A Thinking Person’s Weight Loss and Exercise Program

Keeping Up with Diet and Exercise: A Workbook

Farrokh Alemi, Ph.D.

Duncan Neuhauser, Ph.D.

Shirley M. Moore, RN, Ph.D., FAAN

Linda Headrick, M.D.

Nancy Tinsley

Ethel Smith MD

David Aron MD

Chapter 1 in “A Thinking Person’s Weight Loss and Exercise Program”

Thursday, March 18, 2004

This chapter is based on the following:

• Alemi, F., D. Neuhauser, S. Ardito, L. Headrick, S. Moore, F. Hekelman, and L. Norman. 2000.  "Continuous Self-Improvement: Systems Thinking in a Personal Context."  Joint Commission Journal of Quality Improvement 26(2): 74–86. 
• Alemi, F., S. Moore, D. Neuhauser, L. Headrick, F. Heckleman, and N. Kizys. 1997. "Self Improvement: Applying Total Quality Management Tools to Life Style Changes."  Posted on the Web (http://gunston.gmu.edu/708/frimp.htm) on August 12.
• Lahoz, M. R., and L. Headrick. 2001. "Personal Continuous Quality Improvement Project Workbook" for Project MAINSTREAM Fellows.  HRSA-AMERSA-SAMHSA/CSAT Faculty Development Program in Substance Abuse Education, April.
• Moore, S.  2003. "Introduction to Using Process Improvement Techniques to Achieve Health Behavior Change." Draft.
• Neuhauser, D., S. Ardito, and F. Alemi.  Personal Continuous Quality Improvement Workbook available at http://gunston.gmu.edu/708/pers_cont_qual_work.pdf. 

Extensive additional information on personal improvement can be found at http://improvement.gmu.edu

Douglas was concerned about his weight gain and lack of regular exercise; he set out to change his life based on what he had learned about process improvement.  He posted a calendar on his refrigerator and checked it each day he exercised.  He created a flowchart of how daily routines affected his exercise patterns.  He studied causes of variation in exercising.  Instead of blaming himself and focusing on his motivation he looked for life processes and environmental influences that affected his success.  He found that scheduling the exercise time on his work calendar helped him, that he could exercise on Sunday mornings if he did not stay out late on Saturday nights, and that he could run around the field while he watched his daughter’s soccer game.  He created a storyboard to report his results over 12 weeks.  During weeks one and two he managed to exercise three times a week.  For the next 10 weeks he exercised four or five times a week.  He used a control chart to track his weekly performance.  After 12 weeks, he had higher self-esteem, his energy level had bounded, and his clothes fit more comfortably.  He continued to get positive feedback from his wife and co-workers and thinks that it is easy to keep up with his healthier lifestyle.  Douglas’ story and success is typical of several hundred people who have applied process improvement to their lives.  This chapter presents a workbook you can use to help organize your own exercise and diet routines so that you can enjoy similar results.   

Un-kept Promises? 

As noted in our book's Introduction, many people fail to do what they wish to do. They make resolutions but do not keep them. They plan to change their lives but over time relapse into old habits. This is common but to us seems odd.  Why should people fail this way? 

It is difficult to stay with diet and exercise plans, especially when faced with temptations and desires to the contrary.  Certainly many scientists, clinicians, advertisers, and consultants have worked on the idea of motivating people to stay true to their plans.  But few manage to do it—and all this collective effort has failed to produce a definitive understanding of what is missing.  The situation is even odder when those who fail are highly motivated individuals.  As scientists we are surprised by this because, in the absence of any external barriers, people theoretically should be able to do what they want.  From a strictly scientific point of view, if a force for change exists, the change should result.  In physics, if a force is exerted on a ball, the ball moves in the direction of the force.  When it does not, it signals that our understanding of what forces are in play is at fault.  Let's apply this simple and incontrovertible fact to the matter of personal change, then: When a person wants to change, knows how to change, has the skills to change, is motivated to change but in the end does not, this means something is wrong with our understanding of what it takes to change.  We must have missed an important force that is at play. 

The second fact that strikes us as odd is that although many people are stymied in their efforts, organizations often change, and despite some failures, many organizations change successfully.  Remarkably, then, organizations seem more likely to bring about change than individuals. Well, organizations are made up of people—how is it possible that the same employee is able to change major work habits but fails to make modest personal changes? The answer to this question, we believe, lies in modern management techniques.

