Using the Tree Diagram to Improve Complex Projects
Earlier in the chapter we discussed the use of the tree diagram for planning (see Figure 213). In this section we will discuss using the tree diagram for breaking down complex
improvement projects. The first tree diagrams presented will employ the questions from the
Model for Improvement for guidance in breaking down the project from the aim of the project
to questions that can lead to possible improvement cycles. We will then conclude this
discussion with a healthcare example that employs the use of the Planning type tree diagram
over the time of the project. This example will show how improvement concepts can be
developed into potential changes that will lead to a desired vision developed by an
improvement team.
Examples of the Tree Diagram Integrating the Model for Improvement to Address
Complex Projects
Figure 21-7 has been borrowed from the Improvement Guide to show the complexity of
various types of improvement efforts from the very simple to the most complex. For the next
example of using the Tree Diagram we will focus on an example that is aimed at improving a
process to gather data from sales within an organization.
Figure 21-7: Complexity of Level of Various Improvement Projects – Focus is on
Improving a Process in an Organization
The tree diagram depicted in Figure 21-8 generally follows the flow of the Three Questions in
the Model for Improvement:
1. What are we trying to Accomplish? General Description
 Project Objectives describe objectives to support the overall general description
and the answer to question one. In this example we are trying to “Improve the
process by which we gather data from the product sales force…”
Using the Tree Diagram to Improve Complex Projects
© API/September 2006
1
2. How will we know that a change is an improvement
 For each objective, a measure(s) is selected to answer question two in the
Model for Improvement. Identifying measures related to the objectives usually
provides some intermediate measures for the project (see Improvement Guide
p.55).
3. What changes do we need to make?
 For this question, questions are posed that need to be answered by the people
leading the project. These questions can lead to appropriate PDSA cycle. Also
added are appropriate Change Concepts (Reference: Improvement Guide, p.
295) that can lead to changes and ideas that can be tested immediately.
Figure 21-8: Tree Diagram Using the Three Questions to Improve a Sales Process
1 .What are we trying
to accomplish?
2 .How will we know a change
is an improvement?
Improvement Objectives
/ Measures
Describe Project:
(check one)
_ X_ Redesign existing
Process(es), product or
service
___ Design new process(es),
Product or service
___ Improve the system as a
Whole (mainstay, drivers
& support processes)
Create request process &
measures
M - Process utilization rate
(Collect data)
3. What changes can we make that will
lead to improvement?
Questions to Answer
Change Concept/ Ideas
How do we make it easy for people to
engage the team to deliver surveys?
B14 / Implement a
request form and web link
How do we measure the resources
needed to support the process?
D28 / Implement a
measurement process &
report
How do we assess whether a survey is
needed or not with the existing Time
Analysis survey in place & other data
collected?
A9, D34, D27, G53 /
Engagement guidelines to
assess survey needs
Brief Description: (include
description above)
Improve the process by
which we gather data
from the Product
Sales Force & increase
knowledge retention of
key sales performance
indicators (time spent,
satisfaction, etc…)
consistently through a
single point of capture.
What alternate methods can we advise
the internal partner to use?
M - # of Surveys Received
by Sales, & Time Spent on
Surveys (Collect data)
How is the outcome tracked, monitored
and used for questions asked?
B18, E38 / Communicate
responses
Sales: Have the decision makers
heard the sales feedback?
E42 / Communicate
change based on
feedback
Standardize the survey
launch process
M – Client satisfaction
(Collect data)
To create cadence in the sales work
week how do we create consistency?
How do we draw new clients into the
process?
How do we ensure consistent delivery
of the survey process?
Items in Green
Engagement guidelines to
advise partners
Improving sales data
collection & usage
answer the question “What can we do right now?”
A5, B20, G51, I68 /
Widespread executive
sponsorship for a single
process
H59, F46 / Develop a
checklist for survey launch
–
Using the Tree Diagram to Improve Complex Projects
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2
Figure 21-9: Planning Chart Using Action Items from the Tree Diagram
PDSA Cycles & Activities
Implement Request Form
Implement Measures
Develop Guidelines
Test Guidelines
Implement Guidelines
Develop Process for
Responses
Test Response process
Implement Response Process
Survey Decision Makers
Standardize Survey Process
Test Survey
Implement New Survey
Process
Week 1
Week 2
Week 3
Week 4
Week 5
Week 6
Week 7
Once the tree diagram is detailed to a useful state, the actions associated with Question
Three of the Model for Improvement can be placed in time order. Figure 21-9 describes the
flow of the various action items and PDSA cycles developed from the questions that need to
be answered in the project and potential changes developed by consideration of the Change
Concepts (Reference: Improvement Guide, p. 295).
The tree diagram can also be used to scope large complex projects that would have multiple
application of the Model for Improvement. Figure 21-10 shows the relative position of our next
example as improvement of a subsystem for sales support within a large international
corporation. As we focus on the tree diagram in Figure 21-11, we see that each of the
objectives is large enough to incorporate an improvement effort for each objective. In this
organization, the term “Charter” is reserved for a document that will guide the deployment of
several “Improvement Plans.” Figure 21-12 describes this breakdown of individual
improvement objectives at the Charter level to four individual Improvement Plans. All efforts
are being guided by the Model for Improvement.
Figure 21-10: Complexity of Level - Focus is on Improving a Subsystem
Using the Tree Diagram to Improve Complex Projects
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Week 8
Figure 21-11: Tree Diagram Using the Three Questions to Improve the Sub-system for
Technical Support within a Large Technology Company
1.
2. How will we know a change
is an improvement?
What are we trying
to accomplish?
General Description
of Project
Describe Project:
1.
(check one)
___ Redesign existing
Process(es), product or
service
___ Design new process(es),
Product or service
_X_ Improve the system as a
Whole (mainstay, drivers &
support processes)
Brief Description: (include
description above)
Provide a differentiated
customer experience for
strategic customers, and a
more basic experience for
non-strategic. (reduce
over-delivery)






