Video Transcript: Flowcharts (Part 1)

Bob Lloyd, PhD, Executive Director Performance Improvement, Institute for Healthcare Improvement

We are going to start our flowcharting journey by thinking about three basic types of flow charts. The first one is called a “high-level block diagram.” What you do is just make blocks that contain large groupings of stuff that you need to do in the process or that has to occur in order for the process to work. Typically you have about 3–5 of these, you don’t have 8 or 10 of them. They’re meant to be high-level, big blocks.

For example, let’s think about our morning process. We get up, we get ready, we travel to work, and we arrive at the office. Now, each one of these blocks does go in sequential order, but each block contains many activities. So let’s think about the first block, “get up.” There’s really two things you have to do: Turn off the alarm, and get yourself out of bed.

The second block, however, has many more activities. You might start with making coffee, then you might shower, then you might take care of “personal stuff” — if you’re male, you might need to shave; female, you might do your hair, your makeup, etc. — then you have to figure out what you’re wearing for the day: your dress, your clothing. Then you have to decide “Am I going to make lunch? Do I need a lunch? Am I going to have breakfast?” and, finally, maybe I need to check email before leaving the house. Now we see we have many more things in this second block.

The third block ― travel to work ― well, you might need to get gas if you’re driving. You might need to check the traffic report to see if there’s any congestion or accidents, etc. But there’s really not a lot of things going on. You just get yourself going ― bus, car, whatever ― and, finally, you arrive at the office.

Here, what do you do? You need to think about if you’re driving, “Where do I park?” then I need to go into the building. “Do I stop and have to meet anybody?” “Do I get coffee?” There’s only a few things happening in this block as well.

One of the values of doing a high-level block diagram is it helps you set priorities on where you want to work. You can see at a glance that this block right here, “getting ready,” contains the most items. If we are going to improve our morning process, we might want to start here because we’ve identified all of the details; but, they’re not in any particular order, and there’s no sequential flow. That’s why we go next to a detailed flow chart, where we are going to take the items in this block, and break it out into greater detail.

Now we’ve identified in our high-level block diagram and the top down, the one area that seemed to have the most steps in our morning process, and that was the “get ready” process. So now we’re going to make a detailed flow chart. There are basically three symbols or shapes that we use. The first one is an oval that we use to identify the start of a process and the end of a process. The other basic symbols are a square, which is used to show activities or tasks, and then a diamond, which is used to show questions where you have to branch “yes” or “no.”

So let’s start our morning process. This is going to begin with asking ourselves a couple questions, and then laying out our task. The first task was make coffee. The second task was to take our shower. That led to the third task, which I’m just going to call “personal stuff.” That’s, again, shaving, hair, makeup, etc. ― whatever you need to do personally. Now, we come to the first question and that question is basically, “Do I know what I am going to wear today?” If I do, and I say “yes,” I get dressed. But if I say “no,” now what do I need to do? I need to figure out, “What am I going to wear? And I need to look at my closet and figure out what clothing I need for the day. “Can I dress casual?” Am I going to have a meeting I have to dress up for a little bit more, etc. So now I go in and have to spend time doing this, and then I can come back down and say, “I’ve picked out; now I need to get dressed.”

Now, I’ve run out of room on the bottom of my page, which is very typical with a detailed flow chart because you’re actually laying out all these steps, and you’ve got all these loops you have to go through. One of the things that we use is a symbol, typically letters. I’m going to start with an “A.” You put it in a circle, and that tells you to look for the “A” on the subsequent pages. I’ve made some of these flow charts that end up being 8–10 pages long, so you just go “A,” “B,” “C.” One needs to have some way of continuity.

So now we’re going to look for the “A” on our next page, and it will come off to our next activity, which for our morning sequence, was “Do I need a lunch for the day?” If I do, and I say “yes” — and note that when you’re making yes/no splits, you should always keep them going the same way. I started with my “yeses” going down and my “nos” going to the right. You don’t want to have a “yes” on one of these going down and the next one going down is a “no,” it gets very confusing — So I say “yes,” what do I do? I prepare or pack a lunch, make my lunch. If I say “no,” what do I do? I skip that step and go down to the next activity, which would be a question asking, “Do I have time for breakfast?” Now we’d come out of this particular question with, as you would imagine, “yes I do” or “no I don’t,” and we would continue that process as we go through prepare and eat the breakfast, organize my stuff for the day, “Do I need to check emails?”, grab the newspapers, and head out the door.

So, you see, we’ve gone from listing a bunch of high-level stuff — those four big blocks; wake up, get ready, go to work, and arrive at the office. Now we’ve laid out in sequential order with various branches, the actual activities. This is what you can use to start thinking about how you’re going to try to find which components you would work on to make an improvement.