1:30 to 2:45 p.m. Friday, February 18, 2011
Marsha Moxley
RN, BSN, MA, CPHQ
Vice President Clinical Quality

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

›
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

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.

›
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

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

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

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

3
4
To assist in standardization of systems as graphical format for policy and procedures in organization
To assist training to visually lay out how policy and procedures should be performed by employees

OVAL
Represents
START or
STOP of process/ system; ovals are
“boundaries”
RECTANGLE DIAMOND
Represents
ACTIVITY step(s) of process/ system
Represents
DECISION points; form question; each decision should have yes or no path

TRIANGLE
SMALL
CIRCLE
Represents a
CONNECTION in process flow; more than 1 column or more than
1 page
Represents step where there is
WAITING or
STORAGE occurs
(admission/discharge)
ARROW
Represents step where product
(or patient) is in
TRANSPORT
(To therapy/dialysis)

If you don’t involve the user… you will develop the wrong system.
— Brian Joiner

1
2
Decide on system to flowchart
Define beginning and ending steps of system
TIP These are known as process/system boundaries

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

4
Ask What happens next?
Each subsequent process step will be in a
RECTANGLE

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

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 …

›
Process flowchart
›
Process map
›
Process chart
›
Business process model
›
Process model
›
Process flow diagram
›
Workflow diagram
›
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!

BEFORE

AFTER

Go back to sleep
Alarm goes off
Can I hit snooze button?
Get out of bed, turn off alarm
Let dog out
Take shower
Start coffee
Turn on TV, listen to news
A
A
Blow dry hair
Decide what to wear
Any special meeting?
Get dressed, put on jewelry
Apply makeup
1

Change would be easy … if it weren’t for all the people.

Process: Hospital Key Patient Processes
Admitting Management Physicians/Nurses
Schedule patients
Register patients
Receive patients
Manage patient medical info
Assure quality Care for patients
Release patients
Accounting
Generate billing records
Collect payments

RISK IDENTIFICATION/PREVENTION
New Admission/Re-admission
YES
Is pressure ulcer present?
NO
Complete 24 hr. Admission Assessment
1. Skin assessment to be 1 st section completed
2. Compare assessment findings to risk factors on IPOC.
YES
NO
Assess change in risk status by weekly skin assessments, change of condition, etc.
*See change of condition criteria below
Pressure Ulcer Flow Diagram
1. Discuss risks with resident and family/Risk brochures
2. Implement immediate interventions.
3. Develop individualized care plan.
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
Initiate IPOC – BE565 and place individual resident interventions and mark problems/risk factors
Notify family and document notification
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
TREATMENT: ACTIONS/STEPS
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.

YES NO
Is It Working?
Don’t Mess With It!
Anyone Else
Knows?
NO
Hide It
YES
YOU IDIOT!
You’re SCREWED!
NO
Can You Blame
Someone Else?
YES
NO PROBLEM!
YES
YES
Did You Mess
With It?
NO
Will It Blow Up
In Your Hands?
NO
Look The Other Way

›
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

›
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?

Flowchart a falls system
Decide who will debrief to all
Have some fun!

›
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!

› 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

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Marsha Moxley
RN, BSN, MA, CPHQ
Vice President Clinical Quality