M: cost/incident, vol. self-solve vs.
assisted solve
2.
Improve the system for
technical support,
reducing costs while
maintaining customer
satisfaction.
FY06 Strategic objectives
specifically target $15M in
cost reduction to improve
GM% by 11%. The
majority of the cost
reduction is targeting in
the mainstay of the
system.
Questions to Answer
(Potential Cycles)
Project Objectives
M: CSI/top 20 in region
M: CSI for non-top in reg.
3.
Improve the “self-solve”
web capabilities (greater
coverage across products
for knowledge, patches,
upgrades, defect
management) shifting
away from resources for
assisted solve
M: reduced cost/case, reduced
variation per supplier
Reduce supplier cost/case
for assisted solve from
partners, contractors and
3rd parties.
4.
M: reduced cost/case, cost
attribute per classification
Reduce support costs for
older versions of products,
low GM% accounts, cost of
supporting products with
high defects
3. What changes can we make that will lead to
improvement?









What knowledge is most useful?
How does it affect resolution of customer case
(should be 2x faster, if not a defect)?
Does customer has better experience?
What system(s) are most useful for capturing
customer knowledge?
How should the process and system use be
deployed?
What are measures of effectiveness of this
process relative to the overall system?
What gaps in current KM are most needed to
improve the customer’s self-solve usage?
What process changes are needed to ensure
we fulfill those knowledge gaps initially and ongoing?
What costs are involved in the fulfillment of the
knowledge gaps and how does this impact the
overall delivery of service to customers?
What measures are needed to ensure we
maintain an effective system of delivery for both
assisted and self-solve processes?
What are the variations in supplier costs/case
and what are some of the main reasons for
these?
What opportunities do we have for improving
the system by which suppliers provide service/
support on our behalf, esp. to reduce average
costs?
Which older product versions (>n-2) have the
greatest impact on support delivery cost/call today?
What are the reasons?
Which accounts have the greatest impact on cost/
call and overall costs (GM), and what are the
reasons?
What products currently have high defect rates that
are impacting costs, and what steps are needed to
reduce the impact of these?
Possible Change
Concepts to Apply
16. Find & remove bottlenecks
27. Give people access to
information
40. Focus on outcome for a
customer
7. Reduce classifications
9. Match amount to the need
11. Change tgts / set points
(SLO)
40. Focus on the outcome
for a customer
39. Coach customer to use
product / service
43. Outsource for “free” suppliers provide knowledge
51. Standardization of
processes
45. Work with Suppliers
16. Find & remove
bottlenecks
45. Work with suppliers
(CPE partners)
39. Coach customer to use
product/service (training, KP,
NRCE)
Figure 21-12 describes how the project was managed using a Charter to guide four
Improvement Plans. The project measures were connected to the overall charter. For each of
the four objectives it was deemed appropriate to have a separate Improvement Plan to guide
the effort. The Model for Improvement was then used to manage and coordinate the overall
project.
Using the Tree Diagram to Improve Complex Projects
© API/September 2006
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Figure 21-12: Tree Diagram Using the Three Questions to Improve the Sub-system for
Technical Support within a Large Technology Company
Improvement Plan 1
General Description
of Project
M: CSI/top 20 in region
M: CSI for non-top in reg.
Describe Project:
(check one)
1.
___ Redesign existing
Process(es), product or
service
___ Design new process(es),
Product or service
_X_ Improve the system as a
Whole (mainstay, drivers &
support processes)
Brief Description: (include
description above)
Improve the system for
technical support,
reducing costs while
maintaining customer
satisfaction.
FY06 Strategic objectives
specifically target $15M in
cost reduction to improve
GM% by 11%. The
majority of the cost
reduction is targeting in
the mainstay of the
system.
Questions to Answer
(Potential Cycles)
Project Objectives
Provide a differentiated
customer experience for
strategic customers, and a
more basic experience for
non-strategic. (reduce
over-delivery)
 What knowledge is most useful?
 How does it affect resolution of customer case

(should be 2x faster, if not a defect)?
Does customer has better experience?
 What system(s) are most useful for capturing


customer knowledge?
How should the process and system use be
deployed?
What are measures of effectiveness of this
process relative to the overall system?
Possible Change
Concepts to Apply
Model for Improvement
16. Find & remove bottlenecks
27. Give people access to
information
40. Focus on outcome for a
customer
What are we trying to
accomplish?
Improvement
Plan 2
How will we know that a
change is an improvement?
Model for Improvement
7. Reduce classifications
9. Match amount to the need
11. Change tgts / set points
(SLO)
What change can we make that
What will
are we
trying
to
result
in improvement?
accomplish?
Improvement
Plan 3
How will we know that a
change is an improvement?
M: cost/incident, vol. self-solve vs.
assisted solve
2.
Improve the “self-solve”
web capabilities (greater
coverage across products
for knowledge, patches,
upgrades, defect
management) shifting
away from resources for
assisted solve
3.
M: reduced cost/case, reduced
variation per supplier
Reduce supplier cost/case
for assisted solve from
partners, contractors and
3rd parties.
4.
M: reduced cost/case, cost
attribute per classification
Reduce support costs for
older versions of products,
low GM% accounts, cost of
supporting products with
high defects
Model for Improvement
Act
What change can
we make that
Plan
 What gaps in current KM are most needed to



improve the customer’s self-solve usage?
What process changes are needed to ensure
we fulfill those knowledge gaps initially and ongoing?
What costs are involved in the fulfillment of the
knowledge gaps and how does this impact the
overall delivery of service to customers?
What measures are needed to ensure we
maintain an effective system of delivery for both
assisted and self-solve processes?
 What are the variations in supplier costs/case
and what are some of the main reasons for
these?
 What opportunities do we have for improving
the system by which suppliers provide service/
support on our behalf, esp. to reduce average
costs?



