1. Flow Charting MLC Grantee Meeting March 20, 2009

2. … PHF Mission: Improving public health infrastructure and performance through innovative solutions and measurable results. Innovative Solutions. Measurable Results. http://www.phf.org Jack Moran Senior Quality Advisor jmoran@phf.org T: 202-218-4423

3. Continuous Improvement Plan Do Check/ Study Act The continuous improvement phase of a process is how you Make a change in direction. The change usually is because the process output is deteriorating Or customer needs have changed

4. Quick Check Of Your Enthusiasm Level & Mathematical Skills

5. “If you can't describe what you are doing as a process, you don't know what you're doing.” W. Edwards Deming

6. 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

7. Flow Charting From this visual picture we can see a process and the elements comprising it Shows how interactions occur Makes the invisible visible

8. We should write that spot down Flow Charting Is So Simple Even A Caveman Can Do It

9. Mapping MapQuest Takes directions and coverts them into a picture Shows various routes to a destination Shows communities you pass through to reach a destination Flow Chart Takes procedures and converts them into a visual Shows the routes inputs travel to become outputs Shows handoffs

10. Mapping MapQuest Shows connecting roads Shows faster and slower routes Provides alternative routes Flow Chart Shows connecting processes Highlights areas for improvement Triggers ideas to improve a process

11. Flow Chart Benefits Creates a common vision Establishes the “AS IS” baseline – Current State Baseline to measure improvements Identifies wasteful steps – activities/wait

12. Flow Chart Benefits Uncovers variations Shows where improvements could be made Show potential impacts of improvements Training tool

13. Types of Flow Charts As Is – current state - baseline Could Be – improved state – transition Should Be – optimal state

14. Flow Chart Exercises

15. Basic Flow Chart Symbols Activity: Operation/Inspection Decision Start/End Bookends Wait/Delay Flow Lines

16. 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

17. 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

18. 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 though it in real time

19. Flow Charting Steps Circulate the flowchart to other people involved in the process to get their comments Make changes if necessary Identify time lags and non-value-adding steps.

20. Flow Chart Construction There is no one right way to develop a flowchart, but the following guidelines provide a general structure: Start with a simple one-line description or title of the process being flowcharted, e.g., "How to..." Using a top-down hierarchy, start with an oval symbol named Start.

21. Flow Chart Construction Connect each successive action step in the logical sequence of events. Reference detailed information through annotations or connectors. Follow the process through to completion, denoted by an oval symbol named End

22. Flow Chart Construction Use common symbols Use a form of Post-It Notes – easier to rearrange Realize everyone is not doing it the same way – there will be disagreements It will take multiple passes to get to the “As Is” State

23. Flow Chart Symbols Activity: Operation/Inspection Decision Start/End Bookends Document Wait/Delay Storage Data Base Transport Input Output Flow Lines A Connector Forms Comment Collector Input/ Output Data Manual Operation Preparation Manual Input Display Unfamiliar/ Research

24. Olmsted County, MN – Performance Appraisal Process

25. Constructing a Flow Chart Asking questions is the key to flow charting a process. For this process: – Who is the customer(s)? – Who is the supplier(s) ? – What is the first thing that happens? – What is the next thing that happens? – Where does the input(s) to the process come from? – How does the input(s) get to the process? – Where does the output(s) of this operation go? – Is their anything else that must be done at this point?

26. SIPOC + CM A High level Process Map Helps in developing the “As Is” State Defines knowns from unknowns Shows gaps in QI Team’s knowledge of a process Focuses data gathering activities

27. High Level S I P O C+ CM Collection Form A Form to identify all relevant elements of a process before starting a flow chart – Suppliers - internal and external – Inputs – Process - activities – Outputs – service provided – Customers – internal and external – + Constraints – facing the system or process – + Measures - being used or to be used

28. Process/Activities: Begins With: Ends With: Inputs: Suppliers: Outputs : Customers: Constraints: S I P O C+CM Collection Form Project Title:____________________ Measures of Effectiveness :

29. Process/Activities: Begins With: Ends With: Inputs: Suppliers: Outputs : Customers: Constraints: Tidbit of valid, valuable info on PH Funding, Priorities, Time Feedback of information effectively received Measures of Effectiveness: $$, support, outcomes, leadership, acknowledgement, recognition, policy or behavior change Current methods and channels to disseminate public health information to elected officials Data, supporting documentation, policies and procedures, maps, health advisories, standards (filters for information), priority communications CDC, community partners, state, local hospitals, PHD functions Information, tangible mechanism of information format, data (who, what, when, where, why, how, etc), Policies and Procedures. Board of Advisors, residents, community, Mayor, community leaders S I P O C+ CM Collection Form Project Title: Effectively and efficiently disseminate information about public health needs and priorities to elected officials

