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Health Care Workflow Process Improvement
Welcome to Health Care Workflow Process Improvement: Process Diagrams. This is Lecture b, Using ISO 5807 Process Diagrams. This lecture covers creating flowchart style process diagrams and the associated standard symbols. Process Diagrams Lecture b This material (Comp 10 Unit 3) was developed by Duke University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC This material was updated by Normandale Community College, funded under Award Number 90WT0003. This work is licensed under the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. To view a copy of this license, visit
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Process Mapping Learning Objectives
Create a process flowchart for a health care system (or system component) using appropriate ISO 5807 symbols and conventions. Choose the correct scope and detail level for a process flowchart and data flow diagram The objectives for this lecture are to: Create a process flowchart for a health care system (or system component) using appropriate ISO 5807 symbols and conventions, Create context and data flow diagrams for a health care system (or system component) using appropriate Yourdon symbols and conventions, Choose the correct scope and detail level for a process flowchart and data flow diagram, Read and interpret Gane-Sarson data flow diagram, Read and interpret an entity relationship diagram in crow’s foot notation, and Read and interpret UML class, activity, and state diagrams.
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Process Mapping Lecture b - Topics
Standard ISO 5807 process diagramming symbols and conventions Reading an ISO 5807 flowchart in terms of the information that could be generated and the workflow steps that are being communicated Create ISO 5807 flowcharts for a health care system (or system component) using correct symbols and conventions In this lecture we will provide further details about the International Standards Organization (ISO) 5807 symbols and conventions. Lecture b also covers reading an ISO 5807 flowchart in terms of the information that could be generated and the workflow steps that are being communicated. And finally, lecture b prepares you to create ISO 5807 flowcharts for a health care system (or system component) using correct symbols and conventions. Importantly, most organizations use flowcharts in information technology and in quality improvement efforts. In health care workflow process improvement, you will also see, interpret, and create flowcharts.
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Methods for Diagramming Processes
Recall that each of the methods for diagramming a process has its own set of capabilities. With ISO 5807 flowcharts a process analyst is able to represent the process or data flow steps, any information transformations that occur or should occur, the order or sequence of the steps involved in the process, and the roles of the persons completing the steps in the process. The flowchart is a useful, and probably the most common tool in mapping the workflow processes in health care. Table 3.2 Methods for Diagramming Processes *UML extends beyond basic process features and models other aspects such as sequence, communication, and interrelationships. We do not cover these aspects here.
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Flowchart A graphic depiction of the steps or activities that constitute a process ISO 5807: 1985 standard - Standard symbols for flowcharts “Graphical representation of the definition, analysis, or method of solution of a problem in which symbols are used to represent operations, data, flow, equipment, etc.” (ISO, 1985) A flowchart is a graphic depiction of the steps or activities that constitute a process. The International Standards Organization (ISO) defines flowchart as a “graphical representation of the definition, analysis, or method of a solution of a problem in which symbols are used to represent operations, data, flow, equipment, etc.” (ISO, 1985) The ISO 5807: 1985 standard defines symbols to be used in information processing documentation and gives guidance on conventions tor their use in data flowcharts and other diagrams. Many organizations require the documentation of dataflow or process flow. Some organizations require a flowchart to accompany every Standard Operating Procedure (SOP). Organizations also use flowcharts to document and communicate the data flow or process flow for information technology and quality improvement projects.
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Flowchart Constructed from standard symbols
Used to communicate processes Software functionality important in flowcharting The shapes available Connectors that attach to the shapes Connectors facilitate editing the flowchart Flowcharts are constructed from standard symbols. It is important that standard symbols be used because flowcharts are used to communicate processes. When people see a specific symbol in a chart, they understand a specific meaning – like a road sign. Thus, to read, use, and create flowcharts, knowing the meaning of the standard symbols is important. The ISO 5807: 1985 specifies the standard flowchart symbols for information processing. Many software applications have flowcharting functionality. Some of these are Microsoft Word, Microsoft PowerPoint, and Visio. The functionality that is important to flowcharting includes the standard shapes are available and there are “connectors” that latch to the shapes and stay attached until you detach them, for example while repositioning the shapes in the drawing canvas. This facilitates editing the flowchart.