Management scientists have studied how people change and turned it into a science. W. E. Deming, for instance, devised Total Quality Management (Continuous Quality Improvement), a step-by-step guide to improving organizations. Organizations have applied these techniques to change the behaviors of their employees. The technique is successful in bringing about lasting behavior change. You almost never hear that an organization has changed work processes for months and then suddenly gone back to old habits.  When it comes to work behaviors, relapse is less frequent.  If continuous quality improvement can be used to bring about lasting change for work behavior, perhaps you can use it to keep up with your diet and exercise plans. In this chapter, you will learn to unlock the secrets of modern management and apply it to your own life.

We assume that you know about nutrition or that you will find out through other sources more information about what foods are good for you and what your ideal weight is.  We have no advice to give regarding what to eat or how to diet.  We assume that you know about the ideal activity level that is best for you, and that you will keep in mind that extremes in diet or exercise can create additional problems.  We have no advice for you regarding how much or when you should exercise, or what types of exercise are best.  We leave these questions up to you and your clinicians.  You need to sort out what diet or exercise plan you want to be on first.  But once you have done so, we can help you keep up with your plans.  In a nutshell, this is where we can make a difference for you: we assume that you have a set of plans and we help you implement them successfully. 

Our approach is not based on motivating you to exert more effort but on helping you build your diet and exercise plans into the fabric of your life.  We assume that you are motivated enough.  What is enough?  We expect you to want to change and be willing to change your environment.  In this approach, you act more like a detective looking for clues and less like an enforcer insisting on compliance.  We do not want you to do more (enough has been asked from you); we want you to think differently.  In this sense, we provide a smart approach to keeping up with your resolution.

Steps in Process Improvement

We recommend the following steps in conducting a personal process improvement program:

1.      Put together a team of process owners willing to work with you.

2.      With your team, describe what you want to accomplish.

3.      As a team, describe life processes and how they affect your diet and exercise plans. 

4.      As a team, make a list of possible systemic (life style) changes.  Implement several of the changes. 

5.      Gather data and monitor progress.  Check if change has led to improvement.

6.      Engage in cycles of improvement.

7.      Tell your story.

Each of these steps is further described below.

Step 1:  Put Together a Team

Our central thesis is that to change your diet and exercise you need to change the system around you.  By the system around you, we mean your environment and the routines in your life.  A system contains any person or thing that affects your behavior—in short, the world around you.  If changing yourself was difficult, then changing the world, which involves many more people, should be much more challenging. Fortunately, modern management has thought through this and has a solution: Get together with the people closest to the system that you want to change.  If you want to change your diet, these will be people who prepare the food at home, people who shop for the food, those who arrange for social events, and so on.  These individuals are not necessarily your buddies but people who share your diet or preparation of the food.  Work on defining the problem and seeking solutions together. In management this is called "organizing cross-functional teams." In your life, of course, you probably call it “getting together.”  When you involve others, you see the change from their perspectives, you get reinforcement and help, and you become more committed to the change you want to accomplish—and perhaps most important, the focus of attention changes from individual effort to elements in the shared environment.

The secret in getting teams to work on a problem is to have them come up with the definition of the problem, not just solutions to it. This means you may need to focus on a shared problem and not aspects that affect you uniquely.  What food is put on the table is a shared problem while which food items you choose to eat seems a private matter.  In defining the problem you need to move away from personal choices to issues that affect everyone living together.  In time, any joint problem will affect all of you, so the mere admission that you are in this together will help team members become closer and more aware of how they influence one another. 

            We need to make a distinction between a process owner and a buddy before we go any further.  A process owner is a person who contributes to the production of the exercise activities or food.  A buddy, by contrast, is a friend who may have the same goals as yours but often does not participate in the production of the items you need.  For example, when a friend diets with you we call him or her "a buddy" but when your spouse prepares your food we call that person a process owner, even though this person is not dieting.  We are asking you to involve process owners as opposed to buddies in the improvement team. The purpose is to avoid bringing together people who want to diet with you, gathering instead those whose decisions affect your diet.

For most people, a spouse or significant other is the most likely person to involve in their efforts to lose weight or exercise more.  Again, this does not mean that the spouse should also lose weight or exercise.  All it means is that collectively you and your spouse will look at changes in the environment that could help.  If you do not have a spouse, other members of your household or a close friend or family member can also help.

