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Purpose: A flowchart is a pictorial representation of the steps in a given process. The steps are presented graphically in sequence so that team members can examine the order presented and come to a common understanding of how the process operates.
Flowcharts can be used to describe an existing process or to present a proposed change in the flow of a process. Flowcharts are the easiest way to "picture" a process, especially if it is very complex. Flowcharts should include every activity in the process. A flowchart should be the first step in identifying problems and targeting areas for improvement.
Steps in Flowcharting a Process:
When drawing a flowchart, constantly ask "what happens next?", "is there a decision made at this point?", "does this reflect reality?", "who else knows this process?", etc. When possible, do a walk-through of the process to see if any steps have been left out or extras added that shouldn't be there. The key is not to draw a flowchart representing how the process is supposed to operate, but to determine how it actually does operate. A good flowchart of a bad process will show how illogical or wasteful some of the steps or branches are.
- Decide on the process to flowchart.
- Define the boundaries of the process: the beginning and the end.
- Describe the beginning step of the process in an oval.
- Ask yourself "what happens next?" and add the step to the flowchart as a rectangle. Continue mapping out the steps as rectangles connected by one-way arrows.
- When a decision point is reached, write the decision in the form of a question in a diamond and develop the "yes" and "no" paths. Each yes/no path must reenter the process or exit somewhere.
- Repeat steps 4 and 5 until the last step in the process is reached.
- Describe the ending boundary/step in an oval.
Symbols in a Flowchart:
Defines the boundaries of a process; shows the start or stop of a process. Designates a single step in a process. Briefly describe the step inside the box. A diamond signifies a decision point in the process. Write the type of decision made inside the diamond in the form of a question. The question is answered by two arrows--"yes" and "no"--which lead to two different branches. A small circle that surrounds a letter signifies where you pick up a process on the same page; represents a connection.
Flowcharting a Clinic VisitIt cannot be emphasized enough how important it is for people to understand how work gets done. Managers do not understand the details (and the devil is in the details!) but are often held accountable for the outcomes of their area without a clear understanding of what contributes to the outcomes. Workers get very frustrated when things go wrong and often assume that others are deliberately trying to make their lives difficult. Conflict management is much easier to deal with when everyone can see problematic system!
Getting a picture of how a clinic functions begins with a high level flowchart, usually depicted horizontally and called the core process. It is the "backbone" of the clinic operations to which other sub-processes can be attached. Once the core process flowchart is done (this should take about an hour), it should be given to staff and physicians for their input. It is common for the flowcharting process to have many iterations, as revisions and changes almost always need to be made before the flowchart accurately reflects the actual process. The trick is to keep the initial charting "high level" and not get stuck in details just yet. I personally like to segment the core process into components, such as: access, intake, assessment/evaluation, treatment, discharge/follow-up, for manageability and to help identify indicators.
Once the core process is agreed upon by those who work in the clinic, the next step is to decide which processes need attention (the bottlenecks for patient flow).
The hardest part of flowcharting is keeping it simple enough to be workable, but with enough detail to show the trouble spots. I recommend that the flowchart for sub-processes be vertical (as opposed to the core process that goes horizontally), keeping the smoothest flow to the left of the page, and the complexity to the right. This does not always work out perfectly, but when it does, it allows us to see the non-value added steps very quickly. I also like to leave lots of room for comments, since revisions are the rule. The more buy-in, the more revisions you have. Another trick I have learned is to capture the "issues" that surface when you're trying to create a flowchart. These issues may not be boxes in the process, but they will eventually be clues as to what needs to be addressed. For example, patients forget to bring their x-rays. I write these issues on the bottom of the flowchart so that they do not slow us from moving ahead with the processes steps.
Once a flowchart has been created and agreed upon, the next step is to study to see where improvements can be made. It is helpful to create a flowchart of the actual process first so you can truly see where the improvement opportunities are. If you are creating a new process, then the ideal flowchart can be created first. Having the processes clearly outlined will allow everyone to see what is suppose to happen and will also allow you to identify performance indicators/measures that will tell you how your clinic and processes are functioning.
Performance measures are best identified by dividing your flowchart into segments. These segments can be gleaned from the process itself. For example, in the clinic, there is a segment that deals with patients calling in for appoitments, a second segment that involves the registration of the patient when he/she arrives, a third segment that is the actual office visit, the a discharge segment. The question you want to ask is: how are each of these segments working? How would I know:? If you want to answer that question, you need to look at where performarnce measures would fit.
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