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

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

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

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

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

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

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

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.