THE IMPROVEMENT GUIDE

A Practical Approach to Enhancing Organizational Performance

Second Edition

Gerald J. Langley

Ronald D. Moen

Kevin M. Nolan

Thomas W. Nolan

Clifford L. Norman

Lloyd P. Provost

I am not sure what makes a “classic,” but I am sure this book is one. It is, overall, the most useful text I know for the student of the modern approach to system improvement—accessible, sensible, systematic, and remarkably complete.

My journey into the world of quality improvement began in the mid-1980s. I was responsible for reporting on the quality of health care in the largest health maintenance organization in New England, the Harvard Community Health Plan. I was classically trained as a physician and as a health services researcher and was teaching both pediatrics and health care evaluation (statistics, decision theory, cost-effectiveness analysis, and such) at Harvard Medical School and the Harvard School of Public Health. I thought that I understood quality in health care, that I knew how to assess it, and that I knew how to improve it. I was wrong on every count.

Like most people with my training, I actually knew far more about fragments than about the whole; my understanding of approaches to quality of care came from what health care experts called “quality assurance,” and what W. Edwards Deming would have called (as I would soon thereafter find out) “reliance on inspection to improve.” The foundational sciences of modern quality management outside health care, such as systems theory, analytical studies and the study of variation, human psychology in production systems, and the epistemology of cycles of change and learning (especially local cycles), were not well understood or highly honored in the world of health care. Few of us were systems thinkers and fewer still had any theoretically grounded approach to the improvement of care beyond inspection and accountability. Health care leaders generally assumed that the growth of subject-matter expertise and scientific knowledge were sufficient for the growth of systemic capability.

Serendipity brought me under the wing of generous improvement scholars patient enough to teach me. My friend Paul Batalden started me on the path. Paul, so far as I know, was the first medical leader who really came to understand and value what Deming had to teach. Deming's four-day seminar followed (at Paul's suggestion), along with visits to world-class corporations outside health care. Most crucially for me, I formed what has since become a deep professional tie with A. Blanton Godfrey, who, when I met him, was the head of Quality Systems and Theory at AT&T Bell Laboratories. Soon thereafter he became Joseph Juran's hand-picked choice to lead the Juran Institute. In 1986, with a small grant from the John A. Hartford Foundation, Blan Godfrey and I started a National Demonstration Project on Quality Improvement in Health Care, and NDP remained for four more years the generative center of my own personal learning about improvement. I also served between 1989 and 1991 as a member of the panel of judges of the then-new Malcolm Baldrige National Quality Award, a cat-bird seat if ever there was one from which to study the best of the best in detail, in the company of some of the most capable improvement scholars and practitioners in the world.

As my network of mentors and my shelf of books grew, the field of quality management became, for me, first a country and then a continent. To this day, I remain excited by the vastness of the field and by its endlessly challenging intellectual texture. Deming's formulation of the four areas of “profound knowledge” (knowledge of systems, knowledge of variation, knowledge of psychology, and knowledge of how knowledge grows) is deceptively efficient, for it encodes more topics and more sciences than any reasonable human being is likely to master in a lifetime.

The problem is that managing quality is not just an intellectual endeavor; it is a pragmatic one. The point is not just to know what makes things better or worse; it is to make things actually better. In the world of manufacturing or service industries, it is organizational survival, jobs, and the fate of the consumer that all hang in the balance. In health care, it is all of that plus (sometimes) life and death. Modern quality management stands in the same relationship to the scientific disciplines of “profound knowledge” as modern medical care does to biomedical science. It is an applied field tethered to strong, formal science. Practitioners who lose touch with the science run aground; scientists who lose touch with applications fly off into irrelevance.

Moving from theory to application is so difficult that it tempts one to reach for what Deming called “instant pudding,” by which I think he meant the quick and memorable formula that makes deep thought unnecessary and that takes uncertainty out of the picture. Countless consultants and airport-bookstore authors make a good living on instant pudding. It is attractive because it is easier than thinking. It is also, usually, unhelpful, at least for the long haul.

Finding the alternative to instant pudding is a daunting task: to build a bridge from the sciences of improvement to the practice of improvement without either claiming too much or collapsing too much. I wish that system improvement were simple, but it is not. Getting around is more like navigating Paris than like flying from Boston to Los Angeles.

Enter The Improvement Guide. I don't know how the authors did it, but they managed in this book to make proper improvement methods accessible without robbing them of their needed depth. They have neither oversimplified nor given way to the arcane. They put tools in our hands without claiming that the tools are magic.

The best of the tools is the Model for Improvement. With humility, the authors share their premise that the three questions (“What are we trying to accomplish?” “How will we know that a change is an improvement?” and “What change can we make that will result in improvement?”) linked to learning through testing—the “Plan-Do-Study-Act” cycle—embed a significant proportion of the pragmatic tasks that can link system knowledge to effective redesign. This model is not magic, but it is probably the most useful single framework I have encountered in twenty years of my own work on quality improvement. It can guide teams, support reflection, and provide an outline for oversight and review; it is thoroughly portable, applying usefully in myriad contexts. The model gets even more traction with the use of the rich family of change concepts these authors have harvested from their collective experience, and that they summarize in their stunningly helpful Appendix A.