Which older product versions (>n-2) have the
greatest impact on support delivery cost/call today?
What are the reasons?
Which accounts have the greatest impact on cost/
call and overall costs (GM), and what are the
reasons?
What products currently have high defect rates that
are impacting costs, and what steps are needed to
reduce the impact of these?
40. Focus on the outcome
for a customer
39. Coach customer to use
product / service
43. Outsource for “free” suppliers provide knowledge
51. Standardization of
processes
What are will
we trying
result to
in improvement?
accomplish?
Improvement
Plan 4a
How will we know that Study
change is an improvement?
Do
Model for Improvement
Act
What change can we
make thatPlan
What will
are we
trying
to
result
in improvement?
accomplish?
System Measures
How will we know that Study
a
change is an improvement?
45. Work with Suppliers
16. Find & remove
bottlenecks
Do
Act
What change can
we make that
Plan
will result in improvement?
230
210
190
J
M
M
J
S
N
J
M
M
J
S
N
J
M
N
J
M
M
J
S
N
J
M
M
J
S
N
Study
95
90
85
80
75
45. Work with suppliers
(CPE partners) J M M J S
39. Coach customer to use
product/service (training, KP,
NRCE)
15
M
J
S
Act
Plan
Study
Do
N
Do
10
5
0
J
M
M
J
S
N
J
M
M
J
S
N
J
M
M
J
S
J
M
M
J
S
N
J
M
M
J
S
N
J
M
M
J
S
N
J
S
N
Overall System
Charter
N
15
10
5
0
35
25
15
5
J
M
M
J
S
N
J
M
M
J
S
N
J
M
M
Using the Planning Type Tree Diagram to Guide a Complex Project in Healthcare
The tree diagram in Figure 21-13 describes the use of “planning” type tree diagram to guide a
project towards accomplishing a desired vision. In this diagram we have four concepts that
are driving the current changes. From these current changes, potential changes have been
identified that will be necessary to move the overall effort to the desired vision.
Figure 21-14 describes a project in a Healthcare system where changes are being
developed, tested and implemented to improve the relationships between healthcare
professionals and patients. The team started off with several guiding principles:




