Discussion—The Model for Improvement
The Model for Improvement is based on three fundamental questions. Those questions are:

What are we trying to accomplish?
How will we know that a change is an improvement?
What changes can we make that will result in improvement?

Your textbook reading for this module includes Appendix C which contains the fundamental questions for performance improvement posed by the authors. Read this section, consider the questions stated, and respond to the following:

How can the model proposed by the authors be used to implement performance improvement?
How can you apply this model to your chosen public health organization for your course project?

Write your initial response in 4–5 paragraphs. Apply APA standards to citation of sources.

Appendix C The Model for Improvement and Other Roadmaps
How do you make improvements? Historically people have used a trial-and-error approach to improving all aspects of their life. Typically an idea for an improvement (a change) comes to us. These ideas are often reactions to problems or difficulties that we all face in life and in our work, so we make a change and then see if the situation improves. Sometimes we also check to see if anyone complains, or if something else stops working because of the change that we made. Because of its sporadic track record on real, sustainable improvement, this natural trial-and-error approach has often been criticized as “jumping to solutions” without sufficient study.As a response to this criticism, some improvement specialists have turned to extensive study of the problem before a change or trial is attempted. Sometimes this approach leads to a better track record on making sustained improvements, but more often it can lead to an unnecessary delay in making obvious changes—or worse, never actually making changes. The person with the problem gets bogged down in the study, “paralysis by analysis” sets in, or other problems begin to take priority. Also, the search for the “perfect change” sometimes contributes to this paralysis (see mention of the utopia syndrome, in Chapter Six). How do we balance the need to do something with the desire to be sure we know what we are doing before we take any action?This book has presented the Model for Improvement, which attempts to strike that balance. The model is a framework for developing, testing, implementing, and spreading changes that result in improvement. It can be applied to the improvement of processes, products, and services in any organization, as well as improving aspects of one’s personal endeavors. The model attempts to balance the desire and rewards from taking action with the wisdom of careful study before taking action.
Fundamental Questions for Improvement
The Model for Improvement is based on three fundamental questions—What are we trying to accomplish? How will we know that a change is an improvement? What changes can we make that will result in improvement?—and a “cycle” for learning and improvement. Variants of this improvement cycle have been called the Shewhart Cycle, Deming Cycle, and PDSA Cycle. The cycle promotes a trial-and-learning approach to improvement efforts, with encouragement to test an idea rather than do extensive analysis. The cycle is used for learning, to develop changes, test changes, and implement changes.Figure C.1 diagrams the basic form of the Model for Improvement.
Why are we promoting the use of this particular approach to improvement? Our experience with the Model for Improvement since its development in the 1980s shows that it:

• Is useful as a roadmap for small, simple projects as well as large-system projects
• Is useful for both process and product improvement
• Can be used for the design of new processes and products
• Is applicable to all types of organizations
• Is applicable to all groups and levels in an organization
• Facilitates the use of teamwork to make improvements
• Provides a framework for the application of improvement tools and methods
• Encourages planning to be based on theory
• Emphasizes and encourages the iterative learning process
• Allows project plans to adapt as learning occurs
• Offers a simple way to empower people in the organization to take action