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Flowchart Symbols terminal process decision document connector
Reviewing from unit 2: The terminal symbol is a rounded rectangle which identifies the beginning or end of a process or origin and destination of data. The process symbol is a rectangle which designates an activity. Within the rectangle is a brief description of that activity. The decision symbol is a diamond which designates a decision point from which the process branches into two or more paths. The path taken depends on the answer to the question which appears within the diamond. Each path is labeled to correspond to an answer to the question. The document symbol is a human readable document pertinent to the process. The flow line represents a process path which connects process elements. The arrowhead indicates the direction of the flow. The connector is a circle which is used to indicate a continuation of the flow diagram.
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ISO 5807 section 9.2.1 Basic Process Symbol
“This symbol represents any kind of processing function, for example, executing a defined operation or group of operations resulting in a change in value, form or location of information, or in the determination of which one of several flow directions is to be followed.” (ISO, 1985) The Basic Process “symbol represents any kind of processing function, for example, executing a defined operation or group of operations resulting in a change in value, form or location of information, or in the determination of which one of several flow directions is to be followed.” (ISO, 1985) In this example, the basic process symbol represents the following: Patient signs-in and checks-in with the front desk, Receptionist enters the patient into the visit system as present and confirms the insurance information with the patient The nurse pulls the chart from the filing stacks and Escorts the patient to the exam room.
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ISO 5807 section Decision “This symbol represents a decision or switching type function having a single entry but where there may be a number of alternative exits, one and only one of which may be activated following the evaluation of conditions defined within the symbol. The appropriate results of the evaluation may be written adjacent to the lines representing the paths.” (ISO, 1985) Decision symbols can show nominal decisions (yes/no), or decisions with multiple possible outcomes. The decision, or diamond, “symbol represents a decision or switching type function having a single entry but where there may be a number of alternative exits, one and only one of which may be activated following the evaluation of conditions defined within the symbol. The appropriate results of the evaluation may be written adjacent to the lines representing the paths.” (ISO,1985) Decision symbols can show nominal decisions (yes/no), or decisions with multiple possible outcomes. In this example, the patient is given a drug susceptibility test and a decision is made as to the appropriate type of prescription to write based on the test results. Note that the actions are different for the patients who are susceptible and the patients who are not, thus, the decision symbol denotes a point at which the depending on the result of the decision, the process will proceed via different paths.
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ISO 5807 section 9.4.2 Terminator
“This symbol represents an exit to, or an entry from, the outside environment, for example, start or end of a program flow, external use and origin or destination of data.” (ISO 1985) This is an example of the Terminator symbol. The Terminator “symbol represents an exit to, or an entry from, the outside environment, for example, start or end of a program flow, external use and origin or destination of data.” (ISO, 1985) This symbol is described in section of the ISO 5807 documentation. Here the Terminator symbol is used to represent the entry of the patient into the process (health care workflow setting). Example: Terminator symbol use
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Review: What’s Wrong with this Flowchart?
Examine the flowchart closely. Take a few minutes and list the symbols that are correctly and incorrectly used according to the flowchart symbols on the previous slide. Correct symbols are used for the decision boxes and the connectors. Incorrect symbol use is a matter of which notation one is following, and how formal or conformant to any one notation one wants to be, i.e., correctness with respect to notation is a relative matter. Comparing the flowchart on this slide to the list of symbols on the previous slides, i.e., according to the ISO 5807 standard, we see that the rounded-corner rectangle used as a terminator should be a different shape, one with parallel lines on the top and bottom and half-circle curvature on the left and right sides. The arrow heads should be shaded or filled in rather than open. Source: Nahm M. Duke Universtiy, 2012
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Decision With Multiple Outcomes
The process flow diagrams can become quite complicated. The example in front of you is taken from a hospital setting where there are multiple decisions to be made and multiple actions based on these decisions. This complexity is found in most health care settings. In this In-patient hospitalization example, we will walk through key decisions and actions as displayed in this slide. A patient is admitted to the hospital and placed in an examination room The Admission Summary is completed Various observations per the hospital standards are obtained. These can include: Vital signs, temperature Continuous 12-lead monitoring Cardiac enzymes Distal pulse Noting of wounds, pain, and/or other symptoms Presence of a hematoma or clotting time if there is bleeding Medication is administered, and Continuations of the medical assessment which will be determined by preliminary findings. Examples are: If there is chest pain, then collect duration of hospital stay related to chest pain If the patient displays oozing of hematoma, then evaluate for surgical repair of puncture site and prepare for the Operation Room If the patient is improving, then transfer to step-down facility and plan for the patient to be discharged If the patient is not improving, then manage medically by continuing various observations per hospital standards and continuing medical assessments If the patient has a planned Coronary Artery Bypass Graft (CABG) which is expected, then prepare for the Operation Room If the patient has complications from a procedure, either expected or unexpected in this representation, the staff will prepare for the Operation Room. 5. Finally, a discharge summary will need to be prepared. This particular example is part of a larger chart. Note the line entering from the left.
