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Process Maps and Case Studies


1. Safeguarding Adults Overall Process

Safeguarding Adults Overall Process

Click here to download the Safeguarding Adults Overall Process PDF

2. Deciding if you need to Raise a Concern to the Local Authority

Safeguarding Adults Overall Process

Diagram source: Understanding what constitutes a safeguarding concern and how to support effective outcomes (Local Government Association) .

3. When and How to Share Information Flowchart


Seven golden rules to information sharing

Sharing of information between practitioners and organisations is essential for effective identification, assessment, risk management and service provision. Early sharing of information is key to providing effective early help where there are emerging problems.

The GDPR and Data Protection Act 2018 do not prevent, or limit, the sharing of information for the purposes of keeping children and young people safe. Fears about sharing information cannot be allowed to stand in the way of the need to promote the welfare and protect the safety of children and adults.


4. Safeguarding Plan Review Process

Safeguarding Plan Review Process

Click here to download the Safeguarding Plan Review Process PDF

5. Case Closure Process

Case Closure Process

Click here to download the Case Closure Process PDF .

6. Care Act Statutory Guidance Process Maps

The following process maps have been copied directly from the Care Act Statutory Guidance .

Diagram 1B: Part 1

Diagram 1B: Part 1

Diagram 1B: Part 2

Diagram 1B: Part 2

7. Care Act Statutory Guidance Case Studies

The following case studies are all taken from the Care Act Statutory Guidance .

Making Safeguarding Personal

Two brothers with mild learning disabilities lived in their family home, where they had remained following the death of their parents some time previously. Large amounts of rubbish had accumulated both in the garden and inside the house, with cleanliness and self-neglect also an issue. They had been targeted by fraudsters, resulting in criminal investigation and conviction of those responsible, but the brothers had refused subsequent services from adult social care and their case had been closed.

They had, however, had a good relationship with their social worker, and as concerns about their health and wellbeing continued it was decided that the social worker would maintain contact, calling in every couple of weeks to see how they were, and offer any help needed, on their terms. After almost a year, through the gradual building of trust and understanding, the brothers asked to be considered for supported housing; with the social worker's help they improved the state of their house enough to sell it, and moved to a living environment in which practical support could be provided.

Financial Abuse

This case study highlights the need for local authorities not to underestimate the potential impact of financial abuse:

Mrs B is an 88 year old woman with dementia who was admitted to a care home from hospital following a fall. Mrs B appointed her only daughter G, to act for her under a Lasting Power of Attorney in relation to her property and financial affairs.

Mrs B's former home was sold and she became liable to pay the full fees of her care home. Mrs B's daughter failed to pay the fees and arrears built up, until the home made a referral to the local authority, which in turn alerted the Office of the Public Guardian (OPG).

The OPG carried out an investigation and discovered that G was not providing her mother with any money for clothing or toiletries, which were being provided by the home from its own stocks. A visit and discussion with Mrs B revealed that she was unable to participate in any activities or outings arranged by the home, which she dearly wished to do. Her room was bare of any personal effects and she had limited stocks of underwear and nightwear.

The Police were alerted and interviewed G, who admitted using the proceeds of the mother's house for her own benefit. The OPG applied to the Court of Protection for suspension of the power of attorney and the appointment of a deputy, who was able to seek recovery of funds and ensure Mrs B's needs were met.

Spotting signs of abuse and neglect

This case study demonstrates how anyone can become aware of information suggesting that abuse and neglect is occurring:

Mr A is in his 40s, and lives in a housing association flat, with little family contact. His mental health is relatively stable, following a previous period of hospitalisation and he has visits from a mental health support worker.

He rarely goes out, but he allows people into his accommodation because of his loneliness. The police were alerted by Mr A's neighbours to several domestic disturbances. His accommodation had been targeted by a number of local people and he had become subjected to verbal, financial and sometime physical abuse. Although Mr A initially insisted they were his friends, he did indicate he was frightened; he attended a case conference with representatives from adult social care, mental health services and the police, from which emerged a plan to strengthen his own self-protective ability as well as to deal with the present abuse.

Mr A has made different arrangements for managing his money so that he does not accumulate large sums at home. A community-based visiting service has been engaged to keep him company through visits to his home, and with time his support worker aims to help get involved in social activities that will bring more positive contacts to allay the loneliness that Mr A sees as his main challenge.

Carers and Safeguarding

This case study shows how carers can be abused by the adult they are caring for, and how to support them when this happens:

Mrs D lives with her husband, B. B has a long term brain injury which affects his mood, behaviour and his ability to manage close family relationships. This has often led to him shouting and hitting out at his wife, who is also his main informal carer. Mrs D told a professional who was involved in supporting her that she was becoming increasingly frightened by B's physical and verbal outbursts and at times feared for her personal safety.

Other family members were unaware of the extent of the harm and that Mrs D was exhausted and considering leaving the situation. The local authority became involved.