Experts in complexity science have been critical of quality improvement frameworks that follow a linear sequence of steps to accomplish a project. Complexity science suggests that inconsistent outcomes may result from an implicit assumption of linear, mechanistic relationships between cause and effect in implementing organizational interventions. Studies of innovation have shown that discovery, learning, and intervention cannot be reduced to a linear model. Instead, researchers suggest the “innovation journey is a nonlinear cycle of divergent and convergent activities that may repeat over time.”Complex, adaptive systems, which describe organizations in which we apply improvement methods, are characterized by individuals who can learn, interconnect, self-organize, and co-evolve with their environment in nonlinear and dynamic ways. A step-by-step framework associated with many improvement roadmaps may not support this way of thinking.In contrast, a complex systems approach would suggest that each environment is unique, and that outcomes of interventions may be greatly affected by situational differences. Some of the frameworks (such as the QC story) make it clear that the sequence of steps implied in the framework is not the way that most improvement projects are actually done. Rather, the steps are used to describe the completed project in a uniform way that everyone can understand.The Model for Improvement encourages the nonlinear learning and adaptation suggested by complexity science. By encouraging early testing of ideas in the specific environment of interest, the model allows the intervention to gradually be modified and then optimized to the uniqueness of the system where implementation is taking place.
Alternative Roadmaps for Improvement Projects
Many authors and experienced improvers have recognized the importance of an organization having a consistent framework for conducting their improvement initiatives. This consistent, structured approach affords a common language and allows improvement teams to be formed from different departments and groups in the organization. As well as accomplishing a specific improvement, participants following the structure become better improvers.In addition to the Model for Improvement, there are a number of other frameworks or roadmaps that have been used to guide improvement projects. These frameworks are briefly described in this appendix:

• Juran’s Universal Sequence for Quality Improvement
• Six-Sigma DMAIC
• Six-Sigma DFSS
• Seven-step problem-solving model
• The 8-D Model
• The QC Story
• Lean improvement

Juran’s Universal Sequence for Quality Improvement
On the basis of his years of experience in quality improvement projects, Joseph Juran observed that improvement in a variety of contexts and environments was carried out following a “universal sequence of events”:

1. Identify a problem—something wrong with a product, service, or process that has an impact on the performance of the organization
2. Establish an improvement project
3. Measure and analyze the current process to establish knowledge of baseline performanceDiagnostic Journey (from Symptom to Cause)
4. Analyze the symptoms
5. Generate theories as to the causes of the symptoms
6. Test the theories
7. Establish the causesRemedial Journey (from Cause to Remedy)
8. Develop remedies
9. Test and prove the remedies in operations
10. Deal with resistance to change
11. Establish controls to hold the gains

This universal sequence has been the basis for many of the other frameworks presented here. The sequence puts emphasis on understanding how the current process or product performs and identifies causes of the problem (that is, the diagnostic journey) before beginning to think of remedies.
Six-Sigma DMAIC
DMAIC (define-measure-analyze-improve-control) is a basic component of the Six Sigma methodology. Six Sigma was developed in Motorola in the late 1980s and built on TQM (total quality management) programs with a focus on reducing variation. The Six Sigma methodology has evolved into a number of distinct versions. For example, one version is called “Lean Six Sigma” to incorporate the ideas of lean improvement (see later discussion).There are many versions of the five steps of the Six Sigma DMAIC roadmap for improving existing processes. These are typical definitions of the five steps:

1. Define process improvement goals that are consistent with customer demands and the organization’s strategy.
2. Measure the current process (defect focus) and develop baseline for future comparison.
3. Analyze to verify relationship and cause and effect of factors. Attempt to identify all factors that could be relevant.
4. Improve or optimize the process on the basis of the analysis. Transition to standard processes.
5. Control to ensure that any variances are corrected before they result in defects.

In many published descriptions of the DMAIC framework, the measure and analyze steps do not emphasize Shewhart’s theory of common and special causes.Various tools and methods are associated with each step of DMAIC. For example, the define step typically includes:

• Establish a sound project foundation

• Ensure leadership and team are aligned
• Form improvement team
• Develop a problem statement and a business case

• Scope document

• Set goals (deliverables, timeframe, budget)
• Keep team on target (scope creep)

• Process documentation

• Suppliers-inputs-process-outcomes-customers (SIPOC) diagrams
• Stakeholder analysis
• Process maps and value stream maps

• Voice of the customer

• Establish or validate customer needs
• Internal and external customers
• Interviews, surveys

Similar guidance for tools and methods are associated with each of the other four steps.
Six-Sigma DFSS
The DFSS roadmap stands for “Design for Six Sigma.” There are many versions of DFSS in the literature and application, with steps defined differently. DFSS was developed for improvement projects directed at design or redesign of a product or service. One popular DFSS methodology is called DMADV, which has parallels to DMAIC. The five steps of DMADV are defined as:

1. Define the project goals and customer (internal and external) requirements.
2. Measure and determine customer needs and specifications; benchmark competitors and industry.
3. Analyze the process options to meet the customer needs.
4. Design the process to meet the customer needs.
5. Verify the design performance and capability to meet customer needs.