30. Cautions In most processes: – Few people have seen the total process and fully understand the process – Departments are managed, processes are often unmanaged – Those that designed the process are no longer there – Work is being done that adds no value to customers – Work the customer needs isn’t being done – Rework is built into the process – Inefficiencies are built into the process – Workarounds have been developed that make the process appear to be working better than it really is

31. Flow Charting Forms Flow Process Chart Before and After Comparison Flow Chart Work Flow Analysis Form Others?

33. Before and After Comparison Flow Chart

34. Adding Time Lines As Is Flow Chart Could Be Flow ChartShould Be Flow Chart Time

36. Flow Chart Quality Improvement Analyze the “As Is” flow chart Look for Critical Processes Look for Handoffs Analyze with a Cause and Effect Diagram Develop potential solutions Develop the “Should Be” state Communicate all changes Track implementation progress Document results Present results

37. Analyzing A Flow Chart Examine each: – Activity symbol – value/cost? – Decision point – necessary/redundant? – 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?

38. Improvement Opportunities What to look for on a Flow Chart: – Duplication of effort – Unnecessary Activities/Steps/Tasks – Delays/Waits – Transports – Storage – Illogical Sequencing of Activities – Unclear Lines of Responsibility – Opportunities for Error – Supplier Error Opportunities – Disconnects

39. Improvement Opportunities Use a Cause and Effect Diagram to investigate areas identified on the “As Is” flow chart as areas that could be improved Can complete a micro level flow chart on specific process steps as required Fix the low hanging fruit first – quick success Involve customer/suppliers before any changes are made

40. How Improvements Are Made Standardizing – all the same Automating – if possible – Timing? Eliminating – unnecessary steps/waste Combining/Rearranging – parts/steps Simplifying – reducing complexity Changing – people/place/sequence Reducing – storage/transports/rework

41. Continuous Improvement Plan Do Check/ Study Act The continuous improvement phase of a process is how you Make a change in direction. The change usually is because the process output is deteriorating Or customer needs have changed

42. Process Analysis Guide Detailed Flow Chart Identify Problem Areas Root Cause Analysis Pareto Critical Mass Recommended Opportunities

43. More Resources Online QI Training – access course through TRAIN by searching for course ID #1014545 www.train.org Public Health Infrastructure Resource Center www.phf.org/infrastructure/ www.phf.org/infrastructure/ Public Health Memory Jogger II PHF QI Learning Series Catalog www.phf.org/pmqi/PHF_QI_Learning_Series_082008. pdf Public Health Quality Improvement Handbook, Quality Press, American Society of Quality, Spring 2009

44. Gantt Chart MLC Grantee Meeting March 20, 2009

45. History The first Gantt Chart was developed by Karol Adamiecki, who called it a Harmonogram Because Adamiecki did not publish his chart until 1931, this famous chart bears Henry Gantt's name (1861–1919) designed his chart in 1910 Wikipedia, the free encyclopedia

46. Gantt Chart Henry L. Gantt – WWI – Franklin Arsenal 1910 – Progress Chart Work planned and accomplished are shown in the same space Emphasizes work movement through time Deals with plans and progress Helps identify and eliminate obstacles

47. Gantt Charts A Gantt chart is a matrix diagram The vertical axis lists all the tasks to be performed for a project Each row contains a single task identification The horizontal axis is headed by columns indicating estimated task duration in hours, days, weeks, months, etc.

48. Gantt Charts Some Examples

50. % Complete

51. Progress Bar

52. Milestone Chart - shows only important project events or milestones:

54. 4/54/124/194/265/35/105/175/245/316/76/146/216/28 Task 1 Task 2 Task 3 Task 4 Task 5 Task 6 Task 7 Task 8 Task 9

55. Gantt Chart – Morning Routine Tasks AM Time Ending Assign To: 66:106:206:30 6:40 6:50 7:00 Wake Up Make Coffee Shower Dress Leave You Coffee Maker You

56. Use Of Gantt Charts Establish order of tasks: – Sequential and Parallel Identify resources requirements Timing of resource needs Identify the critical path Monitor the project “On-Time” Schedule Alerts where remedial action is required

57. Benefits Of Gantt Charts Overview of all the tasks Identifies major milestones Easy to review with top management Guidance – suppose to be here now Alerts to problem areas Measurement of progress Summary document when project is finished Training tools for future projects

58. Some Examples

59. Traffic Light Gantt Chart Task: City of XYZ HD29-Feb7-Mar14-Mar21-Mar28-Mar Finalize assessment analysisX Gain consensus on prioritiesX Identify comm. with elected off.X Plan PHF consultant visitX Set agenda and travel scheduleX City HD/PHF PI meetingX On Schedule Watch Late or at Risk

61. 2008 APHA Program

62. Integrating the Gantt Chart and the PDCA Cycle

63. Livingston County Department of Health – Accreditation Preparation Process