PROCESS FLOW DIAGRAM

EXERCISE:CALLINGDR. HOWARD, DR. FINE,AND DR. HOWARD

Physicians and patients have been complaining about delays in the ambulatory surgery department at
a local hospital. A two-week study conducted by a breakthrough improvement team determined that the
major reason for delays was that the operating rooms (ORs) did not always contain all the supplies
needed to perform the surgical procedures that had been scheduled.
The team is now meeting to construct a high-level flow diagram of the process to identify places for
additional data gathering as the team enters the diagnostic journey. The team also feels that the flow
diagram will be useful in explaining needed changes and for setting up a better monitoring system to
hold the gains when the breakthrough improvement project is completed.
Below is an excerpt of the discussion that takes place in the meeting.
Susan (the team leader): What are the boundaries of the process we want to diagram today?
Terry: Why dont we look at what happens between the time that I, as the surgeon, call to schedule the
surgery and the time, 30 minutes prior to the scheduled surgery, when I arrive to check on the condition
of the patient and the OR.
Susan: Does everyone agree? (Nodding of heads around the table.) So, what happens when the
surgeon calls?
Bill: At that point, the surgeon is talking to me in the Ambulatory Surgery Scheduling Office. We
schedule an OR time slot by making an entry in the Master Schedule database. Of course, we work out
a convenient time with the surgeon and the patient.
Terry: We do this over the phone, in my office, with the patient right there, so everyone knows the
schedule. Anyway, I believe that that is outside the process we are flow diagramming, because our data
showed that we dont have a problem with patients or physicians not showing up. Remember, the
problem is that the OR is not ready on schedule.
Bob: So what happens next, Bill?
Bill: The patient shows up in the department an hour before surgery, we process the patients
paperwork, we call the surgeon to remind him or her of the schedule and advise that the patient has
arrived, and the surgeon then checks in 30 minutes prior to the scheduled time. Its really very simple.
Carolyn: Youve left out a number of steps, Bill. I and the other nurses in the Ambulatory OR check the
Master Schedule database to see what procedures are coming up and what supplies we need to order.
We try to check this two days before the surgery; in other words, if its Monday, we are checking
Wednesdays schedule to allow plenty of time to get supplies. We order the supplies we need from
Bobs people in the supply room.
Bill: How do you know what supplies to order?
Carolyn: I dont think we need to go into the details of that for this high-_level flow diagram. But
basically, we just look at the procedure listed in the database and order a kit for that procedure.
Bob: In keeping with the hospitals cost-containment efforts, Bill, the nurses dont keep many supplies
on hand. We went through a process six months ago to define standard kits for all the procedures we
perform in the Ambulatory OR. The nurses call us and tell us how many kits they need for which
procedures, and we deliver the supplies as soon as we can. But I didnt realize that you were working
on a two-day lead time, Carolyn. That might not be enough time in all cases for routine processing.
Carolyn: If we get very busy, we may not even give you that much notice.
Susan: Okay, so you deliver the kits. Then what happens?
Carolyn: I dont think we need to get into all the detail just now, but we basically set up the OR with the
supplies in the kits. All of this is supposed to happen before the patient shows up for his or her surgery.
In other words, the OR should be completely set up an hour before the scheduled surgery.
Bob: Now we are at the point where Bill was earlierprocessing the paperwork and so on.

1. Based on the dialogue on the previous pages, draw a simple high-level flow diagram of this
ambulatory surgery process on a separate sheet of paper.
2. Convert your flow diagram of the ambulatory surgery process into a matrix flow (Deployment Flow)
diagram on another sheet of paper.
3. Now review the flow diagram step by step. What questions would you like to see answered through
data gathering to help identify which segments of this process to explore further? The overall
objective is to increase the probability that the OR will be completely set up when the surgeon
arrives to check it 30 minutes prior to the scheduled operation.

PROCESS FLOW DIAGRAM: CALLING DR. HOWARD, DR. FINE, AND DR. HOWARD
 Surgeon Calls
to Schedule Surgery

Scheduling Allocates O.R. Time Slot

O.R. Nurses Master Schedule

Review Schedule

O.R. Nurses
Order Supplies

Supplies Dept. Makes and Delivers Kits

Nurses Set
Up O.R.

Patient
Arrives

Paper Work
Completed

Surgeon
Notified

Surgeon Arrives 30 Minutes prior to Surgery to check patient and O.R.

DEPLOYMENT FLOW DIAGRAM:

DISCUSSION:
Ambulatory surgery is a general term for a variety of minor surgical procedures in which the patient
arrives at the hospital at an appointed time, the surgery is performed using mild anesthesia, and patient
returns home without being formally admitted to the hospital. The term Ambulatory refers to fact that
the patient walks in and walks out.

Because the objective is to increase the probability that the O.R. is properly setup, and because BOB
had commented earlier that lead time was an issue for his supplies department, relevant questions
include:
What is the distribution of time between the scheduling of the surgery and the date it is
performed?
How often do the nurses review the schedule two days or more prior to the scheduled surgery?
What is the distribution of time required to make up and deliver the kits? Is it different from
different kits?
How many kits of each type are ordered in a typical month?
What is the distribution of time prior to the scheduled surgery when the kits are delivered (i.e.,
how much lead time do the nurses have to setup the O.R.)?
How often do the surgeons actually show up 30 minutes prior to surgery to check the O.R.?
How often is the O.R. not setup 30 minutes prior to surgery?
Of the times when the O.R. was not ready, how many times were the kits not received? How
many times were the kits received but the nurses to setup the O.R.?
In cases where the kits were not received, had they been ordered? How much lead time was
given? Is it different for different kits?
How often do supplies find that it does not have necessary items to make up a kit? Which kit?
Which items?

Question: Are there any ways to simplify this process?

Answers may vary. An obvious improvement would be a let supplies have access to the schedule
data base and make them responsible for delivering the appropriate kits to the O.R., Allowing
appropriate lead time for the nurses. (Stress that the team would need to investigate the
technological and political feasibility of such a proposal.)