Do not confuse the team’s role with support groups, by the way.  Social support from family members and friends is important; having people around who know you are trying to bring about change can make your task easier.  But that is not why you meet with process owners; you meet with them because the solutions you are seeking will affect them too.  Changing the environment has an impact on everyone sharing it.  Thus if you are going to change shopping patterns, everyone eating with you will be affected.  To be sure, support groups can offer understanding and encouragement.  But what you need and want from your team is more.  You need their active engagement in coming up with possible changes.

Still not sure who is a process owner?  The following survey will help you rate individuals around you to see if they could be considered process owners. 

Because of the importance of selecting the right person to help you out, we have organized a separate chapter on this topic.  You can read more about this in Chapter 4, titled “Improvement Teams.” 

Step 2:  What do you want to accomplish?

            As a team, you need to define the problem you are going to work on. When it was just you, settling on the problem you wanted to solve was easy. It was what you wished it to be. Now, with several people involved, defining the problem requires more finesse. Some people insist on defining the problem by themselves and proceed to other tasks—but remember: your friends and family members won't participate if they do not see it as their problem too.

Fortunately, the management literature has some advice on how to define problems. First, do not blame anyone. A statement such as, "We want to get mom to cook better," succeeds in acknowledging the interdependency among the people who eat at home, but at the same time it blames one person for the problems of another—hardly in line with the productive approach you want.

Second, describe the problem in terms of the experience of the people involved, not the action needed. Thus the problem should not be defined in terms of the need to cook with less fat but in terms of excessive weight, not in terms of your needing free time so you can exercise but of your lack of activity. When you start with the impact of the problem on you and not the solution, you can later collectively come up with creative options acceptable to everybody involved—and everyone has a sense of ownership of the ideas and it is easier to go from discussions to implementation.

            Third, state the problem from varying perspectives. Different wording of the same problem will trigger different ideas in your mind. So if you have focused on a problem, state it now as an opportunity. If your problem was that you were gaining weight, state it now as the opportunity of fitting into your old clothes. If the problem was that smoking was increasing your risk of disease, state it now as the opportunity to smell the garden. The point is that problems should be stated from a variety of perspectives so that different kinds of ideas could be pursued.

            To help you define a problem, we want you to focus on some fundamental questions.  Langley, Nolan, and Nolan (1994) have written extensively on how healthcare organizations improve.  They believe all improvements require answers to underlying questions, two of which are:

1.      What are we trying to accomplish?

v     Provides an aim for improvement efforts.

v     Keeps effort focused.

2.      How will we know that a change is an improvement?

v     Provides criteria or measures for determining if the change resulted in an improvement.  (Not every change leads to an improvement.)

They also raise a third question:  What changes can you make that will result in improvement?  We will raise this question later when we search for solutions.  Table 2 gives some examples of personal improvement efforts according to the three basic questions:

You might ask yourself the same three questions.  Let's look at the first two.  First, what are you trying to accomplish?  You obviously want to focus broadly on losing weight and exercising more.  Sometimes it helps to have a more specific diet or exercise change in mind.  For instance, some have focused on smoking cessation.  Others have focused on reducing junk food intake.  Still others have focused on reducing calories.  This does not mean that you need to focus on one aspect and forget the other.  You can have multiple focuses or take different focuses over time.  The point is to be clear to yourself regarding what you want to do. 

Second, how will you know that a change is an improvement?  It is not enough to say that you know it when you have succeeded.  In weight loss, random variations in weight cloud our judgment regarding true success and failure.  Once you have identified an area to be improved, select a key variable that you will measure and immediately begin to keep data on the process.  For example, if you want to reduce your weight—start today by taking your weight and writing it down in your diary!  Do so before you start changing your behavior.  This data can serve as a benchmark of where you started.  As you go, you will collect more data to see if the changes you have introduced are leading to real improvements.  You are in for surprises.  Many activities that you are sure will work come to naught.  Other activities that seem trivial and minor events do, in fact, help you.  Data, not your intuition, should be the judge of what works for you.  As soon as possible, keep a regular and frequent schedule for collecting the data.  Then, over time, you can examine the data to see what works for you. (See Chapter 5 for details.)

