Local Performance Management Initiative

Process Improvement Guidebook

Developed by

NJAES Office of
Continuing Professional
Education (OCPE)

and

University Center for

Organizational Development
and Leadership (ODL)

Local Performance Management Initiative:

Process Improvement Guidebook
Fall 2012
Developed by:
Office of Continuing Professional Education
(OCPE), New Jersey Agricultural Experiment
Station, Rutgers University
University Center for Organizational Development
and Leadership (ODL), Rutgers University
This guidebook was developed for, and with
support from, the New Jersey Department of
Health and the U.S. Centers for Disease Control
and Prevention. Contents are the sole responsibility
of the developers and do not necessarily
represent the views of NJDOH and CDC.

UCODL
ASB II, Room 217
57 US Highway 1
New Brunswick, NJ
08901-8554
(848) 932-3963
center@odl.rutgers.edu

OCPE
Laws House
102 Ryders Lane
New Brunswick, NJ
08901-8519
(732) 932-9271
ocpe@njaes.rutgers.edu

www.odl.rutgers.edu

www.cpe.rutgers.edu

Contents
Introduction..........................................................................................4
What is a process?..........................................................................4
What is process improvement?........................................................5
Step 1: Identify the process to improve.............................................7
Step 2: Organize the group..................................................................8
Process owner.................................................................................8
Working group.................................................................................8
Consultation group...........................................................................8
Step 3: Map the current process......................................................11
Define (and limit) the process..........................................................11
Construct the process map (diagram)............................................11
Step 4: Identify problems and potential solutions..........................13
Fully identify the problems..............................................................13
Generate plan improvements.........................................................15
Is the solution worth the effort?......................................................15
Step 5: Map the new process............................................................16
Step 6: Implement and communicate changes...............................17
Success factors.............................................................................17
Step 7: Measure success..................................................................18
Step 8: Review and plan for continuous improvement...................20
Long-term ownership.....................................................................20
Self-check questions for process owners.......................................21

INTRODUCTION

What is a process?
A process is a set of work activities that provides a service or product.
Typically a process is made up of a number of small steps that you or someone
else performs to get from the start of the process to the end.
A process may occur within a single organization or it may span several
organizations.
All work is part of a process.
For example:

Obtaining a dog license...

Start of
process

End of
process

Process

Resident applies
for dog license

Resident receives
dog license

Other examples include:

Conducting a pool inspection

Scheduling appointments

Processing a retail food license

Preparing a monthly report

LOCAL PERFORMANCE MANAGEMENT INITIATIVE: Process Improvement Guidebook

What is process improvement?

Process improvement involves analyzing a process from beginning to end to
identify opportunities for improvement.

Benefits of process improvement

Saves time.
Makes life/work easier.
Makes customers/clients more satisfied, more likely to comply with
rules, and more likely to do things right the first time.
Improves employee morale and job satisfaction.
Saves money.
Identifies and removes underlying problems.
Reduces misunderstanding, error and waste.
Creates clarity for those involved.
Provides guidelines and confidence for steps requiring flexibility.
Makes existing good ideas a reality.
Helps people and organizations adapt to change.
Allows for process ownership by those involved.
Builds confidence and pride.
Sets foundation for continuous improvement.

LOCAL PERFORMANCE MANAGEMENT INITIATIVE: Process Improvement Guidebook

Steps in process improvement

Identify the process
to improve
Tool 1: Video
Tool 2: Short and
sweet strategic plan
The templates
provided with this
guidebook are fully
editable Microsoft
Word and PowerPoint
files for you to adapt
to your needs.

