United States   Air And
       Environmental Protection Radiation
       Agency     (ANR-443)
              400 R-92-004
              Marcn1992
xvEPA

Total Quality Management
Making It Relevant
                    TQM
                    TQM
                    TQM
                    TQM
                    TQM
                    TQM
                    TQM
                    TQM
                    TQM
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Total Quality Management—
    Making It Relevant
       EPA-OAR

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                                    ©1992
                         by Organizational Dynamics, Inc.
                      Printed in the United States of America
                               All rights reserved

The contents, or parts thereof, may not be reproduced in any form for any purpose
without the written permission of the publisher, Organizational Dynamics, Inc. (ODI),
Twenty-Five Mall Road, Burlington, Massachusetts, 01803.

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Contents                 Total Quality Management—Making It Relevant





                           Overview: TQM—Making It Relevant                         1



                           Introduction: The Quality Principles                           3



                           Customer Focus: Meeting Requirements                        4



                           Total Involvement: Taking Responsibility for Quality             7



                           Measurement: Monitoring Quality                             8



                           Systematic Support: Leading and Reinforcing                    9



                           Continuous Improvement: Preventing and Innovating           10



                           Introduction: Quality Tools                                 12



                           Tool: Brainstorming                                      13



                           Tool: Multivoting                                        15



                           Tool: Force-Field Analysis                                 16



                           Tool: Action Plan                                        18



                           Tool: Why Technique                                     20



                           Tool: Fishbone Diagram                                   22



                           Tool: Pareto Analysis                                     24



                           Conclusion: Your Role                                    27
                           Total Quality Management

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Overview                 Total Quality Management—Making It Relevant


                            Introduction by William G. Rosenberg

                            Total quality management (TQM) is a way to get work done—better.
                            More specifically at OAR, quality is creating windows of opportunity
                            to achieve significant environmental results. This includes creating an
                            effective coalition through outreach and guidance to the public and
                            other stakeholders to ensure the passage of regulations. Let me tell
                            you why all of this is extremely relevant to everyone at EPA, espe-
                            cially now. In a Wall Street Journal/NEC News Poll released in Au-
                            gust, 1991 eight out often Americans identified themselves as
                            "environmentalists." A recent Roper Poll reported that 85 percent of
                            all Americans are seriously concerned about the environment. If we
                            are to deliver on our promise to be the first line of defense in prevent-
                            ing and solving environmental problems, we have to find a better way
                            to do what we already do well.

                            President Bush called OAR's Clean Air Act "the most significant air
                            pollution legislation in our nation's history." Our unique challenge is
                            to implement that demanding legislation successfully while also mov-
                            ing forward on an ambitious agenda for indoor air quality, and radon
                            and radiation protection. This presents a challenge unprecedented in
                            the Agency's history, and an opportunity to put in place an environ-
                            mental legacy of which we can be proud. That's where a commonly
                            shared approach to work can help. I've discovered that TQM is nei-
                            ther mystery nor magic. It is a set-of quality principles and common-
                            sense tools and techniques. The quality principles are

                              •  Customer focus
                              •  Total involvement
                              •  Measurement
                              •  Systematic support
                              •  Continuous improvement

                            They provide a blueprint to develop a coordinated strategy, driven by
                            top management, aimed at harnessing resources and focusing their
                            use to achieve organizational goals. The tools and techniques are nu-
                            merous and flexible. They can help us continue to do right things
                            right more easily. It's very possible that you're "doing TQM" already
                            and just not calling it that.

                            Some months ago, the members of OAR's executive staff were
                            trained in and used the quality principles, tools, and techniques to
                            analyze how we've gotten work done over the past few years. We
                            talked about what we've done well and why, and what we need to do
                            better. As a result of this work, we initiated a number of projects
                            aimed at improving critical processes within OAR. The offices
                            1  Total Quality Management

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throughout OAR have been asked to develop their own plans to pro-
vide improvement opportunities for you. You should be hearing more
details about local plans and efforts soon.

However, you don't need permission or approval to work better now.
There are a number of actions you can take individually to help OAR
deliver on its commitment to quality.