The survey in Figure 1 helps you define the problem you are going to work on:  

Step 3: Describe Life Processes

We want you to focus on your life processes and not on your motivation or effort.  We define a process to be any series of events, circumstances, or physical influences that affect your diet and exercise.  Most people do not see their lives in terms of processes.  If we ask you, for example, why you do not keep your resolution, invariably you are likely to say that it has to do with what you do or fail to do.  If we ask, "Why do you smoke?” you may say, "Because I do not want badly enough to stop."  If we ask, "Why are you overweight?” you might say, "Because I do not have the discipline to stick to my diet.  If we ask, "Why are you inactive?” you might say, "Because I am tired." These answers have one theme in common.  They see you as the central force behind your behavior.  Surely that is true to some degree, but it is not the whole picture.  Human behavior is also affected by a host of environmental influences.  You may be the actor but you do not act in a vacuum—your environment affects you. 

      It is unfortunate that people blame themselves when much more than they are behind their behavior.  An early management lesson trains people to see the system around the employee. These management programs blame the system and not the person.  In modern management, if employees do not change successfully, it is not their fault—a system should be organized to encourage them to change.  Employers bring about successful change by changing the process of work and not by blaming employees for their effort.  Likewise, if you do not succeed, it is because you have not mobilized the system around you to help. 

Very personal decisions, such as what you eat tonight, are not entirely your decisions to make. Sure, you choose and it is your hands that put the food in your mouth. But your decision is not completely yours; nor is it made tonight. If you share food with others, they influence what is on the table. If you worked long hours and you are tired, maybe you are too exhausted to prepare food. What you bought at the grocery store a few days ago determines what you can eat now. The ease with which you can prepare food influences you, and technology that is in your kitchen determines in part the outcome of your decision. The temperature in your room affects how much energy you consume.  The steps between your floors affect your exercise.  The list goes on and on about all the factors that influence your decision. You open the refrigerator and it seems that you have made a decision about what you want to eat tonight, but in reality a series of decisions made by you and others earlier have pretty much determined what you will do at that point. You are caught in a pyramid scheme in which your own and other people's earlier decisions limit your options.

Now, we are not saying that life is deterministic and what you do is your fate. No, surely, not that at all. We want you to change. But change is not about what you do now. To change successfully you must set out to change the system around you. You must come to realize how the past and the present are intertwined.

It is counterintuitive not to blame your will for your actions. But you should not. Change is not easy. Your habits have been learned over many years and are reinforced by many events around you. Changing these habits is difficult and you cannot succeed unless you mobilize the system around you.

There is also another reason why you should not blame yourself.  We know that to succeed you must try and try again.  People who blame themselves give up on this. They fail because they blame their willpower. One of the principles of Continuous Quality Improvement is to avoid blaming others. When you apply process improvement to staying with your weight loss and exercise program, one of the principles to keep in mind is that you should not blame your willpower. 

Listing Periodic Events

The tool used often in describing a life process is a flowchart. This tool is described in Chapter 4.  An alternative to flowcharting is to list periodic events, also discussed in Chapter 4.  Table 3 provides a worksheet for making a list of periodic events. 

Complete instructions for completing a list of periodic reoccurrences is given in Chapter 5 on “Tools for Understanding Complex Processes.”  These instructions include the following: 

·        If an activity occurs at different times, list it as a periodic event with the average time of recurrence.

·        Ask each person to individually and silently generate items for the list.

·        Check that all major living activities (eating, cleaning, sleeping, shopping, commuting, etc.) are listed even if these activities do not occur with specific periods.  List the most likely time for their occurrences.

·        Include any activity that is part of food production (e.g., shopping, preparing food, placing snacks around the house, etc.) or part of preparing for exercise (e.g., washing exercise clothes, getting exercise equipment, making appointments, paying for gym membership, arranging to meet team members).  

·        Include events and activities that prevent you from exercising or dieting.  For example, include getting home too late from work to go to gym, or having too little time to cook because you are helping the kids with homework.

·        Include social activities.  For example, eating out may affect your diet.

·        Include any rituals associated with exercise and food consumption (e.g., eating together, driving kids to games, etc.)