Organize the group

Template 1:
Organizing notes

Map the current

process
Template 2:
Current process map

Identify problems and

potential solutions
Template 3:
Problems and
solutions
Template 4:
Improved process
map

Map the new

process

Implement and
communicate changes

Template 5:
Action plan

Measure success
Template 6:
Measurement data

Review and plan

for continuous
improvement
Template 7:
Review

LOCAL PERFORMANCE MANAGEMENT INITIATIVE: Process Improvement Guidebook

STEP 1

Identify the process to improve

When choosing a process to improve, identify one that:
Is within the control of the process improvement group.
Is done often enough that it will make a big difference.
Can be improved substantially through changes.
Will have high impact on customer/client and staff satisfaction.
Can be improved with existing resources.
Is not so large that it cannot be managed (if necessary, start with smaller
sub-processes with the greatest potential impact and then look at wider
change within or between organizations).
TOOL 1: WATCH THE VIDEO

Small Steps, Big Improvements:

Selecting a Process for Improvement (2:46)

CASE STUDY: Food safety inspections

This guide uses a sample case study to show how the steps might work
in a particular scenario.
In our case study, a health department explores how the process of reporting
restaurant food safety inspections can be improved specifically to address
clients who repeatedly score poorly. The local area appears to have a high rate of repeat offenders
compared to other jurisdictions, but data to measure this is currently difficult to access.

LOCAL PERFORMANCE MANAGEMENT INITIATIVE: Process Improvement Guidebook

STEP 2

Organize the group

Key roles in a process improvement project will typically include a process
owner, a working group (or advisory group), and a wider group to be consulted.

Process owner
This person should have key knowledge of the entire process, but may
not necessarily hold a formal management position. They should have (or
be empowered with) the authority to move the process forward, such as
conducting interviews, compiling data, and calling meetings. The process owner
should be an excellent communicator, and trusted by key players. The process
owner should have sufficient work time to manage and complete the process in
a timely manner.

Working group
The working group should include key players who are interested, capable
and willing to undertake the process improvement project. The group will likely
meet several times to provide insight and guidance, and take on tasks between
meetings: such as interviewing the people who are part of the process, as well
as other knowledgeable people and stakeholders. The group should be broad
enough that key personnel involved are included or represented, but not so
broad that progress is unreasonable slowed.

Consultation group
The wider consultation group should include people who can provide insight
into the process to be improved, for example consumers/clients, counterparts in
other units or organizations, or senior managers not in the working group.
TEMPLATE 1: PROCESS NOTES
This guide includes a package of six templates that can be used during
the process improvement process: three Microsoft Word files and two
PowerPoint files. Each are fully editable so that they can be adapted to
suit individual needs.
Template 1 provides the foundation by pulling together the starting notes
for process improvement.

LOCAL PERFORMANCE MANAGEMENT INITIATIVE: Process Improvement Guidebook

CASE STUDY:
Establishing the health inspection
process improvement working group
The local health department unit responsible
for restaurant inspections includes a supervisor,
eight inspectors, an administrative assistant,
and a clerk.
In this scenario, a working group is created involving the supervisor, two
of the inspectors, and the administrative assistant, who is made the
process owner.
The wider group to be consulted includes all inspectors, a neighbouring
county with a newly streamlined reporting system, other nearby
jurisdictions, and a random selection of five restaurant owners who have
repeatedly failed their inspections.
Troubleshooting: At the first meeting, the working group investigates
whether the administrative assistant really has the time to oversee the
process improvement, which they anticipate will take 30 to 40 hours of
her time over six to eight weeks. No further staff resources are available.
One of the already identified issues in the unit is that previous
inspections are available only on paper and are difficult to consult quickly
or in the field; the unit clerk has been scanning these into the network
system. One full year of scans has already been completed.
The unit supervisor agrees to suspend the scanning for previous years,
temporarily freeing up the clerk to take on more administrative duties.
The question of whether one year is sufficient is added as a question for
the process owner to pursue in her consultations with inspectors.

At the first meeting,

the working group
opened the discussion
by reviewing their
units purpose and
mission statement:
to serve and protect
local citizens through
restaurant health
inspections. They also
examined an existing
long-term strategy
for their wider health
department. This
helped to ground and
focus their process
improvement goals
(see page 10).