 1. Educate yourself on the quality principles. This document should
    help.

 2. Identify those constituents or clients who receive the outputs of
    your work. In a true sense, these people are your customers.
    Even if they are regulated constituencies, they should be satisfied
    with your working relationship and have an understanding of
    what's expected of them. In other words, they should feel able to
    work with what you give them. (This is not to say they will be
    happy!) Experiment with the alignment questions under the cus-
    tomer focus principle to help in your negotiations.

 3. Try the seven quality tools detailed in this document—brain-
    storming, multivoting, force-field analysis, action plan, why tech-
    nique, fishbone diagram, and pareto analysis. These tools will
    help you expedite meetings, make decisions, identify obstacles to
    change, ensure accountability, and find root causes of problems
    getting in the way of constituent satisfaction.

An environmentally awakened American public has provided impe-
tus for the Clean Air Act. You can bet that they are not going back to
sleep and that they will continue to drive far-reaching regulatory
change. In the months and years ahead, OAR needs to be ready to
play an even bigger role in creating windows of opportunity for sig-
nificant environmental improvement.
2  Total Quality Management

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Introduction
The Quality Principles
                            For the principles of quality to become the way we get work done at
                            OAR, we have to break out of established ways of thinking and act-
                            ing. Accomplishing breakthrough regulations can be aided by knowl-
                            edge of and dedication to the five basic principles—or pillars—of
                            quality.

                             •  Customer focus
                             •  Total involvement
                             •  Measurement
                             •  Systematic support
                             •  Continuous improvement

                            These five principles, each with three corresponding dimensions, are
                            explained in detail on the pages that follow.
                                 The Quality Advantage
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Organizational Values
                            3 Total Quality Management
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Customer Focus
Meeting Requirements
                            Within OAR, we supply services, products, and information to one
                            another. These exchanges link us as internal customers and suppliers.
                            We can better meet the needs of our final, external customers when
                            we work to meet the requirements of our internal customers.
Dimensions
 1. External customer orientation

    Goal: OAR employees know who uses our services and
    products. We also know what those constituencies do with the
    outputs we supply.

 2. Internal customer orientation

    Goal: OAR employees understand that we are customers of and
    suppliers to others within OAR. We understand that satisfying
    internal customer-supplier requirements affects the quality of the
    services and products provided to our external clients.

 3. Trends in customer satisfaction

    Goal: OAR employees understand that the final judges of quality
    are the clients who use our outputs. We are concerned with the
    trends in their satisfaction. OAR places a high priority on being
    close to clients—responding to their needs, and dealing quickly
    and effectively with their problems.
                            Making TQM Relevant

                            AIRS (Aerometric Information Retrieval System) is a good example
                            of a quality improvement initiative sensitive to external customer
                            concerns and needs. It is designed to be a user-friendly source of data
                            and documentation on ambient air quality and point source emissions.
                            AIRS represents a consolidation of a variety of existing systems. The
                            improvements were driven, in part, by input from its users—the
                            states, the regions, and local sources. Some of the input was received
                            at the annual user conference—an important forum for soliciting cus-
                            tomer-focused ideas for continuous improvement. AIRS is operated
                            by the Technical Support Division of the Office of Air Quality Plan-
                            ning and Standards.
                            4  Total Quality Management
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Customer-Supplier Alignment

Alignment, or the matching of supplier capabilities with customer
needs, is a requisite of meeting their requirements. The process of
alignment begins with a redefinition of the customer-supplier rela-
tionship. Rather than seeing each other as adversaries trying to take
advantage of each other, customers and suppliers work together as
collaborators to achieve alignment. That collaboration must also help
promote the overall goals of OAR.
     3
    je
    S
     §.
    5
                                    OAR
                                    Goals
                  Customer Needs



To help build customer-supplier alignment, identify your own cus-
tomers and suppliers and meet with them to discuss and agree upon
requirements. Try asking the following questions:

  •  What do you need from me?

  •  What do you do with what I give you?

  •  Are there any gaps between what I give you and what you need?
 5 Total Quality Management
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Making TQM Relevant

"It's a better situation when people who are adversaries can sit down
at the table and talk about it rather than throw bricks at each other in
courtrooms and the press."

