Vol. 11, No. 8
August 2009
PQ Systems
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Use flow charts
to simplify processes, advance learning

At the end of the day, Dr. Della Kitt’s feet and legs were so tired that sometimes she could barely walk to her car parked in the hospital parking lot (even though physicians’ parking was closest to the door). She was one of the physicians who served St. Curitall Hospital as what is known as “hospitalists,” overseeing the care of patients admitted to the hospital each day.

Dr. Kitt invested in new shoes, iced her feet at the end of the day, and massaged her ankles whenever she could. While she had some relief from these approaches, she knew that because she walked so many miles as a hospitalist who attended to many patients, sore feet might just be part of the territory.

Nurse Drew Lotts suggested using a Segway to get around the hospital—but Dr. Kitt felt that arriving on the gyroscopic vehicle might alarm her patients. Nurse Lotts, looking at Dr. Kitt’s schedule for patient visitations, noted the number of times that her route repeated itself: from ER to second floor surgical patients, to fourth floor, then back to second floor, and so on. By the time she finished these rounds, she could barely remember the first patient of the day, and clearly had little time to reflect on each patient’s condition. Her job had become mindless and frenetic as she rushed around.

“Why are you running back and forth like this? You’re like a chicken with its head cut off,” Nurse Lotts commented. Dr. Kitt couldn’t really answer, except to say that when she received a name of a patient who had been admitted, she would run off to see that patient, then back to her office to check for additional admissions, then to the next patient, and so on.

Lotts saw this as an inefficient process, and began to think of ways to improve it.

When a process seems inefficient or dysfunctional, one’s first inclination is to jump in and change something (for example, “Get a Segway”). We all know that behavior. Understanding a process is the often-overlooked first step toward improvement. This understanding takes time, but assures greater success in the long run.

Drew Lotts asked Della Kitt to give him a copy of her itinerary for several days, in order to study it and see what patterns emerged. After examining this process carefully, he saw that Dr. Kitt was visiting patients as soon as possible after being notified of each one’s admission. So she was running around the hospital in a somewhat random way, depending on the number of notifications she received. Her goal, of course, was to see patients as soon as possible after admission, but she was spending far too much time going from floor to floor and back again, often making this goal unrealistic.

Lotts did a simple flow chart of the process as it existed:

Figure 1: Dr. Della Kitt’s patient visits

It seemed to Lotts that the process could be streamlined. Dr. Kitt did not need to go to every patient’s room immediately, unless a condition demanded urgent attention. Nursing staff could attend to the task of assuring a patient’s comfort until Dr. Kitt arrived. If notifications of admissions were provided in a timely way by groups, Dr. Kitt could organize her visits by floor. Overnight admissions could be addressed as a group, perhaps, and later admissions could be added to her list as the day went on. With a dozen names of patients at one time, for example, she could organize her visits by floor until the list had been exhausted.

One tool that helps to understand a process is the flow chart. Creating a flow chart of a process clarifies the inefficiencies in that process, often making improvement steps obvious from the beginning. A picture of a process is a powerful communication tool, making process redundancies jump off the page, so to speak.

As Nurse Drew Lotts realized, it was important to list the steps in the process as it existed, and then to create a flow chart that reflected these steps. A process flow chart or “top-down chart” focuses on the steps in a process, rather than on the people who are responsible for these steps. A deployment flow chart, on the other hand, not only illustrates the steps in a process, but identifies the people who are responsible for each of these steps, as we will see.

Flow charts can help to improve work flow by creating a visual snapshot of a process, as the hospital example above demonstrates. They can also be used in home or classroom environments. Any time there is a process, there can be a flow chart. And any time a flow chart is created, learning about the process ensues. The following examples demonstrate ways to approach flow charting to develop clarity in making decisions about everything from going on a diet to making plurals from singular nouns.

In addition to providing a clear and visual picture, flow charts can help to identify decision points, thereby improving a process. It may be more inspiring to review these decision points and their implications if one wants to lose weight, for example, than to simply make a general resolution.

Figure 2: Losing weight

Flow charts can also support learning. If you’re confused about the rules for making plural words from singular words, this simple chart may help:

Figure 3: Deciding whether to add ‘s’ or ‘es’ for plural words

And thinking about the best way to drive home after work creates a mindful consideration of alternatives when a flow chart is used. (How many times have you driven somewhere, only to think to yourself that you really meant to stop at the cleaners on the way—or find that you can’t really remember anything you saw on the way?)

Figure 4: Deciding the best way to drive home

Flow charts can be created even for those who can’t read—young children or adults in literacy programs, for example—by substituting photos for words in each stage of the process. A four-year-old can follow directions for washing her hands by consulting this kind of visual flow chart, and a carpenter with limited reading skills can still be successful in following directions. Even inviting people to a party can be supplemented with a photo guide to directions for getting to your home—not because guests cannot read, but as a fun way to assure that they find the party.

The real power of flow charts to bring about improvement is not diminished by the applications such as these from everyday life. A quality handbook for any organization should include flowcharts of key processes, enabling improvement teams to examine these processes for continuous improvement as well as educating those responsible for the processes about how they work.

In the somewhat more sophisticated process of data analysis, simple flow charts can also be useful. The following flow chart, for example, simplifies the somewhat complex task of deciding which control chart to use in a given situation:

Figure 5: Deciding which chart to use

A purchase order flow chart helps to clarify the process of purchasing. This is the kind of chart that belongs rightfully in a quality manual.

Figure 6: Processing a purchase requisition

While we have focused on what is known as top-down flow charts, the tool can be modified to create a deployment flow chart when it is important to identify who has responsibility for each step. A simple deployment flow chart might look like this:

Figure 7: Deployment flow chart

In its quiet way, the flow chart plays a significant role in any improvement process, by demonstrating graphically the way a process works before and after improvement steps. It can serve in a larger role as well, supporting learning, monitoring steps toward a goal, and even providing directions about what to do. And by focusing on the steps in a process, the flow chart contributes to a mindfulness about an activity.

While the Buddha may not have used flow charts, he was clearly aware of the value of mindfulness in life, naming it among the stages in the Noble Path. By understanding her process, Dr. Della Kitt might be able to turn a meaningless pace into a mindful process.

Her patients would like that.



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