Process Mapping—sometimes

called Flowcharting or IS Maps

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Quality Improvement Works on Existing
Processes

• A process is a series of steps or actions

performed to achieve a specific
purpose.
• A process can describe the way things
get done.
• Your work involves many processes.

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 What is a Process Map?

• A pictorial representation of the

sequence of actions that comprise a
process.

3
 Why is Process Mapping
Important?

• It provides an opportunity to learn about

work that is being performed.
• Dr. Myron Tribus said,
“You don’t learn to process map,
You process map to learn.”
• Most processes today are undocumented
or are evolving.

4
What Dr. Deming said

“You cannot improve a process

until you understand it!”

“If you can't describe what you are

doing as a process, you don't know
what you're doing.”

5
 Process Maps are Used to:
• Document the way we do our work.
 Provide a reference to discuss how things
get done.
 Describe and understand the work we do.

• Analyze and improve on processes.

 Identify of areas of complexity and re-work.

 To generate ideas for improvement.

 Illustrate process improvements.

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 Preparing to Process Map
• Assemble the Team.
• Agree on which process you wish to
document.
• Agree on the purpose of the process.
• Agree on beginning and ending points.
• Agree on level of detail to be displayed.
• Start by preparing an outline of steps.
• Identify other people who should be involved
in the process map creation, or asked for
input, or to review drafts as they are
prepared.
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 Symbols used to Process Map
• Start & End: An oval is used to show the materials, information or
action (inputs) to start the process or to show the results at the end
(output) of the process.

• Activity: A box or rectangle is used to show a task or activity

performed in the process. Although multiple arrows may come into
each box, usually only one arrow leaves each box.

• Decision: A diamond shows those points in the process where a

yes/no question is being asked or a decision is required.

• Break: A circle with either a letter or a number identifies a break in the

Flowchart and is continued elsewhere on the same page or another
page.

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 Hints and Tips

• Process Map what is, not what you

would like the process to be.
• Process Mapping is dynamic. Use Post-
it notes, dry erase markers, pencil, etc.
• All Process Maps must have start and
stop points.

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Process Map of Conference Approvals
Sample

• Do a Process Map that documents the

process used to obtain approval to
attend conferences.

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Sample One

11
Sample Two

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Sample Three

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 Hints and Tips
• Brainstorming and Affinity Diagrams can be used to identify
processes you wish to do a process map on.
• There is no single right way to do a process map. It is a tool to
learn about your organization and work.
• Process Maps can be used in a variety of settings outside Quality
Improvement, such as:
 Orienting new employees
 In-service presentations
 Brainstorming possible process changes
 Creating or revising policies and procedures that support the
 process
 Creating measures
 Identifying logical outcomes of a process

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 Summing UP
• Process Map to learn.
• Process Map to document a baseline to
measure improvement vs. change.
• Process Map to point to where data may be
that describes the current process.

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 QI Tool Exercises
Scenario
• Highlighting Excellence Health Department
• Improvement sought-Improved Customer
Satisfaction with health department services
• Area of Concentration-Customer Satisfaction
Survey
• Please take a moment to read the Scenario
write-up that is in your binder

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17
Check Sheets

observing a process

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 Check Sheets: Purpose
• To turn observational data into numerical data
– From records
– Newly collected

• To find patterns using a systematic approach

that reduces bias

• Use check sheets when data can be observed

or collected from your records
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 Check Sheets: Step by Step
• Step 1
– Decide what to observe
– Define key elements
– Established shared understanding
• Step 2
– Identify where, when, & how long
– Think about confounding factors
• That you want to eliminate
• That you want to study

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 Check Sheets: Step by Step
• Step 3
– Design your check sheet
– Develop a protocol

Problem/Project Name: Name of Observer: Other:

Location of Data Collection: Dates of Observation:

Dates of Data Collection

Total
Event

C
Grand
Total
Total

21
 Check Sheets: Step by Step
• Step 4
– Identify and train your observers
– Practice & adjust
• Step 5
– Collect data
– Review & adjust
• Step 6
– Summarize data across observations & observers
– Study the results

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 Hints and Tips
• Make sure you’re getting clean data
– Define, train, check, adjust, & repeat!
– Consider and address potential sources of bias

• Use “other” categories sparingly

• Strike a balance
– Fine vs. inclusive categories
– Few vs. many categories

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 Exercise

• When customers report dissatisfaction with LHD services,

staff track the primary reason for customer dissatisfaction

• They believe dissatisfaction may be caused by several

conditions that they can document:
• LHD does not offer service client needs
• Needed service was difficult to access
• Wait times were too long
• Interaction with LHD staff was poor
• LHD provided inaccurate information

• Use your handout to set up the check sheet for this

situation
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Pareto Charts

80% of the problem

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 Pareto Charts: Purpose
 To identify the causes that are likely to have the
greatest impact on the problem if addressed

 “80% of the effects come from 20% of the

causes”