Urvan R. Sternfels, President
National Petroleum Refiners Association
New York Times, September 23,1991
"U.S. Agencies Use Negotiations to Pre-empt Lawsuits Over Rules"
6 Total Quality Management
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Total Involvement       Taking Responsibility for Quality
                             Quality is not just the responsibility of management or quality con-
                             trol. Everyone in OAR must be involved in achieving quality.
Dimensions
1.  Top-down leadership

   Goal: Quality principles are driven by senior management and
   administered by middle management. Management demonstrates
   its commitment to the principles by educating themselves, pro-
   viding resources and support for improvement activities, and
   visibly using and supporting the process and tools in its own
   work. Quality is as important as budget or schedule on the scale
   of organizational priorities.

2.  Bottom-up employee involvement

   Goal: Employees at all levels are encouraged to take part in for-
   mal and informal, individual, and team-based quality improve-
   ment activities. Suggestions for improvement from lower levels
   are given serious consideration.

3.  Side-to-side integration

   Goal: There is coordination among work units and across func-
   tions. Teams composed of people from different areas tackle
   common problems  collaboratively. External suppliers are part of
   quality improvement efforts.
                             Making TQM Relevant

                             The OPPE (Office of Policy, Planning, and Evaluation) has initiated
                             four TQM pilot projects on work planning, the performance appraisal
                             process, office space, and financial management and tracking. A fifth
                             project will be added soon on the value added by the regulatory re-
                             view process. Senior managers meet on a regular basis to establish
                             and track the progress of these initiatives. Status reports and TQM
                             implementation planning are conducted on a periodic basis and pre-
                             sented in thirty-minute sessions added to the Assistant Administra-
                             tor's weekly staff meetings. These sessions ensure the active partici-
                             pation and involvement of senior management and employ the tools
                             and concepts of TQM.
                             7 Total Quality Management
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Measurement
Monitoring Quality
                             OAR cannot meet quality goals unless it establishes baselines and
                             charts progress against them. Deciding what to measure should be
                             heavily influenced by client requirements.
Dimensions
 1. Self-measurement

    Goal: We verify the quality of our own work rather than depend
    on others to inspect for quality. We seek and receive regular
    feedback from our managers. Teams keep records on their efforts
    to improve quality.

 2. Measures of work

    Goal: OAR has a consistent set of quality measurement stan-
    dards that are reevaluated periodically. Work groups monitor
    how well they're following work procedures and track indicators
    that can give them early warning of problems. OAR collects in-
    formation on the extent to which timely corrections are made.

 3. Measures of user feedback

    Goal: Work groups measure how well they meet the needs of
    those who depend on them. They seek and receive regular feed-
    back from their clients. Problems are reported quickly to allow
    for speedy correction.
                             Making TQM Relevant

                             The OAQPS (Office of Air Quality Planning and Standards) is in the
                             process of developing a TQM project to evaluate current environ-
                             mental progress indicators. The current environmental trends report is
                             viewed as a useful document, but it only addresses the six pollutants
                             that have national ambient air quality standards. This assessment will
                             seek to improve the quality of the indicators currently being used and
                             to provide a vehicle for improving OAR-wide communications rela-
                             tive to environmental quality improvements. New indicators will also
                             assist us in measuring progress relative to the implementation of the
                             Clean Air Act, assist in identifying gaps in our knowledge base, and
                             help us to see the long-term picture. OAQPS intends to invite partici-
                             pation from all OAR offices for this project.
                             8 Total Quality Management
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Systematic Support     Leading and Reinforcing
                            All systems in OAR, such as planning, budgeting, scheduling, and
                            performance management, need to support the quality effort.
Dimensions
1.  Training and resources

   Goal: OAR provides the resources and education needed to im-
   prove quality. Employees are given the time to be trained, and
   the tools and support necessary to apply our new skills to our
   jobs.

2.  Recognition and rewards

   Goal: OAR demonstrates its commitment to quality by recogniz-
   ing and rewarding those who work to improve the quality of
   products, services, and work processes. Employees who strive
   for quality have a better chance for advancement.