The situation presented significant personal risk to Mrs D but there was also a risk of fragmenting relationships if the local authority staff were not sensitive to the needs of the whole family. The practitioner, under supervision from her social work manager invested time in meeting with Mrs D to explore her preferences around managing her safety and how information about the situation would be communicated with the wider family and with B. This presented dilemmas around balancing the local authority's duty of care towards

Mrs D with her wishes to remain in the situation with B. Placing emphasis on the latter inevitably meant that Mrs D would not be entirely free from the risk of harm but allowed the practitioner to explore help and support options which would enable Mrs D to manage and sustain her safety at a level which was acceptable to her.

The practitioner received regular supervision to allow time to reflect on the support being offered and to ensure that it was 'person centred'. The outcome for Mrs D was that she was able to continue to care for B by working in partnership with the local authority. The practitioner offered advice about how to safely access help in an emergency and helped her to develop strategies to manage her own safety – this included staff building rapport with B, building on his strengths and desire to participate in social activities outside the family home. The effect of this was that some of the trigger points of him being at home with his wife for sustained periods during the day were reduced because he was there less.

Mrs D also had a number of pre-existing support avenues, including counselling and a good relationship with her son and her friends. The situation will be reviewed regularly with Mrs D but for the time being she feels much more able to manage.

Multi-Agency Safeguarding Role

This case study demonstrates how agencies should work together to prevent abuse and neglect from occurring/reoccurring:

Miss P's mental health social worker became concerned when she had received reports that 2 of Miss P's associates were visiting more regularly and sometimes staying over at her flat. Miss P was being coerced into prostitution and reportedly being physically assaulted by one of the men visiting her flat. There was also concern that she was being financially exploited. Miss P's lack of understanding of how to protect herself when living alone was exacerbated by her mental health needs and consequent inability to set safe boundaries with the people she was associating with.

The social worker recognised that the most appropriate way to enable Miss P to manage the risk of harm was to involve Miss P's family, which she agreed to, and other professionals to develop and coordinate a plan which would enable her to continue living independently but provide a safety net for when the risk of harm became heightened. Guided initially by Miss P's wish for the 2 men to stay away from her, the social worker initiated a planning meeting between supportive family members and other professionals such as the police, domestic violence workers, support workers and housing officers. Although Miss P herself felt unable to attend the planning meeting, her social worker ensured that her views were included and helped guide the plan. The meeting allowed family and professionals to work in partnership, to openly share information about the risks and to plan what support Miss P needed to safely maintain her independence.

Tasks were divided between the police, family members and specialist support workers. The social worker had a role in ensuring that the plan was coordinated properly and that Miss P was fully aware of everyone's role. Miss P's family were crucial to the success of the plan as they had always supported her and were able to advocate for her needs.

They also had a trusting relationship with her and were able to notify the police and other professionals if they thought that the risk to Miss P was increasing. The police played an active role in monitoring and preventing criminal activity towards Miss P and ensured that they kept all of the other professionals and family up to date with what was happening. Miss P is working with a domestic violence specialist to help her develop personal strategies to keep safer and her support worker is helping her to build resilience through community support and activities.

Criminal offences and safeguarding

These case studies shows how agencies can work together to provide a co-ordinated response during a criminal investigation:

Case study 1: Miss Y

Miss Y is a young woman with a learning disability with limited support from her family and was not engaged with health and social care services. Miss Y was befriended by an individual who took her to parties where she was given drugs and alcohol and forced to have sex with different men. Sometimes she would be given money or gifts in return for having sex with the men.

Miss Y disclosed this to a social worker and it was discovered that there were a number of young people and vulnerable adults who were being sexually exploited by multiple perpetrators. Miss Y lacked mental capacity in order to be able to consent to having sex, as well as in relation to her accommodation, finances or personal safety.

The perpetrators sought out Miss Y and others because of their perceived vulnerability – whether that was because of their isolated situation and social circumstances coupled with age, disability, mental illness, or their previous history as a victim of abuse. The process to safeguard Miss Y involved a coordinated response between the police, social care, health and voluntary and community sector organisations.

This included the police investigating the perpetrators for rape, sexual assault, trafficking and drug offences. The Court of Protection and Deprivation of Liberty Safeguards were also used initially to safeguard Miss Y.

Case Study 2: Mr P

Mr P has mild learning disabilities. The safeguarding concern was financial and other abuse and neglect by his brother, with whom he lived. His support worker had noticed that Mr P had begun to appear agitated and anxious, that he looked increasingly unkempt and that he was often without money; then he suddenly stopped attending his day centre.

When the support worker and the safeguarding officer followed up, Mr P told them that at times he was not allowed out at all by his brother and was confined to his bedroom. He was only allowed to use the bathroom when his brother said he could, and often didn't get enough to eat. He was also very worried because his bank card no longer worked, and he had no money, so couldn't buy food for himself.

