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Open Access Highly Accessed Research article

Does the process map influence the outcome of quality improvement work? A comparison of a sequential flow diagram and a hierarchical task analysis diagram

Lacey Colligan1, Janet E Anderson2*, Henry WW Potts3 and Jonathan Berman4

Author Affiliations

1 Medical Informatics Systems Engineering Training Program (MINDSET), Systems and Information Engineering, University of Virginia, Charlottesville VA 22903, USA

2 NIHR King's Patient Safety and Service Quality Research Centre, King's College London, Strand Bridge House, 138-142 Strand, London WC2R 1HH, UK

3 Centre for Health Informatics and Multiprofessional Education (CHIME), UCL Medical School, University College London, Archway Campus, Highgate Hill, London N19 5LW, UK

4 Greenstreet Berman Ltd Fulcrum House, 5 Southern Court, South Street, Reading RG1 4QS, UK

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BMC Health Services Research 2010, 10:7  doi:10.1186/1472-6963-10-7

Published: 7 January 2010



Many quality and safety improvement methods in healthcare rely on a complete and accurate map of the process. Process mapping in healthcare is often achieved using a sequential flow diagram, but there is little guidance available in the literature about the most effective type of process map to use. Moreover there is evidence that the organisation of information in an external representation affects reasoning and decision making. This exploratory study examined whether the type of process map - sequential or hierarchical - affects healthcare practitioners' judgments.


A sequential and a hierarchical process map of a community-based anti coagulation clinic were produced based on data obtained from interviews, talk-throughs, attendance at a training session and examination of protocols and policies. Clinic practitioners were asked to specify the parts of the process that they judged to contain quality and safety concerns. The process maps were then shown to them in counter-balanced order and they were asked to circle on the diagrams the parts of the process where they had the greatest quality and safety concerns. A structured interview was then conducted, in which they were asked about various aspects of the diagrams.


Quality and safety concerns cited by practitioners differed depending on whether they were or were not looking at a process map, and whether they were looking at a sequential diagram or a hierarchical diagram. More concerns were identified using the hierarchical diagram compared with the sequential diagram and more concerns were identified in relation to clinical work than administrative work. Participants' preference for the sequential or hierarchical diagram depended on the context in which they would be using it. The difficulties of determining the boundaries for the analysis and the granularity required were highlighted.


The results indicated that the layout of a process map does influence perceptions of quality and safety problems in a process. In quality improvement work it is important to carefully consider the type of process map to be used and to consider using more than one map to ensure that different aspects of the process are captured.