3.  Policies and procedures

   Goal: The rules and procedures by which OAR operates help to
   produce quality. Obsolete policies, redundant approval steps, and
   other structural barriers are removed in the interest of client
   focus.
                             Making TQM Relevant

                             The OAR (Office of Air and Radiation) ran orientation programs for
                             approximately four hundred new hires in fiscal 1990 and again in
                             1991. These programs were designed to provide the tools and contact
                             information new hires need to help ensure their success as Agency
                             employees. Part of the activities included meeting with top-level
                             managers and staff who helped provide the "big picture"—right up
                             front. The orientation also included a series of workshops on techni-
                             cal and human resource issues. These initiatives mark the beginning
                             of proactive, systematic efforts to address the issue of staff develop-
                             ment and support.
                            9 Total Quality Management
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Continuous
Improvement
Preventing and Innovating
                            OAR needs to do things better tomorrow than it did yesterday and be
                            constantly on the lookout for ways to correct flaws, prevent prob-
                            lems, and make improvements. Through continuous improvements,
                            organizations foster creativity and breakthroughs that increase their
                            credibility with their customers.
Dimensions
 1. Prevention and problem solving

    Goal: OAR stresses prevention rather than temporary fixes and
    seeks to learn from mistakes.

 2. Participative management

    Goal: We are encouraged to discuss work problems in an open
    way and to participate actively in decisions on how to do things
    better.

 •3. Initiative and risk taking

    Goal: Even when things are working well, we are encouraged to
    make improvements. All progress requires taking calculated risks
    and creative initiatives. Management fosters a climate in which
    initiative and prudent risk taking are accepted and necessary
    parts of the way work is done at OAR.
                            Making TQM Relevant

                            OAR, in cooperation with the regions, has established a new manage-
                            ment accountability process to assist the regions in implementing the
                            Clean Air Act and other air and radiation program priorities. The pro-
                            cess is called the Memorandum of Agreement (MOA). The first step
                            calls for senior managers to establish national and program-specific
                            priorities which are combined in OAR's program-specific guidance.
                            Regions then translate OAR's guidance into state grant agreements
                            including commitments and schedules to accomplish Agency priori-
                            ties. (There is flexibility in choosing which priorities to support.) The
                            region's MOAs are submitted to OAR program offices for review.
                            10  Total Quality Management
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The offices negotiate any differences and the AA for OAR and the
RA for each region sign the MOA. The OAR program offices are
responsible for tracking regions' progress in meeting their commit-
ments. The advantages of this process over the previous process
include

 •  Explicit national program goals and expectations

 •  Top-down leadership in setting Agency priorities

 •  A plan of action to meet priority commitments

 •  A streamlined review/approval process

 •  Assigned responsibility for tracking progress
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Introduction              Quality Tools
                             Training will be made available to you on a local level as specific
                             processes are identified as improvement opportunities. The training
                             will include a variety of tools and techniques to use at varying phases
                             of a problem-solving process. We've included seven commonly used
                             tools here. We hope you'll try these out with your colleagues. Any
                             new procedure will be awkward and time consuming at first. Please,
                             try them more than once to get a sense of the way they can help you
                             get work done.

                             The tools we've included are

                              •  Brainstorming: A technique for generating a list of ideas about
                                 an issue.

                              •  Multivoting: A technique for narrowing down a list of ideas or
                                 options.

                              •  Force-field analysis: A method for listing, discussing, and
                                 dealing with the forces that make possible or obstruct a change
                                 you want to make.

                             ' •  Action plan: An outline of who will do what, when, and  by what
                                 methods. It ensures that nothing is left to chance as you set out to
                                 implement a new way of doing  things.

                              •  Why technique: A simple yet effective way to move through
                                 layers of causes to get at the preventable root cause of a recurring
                                 problem.

                              •  Fishbone diagram: A diagram showing a large  number of
                                 possible causes for a problem.

                              •  Pareto analysis: A bar chart (Pareto diagram) that visually
                                 represents the distribution of occurrences being studied.
                             12 Total Quality Management

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Tool
Brainstorming
What It Is

What to Use It For
A technique for generating a list of ideas about an issue.
    Generating lists of

    Problems
    Topics for data collection
    Potential solutions
    Items to monitor

    Anywhere you want multiple ideas and/or more group energy
 How to Use It
Step 1.   Decide on a topic (such as "problem ideas" or "ideas for
         solutions").