Mr P consented to move to temporary accommodation, and a case conference was held, which he attended with an advocate. At his request a move to a supported living flat was arranged and his belongings were retrieved from his brother's property. His bank account had been emptied by his brother, so he has made new arrangements for his money.

The police are investigating both the financial abuse and the harm Mr P suffered at his brother's hands. He has begun to talk about his experiences and is gradually regaining his confidence.

Safeguarding Plans

This case study demonstrates how a Safeguarding Plan can be used to develop an adult's capacity to protect themselves from harm:

Mr A is 24 and has autism and a mild learning disability. He is a very friendly and sociable young man, who is prone to waving and talking to most people he comes across and who sees everyone as a potential friend. However, he struggles to read the intentions of others and is easily led astray and manipulated.

He lives next door to a pub, where he knows the staff and the regulars. He also lives close to his GP and is able to access his most frequently visited places. He does, however, like to walk into town to talk to people he meets out and about. On such occasions he has been repeatedly tricked into stealing items from a newsagent by a group of teenagers and given large amounts of money away to strangers he strikes up conversations with. Due to his previous experiences, Mr A was identified during a needs assessment as being at risk of abuse and neglect and a safeguarding enquiry was triggered.

The council found that, although Mr A was not currently experiencing abuse or neglect, he remained highly vulnerable to abuse due to his being well-known in his area as someone as easy to manipulate.

To assure his safety in the future, a safeguarding plan was agreed between Mr A and a social worker. This focused on developing his social skills and understanding of relationships and boundaries and the social worker worked with Mr A to consider various support options such as having a buddy or circle of support.

The social worker put Mr A in touch with an autism social group which provided sessions on skills for staying safe. As the group was based in town, Mr A's plan also included a support worker to accompany him. After the first 5 sessions Mr A was able to attend himself but continued to meet with his support worker on a monthly basis as part of the risk management strategy set out in his safeguarding plan.

Positive outcomes for those who self-neglect

Mr M, in his 70s, lives in an upper-floor council flat, and had hoarded over many years: his own possessions, items inherited from his family home, and materials he had collected from skips and building sites in case they came in useful. The material was piled from floor to ceiling in every room, and Mr M lived in a burrow tunnelled through the middle, with no lighting or heating, apart from a gas stove. Finally, after years of hiding in privacy, Mr M had realised that work being carried out on the building would lead to his living conditions being discovered. Mr M himself recounted how hard it had been for him to invite access to his home, how ashamed and scared he was, and how important his hoard was to him, having learnt as a child of the war never to waste anything.

Through working closely together, Mr M, his support worker and experienced contractors have been able gradually to remove from his flat a very large volume of hoarded material and bring improvements to his home environment. It has taken time and patience, courage and faith, and a strong relationship based on trust. The worker has not judged Mr M, and has worked at his pace, positively affirming his progress. Both Mr M and his support worker acknowledge his low self-esteem, and have connected with his doctor and mental health services. The worker has recognised the need to replace what Mr M is giving up, and has encouraged activities that reflect his interests. Mr M has valued the worker's honesty, kindness and sensitivity, his ability to listen and the respect and reciprocity within their relationship.

Safeguarding Adult Reviews (SAR's)

At the age of 72 years, Ms W, although registered disabled, was an active member in her community often seen helping at community events and visiting the local shops and swimming pool. Ms W had a fall in her home which left her lacking in confidence and fearful that she would fall again. As the winter approached, Ms W spent more time alone at home only venturing to the corner shop to buy groceries. As time passed her house came in disrepair and unhygienic as local youths began throw rubbish, including dog faeces into her front garden.

Within a 5 month period Ms W made 7 complaints to the police about anti-social behaviour in her local area, and on 2 occasions was the victim of criminal damage to the front of her house, where her wheelchair accessibility ramp has been painted by graffiti. The police made a referral to social services. As a result, Ms W was placed on a waiting list for a support service.

Four weeks after she was last seen Ms W committed suicide. A Safeguarding Adults Review (SAR) was convened according to the local policy that stated 'the purpose of an SAR is not to reinvestigate or to apportion blame, but to establish whether there are lessons to be learnt from the circumstances of the case about the way in which local professionals and agencies work together to safeguard vulnerable adults. The published report and recommendations which followed demonstrated the lessons from this case. The resultant action plan included:

  • Strengthened relationships and information sharing between police officers, health and the local authority;
  • Clear lines of reporting and joint working arrangements with the community safety partnerships;
  • A robust multi-agency training plan;
  • A targeted community programme to address anti-social behaviour;
  • The development of a 'people's panel' as a sub group to the Safeguarding Adults Board which includes people who access services, carers and voluntary groups;
  • The development of a 'stay safe' programme involving local shops where adults at risk of abuse may report their concerns to a trusted member if their community.

