Step 4: Understand the Problem

“Every system is perfectly designed to get the results it gets.”
– Paul Batalden


Step 4 is about analyzing the current systems and processes and trying to gain insight into why these systems and processes produce the results that we aim to improve.

Key Definitions

A process is “a set of causes and conditions that repeatedly come together in a series of steps to transfer inputs into outcomes.“

A system is “an interdependent group of items, people, or processes with a common purpose.”




  • Administering the PHQ-9 to assess depression is one process of a system that provides care for an individual with depression.
  • Patrolling smoking hotspots on campus is one process in a larger system of enforcement of a Tobacco Free Campus policy.


Deming’s Profound Theory of Knowledge

It is important to understand the current state before you begin testing or implementing changes.  Edward Deming recognized something you may have also noticed: Life is messy and nonlinear. Whenever you make a change — whether you’re working to streamline industry for an entire war-damaged nation, as Deming did in Japan after World War II, or trying to implement a change on your campus — each change will affect other parts of your system. (IHI Open School).  Deming’s Profound Theory of Knowledge is useful contextual framework to help us understand complex systems that influence our outcomes.    Deming described his System of Profound Knowledge as a “lens,” and it is often depicted as a magnifying glass with four overlapping quadrants, each representing an essential component of systems thinking:

Deming Profound Knowledge Magnifying Glass

  1. Appreciation of a system.What is the whole system that you’re trying to manage? How do the different parts interact with and rely on one another?

  2. Understanding variation.What is the variation in results trying to tell you about the system? Why did something go wrong? Why are results so poor? How can you repeat successful results?

  3. Theory of knowledge. What are your predictions about the system’s performance? What are the theories that form the basis for these predictions?

  4. Psychology (human behavior). What are the important interactions among people in the system? How do people in a system react to change? What motivates people to act as they do?

Before you make a change in any system, the lens draws your attention to four areas — all of which you need to consider as a leader of improvement, but don’t consciously notice when you’re immersed within a complex system.

Source:  IHI Open School; 2. The man: overview. The W. Edwards Deming Institute website. Updated 2015. Accessed February 22, 2016


Understanding the Current State

For this step you document the system and processes as they currently exist.  Undertaking this exercise is important because it allows you to:

  • Visualize the activities that make up a particular process
  • Understand interrelationships
  • Define the scope of an improvement effort
  • Help to direct you to which data to collect and which measures to follow
  • Identify obvious changes that can be made

You may want to consider exploring any combination of the following questions:

  • What are we doing now?
  • How do we do it? What are the major steps in the process?
  • Who is involved or affected?
  • Where does the problem occur?
  • When does the problem occur?
  • What happens when the problem occurs?
  • Why does the problem occur?

This step often requires the use of existing data or may require new data collection.


It can be tempting to jump to ideas for solutions.
Instead, use this step, and the tools in this section, to outline
the current process(es) as they actually occur first before
thinking about would should or could be happening.  


There are multiple tools an improvement team can use to help understand and better define a process.  They include:

  • Process Mapping: a useful tool to help develop a picture of a process and communicate it among team members.  Once a process map is developed it can be used to identify problematic areas and opportunities for improvement.
  • Value Stream Mapping: is a more specific type of process mapping, often used with “Lean” improvement initiatives where value-added and non-value added steps in the process are identified.
  • Pareto Charts: is a simple bar chart showing how often a particular incident or event occurs.  Additionally, Pareto charts include a line displaying cumulative frequency that allows for application of the “80/20 principle”.
  • Cause and Effect (Fishbone) diagram: allows for a more intentional approach to identify and ultimately correct the root causes of problems within a process.


Improvement Journey Exercise #4

Create a process map of the system you are aiming to improve.


Once you have completed your process map, move on to Step 5: Establish Measures.