We also ask you to look for stable cycles of activities, where in a routine leads to another set of routines which eventually lead back to the starting routine.  Cycles show how one routine reinforces another.  The cycles are the building blocks that hold our life styles together.  They create inertia for change.  When one routine is changed, the remainder of the cycle works against the change and encourages the routine to return to original habits.  For example, going late to work leads to staying late at work, which leads to getting home late, and preparing food late, which leads to staying up late to watch television in order to allow for digestion, which leads to sleeping late, getting up late and to the start of the cycle of going late to work.  If someone tries to change their dinner plans, they may succeed at first but soon the cycle of getting up late and coming home later takes over.  Soon the person will run out of time for cooking a reasonable meal and he or she is forced, by other routines in his or her life, to return to old dinner habits.  Figure 2 provides a form for entering repeating cycles.  Life style changes begin with detecting these cycles and modifying them.

Figure 2:  A Form for Entering Cycles of Routines

Step 4:  Make a List of Possible Changes

The first piece of advice in generating a list of possible changes is “don’t do it right away.” Delay and postpone any suggestions for change until you truly understand the problem.  People love to solve problems—so much so that some rush to suggest solutions to you even before they know the details of your problem!  Whenever you tell a person you have a problem, they want to suggest solutions to you. Here is a typical exchange:

"What's wrong?"

"Oh, I feel down, a little bit unhappy…"

"Well, why don't you call a friend and go to a movie. It will perk you up."

In this example, the solution seems obvious. But in reality the problem is far more complex than can be solved by a movie. If the problem is so simple that within seconds you can think of a solution for it, you should ask yourself: How come the problem has persisted? Why has it not been solved already? Many do not really know what the problem is but they have solutions for it.  People love to suggest solutions, even if it does not solve any real problem. In jest, we should agree that instead of asking what is wrong, we should bypass the burden of asking and start suggesting solutions to imagined problems.  This tendency to prematurely suggest solutions is very common, and therefore it is important that you consciously fight against it. One way to do so is to spend more time understanding the problem. Making lists of periodic routines and looking for cycles, as outlined by the steps described in the previous section, delays making changes until we understand the problem.  Once the problem is understood, and only then, you need to make a list of possible solutions. 

To list the possible solutions, get your team together for an hour on a specified date.  Ask each team member to silently write on a piece of paper changes all of you collectively can make.  Ask for changes in the environment and not more effort or stronger motivation.  Go around the room and collect the ideas and make a list without evaluating the ideas or their practicality.  Do not ridicule or praise the ideas.  Do not discuss the ideas until all have been collected.  Ask each person to give one idea at a time.  Keep going around until all ideas have been listed. 

When a large set of solutions have been identified, ask the team to rate the ideas.  It bears repeating: look for ideas that are process changes and avoid ideas that lead to more effort or require strong motivation.  To help you evaluate the possible changes, we have developed a survey instrument, shown in Table 4.

Step 5:  Gather Data and Monitor Progress

             When you make a change, a key question to continue to ask is, "How would I know if this change is an improvement?" Collect data that will verify that the change has led to improvement. Many ask, “What for?  If I change, I will know that I have changed.”  Ironically, research shows that people, sure as they may feel in their assessment, frequently misread their own lives. If random chance leads to success, many assume that it was because of their effort. And if they fail, many assume that it was because of external forces. They attribute their success to their effort and their failures to others. While this is a reasonable way of remaining optimistic, it is a poor way of judging change. To examine change over time you need data. Only then can you be sure that change is occurring.

            For most people this is a very hard piece of advice to swallow. In essence, we are advising you not to trust your own judgment. We are asking you to verify what you are accomplishing. It is hard to question your own intuition—especially when it is very obvious. You're saying, "If I feel I am overweight, I must be." Well, the truth could be very different. To change successfully, you need to know whether your efforts are paying off. If they are not, you need to return to your list of solutions and choose several new ones to try. If they are, you need to convince yourself and others on your team that real improvement is happening.

True, collecting data takes time. And it certainly seems frustrating to see how little you are changing. But real change requires understanding, not attitude. Data discipline your intuitions. They help you see through your feelings and find out what is really going on. Remember what we said at the beginning, you are changing a system, not just yourself. Changing a system cannot be willed or wished. It needs the coordinated action of many people. If you are working on the system, you and others need to know that, no matter how slowly, the system is indeed changing. You are like Sherlock Holmes searching for a solution that will bring about the changes you need. Without data you have no clues.

                Table 5 shows a form that is useful for gathering data on diet and exercise.

