Using Flowcharting to Improve Inefficiencies

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

2. Learning Objectives 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

3. 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

4. A flowchart is a picture of the steps(processes) within a system. 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

5. 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.

6. 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

7. 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

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

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

10. 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

11. Flowcharting Symbols DIAMOND OVAL RECTANGLE Represents START or STOP of process/system; ovals are “boundaries” Represents ACTIVITYstep(s)ofprocess/system Represents DECISIONpoints; form question; each decision should have yes or no path

12. Flowcharting Symbols SMALL CIRCLE Represents a CONNECTION in process flow; more than 1 columnor more than1 page Represents step wherethere isWAITING or STORAGEoccurs(admission/discharge) Represents step whereproduct (or patient) is inTRANSPORT(To therapy/dialysis) TRIANGLE ARROW

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

14. Steps to Develop Flowchart Decide on system to flowchart 1 Define beginning and endingsteps of system 2 These are known asprocess/system boundaries TIP

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

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

17. 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

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

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

20. Examples ofVarious Types of Flowcharts

21. Common Namesfor Flowcharts • Process flowchart • Process map • Process chart • Business process model • Process model • Process flow diagram • Workflow diagram • Top down flowchart

22. Top Down Flowchart Step 1: Plan to write AHCAapplication Step 2:Organize/Assign roles;set deadlines Step 3:Submitthe darnthing 1.1 Assess if eligible to apply 1.2 Review AHCA application 1.3 Attend workshop 1.4 Etc. 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. 3.1 Get final clean copy from writer 3.2 Credit card approval 3.3 Submit online 3.4 Go out and celebrate!

23. Workflow Diagram BEFORE

24. Workflow Diagram AFTER

25. Process Map Alarmgoesoff Yes A Can Ihit snoozebutton? Go backto sleep Blow dry hair Decide what to wear No Anyspecialmeeting? Get out of bed,turn off alarm Yes Let dog out No Take shower Get dressed,put on jewelry Start coffee Turn on TV,listen to news Apply makeup 1 A

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

27. Process Chart

28. Business Process Model Schedule patients Register patients Manage patientmedical info Receive patients Assure quality Care for patients Generatebilling records Release patients Collectpayments Process: Hospital Key Patient Processes Admitting Management Physicians/Nurses Accounting

29. RISK IDENTIFICATION/PREVENTION New Admission/Re-admission Complete 24 hr. Admission Assessment 1. Skin assessment to be 1st section completed 2. Compare assessment findings to risk factors on IPOC. YES NO Is pressure ulcer present? Assess change in risk status by weekly skin assessments, change of condition, etc. *See change of condition criteria below YES NO 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 TREATMENT: ACTIONS/STEPS Initiate IPOC – BE565 and place individual resident interventions and mark problems/risk factors Notify physician and document notification Input MD order/treatment into Vista Keane system Notify family and document notification Print new treatment order and place on Treatment Administration Record (TAR) • Notify: • Dietary • Activities • Social Services • 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 • *Change of condition criteria — May include following: • Bed mobility problem • Bedfast • Bowel incontinence • Previous ulcer • Skin desensitized to pain or pressure • Daily restraint Reassess, re-evalute and revise interventions when progress is not noted within 14 days.

30. Flowchart for ProblemResolution

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

32. Let’s give it a try!

33. WhatDidYou Learn?

34. DevelopingFlowchart 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 validateflowchart is accurate vs. ideal

35. Common Questionsfor 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?

36. Case Study Group Exercise

37. Flowcharta falls system Decidewho willdebriefto all Havesomefun!

38. FlowchartingSoftware • 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!

39. References • 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

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