Flowcharting

In this page we will briefly describe flowcharts and some enhancements that make flowcharts an even more powerful tool for understanding and discussing processes.

Objectives

At the end of this page you will know how to...

• Construct a flowchart.
  • Interpret a flowchart to identify process delays, feedback loops, rework, uncertainty, and variation.
  • Enhance a flowchart to illustrate process responsibility.
  • Simplify a flowchart using topdown charting techniques.

• Use a flowchart
  • Documents the current or proposed flow of people, paper, patients, products, materials, etc.
  • Identifies feedback loops.
  • Identifies bottlenecks in process flow.
  • Identifies process uncertainty and variation.

Basic Flowcharts 

Construction

Flowcharts most often use five basic symbols. At times other sysmbols, usually computer symbols, are also used.

Symbols are connected with arrows pointing in the direction of flow. The convention is for flow to move from left to right, or top bottom if space necessitates.

 Interpretation

• Inspection/repair activities - Checking the work of others is wasteful.
• Feedback/rework loops- The flow makes a U-turn and several steps are repeated. This is hideously wasteful. Eliminate them if possible; shorten them at least.
• Waits/holds/stores - Though sometimes unavoidable, waits are always a candidate for elimination in an improvement effort. Two usual causes:
  * Waiting - Patients waiting to checkin, calls on hold, etc.
  * Batching - Waiting for next scheduled pick-up, batching, etc.
• Unnecessary activities- Question each and every activity. Is it necessary? Can the productivity and/or quality improve? Is there a better way to do it?
• Connections - It's not a vacuum between activities. How is the person or the thing getting from A to B?
• Fog - Investigate all uncertainty in a process. don't guess or assume
• Be honest- Fix the process; not the flowchart!
• Start with a high level flowchart for large complex process. Work towards detailed the flowchart. At the very least the high level flowchart makes for a good presentation chart.

Best done in a brainstorming session. Especially interdisciplinary processes. In this setting use Post-it© Notes and draw the chart later.

Example

Example flowchart of Labor, Birth, and Recovery Department Information System

In this flowchart is a very simple version of the flow of information into the LBR computer system.

The data is collected on a document known as the 'blue sheet' and sent to the O.R. Management department for data entry. From there the data is electronically passed to the billing system and a reporting and analysis database.

Several problem areas are apparent from the flowchart. One is the presence of two 'inspection', or checking, steps in O.R. Management. These steps check the work of the people in LBR; an inefficient and problematic checking process because the steps occur outside of the area where the Blue Sheet was filled in. The second problem is the presence of fog, namely the billing process. Nobody involved in the flowcharting process knows anything about the billing process or its requirements.

Topdown Flowcharts 

Use

Used as a step in constructing detailed flowcharts or to simplify - for presentation purposes - a detailed flowchart. This is a great tool for beginning the flowcharting process; it keeps the team from bogging down in minutiae, at least tooo quickly. It also makes a great presentation tool.

It is most useful, however, as a 'process mapping' tool, structuring the entire organization into an integrated flowchart schema. The highest level drawing shows the 'core' (or 'key') business processes and their relationships. The devil is in the details, which the more detailed flowcharts will increasingly iluminate.

The following new prescription process presents a topdown flowchart. This high level view has 5 steps, plus an problem feedback step.

Construction

• Start with a less detailed ("high level") flowchart.
• List the more detailed activities associated with each step (below if flowchart is horizontal, to the right if the flowchart is vertical) in text form.
• Each high level step may have its own flowchart separate from the main flowchart. The process can continue, with more and more detailed flowcharts emerging, until the desired level of detail is achieved.

Interpretation

This flowchart is interpreted in much the same manner as the basic flowchart. What is of interest here, though, is the level of detail. And, the relationships at different levels of detail. "Handoffs" from one workgroup to another are also an important analysis using a topdown flowchart: much easier than with a detailed flowchart.

Example

This example shows the high level flowchart moving down the page and the details to the right. Each high level step contains a flowchart-within-a-flowchart consisting of the details steps. It is this hierarchical scheme that gives rise to the name, topdown flowchart.

Matrix Flowcharts

Use

Shows process responsibilities with process flow. Shows who does what and when. The matrix flowchart is an excellent tool for reviewing and understanding interdepartmental handoffs in a process.

Construction

• Draw a matrix with process flow as one axis, the people/departments in the process as the other axis.
• Draw the process in relation to responsibility

Example

In this example we take the topdown flowchart from the previous pharmacy example and expand it, adding the extra dimension of Who is performing the activity.

Interpretation

The central role of the patient as messenger becomes apparent. The patient performs the crucial step of transmitting the presciption to the pharmacy. This causes several problems:

• Time is lost. The pharmacy waits until the patient delivers the prescription, and begins waiting, before processing. If the Rx was transmitted when written the pharmacy could have started filling it while the patient travelled to the Pharmacy.
• Problem solving is delayed. If a problem exist with the prescription as written it is not correctable until much later in the process, long after the physician has written it.
• Patient as communicator. The patient, probably untrained in medicine is an important communication link between the Pharmacy and the physician. On financial matters the patient becomes the communication link between the Pharmacy and the Finance departments.

All of these add potential inefficiencies and patient dissatisfaction to the process.

The timing of the pharmacist verifying the prescription is very problematic: it will now require someone (either the patient or the pharmacist) reconnecting with the prescribing physician (or nurse) to discuss and resolve the issue. Considerable process disruption is likely if the pharmacist calls the physician (thereby reducing the number of pharmacists available to process prescriptions). The organization also risks patient dissatisfaction is the patient is forced to return to the physician for problem resolution.

Additional Flowchart Analysis

Additional data enhances flowcharts and their analytic capabilities:

• Value added analysis. Coding activities in the flowchart for value added vs. non-value is a powerful way to visualize improvement opportunities.
• Time. Adding a timeline improves the analysts's ability to understand delays and handoffs in the process.
• Multi-media. Pictures or sounds from the process activities conveys a deeper sense of realism.
• Cause-Effect Diagram. Adding cause-effect diagrams to (at least the important) process steps puts that analysis in better perspective and enhances problem solving and root cause analysis. Cause-effect diagrams are covered in a separate Short Takes.

Conclusion

Flowcharts are a powerful tool for generating process knowledge. This knowledge of waste, rework, duplication, over-inspection, and inefficiency is a first step in making breakthrough process improvements.

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References

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