Performance Architecture: Process Inside Out

If you work in manufacturing you are located at the nexus of process civilization as we know it. In your world, a process is based upon a series of planned activities that convert a given input to a desired output. Being in manufacturing is a distinct advantage because you have years of process history to draw upon.

If you work in the service sector you have been extrapolating process development from a manufacturing model and may have been challenged along the way. Geary Rummler made this work easier by expanding the definition of a process to include components that can:

  • Be performed effectively and efficiently
  • Be managed effectively
  • Offer the potential for competitive advantage (Rummler, Ramais, Rummler, p.16)

We believe that Performance Architects, whatever their formal job titles or functional areas, are aligned in seeking out and using evidence-based designs, plans, models, and tools to improve performance in their organizations. Please join us as Roger, wearing both his Performance Architect and end-user hats, shares his recent process immersion experience.

One Author’s Process Journey

Some months ago, by way of a middle-of-the-night visit to the Emergency Room, Roger was admitted to the hospital for a needed surgery. As he lay in his hospital bed waiting for an opening in the day's surgery schedule, Roger thought about the hospital environment and the patient-centric processes he had just experienced, from the Emergency Room, to Admitting, to the caregiving he was receiving as an in-patient. He was reminded of Geary Rummler's comparison of the diagnostic work performed by Performance Architects as they investigate workplace issues and opportunities, with that of physicians as they diagnose medical conditions. (Rummler, p. 132)

As all good Performance Architects and physicians do, Roger launched the analysis of his situation by gathering information. First, he observed his environment and documented it with a photo of the white board in his room:

The White Board

Process-Inside-Out_fig1

In this particular hospital system, the white board is an important communication medium for nurses and other practitioners. They add and update information on it and consult it at shift changes. The patient uses the white board to learn who the day's caregivers are, how to call them, and for other care-related information.

As Roger acquainted himself with the white board, he considered all the stakeholders, including himself, involved in the many medical processes that had brought him to this pre-surgery limbo. And, he compared these stakeholders to those typically involved in workplace processes in non-medical organizations. Roger then considered what was at stake for each of the stakeholders.

The Stakeholder Challenge

A stakeholder is a person or group that has an interest in the success of a process and also interacts with that process. This interaction takes the form of requesting and receiving things from the process upstream (where the work goes next) and downstream (where the work came from). For any process to succeed, all the stakeholders must be identified and then involved in the development or updating of the process.

Sample Stakeholder Roster

Process-Inside-Out_fig2

Does each stakeholder know that their success, the organization's success, and the end-user/patient's success are all interdependent? Omit a stakeholder and the resulting process will be incomplete with an increased risk of failure.

Process & Practices

Regular readers know that Performance Architects always consider processes and practices together. See our previous Column, Practice Makes Process for details. Practices are patterns of behavior. Within a process, the associated practices are planned behaviors that convert the process inputs to the desired outputs. And, as we frequently say, a process is only as good as its practices. A physician, for example, can follow a medical process correctly, but if she has a poor bedside manner the process will be compromised.

Scope Diagram

Let us quickly assure you that Roger's hospitalization, surgery, and recovery were all successful. And, Roger was favorably impressed with the many processes he experienced as a patient. What he noticed was the difference in his comfort level from one process to the next.

While he was recovering at home, Roger realized that when he did not fully understand a process he experienced, such as Pre-Op (surgery preparation), he became confused and concerned. While he was obviously prepared properly for his surgery, the experience was stressful for Roger.

Roger's Patient Care Experience

Process-Inside-Out_fig3

Fortunately, Roger and Paul Harmon had lunch shortly after Roger's discharge and Paul introduced him to the Scope Diagram, which helped Roger pull together all the processes he had experienced. He was able to consider which ones were comfortable and which were not, regardless of the outcome.

Much of Roger's favorable impression of each process was related to the extent and level of detail the medical staff communicated to him. In the operating room, for example, each member of the surgical team introduced him or herself, helping Roger understand how the surgery would be done and the role of each person. See the Surgical Safety Checklist from our Column The Checklist: A Great Equalizer.