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Creating Process Flow Diagrams – A Case Study

Companies  mentioned in this case study are fictitious and are for educational purposes only. Scenarios, events and names mentioned in this case study are fictitious and any resemblance to actual persons, corporations or institutions are purely coincidental.

The Expectation

You have been employed to Pixel-Tech  as  a business analyst during the pandemic of 2020.  You are tasked with coming up with new process steps to resolve Pixel-Tech’s online purchases in-store pickup  process and their tech support process in response to the pandemic.

Pixel-Tech is a large supplier of consumer hardware devices such as laptops, tablets, printers, monitors and cables. They have large stores in every state and also have an online store where customers can purchase items online and have it delivered to their home or delivered to the nearest Pixel-Tech store.

Pixel-Tech also offers tech support services to small and medium size companies. These services include setting up new machine for new employees, responding to support issues from employees such as access controls, errors on their computers, malware and security monitoring etc… Pixel-Tech also helps to physically collect machines that need to fixed and send them to the manufacturers where needed.

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In store pickup process.

Currently the process to handle pickup of online sales is as follows:

When a customers buys and item online they can choose to have it delivered to their nearest Pixel-Tech store as one of their delivery options. When  it  arrives to  the store, the  customer is notified by email and text messages  and goes to the store to pickup. When the customer arrives at the store they usually have to join a line  to wait to receive their item and this wait could take up to 20 minutes. This is because item pickup is done at the customer service line along with other customer service requests.

Once it’s their turn, the customer has to verify their identity  and provide the tracking number sent in the email or text message in order to receive the item. The agent finds the package with the tracking number that matches  what the customer gave and verifies the identity of the customer, then the customer is given their item and can then leave the store.

The Problem

Because of the pandemic and social distancing requirements the store can no longer have log lines for customer service. How can they still provide a good service for their customers who make purchases online and need to  receive the item quickly?

You are also tasked with finding a covid-safe way to help customers pickup their items that are purchased online. Design a new work flow that will demonstrate the new processes.

Tech Support Process

Currently the process to handle support tickets is as follows:

  • The computer given to each employee is tracked with an inventory number
  • A special remote access software is loaded unto the machines
  • When the employee has a problem and needs support then they can enter their a ticket from the special software found  on their desktop or  send an email to [email protected]
  • The communication to Pixel-Tech is logged and given a ticket number and added to the queue
  • A tech support agent who is monitoring the queue will pick the next ticket available in the queue
  • The tech support agent will  contact the employee and remotely connect to the machine where possible to attempt to solve the problem
  • The tech support will update the ticket. If it is solved then the ticket is closed and confirmation is sent  to the employee
  • If it is not solved,  then it can possibly be escalated to a second level support, then third level if needed
  • If the issue cannot be resolved remotely at all, then the tech support agent arranges to pickup the machine from the client’s office location
  • The employee is given a loaner machine to work with while their original machine is being fixed
  • Once the original machine is in the possession of Pixel-Tech, then the agents try to resolve and if not then arrangements are made to repair with the manufacturer
  • When the manufacturer fixes the machine then the machine is returned to the client’s office location, distributed to the employee and the loaner machine is put back in inventory

Since the pandemic, a new process is needed as most clients of Pixel-Tech have employees  who are now working from home and technicians will need to track the inventory that is dispersed in  everyone’s homes.

Come up with a revamped process for the tech support agents in light of the pandemic and given that there is no one working from the office anymore. How can the agents continue to offer the same quality service?

  • Redesign the item pickup for online purchases. How can we do this observing social distancing and reducing the number of people in the store?
  • Think through  tech support having to go to employees homes to recover machines since they are no longer at the office. What could that new process look like?
  • Design the new process flows and prepare a presentation to defend why you chose this new process.

Get the answers for this case study here!

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5 Case Studies Showing The Power Of Process Mapping

Are you tired of inefficient processes that waste valuable time and resources in your organization? Do you feel like you could be doing more with less, but don’t know where to start?

Look no further than process mapping – a powerful tool for streamlining operations and improving efficiency.

In this article, we’ll explore five case studies that demonstrate the power of process mapping in a variety of industries. From improving patient wait times in a hospital to streamlining hiring processes in HR, these case studies will show you firsthand how process mapping can revolutionize your organization.

So buckle up and get ready to take control of your processes – it’s time to see the power of process mapping in action.

Process Mapping: A Tool for Streamlining Operations

You can easily streamline your operations by using process mapping as a tool. Process mapping is a visual representation of a business process that helps to identify inefficiencies and improve the overall efficiency of the process. The benefits of process mapping are numerous, including increased efficiency, reduced costs, improved customer satisfaction, and better decision-making.

However, there are also some challenges associated with process mapping, such as the time and effort required to create a process map, the need for input and collaboration from various stakeholders, and the possibility of resistance to change. To overcome these challenges, it’s important to use effective tools for process mapping, such as flowcharts, swimlane diagrams, and value stream maps.

