Flowcharts

A flowchart is a graphic representation of how a process works, showing, at a minimum, the sequence of steps. Several types of flowcharts exist: the most simple (high level), a detailed version (detailed), and one that also indicates the people involved in the steps (deployment or “swim lane” matrix).

When to Use a Flowchart

A flowchart helps to clarify how things are currently working and how they could be improved. It also helps in understanding the key elements of a process and where one process ends and the next one starts. Developing a flowchart stimulates communication among participants and establishes a common understanding about the process.

Flowcharts can also reveal steps that are redundant or misplaced. In addition, flowcharts can be used to identify appropriate team members, to identify who provides inputs or resources to whom, to establish important areas for monitoring or data collection, to identify areas for improvement or increased efficiency, and to generate hypotheses about causes. Flowcharts can also be used to examine processes for the flow of patients, information, materials, clinical care, or combinations of these processes. It is recommended that flowcharts be created through group discussion, as individuals rarely know the entire process and the communication contributes to improvement.

High-Level Flowchart

A high-level (also called first-level or top-down) flowchart shows the major steps in a process. It illustrates a "birds-eye view" of a process, such as the example in the figure entitled “High-Level Flowchart of Prenatal Care” that shows the major steps that occur from the time a patient arrives at a clinic, until she leaves. It can also include the intermediate outputs of each step (the product or service produced), and the sub-steps involved. Such a flowchart offers a basic picture of the process and identifies the changes taking place within the process. It is significantly useful for identifying appropriate team members (those who are involved in the process) and for developing indicators for monitoring the process because of its focus on intermediate outputs.

High-level flowchart - Prenatal care



Patient registration flowchart

Most processes can be adequately portrayed in four or five boxes that represent the major steps or activities of the process. In fact, it is a good idea to use only a few boxes, because doing so forces one to consider the most important steps. Other steps are usually sub-steps of the more important ones.

Detailed Flowchart

The detailed flowchart provides a detailed picture of a process by mapping all of the steps and activities that occur in the process. This type of flowchart indicates the steps or activities of a process and includes such things as decision points, waiting periods, tasks that frequently must be redone (rework), and feedback loops. This type of flowchart is useful for examining areas of the process in detail and for looking for problems or areas of inefficiency. For example, the “Detailed Flowchart of Patient Registration” reveals the delays that result when the record clerk and clinical officer are not available to assist clients.

Deployment or “Swim Lane” Flowchart

A deployment flowchart maps out the process in terms of who is doing the steps. It is in the form of a matrix, showing the various participants and the flow of steps among these participants. It is mainly useful in identifying who is providing inputs or services to whom, as well as areas where different people may be needlessly doing the same task.

Deployment or "swim lane" flowchart

In this example, the tasks in seeing HIV patients at a health center are described for three different staff members at the facility: the medical attendant, the nurse midwife, and the clinician.

When to Use Which Flowchart

Each type of flowchart has its strengths and weaknesses.  The high-level flowchart addressing major steps is the easiest to construct but may not provide sufficient detail for some purposes. Detailed flowcharts include steps and activities and as well as decision points.  Deployment flowcharts show persons involved in specific steps and activities.

Applications of Different Flowcharts

In choosing which type of flowchart to use, the improvement team should be clear on their purpose for flowcharting. The table below shows which type of flowchart is indicated for which type of purpose.  If you are unsure which flowchart to use, start with the high-level one and move on to detailed and deployment. Note that creating detailed and deployment flowcharts can be time-consuming.

How to Use a Flowchart

Regardless of which the type of flowchart you decide to use, there are several basic steps to its construction.

Basic flowchart symbols

Step 1. Agree on the purpose of the flowchart and which format is most appropriate for the process you are analyzing.

Step 2. Determine and agree on the beginning and end points of the process to be flowcharted.

  • What signals the beginning of this process? What are the inputs?
  • What signals the end of the process? What is/are the final output(s)?

