Scott D Duncan MD MHA FAAP Science of

Scott D. Duncan, MD, MHA, FAAP

Science of Safety We cannot improve quality and safety of healthcare until we view the everyday delivery of healthcare as a science

Flow Charts “If you can’t describe what your doing as a process, you don’t know what you’re doing” W. Edwards Deming • A written description of a process requires a common definition of terms, fluency with the concepts, and the absence of an agenda by the author and reader.

"Draw a flowchart for whatever you are doing. Until you do, you do not fully understand what you are doing. You just have a job. “ "The first step in any organization is to draw a flow diagram to show each component depends on others. Then everyone may understand what their job is. If people do not see the process, they cannot improve it. "

SIPOC+CM • SIPOC is a data collection form that is used before we start to construct a flow chart since it helps us to gather relevant information about the process. • Assists in gathering information about Suppliers, Inputs, Process, Outputs, and Customer of the process. • SIPOC is high level view of the “As Is” state of a process under investigation.

SIPOC+CM When to use it: • When first starting to investigate a process and a team needs to understand the basics that make up the process. • When a team needs a way to get the collective knowledge of the team members about a process recorded in an easy to view format. • When we need to make a concise communication to others about a process and the parameters that it encompasses.

SIPOC+CM Collection Form Begins With: Constraints: Ends With: Process/Activities: Measures Inputs: Outputs: Suppliers: Customers:

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 • From this graphic picture we can see a process and the elements comprising it • Shows how interactions occur • Makes the invisible

Flow Chart Benefits • Problem Identification • Generating Solutions • Test • Disseminate 7

Flow Chart Benefits • Puts a spotlight on waste • Streamlines work processes • Defines and standardizes the steps and sequence • Promotes deep understanding • Builds consensus • Key tool for continuous quality improvement 11

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

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

Flow Charting Steps • Use the simplest symbols possible – Post-Its • Make sure every loop has an escape • There is usually one output arrow out of a process box. Otherwise, it may require a decision diamond. • Trial process flow – walk through people involved in the process to get their comments • Make changes if necessary • Identify time lags and non-value-adding steps.

Adding Time Lines Could Be Flow Chart As Is Flow Chart Time Should Be Flow Chart Time

Flow Charts

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

Process Flow Chart Written physician order scanned to pharmacy from 3 L for a scheduled oral medication. Is the time of order entry prior to 1240? Yes No Is a dose due prior to 1800 on the day AFTER initial order entry? Yes A Is a dose due prior to 1800 on the day AFTER initial order entry? Yes No B C No D

Process Flow Chart A Order entry by the pharmacist Label will print Pharmacy technicians receives label(s) for a patient specific oral medication. Technician draws up the appropriate patient specific dose into an oral syringe and labels the oral syringe with the patient’s label. Syringes are left with the bulk medication bottle for pharmacist verification. Pharmacist verifies that medication dispensed matches the medication ordered on the label and initials the medication label. Medication is tubed to 3 L.

Process Mapping: Initial Workflow 23

Analyzing A Flow Chart Assessing the current process map with the goal of improving patient flow by looking for steps that: i) Definitely add value ii) Add no value, but are unavoidable iii) Add no value, but are avoidable Once completing a process map, return to the site and discuss it with employees to ensure its accuracy. Together, consider how the map could be used to make improvements to the system.

Analyzing A Flow Chart Examine each: – – – – – Activity symbol – value/cost? Decision point – necessary/redundant? Choke Points – bottlenecks? 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?

Process Mapping: Areas for Improvement 26