Scope Diagram

Process-Inside-Out_fig4

Understanding the Scope Diagram

A Scope Diagram is a useful tool for deconstructing a process to understand it as well as for building a new process. We'll use it to understand one of the processes Roger experienced, Post-Op recovery.

When a patient's surgery is complete, he is wheeled into the Recovery Room where a nurse cares for him as he awakens from anesthesia and becomes aware of his surroundings. The nurse monitors the patient's pain level, degree of disorientation, and all other medical factors. The surgeon comes in to talk with the patient and assess how he is doing, order medications, etc. The patient remains in recovery until he is stable enough to go to his hospital room, or to be discharged if he is an outpatient.

Let's follow the Diagram for the Post-Op recovery process as Roger recalls it.

Inputs include:

  • An anesthetized patient
  • A completed surgical procedure
  • Treatment components such as ice pack, IV tube/bag/pole, etc.

Outputs include:

  • A conscious patient
  • Post-operative medications
  • Patient care instructions
  • Orders for physical therapy
  • Dietary orders

Guides include:

  • Nurse: Patient ratio
  • Time in recovery room per patient
  • Communication with patient's family/friends
  • Monitoring of vital signs
  • Procedures for post-operative emergencies, allergic reactions to medications, etc.
  • Liquid refreshments made available

Enablers include:

  • Nurses and other medical personnel
  • Computers and programs for charting by nurses and surgeons

Using the Scope Diagram

If any stakeholder, including Roger, had a concern about the Post-Op process, completing a Scope Diagram would likely identify the probable source.

The Scope Diagram is a flexible tool to use before, during and after the development of a process. Use it to:
  • Define the four Types of Interactions at the start of any process analysis
  • Identify, in advance, where process difficulties may occur
  • Troubleshoot a process to locate the source of a problem

Conclusion

The Scope Diagram is a useful planning tool for process design and problem analysis. Based on Roger's hospital stay, where processes connect as the patient moves through the system, we see the Scope Diagram helping to identify critical process components across an entire system. Coupled with careful and complete identification of the stakeholders for each process, and ensuring their active involvement in process development, Performance Architects in all organizational functions can ensure they build effective processes. Most of the processes Roger experienced in his medical journey were successful because the Performance Architects included the patient as a stakeholder.

References

Addison, R., Haig, C., Kearny, L. (2009). Performance architecture: The art and science of improving organizations. San Francisco, CA. Pfeiffer.

Gawande, Atul. (2010). The checklist manifesto • How to get things right. New York, NY. Metropolitan Books.

Harmon, Paul. (2014). Business process change, 3rd Ed.: A business process management guide for managers and process professionals. Needham, MA. MK/OMG Press.

Rummler, G. (2004). Serious performance consulting – according to Rummler. Silver Spring, MD. International Society for Performance Improvement.

Rummler, G., Ramais, A., Wilkins, C. (2011). Rediscovering value – Leading the 3-D enterprise to sustainable success. San Francisco: Jossey-Bass.

Roger Addison & Carol Haig

Roger Addison & Carol Haig

Roger Addison has a Ph.D. in Educational Psychology from Baylor and is Certified in Performance Improvement Technologies (CPT). He is the co-author of Performance Architecture and an internationally respected performance improvement consultant. He is the founder and Chief Performance Officer of Addison Consulting. Previously he was the Senior Director of Human Performance Improvement for the International Society for Performance Improvement (ISPI) where he was responsible for educational programs and implementing performance improvement systems. Carol Haig is a Certified Performance Technologist (CPT) and has more than 30 years of multi-industry experience partnering with organizations to improve their employees' performance. Carol is known for her superior skills in project management, analysis and problem/opportunity identification, and instructional design and facilitation. She has consulted with executives and line managers, established and managed training departments, trained trainers, written for professional publications and mentored performance consultants. She is co-author of Performance Architecture.
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