 To bring focus to a small number of potential

causes

 To guide the process of selecting improvements

to test

 Use when you have, or can collect, quantitative

or numeric data on several potential causes
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 Pareto Charts: Step by Step

• Step 1
• Identify potential causes of the problem you wish
to study

• Step 2
• Develop a method for gathering your data
• Historical data
• Collection of new data
• Check Sheets
• Surveys

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 Pareto Charts: Step by Step

• Step 3
• Collect your data
• Each time the problem occurs, make note of the
primary cause

• Step 4
• Order your results & calculate the percentage of
incidents that fall into each category

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 Pareto Charts: Step by Step

• Step 5
• Display your data on a graph
• The most commonly occurring cause should appear first, and the
causes should appear in order
• Word or Excel can be used, but paper and pencil work too
• Label the x-axis (horizontal) with the causes, the left y-axis (vertical)
with the percentage of occurrences with each cause, and the right y-
axis with the cumulative percent.
• Graph your data

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Genesee County Pareto

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 Pareto Charts: Step by Step

• Step 6
• Make sense of your results by examining your data
• Are a few causes driving the problem?
• Can this information help you make decisions about the
solution you want to try?
• Does this information impact how you want to structure
your aim statement or theory of change (if-then)?
• Can you use this information to measure your results?

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 Pareto Charts: Hints and Tips

• You’ll only learn about causes that you investigate - be inclusive!

• Check and double check your data

– Little errors can make a big difference

• Results can be used in more than one way and they can be used
differently at different points in time
– Revisit your Pareto throughout your project – the meaning may change for
you as you go

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 Pareto Charts: Exercise
Problem: Client Dissatisfaction Name: J. Heany Time: 9-5
Location: Excellence Health Department’s Dates: Week of 9/6, 9/13, 9/20, 9/27,
Customer Service Department 10/4, 10/11, 10/18
Date
Total
Reason 9/6 9/13 9/20 9/27 10/4 10/11 10/18

Service not offered 3 4 3 2 3 4 0 19

Service was difficult
10 12 6 3 0 0 0 31
to access
Long wait times 0 0 2 3 6 1 0 12
Poor staff
2 2 1 2 0 0 1 8
interaction
Inaccurate
2 3 1 2 1 0 1 10
information
Total 17 21 13 12 10 5 2 80

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BREAKTIME

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Cause and Effect Diagrams

Moving from Treating Symptoms

To

Treating Causes

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Problem Solving – What we usually see is the tip of iceberg – “The Symptom”

The Symptom

The Root Causes

Invisible

Hidden

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Problem Solving
• When confronted with a problem most people
like to tackle the obvious symptom and fix it

• This often results in more problems

• Using a systematic approach to analyze the

problem and find the root cause is more efficient
and effective

• Tools can help to identify problems that aren’t

apparent on the surface (root cause)

37
Fishbone Diagrams
and
5 Whys

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 Fishbone Diagrams: Purpose

 To identify underlying or root causes of a problem

 To identify a target for your improvement that is

likely to lead to change

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 Fishbone Diagrams: Construction
• Construction
 Draw an arrow leading to a box that contains a statement of the
problem
 Draw smaller arrows (bones) leading to the center line, and label
these arrows with either major causal categories or process
categories
 For each cause, identify deeper, root causes

Cause 1 Cause 3

Effect/Problem

Cause 2 Cause 4

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 Berrien County Fishbone

Root causes for lack of BCHD general PH articles

Causes
Process Topics

Articles for events only

No time to develop
Effect
Confusion/duplication
Minimal articles

Secluded media team Sporadic writing

One writer, poor health
No long-term arrangements

People/Staff
Media Relations
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Cause and Effect Diagram

Pre Natal Early Feeding

Life Style
Practices Practices
Excess Maternal Decreased Breast Bottle Pacifier No Time For TV Viewing
Weight Gain Feeding
Juices Food Prep
Less Fruits and Veg. Sodas/Snacks
Over Weight No Outdoor Play
Newborn
Less Unsafe
Income Maternal
Choices
Obese Children
Built Environment For Unhealthy Food
Strollers Not Toddling Choices
Genes Curriculum
Few Community
Less Indoor Mobility Recreational No Sidewalks
Syndromes
Areas or Programs
TV Over Weight Less Exercise @ School
Pacifier Pre School

Genetics Environment Polices

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 Fishbone Diagrams: Hints & Tricks
• Find the right problem or effect statement
 The problem statement should reflect an outcome of a process that
you control or influence
 Be specific
 Reach consensus
• Find causes that make sense and that you can impact
 Generate categories through:
 Brainstorming
 Looking at your data
 Ask “why?” to achieve a deeper understanding
 Know when to stop
 Stick to what you and your managers can control or directly
influence
• Make use of your results
 Decide if you need more data
 Consider causes that come up again and again, and causes that
group members feel are particularly important

Memory Jogger, page 32

43
 Exercise
Fishbone Diagram
Customer Satisfaction
• By Table
• Draft a Fishbone Diagram listing effect(s),
major causes, and data related causes (root)
• It is OK if data related causes show up in more
than one major cause area
• HINT: The pareto chart makes a good starting
point
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 Five Whys

• The 5 Whys is a question-asking method

used to explore the cause/effect relationships
underlying a particular problem. Ultimately,
the goal of applying the 5 Whys method is to
determine a root cause of a problem.

