To use a general systems flow chart requires two conditions. First, the work process should be complex. It should involve at least two or more people engaged in at least two or more steps to accomplish some predetermined objective, such as sending a letter or admitting a patient to a hospital. Second, the work process must have a formal start and stop point. General systems flow charting requires the ability to define when a complex process starts and stops, even if the process or operation is continuous or repetitive. For example, a hospital continuously admits patients. Even though the complex process of admitting patients may be continuous, it can be defined as a process with a formal beginning (e.g., when a specific patient arrives at the door) and end (e.g., when the patient is formally admitted into the hospital).

When these two conditions are met, general systems flow charting provides health services managers the basis to describe complex work processes and then to use the descriptions to analyze, improve, and/or change the complex work process. As implied by the name of the technique, two general properties are included in general systems flow chartssystems and flows. Charts depict and describe a system or subsystem (i.e., inputs, conversion processes and outcomes, and feedback loops) as well as the flow or sequence of inputs and conversion processes and feedback loops.

A general systems flow chart should be developed for any new complex work process in the healthcare organization. After a new system is designed using general systems flow charting, written work procedures can then be developed and work tasks grouped into new or revised job descriptions to support the new system.

General systems flow charting has returned as a foundation methods competency in health services management. The technique was initially developed by industrial engineers and then used by systems analysts when they designed computer-based information systems. For many healthcare organizations, general systems flow charts are new, even though their original popularity was decades ago in production line settings. Today, interest in total quality management (TQM) has again made the technique most relevant and served to introduce the method into healthcare organizations. The technique forces examination of the micro work process used to convert inputs into outcomes. It provides a systematic approach to determine how things are done and change processes to achieve higher levels of efficiency and effectiveness. This is a technique with very broad applications. Although it looks basic, as a technique it is one of the most robust in the health services managers repertoire.

All techniques have specific rules and convention. For example, mathematical forecasting relies upon the rules of algebra to solve mathematical equations. Although not mathematical, general systems flow charting also has specific rules.

• 1. Charts flow from top to bottom and from left to right.
• 2. Decisions included in a chart must be able to be answered as either YES or NO. If possible, the routine or most common answer flows downward; the non-routine answer flows horizontally.
• 3. Lines on charts have arrowheads that indicate flow and sequence.
• 4. Specific symbols are used. Figure 3-1 includes the commonly used symbols.

Using these symbols and descriptive labels, charts are constructed that describe the operation of a current work process. Managers create charts that describe how the current processes work. In the development of these charts, the manager must ensure that all logical possibilities are included on the chart.

Flow Chart Symbols

Figure 3-1 Flow Chart Symbols

Certain prerequisites must be satisfied before the actual general systems flow chart is constructed. The health services managers must know the goal of the system or work process being analyzed. The goal might be to prepare and mail a letter. It might also be to admit a patient into the hospital. Or, it might be to render appropriate patient care to patients who arrive for service. Whatever the goal, the manager must know the goal and use this goal as the central and unifying theme of the general system flow chart. Knowing the goal of the system or work process also provides the ability to use general systems flow charts to improve operations. Improvements can involve increased efficiency and/or increased quality of service. Rarely, if ever, will the manager be asked to merely analyze a system without an agenda for change, such as to fix a problem, increase its efficiency or enhance its quality. Therefore, the agenda for change becomes an important aspect of the goal statement.

The general systems flow chart must describe how the current work operation is done. The creator of the chart must determine what is done, by whom, and in what sequence. Often this information is determined by interview and/or direct observation. Copies of documents created and used in the work process are collected and traced. This type of information is needed before the chart can be constructed. The description of the current system that emerges from these questions and information is expressed in a general systems flow chart.

After the flow chart is developed and verified, the manager uses the general systems flow chart to design improvements to fix the system. Often, redesign will involve the workers directly affected by any change. Often, redesign will involve some actual trials before the redesign is finalized.

LEARNING OBJECTIVE 2: TO CONSTRUCT A GENERAL SYSTEMS FLOW CHART

Creating general systems flow charts usually takes a few tries before they are completed correctly. The process of constructing and drawing the chart often identifies new questions or issues that lead to beginning again with a clean sheet of paper and collecting more data. After the chart has been prepared and verified (verbally checked to ensure that all pathways and options lead to a logical stop point), the manager can use the chart to try some new ways to accomplish system goals. Perhaps, these new ways might involve simplifying procedures or the process. Often, systems seem to grow needless steps that can be eliminated. In other instances, many steps can be repackaged into more efficient work packages. In still other instances, individual steps can be reordered and/or new steps added so that system outcomes better correspond with system goals. The primary point being that these new ideas for improvements need to be developed as changes to the original systems flow chart and field tested in the general system flow chart to insure that desired outcomes are realized.

