Understanding and Using Process Flow Charts to Improve Care
Learning Objective: At the completion of this session, the learner will:
 Demonstrate an understanding of how information regarding a care process can be organized into a process flow chart
 Understand how the process flow chart may help to identify unwanted variation in a clinical process
 Understand how the process flow chart may be utilized to identify high impact areas for instituting change in a clinical process
Clinical Process Review:
You are serving as a clinical nurse on a floor in which you frequently admit patients with community-acquired pneumonia. You are aware that early antibiotic
administration to such patients is associated with improved patient outcomes, and that this is also being reported by your hospital to the Joint Commission as one of the
core quality measures. Most of the patients admitted with pneumonia are being admitted through the Emergency Room, and are now usually receiving the first dose of
antibiotics prior to leaving the ER. However, about 20% of the pneumonia patients are being admitted from outpatient clinics, and for most of these admissions, getting
the first dose of antibiotics in within four hours has proven difficult.
Several nurses on your floor have stated that they feel that the delay is primarily occurring in pharmacy. You know that you’ve had three patients admitted within the
last week with pneumonia. With your unit charge nurse’s permission, you audit the charts for these three patients to see if you can tell where the delays are occurring.
The information you recorded from these reviews is contained on the following page.
Answer the following questions from the information on the next page:



From this information, does the pharmacy appear to be the area where intervention is needed to shorten the time to antibiotic administration?
Do you see any evidence of variation in care that might be contributing to the delays?
What would you consider the most productive areas for intervention?
Process Flow Chart for Ward Administration of First Dose Antibiotics in Community-Acquired Pneumonia
Patient
arrives on
ward
Admit
orders
written
Orders
taken off
Orders
faxed to
pharmacy
Pharmacy
Tech fills
orders
Pharmacist
verifies
order
Medication
administered
by floor
nurse
Numbers in small boxes represent elapsed time (hours:minutes) between steps
Patient 1
1:31
86 yo admitted
directly to 4E from
clinic with
pneumonia at 3PM
1:12
0:05
0:05
0:10
1:25
Levaquin 500 mg
daily IV ordered
(routine)
1:02
0:45
Total time = 4:28
0:03
0:06
0:12
2:05
Patient 2
46 yo admitted to
6 W from Urgent
Care Clinic with
pneumonia at 6PM
Patient 3
0:15
78 yo admitted
to 4E from clinic
with pneumonia &
renal failure at 1PM
Mean
0:56
Rocephin 1 g
daily IV ordered
(“1st dose Now”)
Total time = 4:13
0:15
0:04
0:03
0:35
Levaquin 500 mg
daily IV orderd
(“1st dose ASAP”)
0:44
1:45
Pharmacist called
ward to check dose
due to dx of renal
failure
0:04
0:04
0:19
1:45
Total time = 2:57
Mean 3:53