Operation Charting Forms

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					Flow Charting
MLC Grantee Meeting
March 20, 2009
 Jack Moran
 Senior Quality Advisor
 T: 202-218-4423

…PHF   Mission:
 Improving public
 health infrastructure
 and performance
 through innovative
 solutions and
 measurable results.

                       Innovative Solutions.
                       Measurable Results.
Continuous Improvement

    Act     Plan
                   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
Quick Check Of Your

        Enthusiasm Level
        Mathematical Skills
“If you can't describe what
you are doing as a process,
you don't know what you're

    W. Edwards Deming
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
Flow Charting
  • From this visual picture we can see
    a process and the elements
    comprising it
  • Shows how interactions occur
  • Makes the invisible visible
Flow Charting Is So Simple Even A Caveman Can Do It

                                                      We should write
                                                      that spot down
         MapQuest               Flow Chart
 • Takes directions and   • Takes procedures and
   coverts them into a      converts them into a
   picture                  visual
 • Shows various routes   • Shows the routes
   to a destination         inputs travel to
 • Shows communities        become outputs
   you pass through to    • Shows handoffs
   reach a destination
        MapQuest                 Flow Chart
 • Shows connecting       • Shows connecting
   roads                    processes
 • Shows faster and       • Highlights areas for
   slower routes            improvement
 • Provides alternative   • Triggers ideas to
   routes                   improve a process
Flow Chart Benefits
 • Creates a common vision
 • Establishes the “AS IS” baseline – Current
 • Baseline to measure improvements
 • Identifies wasteful steps – activities/wait
Flow Chart Benefits
 •   Uncovers variations
 •   Shows where improvements could be made
 •   Show potential impacts of improvements
 •   Training tool
Types of Flow Charts

  • As Is – current state - baseline

   • Could Be – improved state –

  • Should Be – optimal state
Flow Chart Exercises
Basic Flow Chart Symbols




    Flow Lines
Flow Charting Construction
 • Clearly define the process boundaries to be
 • Define the first and last steps – start and end
 • 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 only one output arrow out of a
   process box. Otherwise, it may require a decision
 • Trial process flow – walk though it in real time
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.
Flow Chart Construction
 • There is no one right way to develop a flowchart,
   but the following guidelines provide a general
 • 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.
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
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
 • It will take multiple passes to get to
   the “As Is” State
                                             Flow Lines
Flow Chart Symbols
     Start/End              Manual
                                         A   Connector
     Bookends               Operation
                            Data Base
     Activity:                               Comment
     Operation/Inspection                    Collector
      Output                Transport         Manual
      Data                                    Input

     Document                Input

     Forms                   Output           Unfamiliar/
Olmsted County , MN – Performance Appraisal Process
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
    – 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

 • 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
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
                      S I P O C+CM Collection Form
  Project Title:____________________
                                                     Ends With:

Begins With:

                                                       Measures of Effectiveness:

   Inputs:                              Outputs

                                   S I P O C+ CM Collection Form
  Project Title: Effectively and efficiently disseminate information about public
  health needs and priorities to elected officials
                                                                                                    Ends With:

                               Constraints:         Funding, Priorities, Time                       Feedback of
Begins With:                                                                                        information
                                                                                                    effectively received
Tidbit of valid,
valuable info on
PH                            Process/Activities:
                                                                                                      Measures of Effectiveness:
                                                                                                      $$, support, outcomes,
                                 Current methods and channels to disseminate                          leadership,
                                 public health information to elected officials                       acknowledgement,
                                                                                                      recognition, policy or
                                                                                                      behavior change

   Inputs:                                                              Outputs      Information, tangible mechanism of
                                                                        :            information format, data (who, what,
                Data, supporting documentation,                                      when, where, why, how, etc), Policies
                policies and procedures, maps, health                                and Procedures.
                advisories, standards (filters for
                information), priority communications

   Suppliers:                                                                               Board of Advisors, residents,
                     CDC, community partners, state,                                        community, Mayor, community
                     local hospitals, PHD functions                                         leaders
 In most processes:
   – Few people have seen the total process and fully
     understand the process
   – Departments are managed, processes are often
   – 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
Flow Charting Forms

 • Flow Process Chart
 • Before and After Comparison Flow
 • Work Flow Analysis Form
 • Others?
Before and After Comparison Flow Chart
Adding Time Lines
As Is Flow Chart          Could Be Flow Chart          Should Be Flow Chart

                   Time                         Time
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
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?
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
Improvement Opportunities
 • Use a Cause and Effect Diagram to
   investigate areas identified on the “As
   Is” flow chart as areas that could be
 • Can complete a micro level flow chart
   on specific process steps as required
 • Fix the low hanging fruit first – quick
 • Involve customer/suppliers before any
   changes are made
How Improvements Are Made
 • Standardizing – all the same
 • Automating – if possible – Timing?
 • Eliminating – unnecessary
 • Combining/Rearranging – parts/steps
 • Simplifying – reducing complexity
 • Changing – people/place/sequence
 • Reducing – storage/transports/rework
Continuous Improvement

    Act     Plan
                   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
Process Analysis Guide

                                     Pareto     Opportunities
                           Root       Mass
               Identify   Analysis
    Detailed   Problem
     Flow       Areas
More Resources
• Online QI Training – access course through TRAIN
  by searching for course ID #1014545
• Public Health Infrastructure Resource Center
• Public Health Memory Jogger II
• PHF QI Learning Series Catalog
• Public Health Quality Improvement Handbook,
  Quality Press, American Society of Quality, Spring
 Gantt Chart

MLC Grantee Meeting
March 20, 2009

  • The first Gantt Chart was developed
    by Karol Adamiecki, who called it a
  • Because Adamiecki did not publish
    his chart until 1931, this famous
    chart bears Henry Gantt's name
    (1861–1919) designed his chart in
   Wikipedia, the free encyclopedia
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
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
 • The horizontal axis is headed by columns
   indicating estimated task duration in
   hours, days, weeks, months, etc.
Gantt Charts

 • Some Examples
% Complete
Progress Bar
Milestone Chart - shows only important project events or milestones:
         4/5   4/12   4/19   4/26   5/3   5/10   5/17   5/24   5/31   6/7   6/14   6/21   6/28

Task 1

Task 2

Task 3

Task 4

Task 5

Task 6

Task 7

Task 8

Task 9
Gantt Chart – Morning Routine
    Tasks                       AM Time Ending     Assign To:

                 6 6:10 6:20 6:30 6:40 6:50 7:00

    Wake Up                                         You

   Make Coffee                                       Coffee Maker

    Shower                                           You

    Dress                                             You

    Leave                                             You
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
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
Some Examples
         Traffic Light Gantt Chart

Task: City of XYZ HD                     29-Feb       7-Mar       14-Mar   21-Mar   28-Mar

Finalize assessment analysis         X

Gain consensus on priorities         X

Identify comm. with elected off.     X

Plan PHF consultant visit                         X

Set agenda and travel schedule                                X

City HD/PHF PI meeting                                        X

                    On Schedule


         Late or at Risk
Integrating the Gantt Chart and the PDCA Cycle
Livingston County Department of Health – Accreditation Preparation Process
Livingston County Department of Health – Accreditation Preparation Process

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