By using these tools, you can identify areas of improvement in your processes, make data-driven decisions, and ultimately increase the effectiveness of your operations.

Case Study 1: Improving Patient Wait Times in a Hospital

By streamlining patient flow, you can greatly improve efficiency in healthcare settings. This was demonstrated by a case study where a hospital was able to drastically reduce patient wait times. The hospital used process mapping techniques to identify bottlenecks in their patient flow and implemented solutions to improve efficiency.

One key change was the use of a triage system. Incoming patients were quickly assessed and directed to the appropriate department. Additionally, the hospital staff was retrained on how to prioritize patients and manage their time more effectively.

As a result, patients experienced shorter wait times and were happier with their overall experience. This case study shows the power of process mapping for healthcare optimization and highlights the positive impact that it can have on patient satisfaction.

Case Study 2: Optimizing Supply Chain Management in Manufacturing

If you want to improve efficiency and reduce costs in your manufacturing business, optimizing your supply chain management is key.

One case study showcases the power of supply chain optimization. A manufacturing company was struggling with long lead times, high inventory costs, and poor delivery performance.

By mapping out their current process and identifying bottlenecks, they were able to implement changes. These changes included vendor consolidation, inventory reduction, and improved communication with suppliers.

These changes led to a 40% reduction in lead times, a 25% reduction in inventory costs, and a 98% on-time delivery performance. By taking a methodical approach to supply chain optimization, this manufacturing company was able to improve their overall efficiency and profitability.

Case Study 3: Enhancing Customer Service in a Call Center

Get ready to discover how you can significantly improve your call center’s customer service with some simple changes.

Measuring success is crucial in any business, which is why this call center decided to implement process mapping to enhance their customer service. By analyzing their current call center efficiency, they were able to identify areas that needed improvement.

Here are three sub-lists of changes they made:

  • They created a standardized script and trained their agents to follow it, ensuring consistent and professional communication with customers.
  • They implemented a call monitoring system, allowing supervisors to provide real-time feedback and coaching to agents, leading to improved performance.
  • They established a feedback system for customers to provide input on their experience, enabling the call center to make data-driven decisions and further improve their service.

By taking a methodical approach and focusing on improving specific areas, this call center was able to enhance their customer service and increase customer satisfaction.

If you want to achieve similar results, consider implementing process mapping and measuring success in your call center.

Case Study 4: Reducing Errors in Financial Reporting

You can drastically reduce errors in your financial reporting and avoid costly mistakes with some simple changes.

Process mapping can help you identify where errors are occurring and create a system that minimizes the chance for mistakes. By breaking down each step in your financial reporting process and identifying where errors are most likely to occur, you can implement checks and balances that catch mistakes before they become bigger problems.

By streamlining your process and implementing clear guidelines for each step, you can create a system that is both efficient and effective, reducing the likelihood of errors occurring.

Take control of your financial reporting process and reduce errors by using process mapping to create a streamlined and error-free system.

Case Study 5: Streamlining Hiring Processes in HR

In streamlining your hiring processes, HR departments can increase their efficiency and productivity, ultimately reducing the time it takes to fill open positions and saving the company money.

Did you know that according to a study by Glassdoor, the average job opening attracts 250 resumes, but only four to six of those candidates will be called for an interview?

By implementing process mapping, HR teams can identify bottlenecks and streamline their recruitment process to improve efficiency and minimize errors.

Here are four ways that process mapping can improve your hiring process:

  • Identifying which job boards and recruitment channels are most effective in attracting qualified candidates;
  • Creating a standardized interview process that ensures all candidates are evaluated consistently and fairly;
  • Automating the screening process to quickly weed out unqualified candidates; and
  • Ensuring that all necessary paperwork and documentation are completed accurately and in a timely manner.

By focusing on these areas, HR teams can make their hiring process more efficient and effective, ultimately saving time and money for the company.

Key Benefits of Process Mapping for Businesses

Now that you’ve seen how process mapping can streamline hiring processes in HR, let’s dive into the key benefits that process mapping can bring to businesses. With process mapping, you can not only increase efficiency, but also make strategic decisions that will have a long-term impact on your organization. To help illustrate this, let’s take a look at the following table:

As you can see, the benefits of process mapping go beyond just improving efficiency. By making strategic decisions and optimizing processes, you can improve communication, increase accountability, enhance the customer experience, save costs, and gain a competitive advantage. So why not start process mapping today and take control of your business’s success?

Tips for Implementing Process Mapping in Your Organization

Get ready to revolutionize the way you do business by implementing these expert tips for optimizing your organization’s efficiency and success.

When it comes to process mapping, implementation challenges can arise, but best practices can help you overcome them.

Start by identifying the process to be mapped and the stakeholders involved. It’s important to involve all stakeholders in the mapping process to ensure everyone’s needs are met and to avoid any resistance to change.

Next, gather data on the process, including its inputs, outputs, and potential bottlenecks. Use flowchart symbols to visually represent the process, and ensure the map is easy to understand and follow.