Other DFSS approaches have been described to emphasize various steps in the process or product design steps:

• DMADOV: define, measure, analyze, design, optimize, and verify
• DMCDOV: define, measure, characterize, design, optimize, and verify
• DCOV: define, characterize, optimize, and verify
• DCCDI: define, customer, concept, design, and implement
• DMEDI: define, measure, explore, develop, and implement
• DMADIC: define, measure, analyze, design, implement, and control

The particular version of DFSS is designed to align with an author or organization’s product design process. All of the DFSS versions connect to these improvement tools and methods:

• Quality function deployment
• Failure modes and effects analysis
• Benchmarking
• Design of experiments
• Simulation
• Statistical optimization
• Mistake proofing

Seven-Step Method Problem-Solving Model
The “Seven-Step Method,” also called the “Seven-Step Problem-Solving Model” and “Seven-Step Practical Problem Solving,” is a disciplined framework for completing an improvement project and a useful framework for documenting the project. This model was promoted to go beyond plan-do-check-act cycles to provide:

• A framework with which we can visualize progress through a project
• Check steps that allow us to see that we are not trying to proceed too quickly through part of the improvement process without having gained sufficient understanding
• A means of documenting a project

This model is directed primarily at eliminating quality problems, as opposed to the design or redesign of products or processes. Here are typical descriptions of the seven steps in the model:
Step 1: Define Project Purpose and Scope

• Focus on strategically important problems
• Choose an appropriate project team and team leader
• Clarify the project mission
• Determine how much progress can be expected
• Formulate a framework and execution plan for the project

Step 2: Current Situation

• Understand the present process
• Determine customer needs and expectations
• Flowchart the process
• Collect data to identify the real problem
• Standardize the process, if necessary

Step 3: Cause Analysis

• Dig down for the root causes of the problem
• Identify the major potential causes
• Verify them with data, if possible

Step 4: Solutions

• Choose between alternative solutions
• Keep solutions simple
• Identify barriers to implementing solutions
• Plan and make necessary changes (use plan-do-check-act)

Step 5: Results

• Evaluate the solutions
• Collect data, to compare before and after improvement
• Compare results with what we expected

Step 6: Standardization

• Standardize the new process
• Document the changes made
• Error-proof the process

Step 7: Future Plans

• Review what has been learned from this project
• Decide whether to continue with this project, or
• Close project and move on to a more pressing project

Toyota’s “Practical Problem-Solving Process” is a similar model with seven steps:

1. Initial problem perception
2. Clarify the problem
3. Locate area or point of cause
4. Five whys, investigation of root cause
5. Countermeasure
6. Evaluate
7. Standardize

FOCUS-PDCA is another framework developed in the late 1980s as a way to better use PDCA (plan-do-check-act) on improvement projects. The framework is designed for both problem solving and process improvement. The steps of the framework follow from the name:

Find a process to improve
Organize a team that knows the process
Clarify the current knowledge of the process
Understand the causes of process variation
Select the process improvement
Plan improvement, data collection (key quality characteristics and other)
Do improvement, data collection, data analysis
Check data for process improvement, customer outcome, lessons learned
Act to hold the gain, reconsider owner, and continue improvement

The 8D Problem-Solving Methodology
The 8D problem-solving methodology (8D = eight disciplines) was developed in Ford Motor Company in the mid-1980s to be used by their suppliers to improve the resolution of problems. It appears in a variety of forms used to define eight disciplines. Sometimes it is defined as a nine-step problem-solving process:

D0: preparing for 8D
D1: assembling the team
D2: describing the problem
D3: developing interim containment actions
D4: defining the root cause
D5: choosing permanent corrective actions
D6: implementing permanent corrective actions
D7: preventative actions
D8: recognition of the team