In order to analyze the data collected using the form in Table 5, you can use a run or control chart. We give detailed examples of control charts in Chapter 6.  Here it may be useful to focus on the key aspects of these tools.

Run Charts

A run chart is a simple plot of data to provide an instant interpretation of the weight loss or exercise results.  Time is plotted on the x-axis.  The value measured (e.g., weight) is plotted on the y-axis. The advantage of a run chart is that it is a quick way to examine your progress.  The disadvantage is that it does not help you decide whether changes are due to chance or are real.  Michelle decided to reduce her caffeine consumption.  Her plan was to substitute coffee, tea, or cocoa with decaffeinated beverages.  She stopped buying coffee and had only tea or cocoa at home.  She prepared a run sheet to chart her progress.  She recorded caffeine consumption in cups of coffee (others who want to be more precise can use milligrams).  Figure 3 shows Michelle's coffee consumption over a 28-day period.  After the initial week of observation, we see a marked decrease. 

Figure 3:  Michelle’s Coffee Consumption

Control Charts

Control charts look at sources of variation in a data set and allow you to distinguish which observations are due to chance events and which ones represent real changes in your weight or exercise patterns.  You calculate an upper and a lower control limit; values that fall outside these limits represent real changes.  Observations that fall within these limits represent random fluctuations in weight or exercise time.  You can use different types of control charts depending on whether you have continuous or discrete variables.  A continuous variable produces numbers where the values between assigned numbers are meaningful.  For a discrete variable, the values between assigned numbers are not possible.  For example exercise time and weight are continuous variables while missed exercise (yes=1, no=0) or lapse in diet (yes=1, no=0) are discrete measures.  Chapter 6 gives details on how to construct different types of charts.  Here we give an example for monitoring one's calorie intake for 20 days. 

The advantage of a control chart is that it helps detect if a process is out of control (outside tolerable limits).  It distinguishes between random variation and real improvement.  The disadvantage of this type of chart is that it does not suggest the cause or how to eliminate (control) the variation.  Also, control limits must be reset if the process has changed.  For example, if you are charting your speed at jogging, over time your speed may change (you are getting better).  If you are getting better, a reevaluation of the chart (mean, upper, and lower control limits) is necessary.

            Let’s look at another of Michelle’s personal improvement projects.  She wanted to lose weight.  Her plan was to chart her caloric intake.  She began by keeping track of total calories consumed on a daily basis for the first 20 days, the active period of her diet.  For her control chart she calculated the limits using the formulas in Chapter 6.  She used these limits to examine data for later weeks to see if she had been able to keep up with her pattern from the first three weeks.  Figure 4 shows one month of data.

Figure 4:  Michelle’s Calorie Intake over One Month

 What do the numbers in her control chart tell Michelle?  If she monitors her calories by plotting them on the chart, she can determine if the drop has been large enough to depart from her pre-diet pattern.  The first 10 days indicated her calorie intake before diet.  There is an immediate drop followed by a slight increase in calorie intake during the diet.  The best days are past days 24 which are all lower than the lower control limit and thus indicate a departure from her pre-diet calorie intake.  Obviously calorie intake fluctuates from day to day.  She can use the control chart to understand if her intake is lower by more than what can be expected from random chance variations.  If the point in the chart falls below the lower control limit, then this pattern cannot be expected from just chance events and represent a real reduction in calorie intake.  All points within the upper and lower control limits could be due to chance.   

A self-help guide on how to create control charts for exercise and diet are presented in Chapter 6, “Control Charts for Diet and Exercise.” 

Step 6:  Engage in Cycles of Improvement

The Plan-Do-Study-Act (PDSA) cycle is a method by which one or two ideas for change can be tried out on a small scale and examined for success prior to continuing with further changes.  Since you need to study the success, you must continue your measurement.  The PDSA also is referred to as the PDCA (Plan-Do-Check-Act) cycle.  To begin a PDSA cycle, start by looking at your list of ideas for change.  Select a few ideas that you really would like to try and that you believe will help you lose weight or exercise more.  Develop a Plan: determine when you will start, what you will do, and who will be involved in bringing about the change.  Write down the plan delineating clear goals.  Be sure that you continue with your data collection effort.  The next step is to implement the plan.  At start time, engage in a small ritual to mark the new era and carry-out (Do) your plans.  After you have pursued the plan for a period of time, Study the results.  Ask yourself, What am I learning as I am doing?  Do the data support my impression that change is leading to improvement?  Do I need to modify the plan or make alterations?  If modifications are necessary, then make them and Act.  Also important in the "act" phase is positive action to consolidate, strengthen, and support the gains to date.  This may mean celebrating your success to date. 