Finally, regularly review and update the process map to reflect any changes in the process or business needs.

By following these tips, you’ll be able to successfully implement process mapping in your organization and achieve greater efficiency and success.

Congratulations! You’ve now learned about five case studies that highlight the power of process mapping in streamlining operations across different industries.

Just like how a GPS system guides you to your desired location, process mapping helps businesses navigate through complex processes and reach their goals efficiently. In essence, process mapping is like a blueprint that helps businesses build a solid foundation for success.

By identifying and eliminating inefficiencies, businesses can save time, reduce costs, and improve customer satisfaction. It’s like renovating a house – you start by identifying the problem areas and then work on fixing them. Once the renovations are complete, you have a beautiful, functional space that meets your needs.

Similarly, by implementing process mapping, businesses can transform their operations and achieve their desired outcomes. Remember, process mapping is not a one-time fix, but a continuous improvement process.

By regularly reviewing and updating processes, businesses can ensure they remain efficient and effective in a constantly changing environment. So, don’t hesitate to start process mapping in your organization.

With the right tools, techniques, and mindset, you can take your business to the next level and achieve your desired outcomes.

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Journey Mapping: A Product Development Process Case Study

Product teams should regularly assess the product development process itself. Sebastian Gherman, a Toptal senior product manager, outlines his approach.

Journey Mapping: A Product Development Process Case Study

Underpinning every successful product is a successful product development process. As a senior product manager at Toptal, I’ve found that treating that process as a product in its own right results in measurable improvements that touch every facet of our work.

The team I lead comprises an engineering manager, nine software engineers , and one quality assurance engineer. Our work covers a wide spectrum of products and features that facilitate a healthy supply-and-demand balance for our talent network. In the sections that follow, I share how we evolved our product development process using customer journey mapping and arrived at greater efficiency, communication, and collaboration.

When the Process Is the Product, the Team Is the User

Products that are unsuccessful or ineffective often result from what a team, or even a single person, thinks users want and need, not what they actually want and need. A good product, however, is built on the qualitative and quantitative data derived from extensive user research sessions. Likewise, the product development process itself can be unsuccessful or ineffective when it is designed by a leader who assumes they know what their teams need.

As product manager or team lead, you should engage in the same kind of user research that you would carry out for a product—shadowing, interviewing, and surveying—with your team to make sure your process is similarly successful. The goal is to understand how your team is using the product development process and address any pain points they encounter along the way.

Build a Customer Journey Map

There are various ways to collect feedback from users, but customer journey mapping is the product discovery technique I use with my engineers. The result is a diagram that illustrates the steps users go through when engaging with your company, whether that be through a product, online experience, retail experience, service, or any combination of these. The more touchpoints your users have, the more complicated—and therefore necessary—a map becomes.

This technique explores users’ actions and emotions around that engagement to reveal pain points and opportunities. It’s an excellent way to uncover problems in your process.

Within the diagram, users are depicted as hypothetical personas. Each persona should have a short bio, including a description of their inner motivations and responsibilities, as this helps to humanize them. Each persona should represent a key type of user to offer a sense of the diverse wants and needs the solution must address.

Journey maps are organized by user stages. Each stage represents a major goal the user is trying to achieve in their overall journey. For each stage, and for each persona, ask your team to consider:

  • Actions: What does the user do?
  • Emotions: How does the user feel?
  • Pain Points: What bothers the user?
  • Opportunities: What are some possible solutions?

Asking the team “What bothers you about this product and how can we fix it?” would not be a useful way to gather information because, at the time the question is asked, they may not recall use cases or how they felt when they experienced an issue. Asking them to split the interaction into steps and asking them how users encounter each step helps the team surface the emotions associated with each stage of the journey.

Applying This Theory to Our Toptal Team

To understand how this theory applies in action, consider the journey map for the product development process that I created with my engineering team.

Using Miro , I created the journey map board, splitting the product development process into eight major stages:

  • Roadmap Planning, and Defining Objectives and Key Results (OKRs)
  • Product Specification
  • Technical Analysis and Work Breakdown
  • Implementation
  • Quality Assurance and User Acceptance Testing (UAT)
  • Pre-release
  • Post-release

I chose two personas—software engineer and product manager—as these are the main users who engage with the process.

  • Sergey, the software engineer: Sergey ensures the initiatives are delivered on time and to a high standard, while maintaining a robust code base and understanding of the latest technologies and tools.
  • Matt, the product manager: Matt ensures the team prioritizes its efforts by working on the most impactful initiatives first. He also listens to stakeholder needs and communicates updates to the team regularly.

Prior to the session, I filled out the journey map for Matt, the persona in my role, in order to get an idea of how much time was required to complete the exercise, as well as to set the team’s expectations of the format. Next, I scheduled two 90-minute sessions across two consecutive days to ensure my team had enough time to complete the exercise without losing focus or energy. Because most engineers are unfamiliar with the journey mapping process, I shared links to the Miro board and a YouTube tutorial to help them prepare. Before the beginning of the first session, I confirmed that everyone understood the concepts.