Wikipedia

45
 Five Whys (cont.)
Example
• My car will not start. (the problem)
• Why? - The battery is dead. (first why)
• Why? - The alternator is not functioning. (second why)
• Why? - The alternator belt has broken. (third why)
• Why? - The alternator belt was well beyond its useful
service life and has never been replaced. (fourth why)
• Why? - I have not been maintaining my car according to the
recommended service schedule. (fifth why, root cause)

Wikipedia

46
 5 Why’s and How’s
• A major advantage to the 5 Whys technique is that
it is relatively easy to use and apply
• In many organizations, problem solving is a
deductive exercise conducted in a meeting room
where those doing the problem solving are
separated from the actual process where the
problem occurred. “Go and See”
• The 5 Whys requires skill to use well and most
important, should be grounded in observation,
data, and not deduction.

47
 5 Whys Limitations
Using 5 Whys does not always lead to root cause identification
because:
– Listing causes in the absence of data.
– Assumes each symptom has only one sufficient cause.
– Varying skill with which the method is applied.
– The method is not necessarily repeatable.
– Linear approach that does not pick up interactions.
– Inability to distinguish between causal factors and root
causes.

• If it is used with no data it can lead to bad judgment calls which

pick the wrong root cause(s).

• Solutions are then implemented that address the wrong root

cause.

• These wrong solutions may cause more problems and make

the situation worst.
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How To Overcome The Limitations:
Use Data

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 Exercise
5 Whys
Customer Satisfaction

• By Table
• Perform 5 whys on the two causes that
received the greatest number of responses as
shown in the Pareto Chart (Service was
difficult to assess and Service not offered).

50
 Summing UP
• Use Fishbone and 5 Whys to explore and
graphically display in increasing detail all of
the possible causes related to the problem.
• Use Fishbone and 5 Whys to find dominant
causes rather than symptoms.
• Use Fishbone and 5 Whys to identify the root
cause of the problem we seek to improve.

51
 Run Charts

tracking process performance

52
 Run Charts: Purpose
 To study data measured over time

 Run charts help to:

 Study the performance of a process
 Identify trends
 Measure change in performance following a
change in process

 Use when you have, or can collect:

 Quantitative data
 On a measure of the performance of a process
 Over time

53
 Run Charts: Step by Step

• Step 1
• Decide what data you need
• Are the data you need already tracked?
• Do the data need to be collected?
• Determine the timeframe & number of data collection
points
• Should you make your count annually, quarterly, monthly,
weekly, daily, hourly?
• Try to gather data from 20+ time points in order to establish
a trend

• Step 2
• Gather your data

54
 Run Charts: Step by Step
• Step 3
• Graph your data
• On the Y-axis, set up a scale that corresponds with your
measure
• On the X-axis, set up a scale that corresponds with your
measurement timeframe
• Plot your data on the chart, placing one dot at each
measurement point
• Draw a line through your dots
• Calculate the mean score and draw a line at the mean
• Mark the timing of your change
• Excel, Word, and other programs can help!

55
 Sample Run Chart
Number of New BCCCP Clients by Month
in 2007 and 2008

50
Number of New Clients

45
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 Run Charts: Step by Step
• Step 4
• Make sense of your results by examining your data
• Does the mean reflect an appropriate level of service or outcome
of your process?
• Is there a trend that should be investigated?
• Do you see a shift in your data? Are there 8 or more consecutive
points on one side of the center line?
• Do you see a trend in your data? Are there six consecutive jumps
in the same direction (up or down)?
• Do you see a pattern in your data? Does a pattern recur eight or
more times in a row?

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 Run Charts: Hints and Tips

• Every process will have some variation

– Be cautious about assuming that variation from the average has meaning

• Be sure to track data over a long enough period of time

– This will help you identify the true mean and the true level of variability
within the process

58
 Run Charts: Exercise
Month Response Response
rate in ‘08 rate in ‘09 Each month the health department
tracks customer satisfaction survey
January 2 1.8
data to measure the impact of
February 2.3 1.9 implementing an integrated service
model starting in April 2009.
March 2.2 2
April 2.5 3.5 Client satisfaction measured by mean
May score on survey item:
2.6 3.8
“The health department makes it easy
June 2.2 3.9 to get the services I need.”
July 2.1 4
August 1.9 4.1
September 1.9 4.3
October 2 4.5
November 2.1 4.5
December 2.2 4.5 59
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