At the end of the meeting, all members leave with tasks to be

completed largely interviews with key stakeholders and agree
that the administrator is empowered to be taskmaster to ensure
these steps are completed (or re-delegated) before the next meeting.

LOCAL PERFORMANCE MANAGEMENT INITIATIVE: Process Improvement Guidebook

FIRST STEP FOR WORKING GROUPS

Consult existing plans, and mission and

vision statements (or create them!)
Once formed, the working group may find it helpful to begin by looking
at existing planning documents, such as the organization or units:
Mission and/or vision statements
Previous process improvement or quality improvement reports
Long-term planning documents, such as strategic plans.
Reviewing the core goals and objectives of the organization can
provide valuable insight into how the process to be improved should be
envisioned.
If your organization or unit does not have a strategic plan, consider
taking the time to briefly discuss your shared goals, priorities, and
strategies.
For example, examining core values why your organization exists, who
it serves, how it might evolve over time can give particular insights and
perspectives to process improvement planning.
For further guidance, look in the resource package for this guidebook for
Tool 2: Rapid Cycle Summary of Your Strategic Plan.

TOOL 2: STRATEGIC PLANNING

Tool 2 is the Microsoft Word document Rapid Cycle Summary of Your
Strategic Plan. It provides guidance to focus discussion, and ends with
a template you can use to create a one-page strategic plan summary for
your organization or unit.

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LOCAL PERFORMANCE MANAGEMENT INITIATIVE: Process Improvement Guidebook

STEP 3

Map the current process

Define (and limit) the process
To ensure that process improvement is focused and targeted, first:
Define the beginning and end of the process.
Define what is inside the process and what is outside.

Construct the process map (diagram)

Do not diagram the ideal diagram how the current process actually
functions.
Keep it fairly high level (details of each activity can be charted later).
Make sure all activities are taken into account, even the undesirable
ones.
Rely on people who actually do the work, not on individual team
members observations.
Verify and refine the map through consultation with the people who
actually conduct the process.

TEMPLATE 2: PROCESS MAP

Template 2 is a PowerPoint file that can be used to map out the current
process. Benefits include visual understanding of process and editability.

Look in the resource package for this guidebook for Template 2.

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CASE STUDY:
Mapping the health inspection
reporting process
The administrative assistant (process owner)
was already very familiar with the process
involved in inspection reporting. She drafted the
process map, and quickly consulted others in
the office (the supervisor, the clerk, and two of the inspectors) for their
feedback.
The process owner also noted on the process map some of the obvious
issues with the process as it currently exists.

Administrator distributes
assignments

Notes on current process

Inspector does not always
check past reports in the filing
cabinet or on the server

Inspector conducts inspection

Inspector leaves written

report with establishment

Inspector returns to office,

gives copy of report to clerk
Clerk types up report,
gives one paper copy to
supervisor, files one paper
copy in cabinet, adds data
to master file on network
Inspector connects laptop
to network to get updated
master file for next day

12

If fined, establishment sends

in payment; administrator
tracks and confirms payment

Handwriting on reports are

often hard for clerk to read

5 of 8 inspectors do not
regularly update to network
Re-inspections are
inconsistent (or do not occur
until the following year)

LOCAL PERFORMANCE MANAGEMENT INITIATIVE: Process Improvement Guidebook

STEP 4

Identify problems and

potential solutions
Mapping the current process will immediately reveal gaps and potential
solutions. Deeper insights will be revealed through the wider consultation
process that follows. If conducted by the working group, all interview notes
including problems and proposed solutions should be provided to, and tracked
by, the process owner to create a full picture.

Fully examine problems with the process

There is a natural tendency to jump to solutions without fully examining all of the
underlying problems and their causes.
Make sure that you:
Identify why the problem exists and where in the process it occurs.
Examine how each problem contributes to overall performance.
Identify underlying problems not just their symptoms.
Determine which problems are most critical.
Highlight unnecessary steps that can be eliminated.
Identify activities that are best done at the same time rather than
waiting for the first step to complete.
Examine anything that gets lost or misinterpreted between steps.
Separate occasional problems from chronic problems which may
have been accepted as the way things are and are often more
difficult to solve.
Determine the extent to which roles and responsibilities related to the
process are clearly defined and well-communicated.
Assess problems in light of your overall vision and/or strategic plan.
Determine gaps that exist between your performance and that of bestin-class organizations.