The first time a chart is drawn is never the last. Novices usually have many editions before the chart meets requirements. Experienced managers usually are more efficientexperience provides sharper senses to detect flow and sequence in a system. Do not underestimate the difficulty associated with using this simple technique. The only way to create a general systems flow chart is by trial and error. Create a version and then test it to determine whether it actually reflects how the process is done. Be prepared for many drafts before the process is completed.

The first task, sometimes referred to as a task list, is to specify in order the individual steps and sequencing in the overall process. Once the task list is established, adding decisions, files, documents, and other aspects of the process creates the general systems flow chart. Sometimes, for purposes of simplicity, charts are prepared in levels. Any chart must incorporate sufficient detail to satisfy its analytical role. It is sometimes very helpful to organize charts into levels. Level I could be a simple summary chart that depicts the system at a macro level, which is then backed up, by numerous charts (Level II) that depict individual steps in the master process depicted on the Level I chart.

Consider the example in Figure 3-2. Examine this chart for flow and sequence. Determine whether the chart is a complete process.

Flow Chart: To Complete an Acceptable Term Paper

As can be seen from this example, more detail could have been added by expanding the number of steps in this chart. The example could be considered a Level I or macro chart with other more detailed charts (Level II) to cover each individual work process such as collect data, write first draft, etc.

This chapter has established general rules and conventions associated with general systems flow charting. Developing the skill to flow chart requires practice as well as patience. Although a basic method, it is very robust in identifying the operation of current work processes and options to enhance the efficiency and quality of work processes. Be aware that contemporary attempts to improve service quality, such as total quality management (TQM) and continuous quality improvement (CQI) rely upon general systems flow charting as a basis for system and process analysis.

Unlike other management methods that rely upon mathematics, general systems flow charting does not involve numbers and equations. In this sense it is not a quantitative method. It does, however, provide the manager a form of symbolic logic to use to describe and improve operations and design new systems. As such, general systems flow charting is a systematic method that should be incorporated into the repertoire of any health services manager.

Figure 3-2 To Complete an Acceptable Term Paper

EXERCISE

• 3-3 Using the following narrative, create a general system flow chart. When a patient arrives at the clinic the patient first sees the receptionist, who checks to see if the patient was seen before. If so, the receptionist pulls the medical record from the file. If the patient is new, the receptionist has the patient complete the necessary forms and creates a medical record. Patients are seen by the physician in the order they arrive. If one of the two examination rooms is empty, the nurse escorts the patient to the examination room and records the complaint. The nurse performs routine tests. The nurse writes the complaint and findings on a medical examination form, a form that will be subsequently filed with the patients medical record. The physician examines the patient and orders medical tests, if necessary. A diagnosis and treatment plan is presented to the patient by the physician; a written copy of this plan and any other appropriate instructions. [Notes are written on the medical examination form.] When the physician releases the patient, the patient returns to the receptionist, who prepares a bill. If the patient has health insurance, the bill is sent to the health insurance carrier. The patient leaves after either paying the bill (by cash, check, or credit card) or signing the forms to authorize payment by his or her health insurance company. If the health insurance company refuses to pay or partially pays the bill, the receptionist bills the patient by mail. Any patient with an unpaid bill or bad credit history is refused subsequent treatment until the old bill is paid.
• 3-4 Every pharmaceutical listed on the hospitals formulary has a minimum reorder level. When the inventory level of the specific drug reaches this minimum reorder level, an order is issued to replenish the available supply maintained in the pharmacy. This is done to ensure that the pharmacy always has available inventory to meet the medical needs of patients. The system requires that the chief pharmacist authorize all orders. Using the following narrative, create a general systems flow chart. At 6 am each day the pharmacy information system reports the existing inventory level for each item listed on the hospitals formulary. It produces three lists. List A includes those drugs that will need to be reordered today. List B includes those drugs that will need to be reordered in 2 to 21 days. List C includes drugs that will need to be reordered in more than 21 days. The chief pharmacist must review list A, authorize the purchase, and then send list A to the director of materials management, who must order the drug. When drugs are received by central supply, the receipt for the order (if documented), and the order are sent to the pharmacy for storage in inventory. Once you have completed the flow chart of the existing system, suggest three improvements to enhance the pharmacy inventory system. Aside from lists A, B, and C, what other reports should the pharmacy inventory control system produce? Should special provisions exist for ordering and handling narcotics? Where would you expect the existing system to breakdown?