You Know Me; Changes to establish the relationship with the patient
The Care Team; Changes to be made by key contacts in the care team
Collaboration; Changes to better understand and work with the patient
Options and Tools; Methods and Tools to enhance communication and the
relationship.
Using the Tree Diagram to Improve Complex Projects
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5
From these concepts, changes known to the team were identified that could be tested now.
As the team developed and tested and these changes, other potential changes were
identified. In addition to this thought process, the team used the overall vision to develop
other potential changes that would be required to move the team to accomplishing their
vision. As the team developed the plan for these changes they also included a timeline to
forecast when the changes could be integrated into the system.
Figure 21-13: Using the Planning Type Tree for Planning Changes Over Time Directed
to a Desired Vision in Healthcare – Conceptual Example
Concept
•
Current Change
•
Concept
•
•
Current Change
•
Concept
•
Potential Change
•
Potential Change
•
Potential Change
Planned Change
Current Change
•
•
Concept
•
Planned Change
Potential Change
Team Vision
The team’s
vision/
personalizatio
n of the
concept
design
Planned Change
Current Change
TODAY
Mar. 2006
3 Mos.
June 2006
6 Mos.
Sept. 2006
9 Mos.
Dec. 2006
12 Mos.
PROJECT TIMELINE
Using the Tree Diagram to Improve Complex Projects
© API/September 2006
6
Figure 21-14: Using the Planning Type Tree for Planning Changes Over Time Directed
to a Desired Vision in Healthcare – Detailed Example
You Know Me
•
Care Team
•
•
•
•
Collaboration
•
•
•
Options/Tools
•
•
•
Kp.org sign-up
kiosks & info
Patient contact
preferences
Nickname in
header
Receptionist colocated with team
CA reviews after
visit summary with
patient
RN pre-screening
charts
Proactively
identifying patient
needs
Reaching out to
patient and
subsequent followup
Telephone visits
•Pre-visit prep
with patients to
elicit what
matters
• New roles for
members of the
care team based
on the work
•
Ask patients to do
collaborative goal
setting during visit
•
Build Care plan
into chart –
consistent place
•
Virtual visits with
agreeable
members
•
New members of
the care team
based on the work
•
Action plans based
on evidence-based
care developed
with patients
•
e-visits as the
standard
mechanism for
follow-up
•
What matters to
patient addressed
by care team
•
Collaborative care
plan guides all
interactions
•
Panel View tool to
manage patients
The care team,
supported by
optimizing the
relationshipbased care of a
population of
patients
Group visits
Health
Assessments
TODAY
Mar. 2006
3 Mos.
June 2006
6 Mos.
Sept. 2006
9 Mos.
Dec. 2006
12 Mos.
PROJECT TIMELINE
Summary
This paper has discussed several key points related to using tree diagrams to breakdown
complex improvement projects:
1. The Model for Improvement and use of the Three Questions can be used in
conjunction with the Tree Diagram to break down improvement projects.
2. Obvious PDSA cycles can be identified and testing started on changes that can lead to
improvement.
3. Time lines can be constructed to give guidance to the team.
4. Larger projects can be scoped down using the Tree Diagram. Charters can be used to
manage these larger projects with sub-charters or improvement plans.
Using the Tree Diagram to Improve Complex Projects
© API/September 2006
7
References
Bowles, John. The Society of Automotive Engineering’s Failure Modes and Effects
Analysis (Proposed Document) 1996.
Juran, J.M., Gryna, Frank. Juran’s Quality Control Handbook Fourth Edition
McGraw-Hill Book Company. 1988.
New York:
Mizuno, S., ed. Management for Quality Improvement: The 7 New QC Tools.
MA: Productivity Press, Inc. 1988.
Cambridge,
Shiba, Shoji, Alan Graham, David Walden. A New American TQM: Four Practical
Revolutions in Management. Portland, OR: Productivity Press. 1993.
Wilson, Paul F., Larry D. Dell, Gaylord F. Anderson. Root Cause Analysis: A
Total Quality Management. Milwaukee: ASQC Quality Press. 1993.
Tool for
Exercises
1. Consider a recent problem in your organization and develop a problem tree diagram.
2. Select a work objective that is currently a challenge and develop a planning type tree
diagram.
Using the Tree Diagram to Improve Complex Projects