TEMPLATE 3
Template 3
Problems and
solutions is a Word
file that can be used
to track issues and
proposed solutions
as that data is
gathered.
Look in the resource
package for this
guidebook for
Template 3.

Examine whether the problem can be counted or tracked so that the

success of process improvement can later be measured.

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CASE STUDY:
Fully identifying problems with inspection
reporting and repeat offenders
In research and interviews conducted for
the health inspection process improvement
project, members of the working group received
extensive feedback, criticisms, and potential
creative solutions to a variety of concerns, from a range of staff, key
stakeholders, and counterparts in other jurisdictions.
Data gathered that was determined to be outside (or additional to) the
process scope was forwarded separately to the unit supervisor for
example, Inspectors often leave the field without the tools, signage or
forms they need; the training shadow process is far longer than it
needs to be; consistent routine by inspectors means establishments
can too often predict when inspector is coming...
In focusing on the key questions the reporting process and repeat
offenders deeper gaps were revealed.
Inspectors were frustrated that fines and penalties in the jurisdiction
were too low, but changing them required complicated legislative
steps. They did not see report tracking and re-inspections of repeat
offenders as useful, as establishments simply paid the fines as the
cost of doing business and carried on without making changes.
Nearby jurisdictions with low rates of repeat offenders had one
thing in common: they posted inspection reports on the Internet.
Particularly high compliance rates were achieved where consumers
came across inspection reports simply by Googling the name of the
establishment (e.g. reports were not buried in databases or PDFs).
Repeat offender establishments reported that inspectors were often
quick to write up reports, but did not appear to be approachable in
terms of providing practical guidance or assistance with solutions.
While no-one in the office found the paper files to be useful or easy
to access, staff had not been trained to use existing web-based
technologies to their full capacity.
While laptops in the field did not have the wireless functionality to
access network data at the office, all eight inspectors reported they
could do so using the handheld (cellular) devices provided by the
office, without further cost or training, if the data was made available
on-line.

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LOCAL PERFORMANCE MANAGEMENT INITIATIVE: Process Improvement Guidebook

Generate plan improvements

Once you have identified the problems and proposed solutions for your process,
the working group should select which process improvement ideas to move
forward with.
Questions to be considered include:
What easy solutions (low hanging fruit) can easily be implemented?
Of the more difficult solutions, what steps can be initiated now, even if
the solution cannot be implemented right away?
Which gaps or problems are so critical that existing resources should
be re-allocated to solve them?
What are the barriers or likely opposition to the improvements, and
how can they best be negotiated or overcome?
How can the improvements be communicated to smooth the transition
and ensure buy in from stakeholders?
How will the improvements be measured?
Use reverse brainstorming. Ask: Whats wrong with this solution?
Ask: Is the process change worth the time and energy needed? It may
be a wiser choice to cancel a marginal, high-cost improvement than
to implement it.
It may be helpful for your working group to place potential solutions on a graph
like this one, to help prioritize improvements.

HIGH COST/
DIFFICULT

FOCUS
EFFORTS
HERE
LOW COST/
EASY

BIG IMPACT

SMALL IMPACT

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STEP 5

Map the new process

In constructing a diagram showing the new process:

TEMPLATE 4

Diagram how the new process will ideally function.

Template 4
Improved process
map is a PowerPoint
file that can be
used to visually
demonstrate the
proposed new
process.
Look in the resource
package for this
guidebook for
Template 4.

Keep it fairly high level; address details in revised documentation or job

descriptions, as needed.
Verify and refine the map through consultation with key players before
it is released for implementation.