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ISO 5807 Section Document “This symbol represents human readable data, the medium being, for example, printed output, an OCR [optical character recognition] or MICR [magnetic ink character recognition] document, microfilm, tally roll, data entry forms.” (ISO 1985) “This symbol (a rectangle with the bottom long side is curved such that the left side is lower) represents human readable data, the medium being, for example, printed output, an OCR [optical character recognition] or MICR [magnetic ink character recognition] document, microfilm, tally roll, data entry forms.” (ISO, 1985) Here the staff member reviews the patient’s charts and files them. The documents in the patient chart, i.e., the patient chart, is represented by a document symbol. Example of document symbol use
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Manual input versus manual operation
ISO 5807 section Manual input “This symbol represents data, the medium being of any type where the information is entered manually at the time of processing, for example, on-line keyboard, switch settings, push buttons, light pen, bar-code wand.” (ISO 1985) ISO 5807 section Manual operation “This symbol represents any process performed by a human being.” (ISO 1985) According to ISO 5807 section , the symbol for manual input is a quadrilateral with two parallel sides, two 90° angles, one obtuse angle and one acute angle. “This symbol represents data, the medium being of any type where the information is entered manually at the time of processing, for example, on-line keyboard, switch settings, push buttons, light pen, bar-code wand.” (ISO, 1985) According to ISO 5807 section , the symbol for a manual operation is an isosceles trapezoid (a quadrilateral with two parallel sides and the sides that aren't parallel are equal in length and both angles coming from a parallel side are equal). “This symbol represents any process performed by a human being.” (ISO, 1985)
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Example: Manual Operation and Manual Input
In this example, the manual operation of receiving the forms and manual input of keyboard entry of data are represented. The example is as follows: Billing form arrives at the receptionist. Afterward, presumably the receptionist locates the patient in system and performs keyboard entry of the patient form. For this operation, the form for the patient visit appears on the screen; The standard claim form is an input to the process.
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Data Symbols ISO 5807 section 9.1.1.1 Data
“This symbol represents data, the medium being unspecified.” (ISO 1985) ISO 5807 section Stored data “This symbol represents stored data in a form suitable for processing, the medium being unspecified.” (ISO 1985) According to ISO 5807 section , the symbol for Data is a parallelogram (opposite sides are parallel and equal in length, and opposite angles are equal). “This symbol represents data, the medium being unspecified” (ISO, 1985). According to ISO 5807 section , the symbol for stored data is a four-sided figure with two-parallel sides, one rounded concave end and one rounded convex end. “This symbol represents stored data in a form suitable for processing, the medium being unspecified” (ISO, 1985).
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Data Symbol Example Here is a Data Symbol example:
The process starts with the logging of a Patient, presumably into a data system. Afterwards, two things occur in parallel: 1) a data record from a referring physician is sent to the database for storage, and 2) data is collected during the Patient visit. After the “during patient visit data collection” which presumably occurs on a paper form – signified by the manual process symbol, a data entry operator locates the Patient record in the system. After which two things occur, 1) the entry form for Patient visit appears, and 2) keyboard entry of patient form followed by storage of the data in a database. In this example data are represented in two distinct ways. Note that the generic data symbol is used for data from the referring physician. It does not specify medium, such as disc or electronic file transfer, however, because the data go directly to the database, it would be reasonable to infer electronic transfer. Use of the stored data symbol for the office database also signifies data; the symbol specifically indicates stored data. The vertical cylinder could have also been used. In flowchart creation for process analysis, the chart should be specific enough so that the assumptions signified in the example by the word presumably, and the assumption about the medium of data transfer are not required. Such assumptions should trigger the analyst to learn and diagram in more detail.
