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 matrix).

When to Use It

A flowchart helps to clarify how things are currently working and how they could be improved. It also assists in finding the key elements of a process, while drawing clear lines between 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 also uncover steps that are redundant or misplaced. In addition, flowcharts are 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 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.

Types of Flowcharts

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. 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. 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 Matrix 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 chiefly 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. See the Deployment of Matrix Flowchart.

When to Use Which Flowchart

Each type of flowchart has its strengths and weaknesses; the high-level flowchart is the easiest to construct but may not provide sufficient detail for some purposes. In choosing which type to use, the group should be clear on their purpose for flowcharting. The table below entitled "Type of Flowchart Indicated for Various Purposes" gives some indications, but if you’re unsure which to use, start with the high-level one and move on to detailed and deployment. Note that the detailed and deployment flowcharts are time-consuming.

How to Use It

Regardless of the type of flowchart, there are several basic steps to its construction.

Step 1. Agree on the purpose of the flowchart and which format is most appropriate.

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. Identify the elements of the flowchart by asking:

• • Who provides the input for this step? Who uses it?
• • What is done with the input? What decisions are made while the input is being used?
• • What is the output to this step? Who uses it to do what?
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Basic Elements for Various Types of Flowcharts

If you are developing a flowchart to identify weaknesses in your processes, the steps and decision points you put into the flowchart should reflect the true process (what is actually done, not what perhaps should be done). Accuracy in creating the flowchart will assure you of being able to see what can or needs to be improved. If ideas for improvement are generated while developing the flowchart, do not discuss their merits at this time, but record them for future discussion.

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.

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 symbol ( ) may not be needed if the flowchart is not related to waiting times.

Analyzing the 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 loop that indicates work being redone (rework): Does this rework loop prevent the problem from recurring? Are repairs being made long after the step where the errors originally occurred?
• • Examine each 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 document 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 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 fuzzy areas or places where the process leads off to nowhere? Are there parallel tracks? Is there a rationale for those?

Caution

Flowcharts for quality improvement should always reflect the actual process, not the ideal process. A flowchart must reflect what really happens.

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.