CASE STUDY:
New process map
The administrative assistant received training
in advance of the new process being
implemented. Establishments were notified
with sufficient time and guidance to be in compliance. All inspectors
confirmed they had the skills and tools to implement the new process.
The supervisor shortened the training period (upon proven capability) to
free up inspector resources. Upper management approved of the plan.
Administrator distributes assignments
Inspector accesses online past
reports, then conducts inspection
If problems are found, establishment
is given written report, and time and
guidance to solve the problem
Inspector uploads electronic report to
online database, supervisor e-notified
After minimal but sufficient time to
solve the problem, inspector conducts
unannounced follow-up inspection
Administrator confirms fines are paid

16

If problems resolved,
inspector updates
online database
If problems persist, inspector
forwards report to clerk to
post in public area online,
supervisor e-notified

LOCAL PERFORMANCE MANAGEMENT INITIATIVE: Process Improvement Guidebook

STEP 6

Implement and
communicate changes
Merely issuing a document or stating that there is a new process will not ensure
people will follow it.
Start by creating an implementation or action plan:
Solicit feedback from key players before the action plan is released.
Set a reasonable implementation date, allowing for unanticipated
barriers (e.g. delays in the availability of training or testing).
List each individual action that needs to be completed (e.g. education,
training, communication, approvals, notification), along with who will do
it, and when they will do it by.
Communicate the implementation plan widely. Use this opportunity to
reinforce buy-in by briefly summarizing how the plan evolved, why it is
being implemented, the outcomes hoped for, and how success will be
measured.
The process owner should act as taskmaster to make sure everyone is
getting their tasks done.
If the implementation is to be piloted, inform and educate participants.
Communicate pilot results and next steps widely.

Success factors
Implement changes within a reasonable time frame; set realistic
deadlines for key tasks and steps.
Encourage feedback and address concerns as they arise.
Confirm ongoing progress and support from key players.
Provide timely response to unanticipated barriers or issues (consumer,
cultural, community, regional).
Communicate progress toward implementation.

TEMPLATE 5
Template 5 Action
plan is a Word
file that can help
you itemize in
detail: what, by
whom, when the
steps needed to
implement and
communicate the
revised process.
Look in the resource
package for this
guidebook for
Template 5.

Ensure that measures to track success are in place.

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STEP 7

Measure success
Examples of
measures:
No-show
appointments
at the clinic
before process
improvement were
12 per week; now
with telephone
reminders the day
before, no-shows
are less than once
per week.
Under the old
process, it took 8
weeks to complete
the clients license
renewal, now it
takes two weeks.
Before, 40 percent
of applications were
rejected for being
incomplete; now, 5
percent are.
The old process
was deemed
cumbersome by
6 out of 7 staff in
the process; now,
all report being
satisfied that the
system is efficient.

Measures are needed to ensure that the new process is working, and to set the
stage for continuous improvement. Measures should:
Be realistic for staff to collect and track.
Help identify and correct process problems early.
Help identify areas where process procedures should be modified.
In general:
The process group is responsible for defining, collecting, using and
communicating data resulting from the process improvement.
Success should be measured by facts and not intuition.
Only data that will realistically be used should be collected.
Results should be communicated widely particularly to stakeholders
who invested time and energy in improving the process.

Effective measures
Relate to agency standards.
Focus on the process, not the people.
Are understood and accepted by those who implement the process.
Are specific, simple and straightforward.
Provide a way for you to track your agency or units progress on key
goals and priorities for the process.
TEMPLATE 6: MEASUREMENT DATA
Template 6 is a fully editable Word file that can help you determine how
best to track data to show whether the improved process is working:
and if so, how much time and effort it saves, how client/customer
satisfaction has been improved, or the extent to which your unit/
organizations goals are being advanced.
Look in the resource package for this guidebook for Template 6.