Once done with one cycle, you start all over again (improvement is an ongoing process; it never really ends, remember?)  As changes are made to the initial plan, the procedure is similar to developing a new plan and, therefore, the process continues:  Plan, Do, Study, and Act once again.  If the change you made has not led to improvement, go back and try out another one of the solutions. Keep doing this until you hit on the solution that works for you. Be patient as lasting change will not come immediately.

Step 7:  Tell Your Story

Even though we talk of creating a storyboard last, it really is a step that you should keep active throughout your effort to change your weight and exercise frequency.  At the very beginning, when you and your team have decided on what you want to accomplish, you should post a storyboard in a place that you can all see.

You may ask, "Why should I tell the story of my change to myself and my friends? Obviously, we all know what is going on. We do not need to read it on a piece of paper." But as we noted above, the funny thing is that people do not know themselves. They forget how they felt when they started on a change. Circumstances change and a decision a month earlier to work on something may be forgotten. You and your team may lose attention and interest. An unfolding storyboard keeps you focused on the change at hand. 

How to Construct a Storyboard

A storyboard is a communication vehicle to display your project to the public.  It generally presents information in a standardized format facilitating understanding.  There is no one "right" format, but typically the following information should be displayed:

• Your name and your team member’s names
• Your objective
• A description of your PDSA cycles
• What is measured and the data to date
• Results (Was the change an improvement?)
• Next steps

Listed below are additional guidelines on how to construct a storyboard; you may use Microsoft PowerPoint slide templates or pieces of paper.

Publicly post your first slide when you start.  This will remind others that the project has started.  It also facilitates the future implementation of suggestions.

Define your problem without suggesting a solution or blaming others.

When you post the team’s flowchart or list of daily routines, you create a consensus regarding how things happen around your house. 

Having a list of ideas posted reassures team members that their contributions are not lost or ignored.  It enables you to go back and select new ideas as you engage in new PDSA cycles.

Posting the PDSA cycle marks the start of your intervention.

Posting the control chart helps everyone get insights into progress to date.  Do not wait until you have all the data you need.  Start posting the chart as you go along.

Whether you succeed or fail in your improvement efforts, it is important to post your results to the storyboard and to celebrate the fact that you are still at it. When you celebrate your success, when you tell others (and yourself) what you have accomplished, you become more committed. You are less likely to relapse into old habits.  If you do, you have data and information that can help you understand what has changed.  You can more effectively engage in problem solving when you can see the data over time and get insights into your own behavior.

Conclusions

In 1993, Roberts and Sergesketter suggested that personal improvements could follow the same principles as workplace process improvement.  The techniques first proposed by them and further detailed here provide additional strategies for achieving desirable behavior. The addition of the basic tenets of process improvement—identifying specific measurable processes that are important, mapping the existing processes, counting and keeping track of data about the process, designing and implementing short systemic changes, evaluating success, and making provisions for holding the gains—enlarges the repertory of methods available for personal improvement. 

As an individual with minimal free time, you may naturally ask, "What is in it for me? Why should I try this new approach?"  There are two benefits.  First, you are more likely to accomplish your resolution.  Second, the benefits you gain will last as your accomplishments do not depend on your motivation—which may waver at a any point in time. 

If you are interested in the “big” picture, the experience and the tools described here will also provide you with a new way of thinking.  You can apply this now to eating and exercising habits, but you could just as easily apply it later to other areas of your life.  This translates into a variety of improvements such as more free time, better health, a better work environment, improved student or patient or client satisfaction, or improved workflow. 

Many readers will wonder how long it will take before they can expect a significant improvement.  The bottom line is that improvement is an ongoing process; it never really ends.  The good news is that by working in small cycles, we ensure that gains or improvements are long term and the likelihood of failure is minimized.  Keep in mind that while trying something, you also are learning from doing.  Positive results generate additional improvement projects, typically on a larger scale, by applying the same principles and tools to larger issues.  Before you know it you will have several improvement projects running simultaneously.