Using Flow Charts to Understand Care Processes

1. Using Flow Charts to Understand Care Processes

2. 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

3. Mapping Out Processes of Care • Sources of information: • Chart Audits • Discussions with Providers • Interviews with Patients

4. 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.

5. 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?

6. Antibiotic Orders in Pneumonia Pt arrives on ward Pt arrives on ward Admit orders written Admit orders written Orders taken Off Orders taken Off Orders faxed to pharmacy Orders faxed to pharmacy Pharm Tech fills order Pharm Tech fills order R. Ph. Verifies order R. Ph. verifies order Med given Med prepared in pharm. Nurse gives med Nurse retrieves med Med placed in med rm Med brought to floor

7. Antibiotic Orders in Pneumonia Pt arrives on ward Pt arrives on ward Admit orders written Admit orders written Orders taken Off Orders taken Off Orders faxed to pharmacy Orders faxed to pharmacy Pharm Tech fills order Pharm Tech fills order R. Ph. verifies order R. Ph. Verifies order Med given Med prepared in pharm. * * * * * * Nurse gives med Nurse retrieves med Med placed in med rm Med brought to floor *

8. Antibiotic Orders in Pneumonia Pt arrives on ward Pt arrives on ward Admit orders written Admit orders written Orders taken Off Orders taken Off Orders faxed to pharmacy Orders faxed to pharmacy Pharm Tech fills order Pharm Tech fills order R. Ph. verifies order R. Ph. Verifies order Med given Med prepared in pharm. * * * * * * Nurse gives med Nurse retrieves med Med placed in med rm Med brought to floor * * Only steps for which secondary measurements of time intervals readily available

9. Antibiotic Orders in Pneumonia Pt arrives on ward Pt arrives on ward Admit orders written Admit orders written Orders taken Off Orders taken Off Orders faxed to pharmacy Orders faxed to pharmacy Pharm Tech fills order Pharm Tech fills order R. Ph. Verifies order R. Ph. verifies order Med given Med given

10. 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?

11. Antibiotic Orders in Pneumonia Pt arrives on ward Pt arrives on ward Admit orders written Admit orders written Orders taken Off Orders taken Off Orders faxed to pharmacy Orders faxed to pharmacy Pharm Tech fills order Pharm Tech fills order R. Ph. Verifies order R. Ph. verifies order Med given Med given

12. Antibiotic Orders in Pneumonia Pt arrives on ward Pt arrives on ward Admit orders written Admit orders written Orders taken Off Orders taken Off Orders faxed to pharmacy Orders faxed to pharmacy Pharm Tech fills order Pharm Tech fills order R. Ph. Verifies order R. Ph. verifies order Med given Med given Interval in Minutes

13. Antibiotic Orders in Pneumonia Pt arrives on ward Pt arrives on ward Admit orders written Admit orders written Orders taken Off Orders taken Off Orders faxed to pharmacy Orders faxed to pharmacy Pharm Tech fills order Pharm Tech fills order R. Ph. Verifies order R. Ph. verifies order Med given Med given The orange boxes represent high impact areas for further intervention Interval in Minutes

14. Antibiotic Orders in Pneumonia Pt arrives on ward Pt arrives on ward Admit orders written Admit orders written Orders taken Off Orders taken Off Orders faxed to pharmacy Orders faxed to pharmacy Pharm Tech fills order Pharm Tech fills order R. Ph. verifies order R. Ph. Verifies order Med given Med given Antibiotics in clinics? What about order priorities? Can we stock in Pyxis? Notify RN on arrival? Are shift changes a problem? What is the optimal antibiotic?

15. 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

16. 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.