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LOCAL PERFORMANCE MANAGEMENT INITIATIVE: Process Improvement Guidebook

CASE STUDY:
In closing: Measuring success and
repeat offenders in food inspections
One of the issues that led to process
improvement of reporting for restaurant food
safety inspections was that data on repeat
offenders was not being sufficiently tracked.
This made measuring the success of process
improvement more challenging.
To create a baseline so that success could be measured, the process
owner the office administrator asked the supervisor and each of
the eight inspectors to each recall one dozen establishments that had
repeatedly failed food safety inspections.
Once verified, this created a list of 100 repeat offenders. Further
investigation of data sources revealed that 32 percent of the repeat
offenders had failed inspections for three consecutive years or more.
At the top of the list of infractions was the temperature of refrigerators
and coolers used for food storage.
Feedback from the establishments revealed that the majority of
establishments did not know of a source for simple, low-cost
temperature gauges. The restaurant food inspection unit acquired these
units in bulk and provided them to establishments at cost during initial
inspections: $5 per gauge.
One year later, the number of repeat offenders had dropped from 32 per
cent to 19. Violations due to food temperature dropped from 92 per cent
of citations to 34.

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STEP 8

Review and plan for

continuous improvement
Once you attain a new level of improvement, the challenge is to maintain longterm improvement both in the process that has been improved, and in new
areas.
The working group should determine how often the process holder will report on
data from the new process, and how often the wider working group will meet to
review data (e.g. quarterly, annually).
The new level of performance can become the standard against which you
measure your future performance.
Continuously review:
What data to collect.
Who will collect it, how, and where it will be stored.
How long to collect the data.
Who will analyze and report on it.

Long-term ownership

TEMPLATE 7
Template 7 Process
improvement review
is a Word file that
can be used to
ensure that the
process receives
continuous review
and improvement.
Look in the resource
package for this
guidebook for
Template 7.

20

The process owner is responsible for long-term maintenance of the

process.
If not monitored and owned by someone, gains may be lost.
The group should be recalled periodically to assess process
performance based on collected data.
Once the process is established at the new level, consider attacking
the next level of problems within the process.
Once you have established a new, improved level of success for this
process, consider tackling related processes or looking for ways to
improve the outcomes of this process even further.

LOCAL PERFORMANCE MANAGEMENT INITIATIVE: Process Improvement Guidebook

CASE STUDY:
Six-month follow-up on the new
process for restaurant inspections
At a six-month follow-up meeting of the new
process, inspectors reported that one of the
steps in the process giving establishments
time to correct the problem before the results
were published to the public appeared to
be creating a culture where establishments were not proactive about
safety for example, providing gloves for sandwich makers who are also
cashiers, or repairing broken soap or paper towel dispensers as they
knew they would have time to solve any issues before the results were
made public.
The process improvement working group, after additional consultation,
decided that this part of the process would be eliminated in the following
year. This information was provided to establishments well in advance of
the upcoming change. Measures were put in place to track the results.
The working group agreed to meet six months later to determine
whether the revised solution was effective.

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21

Self-check questions for process owners

An important aspect of improvement is to make sure the results of your
improvement efforts do not fade with time. Use the following questions
to assess how well your process is being managed.
1. If you own an ongoing process, do you periodically monitor it
for potential improvements?
2. Who knows you own this process? Do they consult with you
and offer you feedback?
3. Who gives you information, start-up materials or other criteria
for beginning your process?
4. What is the goal or purpose of your process? How does it fit
with your units mission? Does everyone understand the goal?
5. Who are the consumers for the process? How are their needs
being assessed and included in the goal?
6. Are the major affected parties involved in developing changes
and making decisions?
7. How are the needs of the most affected parties considered in
your objectives?
8. Have you identified value-added qualities, steps or traits in the
process which contribute to your goal?
9. Have you and your process group weighed the cost, in
terms of budget, time and energy, of the proposed process
change(s)?
10. What would happen if breakdowns were to occur in this
process?
11. How do you know the process is working? What ongoing
assessment measures do you use?
12. If you own a new process, do you reassess it regularly (every
six months or year, for example)?

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