Scott D. Duncan, MD, MHA, FAAP
Science of Safety
We cannot improve quality and safety of
healthcare until we view the everyday
delivery of healthcare as a science
Flow Charts
“If you can’t describe what your doing as a
process, you don’t know what you’re doing”
W. Edwards Deming
• A written description of a process requires a
common definition of terms, fluency with the
concepts, and the absence of an agenda by
the author and reader.
"Draw a flowchart for whatever you are doing. Until
you do, you do not fully understand what you are
doing. You just have a job.“
"The first step in any organization is to draw a flow
diagram to show how each component depends on
others. Then everyone may understand what their
job is. If people do not see the process, they
cannot improve it."
SIPOC+CM
• SIPOC is a data collection form that is used
before we start to construct a flow chart since
it helps us to gather relevant information
about the process.
• Assists in gathering information about
Suppliers, Inputs, Process, Outputs, and
Customer of the process.
• SIPOC is high level view of the “As Is” state
of a process under investigation.
SIPOC+CM
When to use it:
• When first starting to investigate a process
and a team needs to understand the basics
that make up the process.
• When a team needs a way to get the
collective knowledge of the team members
about a process recorded in an easy to view
format.
• When we need to make a concise
communication to others about a process and
the parameters that it encompasses.
SIPOC+CM Collection Form
Begins With:
Constraints:
Ends With:
Process/Activities:
Measures
Inputs:
Outputs:
Suppliers:
Customers:
Flow Charting
• Flow charting is the first step we take in
understanding a process
• Organized combination of shapes, lines, and
text
• Flow charts provide a visual illustration, a
picture of the steps the process undergoes to
complete it's assigned task
• From this graphic picture we can see a
process and the elements comprising it
• Shows how interactions occur
• Makes the invisible visible
Flow Chart Benefits
• Problem Identification
• Generating Solutions
• Test
• Disseminate
7
Flow Chart Benefits
• Puts a spotlight on waste
• Streamlines work processes
• Defines and standardizes the steps and
sequence
• Promotes deep understanding
• Builds consensus
• Key tool for continuous quality improvement
11
Flow Charting Construction
• Clearly define the process boundaries to be
studied
• Define the first and last steps – start and
end points
• Get the right people in the room
• Decide on the level of detail
– Complete the big picture first – macro view
– Fill in the details – micro view
Flow Charting Construction
• Gather information of how the process
flows:
–
–
–
–
–
Experience
Observation
Conversation
Interviews
Research
• Clearly define each step in the process
– Be accurate and honest
Flow Charting Steps
• Use the simplest symbols possible – Post-Its
• Make sure every loop has an escape
• There is usually only one output arrow out of a
process box. Otherwise, it may require a
decision diamond.
• Trial process flow – walk through people
involved in the process to get their comments
• Make changes if necessary
• Identify time lags and non-value-adding steps.
Adding Time Lines
Could Be Flow Chart
As Is Flow Chart
Time
Should Be Flow Chart
Time
Flow Charts
Flow Chart Symbols
Start/End
Bookends
Activity:
Manual
Operation
Data Base
Operation/Inspection
A
Connector
Comment
Collector
Wait/Delay
Decision
Storage
Input/
Output
Data
Document
Forms
Transport
Input
Output
Display
Manual
Input
Preparation
Unfamiliar/
Research
Process Flow Chart
Written physician
order scanned to
pharmacy from 3L for
a scheduled oral
medication.
Is the time of
order entry
prior to
1240?
Yes
No
Is a dose due
prior to 1800
on the day
AFTER initial
order entry?
Yes
A
Is a dose due
prior to 1800
on the day
AFTER initial
order entry?
Yes
No
B
C
No
D
Process Flow Chart
A
Order entry by the pharmacist
Label will print
Pharmacy technicians receives
label(s) for a patient specific oral
medication.
Technician draws up the
appropriate patient specific dose
into an oral syringe and labels the
oral syringe with the patient’s label.
Syringes are left with the bulk
medication bottle for pharmacist
verification.
Pharmacist verifies that medication
dispensed matches the medication
ordered on the label and initials the
medication label.
Medication is tubed to 3L.
Process Mapping:
Initial Workflow
HIV Positive
Patient comes
to Clinic
Registration
Process with
Receptionist
Patient
schedules
appointment to
review results of
CD4 count
Enrollment
Process
with RN
Blood for CD4
count drawn
Patient
scheduled
to see MD
Yes
Lab
open?
Intervention:
·
Counselling
·
CD4 testing
ordered
No
Patient
returns to lab
for
appointment
Patient
returns to
clinic for
appointment
Patient
registers
Yes
Patient
registers
Pt has
access to
ARVs?
Patient seen
by Physician
No
Patient
scheduled
for CD4
count
Patient Leaves Clinic
Patient
returns to
clinic for
appointment
Patient Leaves Clinic
Intervention:
·
Counselling
·
CD4 test not
ordered
Patient Leaves Clinic
Patient seen
by Physician
CD4 count
reviewed with
patient, and
significance
explained.
Treatment
plan is
developed.
23
Analyzing A Flow Chart
Assessing the current process map with the goal of
improving patient flow by looking for steps that:
i) Definitely add value
ii) Add no value, but are unavoidable
iii) Add no value, but are avoidable
Once completing a process map, return to the
site and discuss it with employees to ensure
its accuracy. Together, consider how the map
could be used to make improvements to the
system.
Analyzing A Flow Chart
Examine each:
–
–
–
–
–
–
–
–
–
–
Activity symbol – value/cost?
Decision point – necessary/redundant?
Choke Points – bottlenecks?
Rework loop – time/cost?
Handoff – is it seamless?
Document or data point – useful?
Wait or delay symbol – why?/reduce/eliminate
Transport Symbol – time/cost/location?
Data Input Symbol – right format/timely?
Document/Form Symbol – needed/cost/value?
Process Mapping:
Areas for Improvement
HIV Positive
Patient comes
to Clinic
Registration
Process with
Receptionist
Patient
schedules
appointment to
review results of
CD4 count
Enrollment
Process
with RN
Blood for CD4
count drawn
Patient
scheduled
to see MD
Yes
Lab
open?
Intervention:
·
Counselling
·
CD4 testing
ordered
No
Patient
returns to lab
for
appointment
Patient
returns to
clinic for
appointment
Patient
registers
Yes
Patient
registers
Pt has
access to
ARVs?
Patient seen
by Physician
No
Patient
scheduled
for CD4
count
Patient Leaves Clinic
Patient
returns to
clinic for
appointment
Patient Leaves Clinic
Intervention:
·
Counselling
·
CD4 test not
ordered
Patient Leaves Clinic
Patient seen
by Physician
CD4 count
reviewed with
patient, and
significance
explained.
Treatment
plan is
developed.
26