Step 2.   Have each member in turn offer an idea about the topic.
         Other members should refrain from any comment, listen
         carefully, and build on each other's ideas.

Step 3.   Have one person record all the ideas on a flipchart.

Step 4.   Continue the process until the team feels it has exhausted its
         ideas on the topic.

Step 5.   Discuss and clarify the ideas on the list.
 Example
A problem-solving team used this tool to come up with a "wish list"
for the new Agency lunchroom. Six people got together and gener-
ated the following list of ideas:
                             Running water and sink
                             Relaxing music
                             Tables and chairs
                             Microwave oven
                             Chandelier/candlelight
                             Full-time attendant
                             Food delivery service
                             Massage lounge chairs
                             Recycling containers
                               Soft drink machine
                               High-capacity coffee maker
                               Refrigerator
                               Toaster
                               Linen tablecloths
                               Fruit-juice fountain
                               Free bagels and cream cheese
                               Multi-beverage dispenser
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Keep In Mind                •  Set a time limit for the brainstorming session.

                             •  Offer ideas only when it's your turn. Between turns, write down
                                ideas so you don't forget them.

                             •  Any idea is acceptable, even if it seems silly, strange, or similar
                                to a previous idea. Some of the best ideas are simply variations
                                on what somebody else just said.

                             •  Say "pass" if you don't have an idea on your turn.

                             •  Never criticize, question, or even praise others' ideas during the
                                brainstorming session.
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Tool
Multivoting
What It is
A technique for narrowing down a list of ideas or options. It is used
in conjunction with brainstorming.
What to Use It For
Selecting a problem, topic for data collection, solution, or item to
monitor
 How to Use It
Step 1.   Use brainstorming to generate a list of topics. Have one
         person record the ideas on a flipchart. Review and clarify
         each idea. With the consent of the group, similar ideas can
         be combined.

Step 2.   Have each member assign ten points to one or more of the
         ideas (e.g., team members can assign all ten points to one
         idea, five to one and five to another, one to each idea, or
         any other combination).

 Step 3.  Ask team members to record their points for each idea on a
         separate Post-it note and to place the Post-it note next to the
         idea on the flipchart, or have team members call out their
         votes in turn.

Step 4.   Tally the votes for each idea. Narrow down the list to the
         four to six ideas that received the most votes.
 Example
The team that brainstormed a wish list for the new Agency lunch-
room wanted to narrow down their list of ideas from seventeen to
five. Each team member was assigned ten points with which to vote
for the topics. Here is the resulting list.
                             Running water and sink (4)
                             Relaxing music (1)
                             Tables and chairs (10)
                             Microwave oven (6)
                             Chandelier/candlelight
                             Full-time attendant
                             Food delivery service
                             Massage lounge chairs
                             Recycling containers (10)
                               Soft drink machine (6)
                               High-capacity coffee maker (8)
                               Refrigerator (12)
                               Toaster (3)
                               Linen tablecloths
                               Fruit-juice fountain
                               Free bagels and cream cheese
                               Multi-beverage dispenser
 Keep in Mind
   . Feel free to distribute your votes in any way you like.

    To preserve anonymity, mulu'voting can also be done by written
    ballot (sometimes called nominal group technique).
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Tool                         Force-Field Analysis
What It Is                   A method for listing, discussing, and dealing with the forces that
                             make possible or obstruct a change you want to make. The forces that
                             help you achieve the change are called driving forces, and the forces
                             that work against the change are called restraining forces.


What to Use It For           • Determining if a solution can get needed support

                               • Identifying obstacles to execution

                               • Suggesting actions for reducing the strength of the obstacles


How to Use It              Step 1.  Draw a force-field chart (a large 7).

                             Step 2.  Write the current situation at the top center of the chart.

                             Step 3.  Write the desired situation at the top right of the chart.

                             Step 4.  Brainstorm for driving forces (pushing toward what you
                                      want) and enter them on the left side of the chart.