For more than a decade, I have had the privilege of working hand-in-hand with the authors of this book. They have become, and they remain, my teachers and my guides. No day in the year gives me as much professional satisfaction as a day spent with them individually or as a group, delving together into new problems at new frontiers, or, even better (when I muster the self-restraint), just standing aside quietly and watching them at their work. Encountering novices, they are patient and nurturing with the first steps of discovery; encountering journeymen, they coach with respect and joy; encountering experts, they remain ever open to the real dialogue that marks true scholars; and when they are meeting somewhere off on their own they share the thrill and camaraderie of the best of expeditions into the uncharted. The authors are not into catechisms; they are learners, and they have never met a doctrine that they weren't willing to question every single day.

This second edition of the book is a gift to anyone in the journey to the practice and leadership of improvement. It is the mainstay text for my own teaching, and its usefulness and clarity speak to the commitment to knowledge and to open-minded inquiry that its authors model for us all.

February 2009

Donald M. Berwick, MD, MPP

President and CEO, Institute for Healthcare Improvement

Cambridge, Massachusetts

This book is for people who want to make improvements—or more specifically, those who realize that making effective changes in how businesses are run is a matter of survival. Change is occurring so rapidly in our society that we have no choice but to embrace it and make it work in our favor. We all have a choice to make: to accept passively the changes that are thrown at us, or to use our resources to create our own changes resulting in improvement. This book should be viewed as a survival guide for people who realize the importance improvement plays in keeping an enterprise viable. It is our hope that the ideas and methods presented in this book will guide you in increasing the rate and effectiveness of your improvement efforts.

As statisticians involved in improvement since the early 1980s, we have seen many tools, methods, and techniques presented as the one best way to achieve results. Many of these approaches indeed have merit. The overall effect, however, has lacked integration. Results have been mixed. In this book we hope to provide a fundamental approach to improvement that promotes integrated improvement activities that deliver more substantial results in less time.

Since the dawn of the twentieth century, a science of improvement has emerged. The intellectual foundation for this science was recognized by W. Edwards Deming and articulated in his “System of Profound Knowledge.” Practical, pragmatic examples of the application of this science have been seen in industries throughout the world. Dramatic results have been obtained. However, this science has been applied in only a small fraction of the circumstances in which it is applicable. The purpose of this book is to describe a system of improvement based on this science that will increase substantially the number of successful applications.

In preparation for the first edition of this book, we studied the needs of people who were attempting to make improvements in quality and productivity in many diverse settings in the United States and abroad. They included manufacturing plants (for computers, food, and pharmaceuticals), hospitals, clinics, trucking firms, construction companies, law offices, government agencies, landscape architecture and maintenance firms, schools, and industry associations. As we observed or participated in these improvement efforts, we asked ourselves what methods would help increase the effectiveness and results of these efforts.

Given this context, we eagerly absorbed, enhanced when we were able, and integrated a variety of methods and approaches. In the United States, many of these approaches were introduced with much fanfare and in a way that implied the method replaced what had come before. For example, in the early 1980s the emphasis was on continuous improvement of processes throughout the organization. The idea was that everyone should have a chance to improve his or her work. This was a positive approach. The emphasis had two weaknesses, however: major subsystems—in particular, business subsystems—were not improved holistically, and the changes that were made were relatively small and produced only incremental improvement. When reengineering (major innovation in large subsystems) was introduced, it addressed those weaknesses. But it came to be seen as replacing the incremental approach to improving process rather than as supplementing it. Our approach integrates these ideas, and other worthwhile approaches, into a complete system.

Second Edition

Since the release of the first edition, we have continued to work with our customers to research the crossroads of the theory underlying improvement and the pragmatic application of fundamental improvement methods. They are the ones who kept us grounded, who helped us take a pragmatic approach to improvement. They learned and we learned. With this second edition of the book, although the underlying concepts have not changed, we feel that we have presented a much more complete and effective set of methodologies for guiding improvement efforts.

We made the following changes to the second edition on the basis of many ideas for improving the book from readers of the first edition and reviewers of the manuscript: strengthened the focus on business operations (throughout the book); laid a foundation for the science of improvement in developing, testing, and implementing changes (Part Two); added chapters on spreading changes and improving large systems (Part Two); expanded the concepts for working with people in improvement (Parts Two and Three); provided more insight into the role and methods for leadership of improvement (Part Three); redesigned Appendix A (Change Concepts) to be more user-friendly; and added an appendix on improvement tools (Appendix B) and one for other improvement approaches (Appendix C).

Many people have helped us with this work or inspired new ideas. We wish to acknowledge our clients who have shown the applicability of the ideas and methods described in this book. Their willingness to test new methods contributed greatly to the material.

Noriaki Kano first introduced us to the ideas that led to the three categories of improvement covered in Part Three. Edward de Bono's work on methods for creativity provoked some new ideas that eventually led to the list of change concepts. We were also influenced by Brian Joiner's book Fourth Generation Management to use stories and examples to convey substantive concepts and methods.

