Appendix C: Example
This appendix provides an example of the functional tree struc-
ture (FTS) process for a medical/surgical nursing department.
1. Organize a team of subject matter experts that includes
the department director members (three to six individuals)
and designate a facilitator. Provide two hours of training
to help them with an introduction to operations improve-
ment (OI), FTS, selected quality management tools, and
2. Have the team create an initial high-level FTS of their
area. Add to the structure the revenue and full-time
equivalent (FTE) employees assigned to each of the func-
tions. In this example, the 3N Medical/Surgical Nursing
Unit was identied as the nursing unit that brought in the
most revenue (Figure C.1).
3. The team then identies, using available data (the number
of cases by diagnosis-related group [DRG] treated in the
unit), the patient types that are most frequently cared for
in the unit (Figure C.2).
132 ◾ Appendix C: Project Starting with Functional Tree Structure
4. Review the data (the number of cases by DRG) and deter-
mine whether the tasks associated with each DRG are
similar to other DRGs. Using a team of process and clini-
cal experts, group like DRGs based on disease etiology
and treatment similarities. Similarities are dened by like
Figure C.1 High level functional tree structure diagram.
Medical Surgical Nursing Unit Patient Population
MS DRG Description Category Number of Cases
470 Major joint replacement or reattachment of lower
extremity w/o MCC
392 Esophagitis, gastroent & misc digest disorders w/o MC
193 Simple pneumonia & pleurisy w MC
189 Pulmonary edema & respiratory failur
641 Nutritional & misc metabolic disorders w/o MC
690 Kidney & urinary tract infections w/o MC
871 Septicemia w/o MV 96+ hours w MC
603 Cellulitis w/o MCC50
Figure C.2 Prioritization matrix.
Appendix C: Project Starting with Functional Tree Structure ◾ 133
treatment schedule, supply utilization, labor (skill) utiliza-
tion, and other characteristics (Figure C.3).
5. List the groups (the DRG categories in this example) in
descending order based on patient cases and create a
Pareto chart to identify the vital few and useful many pro-
cesses within the unit as shown in Figure C.4.
6. For the 3N Medical/Surgical Nursing Unit, build a
detailed FTS diagram showing the DRG categories and
the primary task completed in servicing the patients who
fall into these categories. This task can also be done
by the subject matter experts and department director
7. Starting with the task consuming the greatest amount of
resources, have the team members document all current
treatments, activities, and tasks performed for the targeted
processes. The form in Figure C.6 can be used. Allow
team members 48 hours to complete this homework.
8. The team’s facilitator will compile all tasks and delete
9. The team will then place the tasks in order regarding how
they are performed for each process. It is easier if the
team groups the services and activities done in the rst
Medical Surgical Nursing Units
Patient Volume by Categories
DRG CategoriesSum of Number of Cases Cumulative %
C and C,
I and I,
Figure C.3 Pareto chart showing DRG groups.
134 ◾ Appendix C: Project Starting with Functional Tree Structure
hour the patient is in the unit and then the second hour
and so on until the discharge or transfer of the patient
from the unit.
10. The team then evaluates each task as it relates to cus-
tomer-dened criteria. In this process, the facilitator
will attempt to include customer and expert feedback
on the list. Any decisions or split in the process should
be identied and the path between tasks drawn. With
input from the experts and based on customer-dened
criteria, the list can be simplied. At this time, the team
should assemble a rough process map of the current
11. The next step is to provide the simplied process map
to a management engineer (ME; your process expert),
who will create a current-state process map based on the
information provided using the template in Figure C.7.
12. Reconvene the experts to validate each activity step of the
process map developed by your ME. Review each step,
Sum of Number of Cases Cumulative %
Figure C.4 Pareto chart showing DRG case volumes.