                             Step 5.  Brainstorm for restraining forces (preventing you from get-
                                      ting what you want) and enter them on the right side of the
                                      chart.

                             Step 6.  Discuss the chart and determine which factors could be al-
                                      tered to increase the chances of success.

                             Step 7.  Decide whether your solution is doable. If it is, make a list
                                      of action items to  alter the forces. If it isn't, develop another
                                      solution.
 Example                    At Morton's Service Agency, a team was formed to try to resolve the
                              problem of customers not receiving information they requested at the
                              time of calling. The team decided that, while they could not ensure
                              that a customer could reach a specific person, there could be a way to
                              help ensure that the caller would get the needed information.

                              One solution they were considering was to develop a division direc-
                              tory identifying key people in various areas of expertise, as well as
                              back-up people in each of those areas. Before presenting their solu-
                              tion to management, the team used force-field analysis to identify
                              obstacles to implementing their solution to increase the likely success
                              of their implementation plan.
                              16 Total Quality Management

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                              Morton Service Agency's Force-Field Analysis of Caller
                              Satisfaction
                                               Current Situation
                                       Desired Situation

Callers do not get
information requested

Directory to facilitate
information access
on first call
                                    Driving Forces

                              Agency cares about
                              customers
                              Agency wants to practice
                              what it preaches
                              Low cost due to desktop
                              publishing
                              Management support
                               Restraining Forces
                                                           Difficult to keep directory current
                                                           enough to be useful
                                                           Questions will likely go beyond
                                                           information in the directory
                                                           Employees who receive customer
                                                           calls may not understand directory
                              The team decided that an important restraining force was the basic
                              difficulty of keeping any directory current. They decided to put the
                              directory in a format that could easily accommodate changes. They
                              also decided to come to their weekly meetings prepared to do a quick
                              update of any changes.

                              In order to address the restraining force of questions likely to go be-
                              yond information in the directory, the group decided to keep a log
                              next to the phone to be filled in any time the directory was insuffi-
                              cient to help direct the caller to a person who could be of help. They
                              planned to make necessary additions to the directory based on the
                              log.
Keep in Mind
•  You should always finish a force-field analysis by making a list
   of action items.

•  If restraining forces are too overwhelming, consider a different
   solution.
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Tool                        Action Plan
What It Is                   An outline of who will do what, when, and by what methods. It en-
                             sures that nothing is left to chance as you set out to implement a new
                             way of doing things.


What to Use It For           • Planning the implementation of a solution

                              • Coordinating data collection


How to Use It               Create a chart that shows your plans in an organized way. Include
                             answers to the six questions below.

                              1. What needs to be done (i.e., specific tasks, arrangements, etc.)?

                              2. When does each task need to be done (do some tasks need to be
                                completed before others; when should each task be finished)?

                              3. Who will do each task?

                              4. How will it be done (i.e., specific methods)?

                              5. What resources are needed (i.e., materials, equipment, expert
                                 advice, etc.)?

                              6. Are there special circumstances or needs that should be taken
                                into account?
 Example                   A committee interested in a more efficient and productive system for
                             responding to congressional decided that one action they needed to
                             take was to educate the people in the Congressional Control Office
                             about the best procedures for responses. They developed the action
                             plan on the next page.
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                          Action Plan for Educating the Congressional Control
                          Office
Action to
Be Taken
Gather data
to determine
necessary
components
of training
Develop
training
program
Print
training
booklets
Provide list
of people
to be
trained
Arrange
for
training
logistics
Conduct
training
Date
Completed
10/30
11/30
12/15
11/30
12/5
12/24
People
Respon-
sible
Sam
Myra
Sally
Roy
Rita
Joe
Ralph
Jim
Sally
Roy
Method
• Develop
survey
• Pilot
survey
• Conduct
survey
Follow
model
used in
telephone
training
program
Publishing
Depart-
ment
Check with
Mark
at Control
Office
•Find
location
• Organize
supplies
• Coordinate
times
Experien-
tial, using
cases
Resources
Needed
Desktop
publishing

Check
with
Publishing

Help from
Sally and
Roy in
identifying
needs
• Flipcharts
• Markers
• Training
booklets
• Note paper
• Pencils
Special
Needs
•Data
analysis
assistance
• Advice on
survey
questions

• Editing
assistance
• Lowest
possible
cost

Lowest
possible
cost
Correct
number
of chairs
around
tables
put into
square
Keep in Mind
• Put the action plan in writing.