Step 3. Draw the flowchart for the process

List out the steps involved in the process in the first column of this table. Describe what happens at each step and what outcomes it leads to, and what next step must be taken as a result.  Once all of your steps are listed, you can draw a simple flowchart using the key of shapes provided.

An example of the steps for a flowchart to analyze the labor and delivery process at a health center that addresses post-partum hemorrhage is provided below.

Steps for a flowchart on labor and delivery at a health center

What are the steps?

What happens at this step?  This may be clinical content, a management decision, a community action, or other.

What are the possible outcomes from this step? 

It may be a simple yes or no, it may be multiple possibilities, or it may be uncertain.

Reception and orientation

The mother-to-be is registered and introduced to the midwife

Proceeds to the next step

 

Evaluation and examination

Initial examination before going into the delivery room

Proceeds to the next step

Labor / delivery care

The mother-to-be is monitored, the delivery is attended, and the woman given care as needed if any complications arise

If post-partum bleeding  occurs, then treatment is needed;  otherwise, routine care is provided

Stabilization

Woman with post-partum hemorrhage is treated

Either she is stabilized or referred to the hospital

Routine care procedures and discharge

Routine care is provided to the woman and newborn

Woman and newborn are discharged from the clinic

Detailed flowchart symbols

Step 4. Review the first draft of the flowchart to see whether the steps are in their logical order. Areas that are unclear can be represented with a cloud symbol, to be clarified later. 

Below is a flowchart depicting the steps in the labor and delivery example shown in the table above:

Labor and delivery flowchart

Step 5. After a day or two, review the flowchart with the group to see if everyone is satisfied with the result. Ask others involved in the process if they feel it reflects what they do.

Hints for Constructing Flowcharts

Try to develop a first draft in one sitting, going back later to make refinements. Use the "five-minute rule": do not let five minutes go by without putting up a symbol or box; if the decision of which symbol or box should be used is unclear, use a cloud symbol or a note and move on.

To avoid having to erase and cross out as ideas develop, cut out shapes for the various symbols beforehand and place them on the table. This way, changes can easily be made by moving things around while the group clarifies the process.

Decision symbols are appropriate when those working in the process make a decision that will affect how the process will proceed. For example, when the outcome of the decision or question is YES, the person would follow one set of steps, and if the outcome is NO, the person would do another set of steps. Be sure the text in the decision symbol would generate a YES or NO response, so that the flow of the diagram is logical.

In deciding how much detail to put in the flowchart (i.e., how much to break down each general step), remember the purpose of the flowchart. For example, a flowchart to better understand the problem of long waiting times would need to break down in detail only those steps that could have an effect on waiting times. Steps that do not affect waiting times can be left without much detail.

Keep in mind that a flowchart may not need to include all the possible symbols. For example, the wait/bottleneck symbol may not be needed if the flowchart is not related to waiting times.

Analyzing a Detailed Flowchart to Identify Problem Areas

Once the flowchart has been constructed to represent how the process actually works, examine potential problem areas or areas for improvement using one or more of the following techniques.

  • Examine each decision symbol: Does it represent an activity to see if everything is going well? Is it effective? Is it redundant?
  • Examine each step or activity symbol: Is this step redundant? Does it add value to the product or service? Is it problematic? Could errors be prevented in this activity?
  • Examine each documentation or database symbol: Is this necessary? Is it up to date? Is there a single source for the information? Could this information be used for monitoring performance and improving the process?
  • Examine each wait symbol: What complexities or additional problems does this wait cause? How long is the wait? Could it be reduced?
  • Examine each transition where one person finishes his or her part of the process and another person picks it up: Who is involved? What could go wrong? Is the intermediate product or service meeting the needs of the next person in the process?
  • Examine the overall process: Is the flow logical? Are there unclear areas or places where the process leads nowhere? Are there parallel tracks? Is there a rationale for those?

Points to Remember

Flowcharts for problem analysis should always reflect the actual process, not the ideal process.

Involve people who know the process, either while developing the flowchart or as reviewers when the chart has been completed.

Be sure that the flowchart really focuses on the identified problem or process.

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