© API/September 2006
8
Appendix: Healthcare Examples of the Tree Diagram
Care of Heart Failure
Patients at XYZ
Hospital
Describe Project:
(check one)
_X_ Redesign existing
Process(es), product or
service
___ Design new process(es),
Product or service
___ Improve the system as a
Whole (mainstay, drivers
& support processes)
Improvement Objectives
/ Measures
100% of patients will have
standardized order set used
Questions to Answer
How can we automate this with Excellian
(computerized documentation system)
How do we get this on the chart for every
patient?
B17: Develop computerized
order set for HF patients
E41/H59/B18:Work with Care
Coordinators to put paper order
set on chart and follow up to
ensure it is completed
How do we ensure providers use it and fill it
in on each patient?
99% of pts will receive LVF
assessment and
ACEI/ARB’s as appropriate
How can we assess if LVF assessment is
planned for after DC or done prior to adm?
H59/B18/B19: Include check
boxes on order set that indicate
these elements
How will we know if ACEI/ARB was
considered but contraindicated?
Brief Description: (include
description above)
To improve the care
provided to heart failure
patients by including
evidenced based
interventions thereby
decreasing readmission
rates
Change Concept/ Ideas
99% of pts will receive
smoking cessation advice
Is smoking history getting consistently
assessed on admission?
99% of pts will receive
comprehensive dc instructions
How do we ensure all providers know what
elements need to be included in dc
instructions?
How do providers document instructions
given?
Decrease ALOS
What other factors influence ALOS beyond
4 core measure?
B17: Make this a required field
on admission profile and/or on
order set
H59/B18/B19: Include check
boxes on order set that indicate
these elements
G51: Create a standard HF
pathway
Do these pts follow a typical path?
Prepared by: Martha Frederickson
Are there commonalities among pts with
targeted LOS?
Using the Tree Diagram to Improve Complex Projects
© API/September 2006
9
E41/E40: Have Case managers
follow HF patients while
hospitalized
Improvement Objectives
Measures
Describe Project:
(check one)
___ Redesign existing
Process(es), product or
service
__Design new process(es),
product or service
___ Improve the system as a
Whole (mainstay, drivers &
support processes)
Brief Description: (include
description above)
To decrease the risk and
occurrence of post-op
respiratory complications
after elective general and
vascular surgery in at-risk
patients by initiating a preop pulmonary assessment
and
conditioning/rehabilitation
program.
This will be achieved by:
 Physician engagement –
identify patient
candidates well in
advance of surgery
date
 Development of a
Pulmonary Rehab
Express program for
preop patients
 Availability of
documentation of
rehab parameters upon
arrival on day of
surgery
Develop a standardized pre-op
pulmonary rehab referral form
and process to begin use in
physician office through Pulm
Rehab to Pre-Surgical Screening
(PSS). Include ICD9 codes for
insurance coverage.
Develop Rehab Express program
to accommodate elective general
and vascular surgery patients with
pre-op chronic respiratory risks
(optimal length of time for
conditioning is projected at 2
weeks)
Develop procedure and educate
surgeons, Anesth., Pulmonologists,
office staff, PSS and patients
(develop educational materials).
Develop a process and provide
pre- and post-rehab conditioning
parameters for Anesthesiology at
time of patient admission for
surgery.
Decrease post-op pulmonary
complications including dyspnea,
prolonged ventilator dependency
and pneumonia.
Potential additional measures:
decrease post-op length of stay,
cost per case and readmission for
respiratory conditions.
Category and continuous data on
patients referred, rehab program
completed and pulmonary status
measure improvement.
Questions to Answer
Change Concept/ Ideas
Can Pulmonary Rehab handle added volume? Do they
have a program already or one that could be adapted to
this? Are there forms that could be used/modified for this
program?
Will surgeons agree with the need for pre-op pulmonary
conditioning and refer in advance of boarded elective
surgery? What’s the degree of belief that this program is
needed by surgeons, anesthesiologists & pulmonologists?