• Don't worry about filling in the columns one at a time. The parts
  of the action plan can be filled out in any order.


• You can use a flowchart to show the sequence of activities.
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Tool
What It Is
Why Technique
A simple yet effective way to move through layers of causes to get at
the preventable root cause of a recurring problem.
What to Use It For
The why technique can help you find the root cause of a problem.
You begin by asking why a problem occurs, and then repeatedly ask-
ing why that problem happened, until you have settled on a final,
most important cause.
 How to Use It
Step 1.  Select a recurring problem.

Step 2.  Ask "Why did the problem occur?" to uncover the first-
        layer causes.

Step 3.  Take the causes that you uncovered in step 2 and ask "Why
        did they happen?" to uncover the second-layer causes.

Step 4.  Continue asking why the previous causes happened until
        you believe you have uncovered the most important, root
        cause.
 Example
The why technique can be used to uncover a number of causes at each
level. In the example that follow, a single cause is given at each level
to illustrate the chain of events revealed by the why technique.
                             Late Delivery of Projects

                             Problem
                             Recently, a number of projects have been delivered late.

                             Why did the problem occur? (first-layer cause)
                             Despite our best efforts, we were not able to complete those projects
                             on time. We're spread too thin. It seems as though we've got way too
                             many projects for the number of people in the department.

                             Why did that occur? (second-layer cause)
                             Productivity is down, and employees are calling in sick every day.

                             Why did that occur? (third-layer cause)
                             Our employees have been doing way too much overtime in the last
                             six months—they're getting burned out.
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Why did that occur? (fourth-layer cause)
One big reason is that the computer network is always going down.
This causes repeated work stoppages and even lost files, which must
then be re-created from scratch. Also, file transfers are very slow
over the network, which causes work delays. Basically,  it's taking
our employees longer and longer to do less and less work.

Why did that occur? (fifth-layer cause)
We've outgrown our computer network. MIS tells us that we are now
running 132 terminals over a network designed to handle 100 work-
stations, maximum.
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Tool
What It Is
Fishbone Diagram


A diagram showing a large number of possible causes for a problem.
Detailed causes are attached to a small number of main causes so that
the completed diagram looks something like the skeleton of a fish.
What to Use It For
    Getting the big picture of a problem

    Facilitating team members' use of their personal knowledge to
    identify causes of the problem

    Providing ideas for data collection and/or solutions
 How to Use It
Step 1.  Write the problem on the right side of a flipchart. Draw a
        large arrow that points toward the problem.

Step 2.  Draw arrows indicating the main types of causes (or con-
        tributing factors) and pointing toward the central arrow.

Step 3.  Brainstorm for specific causes. Attach each specific cause
        to an appropriate main cause.

Step 4.  Break down the causes further by brainstorming for
        subcauses.

The most commonly used categories of causes are people, machines,
methods, and materials. These categories usually apply to a wide
range of problems, and using them guarantees that most of the rel-
evant causes will be put into the diagram. Some other possibilities
include policies, procedures, and environment.
 Example
At the top of the next page you will see an example of how fishbone
analysis was used at the Jefferson Health Services Agency to identify
the causes for the high turnover rate of personnel. Using the catego-
ries of people, machines, materials, and methods, a team of supervi-
sors identified possible causes.
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                              High Personnel Turnover Fishbone
     People

         \  lack ol communication
   tow morale  x
                                                               Machines
    \\ stress  \
    economic dimatev
                                                                          inadequate lab equipment
                                                    tatjniie
                                                        doubteshitts

                                                                                not enouqh
                                         \
        no systematic training
                                                         >.

