Video Transcript: Flowcharts (Part 2)

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

Today what we want to do is cover three more types of flow charts. The first one is the “customer-supplier” flowchart. The idea here is that you want to understand who depends on you for work, and then who do you pass the work to next. It’s the ability to understand the handoffs in a fairly complex set of events. In the left column, we have suppliers — that is, people who provide work that allows somebody, their customer, to actually do the next step.

Let’s think about one of the things that we do here at the IHI, which is deliver educational programs. I’m going to put in here “Debbie,” who is one of the people who manages some of our Improvement Advisor programs. What she does is get the organization of the class together. She’ll line up faculty and then get the pre-work organized — that is, material that the participants have to fill out. Her customer is Beth, who actually then receives the work that Debbie does — but, now watch what happens: Beth becomes the supplier because Beth now has to get the material out to the participants, who are her customers. She distributes material (pre-work — they have to fill out some forms, identify what the project is) to her customers, the participants. The participants now become the supplier because they complete the materials, and send them back to Beth.

Beth now, as the customer receiving that work, becomes, once again, the supplier. You can see poor Beth has a lot to do in this process, actually. What Beth does is that she now contacts me, and I organize the materials, the handouts, and get the program ready to go. My customers now are the participants who come to the program. We can continue that to show what happens to the participants: They move over here to the supplier when they fill out evaluations and tell us how they like the program (What could be better? What could we improve?). I receive those, and we distribute them to faculty, and this chain continues.

All too often people get enamored with what they do, and they forget about what comes before, “Who relies on me?” and what comes after, “Who do I pass the work along to?” The customer-supplier flowchart is a very handy way to start thinking about the system and all the handoffs in the system.

The next type of flowchart we’re going to address is what’s called the “swim lane” flowchart, which is also known as a “matrix.” We start over on the left with the activity. We get a request, for example, to teach a class or a program. Then what we do is we lay out the activities by category of individual or function. If you were looking at doing a med administration, this might be “doctor,” “nurse,” “pharmacist,” and then “nurse assistant.” You put functions or people in the “swim lanes,” and then what you start to do is to move the flowchart back-and-forth between people to see how many steps are done at each phase of the process.

Let’s look at, again, doing an educational program. Cindy gets the request and develops a contract. She then gets that contract reviewed and approved by the requestor. After it’s approved, it goes to Debbie, who’s going to schedule the class and align faculty with their schedules to be able to teach that program. What happens next is that Debbie contacts Beth, who sends out the pre-work to the participants. And then she gathers that information back — the completed information — from the participants, and then contacts me to actually setup the content — put the slides together, the handouts, etc. — and then I and my co-faculty will go deliver the program.

That brings us full-circle, back to the end, which is the program is completed, we have evals, and we have a successful demonstration of a program. What’s interesting with these is that you see not only the progression — who depends on who, and who has to wait until somebody else does their work — but it also shows the number of steps. You can imagine, if you laid these out, somebody may have four, five, six, seven, eight steps; and somebody else may only have one. The flowchart of a “swim lane” notion, otherwise known as the “matrix,” is very helpful in getting people to think through the individuals or the functions, as well as the steps that have to be achieved in order for that work to be completed.

The final flowchart that we want to review in this session is what’s called the “cost-added, value-added” flowchart. This is a valuable flow chart that allows you to figure out what steps add value, from the customer’s perspective, and which ones add cost. We’re going to combine the detailed flowchart with this notion of cost and value added. You’ll remember that when we make a detailed flow chart, we always start with an oval, and we end with an oval. So a request comes in to our business development area, and their value-added step is they develop a contract. That contract is sent to the customer, but we may have to wait for the customer to review it and sign it. What you need to remember about wait time is that some waits are necessary. Just as if you were baking a pie or a cake, you put the ingredients together, and there is a required wait time. Not all waiting is waste. But there are times when there’s excessive waits, and that’s what you need to be able to determine. Once the contract is signed, it comes back to us, and we can start to work on lining up a date for the program and faculty. Now, we run into the possibility that we will not get the faculty dates to line up with what the customer wants. The question now — we’ll make a diamond out of this — is “Can the faculty meet the schedule of the program?” If the answer is “yes,” we proceed to add value by developing the program and the content. We’ll say “develop content” at this point.

But, if the answer is “no,” what do you do? You’ll now have to wait until we’re able to come up with dates that match the faculty and the requesting organization. At some point, that is resolved, and you come back, finish developing the content, and you move on to actually deliver the program. Eventually you do evals, and you bring the program to a close. The “value-added, cost-added” flowchart allows you to see, “How many steps do we have involved that actually could involve waits, delays, questions, inspections?” Hopefully these give you some new tools by which you can start working on your improvement strategies and be able to identify the blocks, the delays, the handoffs, and the times in a process when it doesn’t work efficiently.