Scott D. Duncan, MD, MHA, FAAP

Science of Safety

We cannot improve quality and safety of healthcare until we view the everyday

delivery of healthcare as a science

Flow Charts

“If you can’t describe what your doing as a process, you don’t know what you’re doing”

W. Edwards Deming

•A written description of a process requires a common definition of terms, fluency with the concepts, and the absence of an agenda by the author and reader.

"Draw a flowchart for whatever you are doing. Until you do, you do not fully understand what you are

doing. You just have a job.“

"The first step in any organization is to draw a flow diagram to show how each component depends on others. Then everyone may understand what their

job is. If people do not see the process, they cannot improve it."

SIPOC+CM

• SIPOC is a data collection form that is used before we start to construct a flow chart since it helps us to gather relevant information about the process.

• Assists in gathering information about Suppliers, Inputs, Process, Outputs, and Customer of the process.

• SIPOC is high level view of the “As Is” state of a process under investigation.

SIPOC+CM

When to use it:• When first starting to investigate a process

and a team needs to understand the basics that make up the process.

• When a team needs a way to get the collective knowledge of the team members about a process recorded in an easy to view format.

• When we need to make a concise communication to others about a process and the parameters that it encompasses.

Process/Activities:

Begins With:Ends With:

Inputs:

Suppliers:

Outputs:

Customers:

Constraints:

SIPOC+CM Collection Form

Measures

Flow Charting

• Flow charting is the first step we take in understanding a process

• Organized combination of shapes, lines, and text

• Flow charts provide a visual illustration, a picture of the steps the process undergoes to complete it's assigned task 

• From this graphic picture we can see a process and the elements comprising it

• Shows how interactions occur• Makes the invisible visible

• Problem Identification

• Generating Solutions

• Test

• Disseminate

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Flow Chart Benefits

• Puts a spotlight on waste • Streamlines work processes • Defines and standardizes the steps and

sequence • Promotes deep understanding • Builds consensus • Key tool for continuous quality improvement

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Flow Chart Benefits

Flow Charting Construction

• Clearly define the process boundaries to be studied

• Define the first and last steps – start and end points

• Get the right people in the room• Decide on the level of detail

– Complete the big picture first – macro view– Fill in the details – micro view

Flow Charting Construction

• Gather information of how the process flows: – Experience– Observation– Conversation– Interviews– Research

• Clearly define each step in the process– Be accurate and honest

Flow Charting Steps

• Use the simplest symbols possible – Post-Its • Make sure every loop has an escape • There is usually only one output arrow out of a

process box. Otherwise, it may require a decision diamond.

• Trial process flow – walk through people involved in the process to get their comments

• Make changes if necessary

• Identify time lags and non-value-adding steps.

Adding Time Lines

As Is Flow Chart Could Be Flow Chart Should Be Flow Chart

Time Time

Flow Charts

Flow Chart Symbols

Activity:Operation/Inspection

Decision

Start/EndBookends

Document

Wait/Delay

Storage

Data Base

Transport

Input

Output

A Connector

Forms

CommentCollector

Input/OutputData

ManualOperation

Preparation

ManualInput

Display

Unfamiliar/Research

Yes

Yes Yes

No

No No

Process Flow Chart

Process Flow Chart

Process Mapping: Initial Workflow

HIV Positive Patient comes

to Clinic

Enrollment Process with RN

Patient scheduled to see MD

Registration Process with Receptionist

Patient returns to clinic for

appointment

Patient registers

Pt has access to

ARVs?

Intervention:· Counselling · CD4 test not

ordered

Intervention:· Counselling· CD4 testing

ordered

Lab open?

Yes

NoNo

Yes

Patient scheduled

for CD4 count

Blood for CD4 count drawn

Patient schedules

appointment to review results of

CD4 count

Patient returns to lab

for appointment

Patient returns to clinic for

appointment

Patient registers

Patient seen by Physician

Patient seen by Physician

Treatment plan is

developed.

CD4 count reviewed with patient, and significance explained.

Patient Leaves Clinic

Patient Leaves Clinic

Patient Leaves Clinic

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Analyzing A Flow Chart

Assessing the current process map with the goal of improving patient flow by looking for steps that:

i) Definitely add valueii) Add no value, but are unavoidableiii) Add no value, but are avoidable

Once completing a process map, return to the site and discuss it with employees to ensure its accuracy. Together, consider how the map could be used to make improvements to the system.

Analyzing A Flow Chart

Examine each:– Activity symbol – value/cost? – Decision point – necessary/redundant?– Choke Points – bottlenecks?– Rework loop – time/cost?– Handoff – is it seamless?– Document or data point – useful?– Wait or delay symbol – why?/reduce/eliminate– Transport Symbol – time/cost/location?– Data Input Symbol – right format/timely?– Document/Form Symbol – needed/cost/value?

HIV Positive Patient comes

to Clinic

Enrollment Process with RN

Patient scheduled to see MD

Registration Process with Receptionist

Patient returns to clinic for

appointment

Patient registers

Pt has access to

ARVs?

Intervention:· Counselling · CD4 test not

ordered

Intervention:· Counselling· CD4 testing

ordered

Lab open?

Yes

NoNo

Yes

Patient scheduled

for CD4 count

Blood for CD4 count drawn

Patient schedules

appointment to review results of

CD4 count

Patient returns to lab

for appointment

Patient returns to clinic for

appointment

Patient registers

Patient seen by Physician

Patient seen by Physician

Treatment plan is

developed.

CD4 count reviewed with patient, and significance explained.

Patient Leaves Clinic

Patient Leaves Clinic

Patient Leaves Clinic

Process Mapping: Areas for Improvement

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