                                                          \
                                                                              \
                                                                                   ohone system breakdown
                                              X
                                           poor work areas
                                          \ shared desk space
                                   procurement bottleneck
                                \
lack ot advancement
opportunities
                                                       High
                                                    *" Turnover
                                                    of Personnel
                                                                                ideauate trainvra
  \ changing procedures
  changing budget
r recognition
inability to reward

        low salaries
                        lilv to r
                                                                     diffused decision making	
                                                                           \ lack of employee involvement
                                                                        unclear direction to employees
                                   Materials
                                                       Methods
                               The group decided to display their thinking in a very visible, acces-
                               sible area and invited others in the agency to add to or change the
                               categories and items. They determined that the primary causes over
                               which they had control were in the area of methods. They were then
                               able to gather further data to clearly identify the primary causes of the
                               problem and to work on solutions.
Keep in Mind
The most commonly used categories of causes are people,
machines, methods, and materials.

The fishbone diagram only shows possible causes. If in doubt,
check your ideas with data.

In most cases, it is not of great importance where on the diagram
you put a particular cause.

Fishbone diagrams are very useful when displayed publicly. You
can invite people to add causes, and you can show what progress
is being made in eliminating the causes.

You may want to make a second or third fishbone diagram based
on the first fishbone diagram.
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Tool
What It Is
Pareto Analysis
A bar chart (Pareto diagram) that visually represents the distribution
of occurrences being studied. The most frequent occurrence is repre-
sented at the far left, with other occurrences represented in descend-
ing order to the right.
What to Use It For
Identifying the one or two situation categories in which most of your
problems occur
How to Use It
Step 1.  Define the categories to be used in your diagram.

Step 2.  Sort the data into categories. Arrange the categories in de-
        scending order as defined by the data.

Step 3.  Make a bar graph based on the data, with the highest cat-
        egory on the left.

Step 4.  Check your diagram for a Pareto pattern (in which the high-
        est categories are responsible for most of the effects).

Step 5.  Use the Pareto diagram as a guide to action or to further
        analysis.
 Example
A division of Morton's Service Agency was interested in determining
the most frequent concerns expressed by customers when they called
the agency for information. The division formed a representative
QAT in which they determined what they needed to know and devel-
oped a survey to gather the information. They then polled a random
sampling of customers over a one-week period and charted the results
on a Pareto diagram.
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                            Most Frequent Customer Telephone Complaints
120-
110-
100-
90-
80-
•| 70-
3 60-
C cf\
§ 50
"40-
•5
fe 30-
1 20-

z 10-







43%




,


11% I 10% |
Person Didntget Nobody else Left message Not told
requested information tried to but call not that person
unavailable requested help returned requested
was
unavailable
for two
Cateoorv of Comnlaints weeks
                            The QAT found the results very helpful. The top category (43 per-
                            cent) was that the person requested by the caller was unavailable.
                            Realizing that the agency could not always control availability, they
                            combined that category with the second highest, that the caller did
                            not get the information requested (21 percent). They decided that the
                            callers who could not speak directly with the person requested could
                            at least be helped with necessary information by someone else.
                            Therefore, the QAT decided to determine solutions for helping cus-
                            tomers get the information requested on the first call.
Keep in Mind
Find appropriate categories by asking the questions what, where,
when, who, why, and how.

Most problems require more than one Pareto diagram, each
exploring a different question.

Draw the diagrams you want before you begin to collect data.
Include the subcategories and a unit of measure.
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    The information in the Pareto diagram can tell you where to
    focus in solving the problem. If the diagram does not give you
    enough information to proceed to solutions, it may still suggest
    what to investigate next. Typical next steps are a fishbone
    diagram, a flowchart, or more Pareto diagrams (based on new
    data).
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Conclusion               Your Role
                            The American public will continue to challenge EPA to live up to its
                            role as their first line of defense in preventing and solving environ-
                            mental problems. Your role in meeting those challenges includes tak-
                            ing personal responsibility for continuously improving the way you
                            work—day to day. If you are a manager, your role also includes
                            granting amnesty to the people with whom you work. All employees
                            must be free to speak the truth and to take risks in the interest of the
                            greater good of the Agency and the public that we serve.

                            No one will hold your hand. Empowerment comes from within. It is
                            easy and perhaps even reasonable to assume that one person can't
                            make a difference ... except, we all know someone who did!
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