As facilitator, I asked the team to suggest the actions, emotions, pain points, and opportunities for Sergey’s persona. Some team members were shy at first, but once a few people shared their thoughts, the session started to flow. I filled out cards on the Miro board based on their input.

Table showing a sample software engineer journey map board, which details the stages of the product development process (roadmap planning and defining OKRs, product specification, technical analysis and work breakdown, implementation, quality assurance and UAT, pre-release, release, and post-release) and the actions, emotions, pain points, and opportunities associated with these.

Key Learnings From the Journey Mapping Process

The journey mapping process yielded five main takeaways:

  • Keep the sessions short and focused. If there are more than a few stages within the journey map, I advise splitting the effort into two or three sessions to maximize productivity and to prevent team members from losing focus.
  • Be a role model. Filling out the Product Manager swimlanes before the session sets a tone of honesty and openness, and demonstrates how to express these issues, encouraging team members to share their own emotions and pain points more readily.
  • Create emotional safety. Team members may find it intimidating to share their struggles—most likely from a fear of being judged—but try your best not to intervene. Sooner or later, a more courageous team member will break the ice and things will start moving. When that happens, show empathy and appreciation. This will reassure other members that they are in a safe environment and they will feel more comfortable sharing their thoughts.
  • Create a follow-up plan with your team. Some problems may be hard to solve, especially if the solution involves other teams or departments, but plan to keep your team updated about any relevant communication with, or changes from, those responsible parties who may impact the results of the journey mapping process.
  • End with action steps. Create a list of action items, and assign an owner and deadline to each, which will help you realize tangible results from the session. Some examples that resulted in our case are depicted in the following table:

Table showing the action items that resulted from the journey mapping process, detailing the pain points, the action items resulting from these, which team member is responsible for overseeing each item, and the associated deadlines.

Why Was the Journey Mapping Exercise Effective?

The journey mapping exercise was extremely successful in presenting potential opportunities for improvement and fostering team spirit. It helped us in the following ways:

  • It uncovered issues where I believed things were running smoothly and reinforced the importance of not making assumptions. For example, I assumed that everyone had sufficient training on Jira , which was not the case. On the other end of the spectrum, I thought asking the engineering team to record demo videos for new pieces of functionality burdened them, when in fact they valued the exercise because it helped them improve their presentation techniques and lessened their anxiety around being in front of a camera.
  • It illuminated some improvements I could make, such as restructuring initiative cover pages to make them more accessible for engineers.
  • It empowered the engineering team to take responsibility for the outcomes within their control because they were the ones proposing changes that they could test and further iterate. It was primarily a bottom-up process.
  • It revealed that the pain point hot spots were predominantly around roadmap planning and implementation.
  • It forged stronger working relationships among the team by acknowledging shared challenges. For example, a number of individuals on our team thought they were the only ones struggling with the CI/CD pipeline for a particular subsystem when, in fact, most of the team was struggling.

Scaling Considerations

If every product manager or team lead for engineering goes through this process with their team, a common set of problems will likely arise, indicating which issues should be addressed first. Teams should follow the updated process for a few months, then the feedback loop must be revisited again. This cycle should continue until the product development process is natural and easy, and supports the needs of the users in building top-quality software products.

In the case of my team, our new process has delivered tangible improvements on several fronts:

  • The average time for tickets in review has been reduced by 22%.
  • The product OKR completion rate has risen above 90% over the course of the last three quarters.
  • The service-level agreement time for high-priority bugs has been met in 100% of cases.
  • There have been no failed releases due to deployment problems.
  • The average number of post-release reported bugs has decreased by 37%.

If your team is involved in building products , then your process should be subject to continuous scrutiny and improvement. If one function is not performing well, or if its product development process is weaker, that will impact the end result. While I used this practice for an engineering team, it can easily translate to user research , design, UI/UX , and content teams.

Your product development process is your most important product. Use this exercise to help perfect it, and see how much it elevates every product your team makes.

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navigating process maps header

navigating process maps header

Learning Objectives

After reading this article, you will be able to:

(1)  define  process mapping 

(2)  identify  when to use a process map

3)  develop  a low-tech process map

Kevin Curtis inherited a problem that had been hanging around for years. 1  Psychiatric patients in the emergency department were waiting too long for a bed at the University Neuropsychiatric Institute (UNI)—sometimes as much as 8 hours. Curtis engaged his team by using Utah’s value improvement methodology and value engineer Dane Falkner to create process maps—visual tools for improvement. They refined their process map into a cause-and-effect diagram. Using the visual diagram they identified that information flow from the transferring facility was causing delays. It was a breakthrough. Curtis and team designed a new process that organized the information into smaller batches based on when the information was needed. After three weeks of implementing the new process, wait times dropped from 3.8 hours to 1.6 hours, and four-out-of-five transfers were completed in under an hour. The best part? They were able to fine-tune their existing process without adding additional work.

