Using Flow Charts to Understand Care Processes

What is a Flow Chart?

• Picture of the sequence of steps in a process

• Maps out the action steps and decisions within a process, from beginning to end

• Different steps or actions represented by boxes or other symbols

• Help you identify and understand a process

Mapping Out Processes of Care

• Sources of information:– Chart Audits

– Discussions with Providers

– Interviews with Patients

Constructing Flow Charts• Often focus first on index case –

– “What happened in this case?”

• Then can flow chart the usual course of events – “What usually happens?”

• Once you have established an overview of the usual process, if needed, you may drill down to progressive levels of detail to understand nuances of the process.

Antibiotic Orders in Pneumonia

• Community-acquired pneumonia improvement team

• ER admits - antibiotic administration times much improved

• Ongoing delays noted on patients admitted directly to ward from clinic

• Why the delays?

Antibiotic Orders in Pneumonia

Pt arriveson ward

Admitorderswritten

OrderstakenOff

Ordersfaxed to

pharmacy

R. Ph. Verifiesorder

Pharm Tech

fills order

Medgiven

Pt arriveson ward

Admitorderswritten

OrderstakenOff

Ordersfaxed to

pharmacy

R. Ph. verifiesorder

Pharm Tech

fills order

Medpreparedin pharm.

Medbroughtto floor

Medplaced inmed rm

Nurseretrieves

med

Nursegivesmed

Antibiotic Orders in Pneumonia

Pt arriveson ward

Admitorderswritten

OrderstakenOff

Ordersfaxed to

pharmacy

R. Ph. Verifiesorder

Pharm Tech

fills order

Medgiven

Pt arriveson ward

Admitorderswritten

OrderstakenOff

Ordersfaxed to

pharmacy

R. Ph. verifiesorder

Pharm Tech

fills order

Medpreparedin pharm.

Medbroughtto floor

Medplaced inmed rm

Nurseretrieves

med

Nursegivesmed

* * * * * *

*

Antibiotic Orders in Pneumonia

Pt arriveson ward

Admitorderswritten

OrderstakenOff

Ordersfaxed to

pharmacy

R. Ph. Verifiesorder

Pharm Tech

fills order

Medgiven

Pt arriveson ward

Admitorderswritten

OrderstakenOff

Ordersfaxed to

pharmacy

R. Ph. verifiesorder

Pharm Tech

fills order

Medpreparedin pharm.

Medbroughtto floor

Medplaced inmed rm

Nurseretrieves

med

Nursegivesmed

* * * * * *

*

* Only steps for which secondary measurements of time intervals readily available

Antibiotic Orders in Pneumonia

Pt arriveson ward

Admitorderswritten

OrderstakenOff

Ordersfaxed to

pharmacy

R. Ph. Verifiesorder

Pharm Tech

fills order

Medgiven

Pt arriveson ward

Admitorderswritten

OrderstakenOff

Ordersfaxed to

pharmacy

R. Ph. verifiesorder

Pharm Tech

fills order

Medgiven

Review of Flow Chart for Community-acquired Pneumonia

• Study the three patients represented on the flow chart.– Where are the areas of greatest delay?– Is this consistent or variable?– What questions does this suggest?– What additional information is needed in order

to better understand the process?– Is any variability in practice noted?

Antibiotic Orders in Pneumonia

Pt arriveson ward

Admitorderswritten

OrderstakenOff

Ordersfaxed to

pharmacy

R. Ph. Verifiesorder

Pharm Tech

fills order

Medgiven

Pt arriveson ward

Admitorderswritten

OrderstakenOff

Ordersfaxed to

pharmacy

R. Ph. verifiesorder

Pharm Tech

fills order

Medgiven

Antibiotic Orders in Pneumonia

Pt arriveson ward

Admitorderswritten

OrderstakenOff

Ordersfaxed to

pharmacy

R. Ph. Verifiesorder

Pharm Tech

fills order

Medgiven

Pt arriveson ward

Admitorderswritten

OrderstakenOff

Ordersfaxed to

pharmacy

R. Ph. verifiesorder

Pharm Tech

fills order

Medgiven

0

20

40

60

80

100

120

A B C D E F

Interval in Minutes

Antibiotic Orders in Pneumonia

Pt arriveson ward

Admitorderswritten

OrderstakenOff

Ordersfaxed to

pharmacy

R. Ph. Verifiesorder

Pharm Tech

fills order

Medgiven

Pt arriveson ward

Admitorderswritten

OrderstakenOff

Ordersfaxed to

pharmacy

R. Ph. verifiesorder

Pharm Tech

fills order

Medgiven

0

20

40

60

80

100

120

A B C D E F

Interval in Minutes

The orange boxes represent high impact areas for further intervention

Antibiotic Orders in Pneumonia

Pt arriveson ward

Admitorderswritten

OrderstakenOff

Ordersfaxed to

pharmacy

R. Ph. Verifiesorder

Pharm Tech

fills order

Medgiven

Pt arriveson ward

Admitorderswritten

OrderstakenOff

Ordersfaxed to

pharmacy

R. Ph. verifiesorder

Pharm Tech

fills order

Medgiven

Antibiotics in clinics?

What is theoptimal

antibiotic?

Are shiftchanges

a problem?

What aboutorder

priorities?

Can westock inPyxis?

Notify RNon

arrival?

Process Flow Charts

• Summary– Great way to grasp “usual” care delivery– Highlight delays and inefficiencies– Often uncover variable approaches to care– May frame additional information needs or

evidence-based questions

Moving from Identifying Problem Areas to Causation

• Mapping out a flow chart may allow to you identify problem areas within the process you are trying to improve.

• Within each problem focus area, you will need to dig deeper to understand the cause of the problem.