Other applications of the 8D methodology describe a problem resolution framework (to address part supplier problems):

• Part and lot information
• Description of concern
• Containment
• Root cause
• Corrective actions
• Verification of containment and corrective actions
• Action to prevent recurrence
• Congratulate the team

Because the 8D model is designed to solve specific problems that arise, more emphasis is placed on containing the problem (discipline 3) than in most other frameworks. The idea is to implement intermediate actions that will protect the customer from the problem until permanent solution can be developed and implemented. This roadmap also makes recognition of the improvement team for their effort an explicit part of the framework.
The QC Story
The QC Story (or quality improvement story) was developed in Japan by the Union of Japanese Scientist and Engineers (JUSE) Research Committee. It has been used extensively by QC Circles to document their journey on improvement projects. Having a common structure and language helps people working on a project tell their “story” to management and other parties interested in their project. There are seven steps to “telling the QC story”:

1. Situation: identify the problem or opportunity for improvement (plan and problem definition)

• State history
• State priority and impact
• Relate to strategy, customers, and employees
• Define theme for improvement project
• Organize improvement project team
• Create improvement project plan

2. Observation and data: understand the situation

• Understand current circumstances
• Collect and display data
• Establish improvement targets

3. Analysis: find out the main causes

• Establish hypotheses for causes
• Test hypotheses
• Decide on improvements

4. Action: eliminate the causes

• Plan execution of improvements
• Execute improvements

5. Study: confirm the effectiveness of the action

• Verify improvement results

6. Standardization: permanently eliminate the causes

• Establish control methods
• Update appropriate standards
• Implement education and training
• Establish inspections

7. Conclusion: review activities and plan for future work

• Review activities
• Plan next steps
• What other problems did we identify during this work?

Promoters of this framework emphasize that the seven steps in the QC story do not necessarily describe the specific order in which the problem was solved. Because problem solving usually requires a great deal of iteration, during the project it is often necessary to go back to a previous step as new data are found and analyses permit additional insight. However, when it comes time to report on what was done, the seven-step format is the basis for telling the story in a way that makes it comprehensible to all levels of management, suppliers, and customers.
Lean Improvement
Lean Improvement has been defined as “a systematic approach to identifying and eliminating waste (non-value-added activities) through continuous improvement by flowing the product at the pull of the customer in pursuit of perfection.” Lean approaches have been adapted from the Toyota Production System (TPS). There is not a specific roadmap for a lean project.The lean improvement approach is based on five principles:

1. Defining value from the customer perspective
2. Identifying value streams, the activities required to provide the customer with a product or service
3. Making the value added steps flow smoothly
4. The customers “pull” the products and services when needed
5. Everyone is pursuing perfection

Some key definitions are:

• Value: what the customer is willing to pay for; an activity that changes form, fit, or function
• Nonvalue add: no added value from customers’ definition, but must be done under the present conditions (e.g., walking over to the printer, putting together binders)
• Waste: what the customer is unwilling to pay us to do

A lean approach focuses on continuously reducing waste in operations and in product and services and continuously enhancing the value proposition to customers. Some organizations have called their approach to quality improvement “lean six sigma” to incorporate the ideas from both of these improvement strategies. The Six Sigma DMAIC model (described earlier) is then adopted as a framework for improvement projects.The concepts of lean thinking are incorporated into the Model for Improvement in answering the fundamental question, “What change can we make that will lead to improvement?” Many of the change concepts from Appendix A are associated with lean improvement methods. Change concepts 1 through 11 and 23 are about ways to eliminate waste, and concepts 12 through 23 focus on ways to improve workflow. Other change concepts often associated with lean improvement are 24, 46, 48, 50, 51, and 71 (see Appendix A for descriptions of these concepts).
It is widely recognized that organizations benefit by having a consistent framework or roadmap for conducting their improvement initiatives. The Model for Improvement is the framework used throughout this book. A number of other improvement models or frameworks are also available in the improvement literature. 

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