What is process mapping?

rocess mapping is a visual representation of a workflow that identifies each step in a process to clarify how the work is done.

Process mapping is used to highlight issues and  where the process is breaking down in the workflow. Process maps make it easier to  communicate the current or future state of the process you are hoping to improve.

When do I use a process map—and why?

Process maps can be used to visualize unclear processes and identify areas of improvement (future improvement efforts), or as part of your  baseline analysis Baseline analysis defines the current state of a problem both quantitatively and qualitatively. A process map is a qualitative tool to allow a team to “see” a process.”  at the beginning of an improvement effort you are working on. Process mapping is useful when you don’t know where to begin improving, or when you are not sure what the cause of the problem is.

When you don’t know where to begin. Teams often start with a problem and jump to finding a solution. A map of the current state of a process can help confirm what actually needs to be fixed. Sometimes, however, it may reveal the opposite: it’s not a problem (or at least not the big one). By confirming the problem early, you can avoid sinking hundreds of hours into a fruitless effort.

When you don’t know the cause. Sometimes the problem is well established, but the source is unknown. A process map can help clarify where the process breaks down, which can help focus your efforts.

How do I map a process?

I. getting started.

  • Have a plan. Before you begin, start by asking these two questions: What process problem are we trying to solve? What are we trying to see? 2 For example, are there delays? Errors? The Seven Wastes are a useful tool to help clarify what you might be looking for.
  • Go and see the process. Make sure that what you’re mapping is the actual process. In Lean, this is called going to the Gemba—"the real place" in Japanese. By observing and documenting the process in action, you increase the accuracy of your map.
  • Include the team. Process mapping is a team sport. By including the people who actually use the process, you increase accuracy—and improve buy-in down the road when you have a process change to implement.
  • Keep it simple. Workflows can be extremely complex, but your map needs to be easy to understand. At the beginning, it helps to capture enough of the action that people can easily follow the process. You can always add greater detail later as needed.

II. Tools you can use

Low-tech. Keep it no-tech by starting with Post-It notes or a whiteboard. If you don’t have those, a piece of paper will work just fine.

post its

It can be an energetic and fun process when a team collaborates to build a map. A group effort can result in a messy, but closer to accurate, depiction of the work.

rough process

rough process

Snap a photo with your phone for a quick copy to work from.

High-tech. If you have to communicate your process beyond your team, it helps to clean up the work. There are many software and web-based tools you can use. Here are just a few:

  • PowerPoint — commonly seen and easy to present from, PowerPoint (PPT) allows you to create a custom map using basic flowchart symbols
  • Vizio — produces professional grade flowcharts (Note: Not compatible with Mac)
  • Lucidchart  — web-based product that has a free account option sufficient to develop a high quality process map 

III. Symbols and such

There are dozens of symbols you can use to reflect a process. The table below defines the five most common.  

process map symbols

process map symbols

See it in Action

Returning to our intro case study, Kevin Curtis and team first examined the current state of their process and identified each step. Horizontal lanes (below left) indicate the process owners.

current state

current state

They then worked with value engineer Dane Falkner to  identify opportunities for improvement  indicated by the little spikey yellow clouds Also called Kaizen clouds. Kaizen is the Sino-Japanese word for improvement. . Using the visual diagram they identified that a fax from the transferring facility was causing the delays.

cause and effect

cause and effect

Curtis and team designed a new process that organized the fax’s information into smaller batches based on when the information was needed. This map reflects the future improved process state.

future state process map

future state process map

Process maps, like the one Curtis and team helped create at UNI, break down complex work into transparent steps that are more understandable. They make the knowledge of who is doing the work clear and they focus your improvement efforts to help save you time. By mapping each person’s role and the work involved in every transfer and admission, UNI created a revised process that reduced admission time. Admissions are now more predictable and regular, and the eight-hour waits are gone.

  • Johnson S, Ransco M, Daniels C, Falkner D, Curtis C.  How UNI Decreased Delay to Admission (And Improved Team Engagement) . Accelerate University of Utah Health, Case Study. 23 June 2017.
  • Johnson S. Value Improvement Leaders (VIL): Course Archives , VIL #9: Process Mapping.

*Originally published September 2019 

Internal medicine residents Brian Sanders and Matt Christensen team up with senior value engineer Luca Boi to explain why investing your time honing a well-defined problem statement can pay dividends later in the ultimate success of a QI project.

Hospitalist Ryan Murphy introduces quality improvement (QI): The systematic and continuous approach to improvement.

Many people ask, “What am I supposed to report?” or “Does this count?” Hospitalist Ryan Murphy explains the basic vocabulary of patient safety event reporting, informing the way we recognize harm and identify and report threats to safety.

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