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ISO 5807 section Display “This symbol represents data, the medium being of any type where the information is displayed for human use, for example, video screens, on-line indicators.” The display symbol is shaped like the traditional cathode ray tube (CRT) computer monitor viewed from the side. (ISO 1985) The Display “symbol represents data, the medium being of any type where the information is displayed for human use, for example, video screens, on-line indicators.” (ISO, 1985) The Display symbol is shaped like the traditional cathode ray tube (CRT) computer monitor viewed from the side. For people who have only used flat screens, the symbol shape is less intuitive. The flowchart example on the slide shows the following: Patient arrives Receptionist checks Patient in Receptionist locates Patient in EHR Form for Patient visit appears (on computer screen) Keyboard entry of patient information
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ISO section Connector “This symbol represents an exit to, or an entry from, another part of the same flowchart, and is used to break a line, and to continue it elsewhere. The corresponding connector symbols shall contain the same unique identification.” (ISO 1985) Example: Connector use. Above the line is the first page of a document. Below the line is from the second page of the document. According to ISO section 9.4.1, the symbol for a Connector is a circle with a number in it. “This symbol represents an exit to, or an entry from, another part of the same flowchart, and is used to break a line, and to continue it elsewhere. The corresponding connector symbols shall contain the same unique identification.” (ISO, 1985) Example: Page 1 of flowchart: Presumably the patient is escorted to exam room, after which chief complaint & vitals are recorded. Next, the provider is notified that the Patient is ready. After the “Notify provider Patient ready” process box, the connector indicates for the reader to “Go to the next page and start at the circle with a 1 in it”. Continuing on page 2 of the diagram, the reader would start at the circle with a 2 in it, which directs the reader to the next process step, “Examine Patient”. This step in the process is followed by a decision, presumably made by the provider about whether or not an order is required. If an order is required, the process continues to the order writing step. Note that the connector with a “1” connects the process across pages one and two.
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Delay The symbol used to represent a delay in a process looks like a “bullet”. Although not listed in ISO 5807, this symbol is commonly used because in logic diagrams, it represents an “and gate”. An “and gate” denotes that two or more things (thing 1 AND thing 2, two inputs) have to happen before proceeding. Two parallel lines are used to denote that things above them must be done before things below them can be done. In the diagram, processes B and C cannot start until process A has been completed. Adapted from (ISO 1985). The symbols used to represent a delay in a process are given here. The “bullet”, although not listed in ISO 5807, is commonly used because in logic diagrams, it represents an “and gate”. An “and gate” denotes that two or more things (“thing 1”-and-”thing 2,” two inputs) have to happen before proceeding. Two parallel lines are used to denote that things above them must be done before things below them can be done. In the diagram, adapted from the ISO 5807 standard, processes B and C cannot start until process A has been completed. (ISO, 1985)
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Non-Symbol Flowcharting Standard Conventions
This section covers: Use of text descriptions Detail level Flow direction Lines In this section, we will cover non-symbol conventions of flowcharting. These include use of text descriptions, indication of detail level, flow direction, and lines. These conventions are just as important as standard symbols. Not using them leaves the impression that the analyst is not familiar with the standards.
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Text Descriptions Text descriptions are done using “annotations” aka “call-outs.” This keeps the text in the box to a minimum so the chart is more readable. Lengthy text descriptions can be referenced to another page or footnote if necessary. If text descriptions refer to more than one box in a flowchart, a dotted line can be drawn around the steps that the text describes or refers to. This is a call-out It is often important to include text descriptions in a process representation. This is done using “annotations” aka “call-outs.” This keeps the text in the box to a minimum so the chart is more readable. Lengthy text descriptions can be referenced to another page or footnote if necessary. If text descriptions refer to more than one box in a flowchart, a dotted line can be drawn around the steps that the text describes or refers to.
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Detail Level While flowcharts can be used to represent different levels of process detail, items shown on the same diagram should be at the same detail level. The example flowchart at the top shows the main components of the research data collection process at the same detail level; a high-level view of the research data collection process. The bottom diagram is an example of combining items at different detail levels on the same diagram. Note the different level of detail in the bottom flowchart which includes the data processing steps. This would be better in a second flowchart. Combining items at different detail levels can cause confusion.
