Understanding and Using Process Flow Charts to Improve Care

Learning Objective: At the completion of this session, the learner will:

  • Demonstrate an understanding of how information regarding a care process can be organized into a process flow chart
  • Understand how the process flow chart may help to identify unwanted variation in a clinical process
  • Understand how the process flow chart may be utilized to identify high impact areas for instituting change in a clinical process

Clinical Process Review:

You are serving as a clinical nurse on a floor in which you frequently admit patients with community-acquired pneumonia. You are aware that early antibiotic administration to such patients is associated with improved patient outcomes, and that this is also being reported by your hospital to the Joint Commission as one of the core quality measures. Most of the patients admitted with pneumonia are being admitted through the Emergency Room, and are now usually receiving the first dose of antibiotics prior to leaving the ER. However, about 20% of the pneumonia patients are being admitted from outpatient clinics, and for most of these admissions, getting the first dose of antibiotics in within four hours has proven difficult.

Several nurses on your floor have stated that they feel that the delay is primarily occurring in pharmacy. You know that you’ve had three patients admitted within the last week with pneumonia. With your unit charge nurse’s permission, you audit the charts for these three patients to see if you can tell where the delays are occurring. The information you recorded from these reviews is contained on the following page.

Answer the following questions from the information on the next page:

  • From this information, does the pharmacy appear to be the area where intervention is needed to shorten the time to antibiotic administration?
  • Do you see any evidence of variation in care that might be contributing to the delays?
  • What would you consider the most productive areas for intervention?

Process Flow Chart for Ward Administration of First Dose Antibiotics in Community-Acquired Pneumonia

Numbers in small boxes represent elapsed time (hours:minutes) between steps

Patient 1

86 yo admitted Levaquin 500 mg Total time = 4:28

directly to 4E from daily IV ordered

clinic with (routine)

pneumonia at 3PM

Patient 2

46 yo admitted to Rocephin 1 g Total time = 4:13

6 W fromUrgent daily IV ordered

Care Clinic with (“1st dose Now”)

pneumonia at 6PM

Patient 3

78 yo admitted Levaquin 500 mg Pharmacist called Total time = 2:57

to 4E fromclinic daily IV orderd ward to check dose

with pneumonia (“1st dose ASAP”) due to dx of renal

renal failure at 1PM failure

MeanMean 3:53