Success and Effect Diagram

Quality in Healthcare

Success and Effect Diagram: Quality Improvement Is Not Just For Problems

By John W. Moran and Grace L. Duffy

Too often, organizations ignore successes while they focus on problems that need immediate attention. Quality improvement tools and techniques are used extensively to solve problems, but those same methods can also be used to analyze successful processes. Understanding successful processes can give a management team insight on how to improve other processes and continually improve the organization’s efficiency and effectiveness.

What are the attributes of a successful process?

Over the years, as we have come across successful processes, we have asked stakeholders to identify what they considered to be key factors contributing to success. We have collected the following list of attributes of successful processes. This is not an all-inclusive list, but you can use it to start analyzing your own successful processes.

  • Efficient—The process produces the required output at minimum resource cost (“doing the right things right”).

  • Effective—The process does what it is supposed to do and produces outputs that conform to stated requirements.

  • Cost controlled—All costs are monitored and managed.

  • Predictable—The output is consistent.

  • Managed by employees with the right skills and attitudes—Employee skills meet the requirements of the process and are upgraded when the process is improved, and employee attitudes are customer- and quality-oriented.

  • Timely—The process produces its output correctly and on time.

  • Tracked using visible metrics—The process is measured at many points, performance is plotted, and results are made visible to show those performing the process how it is operating.

  • Lean—Process owners have applied lean principles and all process steps are valued added.

  • Optimized for all variables—All variables have been studied and statistically optimized.

  • Continuously improving—The process is always undergoing improvement.

  • Supported by a culture of innovation—The organization empowers employees to improve continuously.

  • Conducted with a sense of ownership—Employees feel a sense of ownership of their work.

  • Uses 5S—There is evidence that the 5Ss have been applied to the organization and its processes.

  • Produces high-quality output—What the process produces meets or exceeds customer expectations.

  • Additional successful process attributes—Add your own attributes to the list!

How to analyze a successful process

One quality improvement tool that can help you analyze a successful process is a success and effect diagram, which is simply a hybrid of the popular cause and effect diagram.

Develop a success and effect diagram in a way similar to how you would construct a cause and effect diagram. Instead of using the five whys, use the five whats as your analysis tool.

Construction steps:

  • As shown in Figure 1, write the success as a symptom statement on the right side of the page and draw a box around it with an arrow running to it. This success is now the effect to analyze.
  • Generate ideas about the main successes of the effect. Use the attribute list detailed above as a starting point. Label these as the main branch headers of the success and effect diagram.
  • For each main success category, brainstorm ideas about the related sub-successes that might affect the issue statement. Use the five whats technique when a success is identified: What caused this success? Keep repeating the question until no other success can be identified. List the sub-successes using arrows.

Figure 1: Success and effect diagram template
Success and Effect Diagram Template

Figure 2 is a success and effect diagram created to analyze a successful top-level organization correspondence process. The team identified headers specific to the successful process they were analyzing. For the header labels, they used the four major headers frequently used with cause and effect diagrams (people, method, material, and machine) to illustrate the parallel associations of the success and effect diagram discovery process.

Under the four major headers they asked what made this successful. The what question can be used on the subheads to drill down into the details of the success.

When finished with the success and effect diagram, the next step is deciding on the few whats to focus on that may cause the success being analyzed. Some—the low hanging fruit—are obvious. Others may require more research using additional quality improvement tools such as:

See more tools and healthcare applications

Figure 2:
Success and effect diagram for top-level correspondence project

Success and effect diagram for top-level correspondence project
View in a pdf format

The five whats technique helps a team zero in on potential root success, as shown in Figure 3. Asking What made this process a success? helps the team stay focused on the analysis until it has identified the root success or successes.

To understand how the process of finding the root success works, consider how the team analyzed the main header of “materials” in the example in Figure 2. The first what starts with “Documents are on time, accurate, and consistent with applicable policy.” This is the observed success.

Next, the team repeated the what question to drill down into root success:

  • Observed success—Documents are on time, accurate, and consistent with applicable policy.

  • Visible success—Meets the customer’s requirements.

  • First-level success—People who are processing documents are trained appropriately.

  • Higher-level success—Customer needs are understood and service level targets are set and monitored.

  • Higher-level success—Customer needs are collected regularly and reported to those performing the process.

Figure 3: Finding root success using the five whats
Finding root success using the five whats

There may be more than one root success that makes a process perform at an optimal level. Each main header needs to be analyzed to determine what made it successful. Many successful processes have compound successes, where different factors combine to make the process a success. Rarely does a successful process have a single root success.

One check that you can make after determining the top few root successes is to determine how the successful attributes relate to each other. You can use an interrelationship diagraph to determine if there are interconnections between the potential root successes. (See The Public Health Quality Improvement Handbook, by Ron Bialek, Grace Duffy, and John W. Moran, ASQ Quality Press, pages 199-201, for more information on the interrelationship digraph.) Determining these interconnections may show patterns that change your team’s decision on which root success(es) make the process effective.

Another approach is to use the root success analysis rating form shown in Figure 4. This matrix offers a way to prioritize the root success(es) uncovered using the success and effect diagram. The matrix allows your team to assess each potential root cause over a number of potential impact dimensions and develop a score. The score can help rank the potential root successes. The attribute having the most impact on process success is ranked No. 1.

Figure 4: Root success analysis rating form
Figure 4: Root success analysis rating form


Using quality improvement techniques and tools to analyze success gives a new dimension to continuous improvement processes. By understanding successful processes, you can uncover what is working well and transfer that knowledge to other processes to make them more efficient and effective. Using quality improvement techniques and tools to understand what makes you successful shines a light on the good work an organization does, not just the areas that fall short.

About the Authors

John W. Moran, Ph.D., Certified Manager of Quality/Organizational Excellence (CMQ/OE), Certified Quality Improvement Associate (CQIA), Certified Management Consultant (CMC), is senior quality advisor for the Public Health Foundation, an ASQ Fellow, and a Senior Fellow at the University of Minnesota School of Public Health.

Grace L. Duffy, Certified Manager of Quality/Organizational Excellence (CMQ/OE), Certified Quality Improvement Associate (CQIA), Certified Lean Six Sigma Master Black Belt (CLSSMBB), is a senior consultant with the Public Health Foundation and an ASQ Fellow.

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