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

3. Learning Objectives › 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 BY END OF SESSION, PARTICIPANTS WILL BE ABLE TO:

4. 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

5. Purpose of Flowchart 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 A flowchart is a picture of the steps (processes) within a system.

6. 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. NATIONAL PATIENT SAFETY FOUNDATION’S (NPSF) PHILOSOPHY

7. 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

8. 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

9. What is Difference Between Process and System? Process Series of actions that lead toward particular result System Regularly interacting or inter- dependent group of items forming unified whole; methodical in procedural of plan — Webster’s New Collegiate Dictionary

10. Why Use a Flowchart? In process improvement, flowcharts are often used to clarify: How process/system is currently being performed 1 To design how system should be performed 2

11. Why Use a Flowchart? To assist in standardization of systems as graphical format for policy and procedures in organization 3 To assist training to visually lay out how policy and procedures should be performed by employees 4

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

13. Flowcharting Symbols 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) Represents step where product (or patient) is in TRANSPORT (To therapy/dialysis) ARROW TRIANGLE

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

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

16. Steps to Develop Flowchart When developing flowchart, steps can be written on sticky notes so that actions can be reordered easily TIP Describe beginning of system with an 3 OVAL

17. Steps to Develop Flowchart Ask What happens next? Each subsequent process step will be in a 4 RECTANGLE

18. Steps to Develop Flowchart When decision step occurs, use a for questions Write yes or no and develop path for each 5 DIAMOND Ensure each decision loop reenters system or is pursued to conclusion TIP

19. Steps to Develop Flowchart Sometimes, due to branching at decision points, system may have more than one ending boundary — especially if complex “super” system TIP Describe ending step in an 6 OVAL

20. Things are the way they are … simply because they got that way. It’s always been done that way …

21. Examples of Various Types of Flowcharts

22. Common Names for Flowcharts › Process flowchart › Process map › Process chart › Business process model › Process model › Process flow diagram › Workflow diagram › Top down flowchart

23. Top Down Flowchart 1.1Assess if eligible to apply 1.2Review AHCA application 1.3Attend workshop 1.4Etc. Step 1: Plan to write AHCA application 2.1Copy of application to team 2.2Assign sections for content experts 2.3Set completion deadlines 2.4Review data, decide improvements 2.5Assign graphs; review options 2.6Assign 1 writer 2.7Etc. Step 2: Organize/ Assign roles; set deadlines 3.1Get final clean copy from writer 3.2Credit card approval 3.3Submit online 3.4Go out and celebrate! Step 3: Submit the darn thing

24. Workflow Diagram BEFORE

25. Workflow Diagram AFTER

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

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

28. Process Chart

29. Business Process Model Process: Hospital Key Patient Processes AdmittingManagementPhysicians/NursesAccounting Manage patient medical info Assure quality Register patients Receive patients Schedule patients Collect payments Generate billing records Care for patients Release patients

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

31. Flowchart for Problem Resolution Flowchart for Problem Resolution

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

33. Let’s give it a try!

34. What Did You Learn?

35. 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

36. 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?

37. Case Study Group Exercise

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

39. Flowcharting Software › Microsoft Word, PowerPoint, Excel (draw function) › www.smart.draw.com www.smart.draw.com › www.breezetree.com www.breezetree.com › www.edrawsoft.com www.edrawsoft.com › www.springcape.com www.springcape.com › Google flowcharting …you will be amazed!

40. References › www.smart.draw.com www.smart.draw.com › www.breezetree.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

41. Marsha Moxley RN, BSN, MA, CPHQ Vice President Clinical Quality Questions ? THANK YOU!