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Flow Flowcharts should “read” from top to bottom or right to left. Affirmative responses to yes/no decisions should all be in the same direction. Flow direction for process steps that show re-work (i.e. queries for data discrepancies going back to a data sender) should be opposite of the direction of the progressing process. In the “incorrect” example on the left of the slide, arrows denoting forward process progress are diagrammed in two different directions. When possible all forward process progress should be in the same direction. The preferred way to diagram this process is shown on the right.
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Flow Flowcharts should “read” from top to bottom or left and right. Lines should run up & down or left and right. Do not use diagonal lines. An “incorrect” diagram is shown on the left. The preferred way to diagram the process is shown on the right. Note this is left and right; not left to right.
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Lines A solid line is used to denote data or process flow. Arrows represent the direction of the flow. A dashed line is used to denote an alternate path. Arrows represent the direction of the flow. A jagged line is used to denote data transfer by a telecommunications link. Arrows represent the direction of the flow. Two parallel lines denote a synchronization between two parallel processes. i.e. that the things above it have to happen and all come to the denoted state before the things below it can occur. There are no arrows on synchronization lines. All lines that represent flow based on decisions should be labeled. Lines should run up & down or left and right. Do not use diagonal lines. There are multiple ways to connect process and data flow. A solid line is used to denote data or process flow. Arrows represent the direction of the flow. A dashed line is used to denote an alternate path. Arrows represent the direction of the flow. A jagged line is used to denote data transfer by a telecommunications link. Arrows represent the direction of the flow. Two parallel lines denote a synchronization between two parallel processes. i.e. that the things above it have to happen and all come to the denoted state before the things below it can occur. There are no arrows on synchronization lines. All lines that represent flow based on decisions should be labeled. Lines should run up & down or left and right. Do not use diagonal lines.
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Process Mapping Summary – Lecture b
At this point you should be able to Recognize and use ISO 5807 standard symbols and conventions, Read and interpret an ISO 5807 flowchart, Create ISO 5807 flowcharts for a health care system (or system component) using correct symbols and conventions. This concludes Lecture b of Process Mapping: ISO 5807. After completing lecture b, you should be able to: Recognize and use ISO 5807 standard symbols and conventions, Read and interpret an ISO 5807 flowchart, and Create ISO 5807 flowcharts for a health care system (or system component) using correct symbols and conventions.
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Process Mapping References – Lecture b
ISO/ANSI 5807 Information processing - Documentation symbols and conventions for data, program and system flowcharts, program network charts and system resources charts Charts, Tables, Figures 3.2 Table: Nahm, M., Duke University, 2012. Images Slide 7: Image of Symbols used in standard flowcharting. Nahm M. Duke University, 2012 Slide 8: Basic process symbol utilization in a flowchart. Nahm M. Duke University, 2012 Slide 9: Flowchart showing decision tree about drug testing. N ahm M. Duke University, 2012 Slide 10: Use of the Terminator symbol in workflow process diagramming. Nahm M. Duke University, 2012 Slide 11: Iikrant (own work). 2006). A flowchart about testing lamp working. [flowchart], Retrieved from Wikipedia Commons Slide 12: Flowchart of decision tree for patients coming into a hospital. Nahm M. Duke University, 2012 No audio.
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Process Mapping: ISO 5807 References – Lecture b
Images Slide 13: Example of document symbol use. Nahm M. Duke University, 2012 Slide 14: Definition of manual input versus manual operation. Nahm M. Duke University, 2012 Slide 15: Example: Manual Operation and Manual Input. Nahm M. Duke University, 2012. Slide 16: Symbols for Data and stored data. Nahm M. Duke University, 2012 Slide 17: Data symbol example. Nahm M. Duke University, 2012. Slide 18: Example of the Display symbol. Nahm M. Duke University, 2012 Slide 19: Example of the Connector symbol. Nahm M. Duke University, 2012 Slide 20: The Delay symbol. Nahm M. Duke University Slide 22: Annotations or "call outs". Nahm M. Duke University, 2012. Slide 23: Example of Detail Level in flow charts. Nahm M. Duke University, 2012. Slide 24: Example of appropriate and incorrect Flow in a chart. Nahm M. Duke University, 2012. Slide 25: Flow: From top to bottom or R to L. Nahm M. Duke University, 2012. Slide 26: Use of line in flow diagrams. Nahm M. Duke University, 2012. No audio.
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Process Diagrams Lecture b
This material was developed by Duke University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC This material was updated by Normandale Community College, funded under Award Number 90WT0003. No audio
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