Ultimately, it was Deming who, in the 1980s and early 1990s, gave the world the theoretical foundation for a science of improvement with his development of the System of Profound Knowledge and who inspired us to write this book. To him we owe our deepest debt, and to his memory we once again dedicate this second edition of the Improvement Guide.

Finally, we heartily express our appreciation to our families for their sacrifices, which allowed us time to do our research and to write the many drafts of both editions of the book.

February 2009

Gerald J. Langley
El Dorado Hills, California
Ronald D. Moen
Clarkston, Michigan
Kevin M. Nolan
Silver Spring, Maryland
Thomas W. Nolan
Silver Spring, Maryland
Clifford L. Norman
Georgetown, Texas
Lloyd P. Provost
Austin, Texas

All of the authors are part of a unique professional collaboration called  Associates in Process Improvement (API). The aim of the collaboration is to develop and apply methods for the improvement of quality and value. The collaboration within API has benefitted individual organizations on six continents, in many industries, and the field of quality improvement in general. The collaboration has resulted in four books, numerous articles, and thousands of presentations. Three of API's current or former clients have been recipients of the Malcolm Baldrige National Quality Award. API's roots are in the theory and philosophy of W. Edwards Deming. Members of API assisted Deming at his pioneering and influential Four Day Seminar from 1980 to 1993. API's Model for Improvement is based on Deming's body of work.

Gerald J. Langley is a statistician, author, and consultant whose main focus in both his consulting work and his research is helping organizations make improvements more rapidly and effectively. His expertise with data and computers plays a key role in this work. As a Senior Fellow of the Institute for Healthcare Improvement (IHI), Langley has served on the faculty of numerous improvement initiatives in areas such as improving medication safety, innovations in planned care, and improving service in health care, but much of his work has been focused on helping reduce health disparities in underserved populations. He earned his BS degree (1973) in mathematics at the University of Texas at Austin and his MS degree (1975) in statistics at North Carolina State University. He has published articles on sampling and survey design, modeling, and fundamental improvement methods.

Ronald D. Moen is a statistician, consultant, and teacher to industry, government, health care, and education. He has MS degrees in mathematics and statistics and has given over eighty presentations and technical papers throughout the United States, Canada, Mexico, Europe, Africa, and Asia over the last thirty-five years. He is coauthor of the book Quality Improvement Through Planned Experimentation, 2nd edition (McGraw-Hill, 1998) and Quality Measurement: A Practical Guide for the ICU (HCPro, 2003). He is the 2002 recipient of the Deming Medal.

Kevin M. Nolan is a statistician and consultant with API. He earned a BS degree in mechanical engineering from the Catholic University of America and MA degrees in measurement and in statistics from the University of Maryland. Nolan has assisted manufacturing, service, and health care organizations to accelerate their rate of improvement. As a Senior Fellow of the Institute for Healthcare Improvement (IHI), he has served on the faculty of numerous improvement initiatives, including improving hospitalwide patient flow and improving performance in emergency departments. He has also supported a number of large-scale spread projects. He is the co-editor of the book Spreading Improvement Across Your Healthcare Organization (Joint Commission Resources, 2007).

Thomas W. Nolan is a statistician, author, and consultant. Over the past twenty years, he has assisted organizations in many industries in the United States, Canada, and Europe, including chemical and automotive manufacturing, distribution, health care, and social services. Among his clients is a recipient of the Malcolm Baldrige National Quality Award. Nolan holds a doctorate in statistics from George Washington University. He has published articles in a variety of peer-reviewed journals as diverse as the Noise Control Engineering Journal and the British Medical Journal. He was the year 2000 recipient of the Deming Medal awarded by the American Society for Quality.

Clifford L. Norman, an author and international consultant with API, earned both his BS degree (1975) in police science and business administration and MA (2002) in behavioral science from California State University. He has held management positions for more than fifteen years in manufacturing and quality positions with Norris Industries, McDonnell Douglas, and Halliburton. Since 1986, Norman has worked internationally in computer, health care, and manufacturing industries using improvement as a business strategy while developing internal consultants for these organizations. Norman helps organizations build productive relationships while viewing the organization as a system, and helps to develop their use and understanding of analytic statistical methods following the Model for Improvement. As an improvement advisor and faculty member for the Institute for Healthcare Improvement (IHI), Norman has been instrumental in developing and supporting the IHI improvement and advisor course. He is a member of the American Society for Quality and an ASQ Certified Quality Engineer (CQE).

Lloyd P. Provost is a statistician, advisor, teacher, and author who helps organizations make improvements and foster continuous learning and improvement. His experience includes consulting in planning, management systems, planned experimentation, measurement, and other methods for improvement of quality and productivity. He has consulted with clients worldwide in a variety of industries, including health care, chemical, manufacturing, engineering, construction, automotive, electronics, food, transportation, professional services, retail, education, and government. Much of his current work is focused on health care improvement in developing countries. He has a BS in statistics from the University of Tennessee and an MS in statistics from the University of Florida. He is the author of several papers relating to improvement and coauthor of Quality Improvement Through Planned Experimentation, 2nd edition (McGraw-Hill, 1998). He was awarded the American Society for Quality's Deming Medal in 2003.