Will busy and different office staffs and PSS cooperate and
support this new initiative? Teach office staff, Pulm Rehab
and PSS the process.
Teach office staff, Pulm Rehab and PSS the process.
Will this program be cost effective?
What happens if a patient’s insurance will not cover or the
patient does not have insurance?
What if there is less than 2 weeks before surgery?


Standardization –
create a formal
process (51)

Develop
operational
definitions (53)

Conduct training
(31)
Will Anesthesia utilize pulmonary rehab information, find it
of value?
What if there is less than 2 weeks before the surgery?
Will patients agree to the program, stick with it once it is
started?
How will we attribute complications to pre-op pulmonary
risk?
Will office, Pulm Rehab and PSS staff support ongoing
evaluation & improvement of the process? Pilot the whole
process on one or two patients to work out the bugs.
Include office, Pulmonary Rehab and PSS stgff in
evaluation and revision of process.
Will timing of NSQIP data be timely enough to monitor the
process?
Will there be enough patients referred in order to evaluate
and do statistical analysis?
9/8/2006

Prepared by: Laura DeSantis
© API/September 2006
10
1. Pulm Rehab
capacity/program
evaluation
PDSA
2. 4/12/2006 Surgery
QA Committeesurgeon buy-in
PDSA
3. 4/28/06 first patient
referral (elective
AAA) 5/2 assessment
completed, 5/5 PR
Express began
PDSA
4. PDSA

Engage/use the physicians and office staff
in ongoing evaluation/process improvement.
Using the Tree Diagram to Improve Complex Projects
Develop
alliance/cooperat
ive relationships
(37)
Coach customers
to use product /
service (39)
Standardization
(51)
Use a
coordinator (41)
Conduct training
(31)
Enable access to
information
PDSA (gant)
Use proper
5. PDSA
