is now in the exam room.
She reviews the patient's chart,
enters the exam room and sees the patient.
The resident then exits the exam room
to consult with the attending physician.
Next, the attending physician enters the exam room
with the resident,
confirms key aspects of the history and exam
as per supervision requirements
and then exits the room.
The resident completes the visit,
prints out the visit summary from the computer
in the exam room,
walks to the printer at the nurse's station,
picks up the printout,
comes back to the exam room
and gives the printed summary to the patient's mother.
The patient and her mother then leave the room
and go to the checkout desk.
The clerk helps them schedule their next appointment
if one is needed.
The child and her mother then leave the clinic.
This is the end of our process.
An important value of the flow chart
is in identifying areas for improvement.
Is the process standardized?
Or are people doing the same work in different ways?
Are steps repeated or out of sequence?
Are there steps that do not add value to the outcome?
Are there steps where errors or delays occurs frequently?
The total time for a typical visit in this clinic
is 120 minutes or 2 hours on average,
including time spent in waiting.
Drawing the process map
helps the clinic staff understand
that much of this time did not add value
to the patient and her family.
Time spent in waiting was essentially waste.
Motion related to walking between the waiting room,
vital science station and exam room was waste.
And this information was obtained
just from a high level process map.
We can get even more granular if we like
by mapping out steps in greater detail
and adding in time spent at and between each step.
The clinic staff identified steps in the process
which they felt could be improved first.
Perhaps the vital science could be measured in the exam room
instead of at a separate vital station.
The resident could review the patient's chart
in advance of the visit,
reducing some waiting time and delay.
Printers could be located closer to or in the exam room.
Or the information could be sent electronically to the patient
if the EMR allows for it
and the family elects this method
of receiving the visit summary.
Remember that quality improvement is a process,
not an event.
A process flowchart helps a team map out steps and activities
and identify those that result in waste
and do not add value to patients.
