Model for Improvement

One of the most common components of political or professional promises is improvement. This is either the process or the fact of getting things better. An equally common component of the subsequent period after election or appointment, is the lack of improvement. Why is this?

It is easy to blame lack of interest, defective structures, lack of support, or simply incompetence as the reason. However, the issue may well be not knowing how to bring about improvement in a sustainable way. The Associates in Process Improvement (API) developed a a model to address this very problem, and its quite simple. This model is named, “Model for Improvement.”

Underpinning any improvement plan are a couple of points. First and foremost is the saying that if you can’t measure it, you can’t improve it. This is not entirely true, but what is true is that if you can’t measure it, you cannot show or prove that you have improved, nor are you likely to know whether you have improved or not.

Questions underpinning improvement

Secondly, there are four questions that improvement processes require to answer:

  1. What is the problem that we are trying to solve?
  2. What are we trying to achieve?
  3. What steps or actions can we take to realize the achievement?
  4. How will we know when we get there?

You ought to answer these questions before you effect any changes otherwise, you run the risk of embarking on a wild goose chase and wasting the resources of you employer or country. Collectively, they constitute the first part of the model for improvement. The second part is what is called the Plan Do Study Act cycle (Also called Plan Do Check Cycles)

PDSA cycles

The PDSA cycles are a repetetive four stage model for implementing an improvement. Once you know what you want to achieve as required by the questions listed above, you make a plan.

Your plan should include SMART objectives in line with your overall goals, strategies, actions, a projection of ALL the resources that will be required to successfully implement the plan, the time required, the people responsible for individual tasks in the plan, the potential risks the plan may phase at implementation, and the actions you project to manage those risks. The plan also includes an endpoint, and measurement tools to objectively assess the impact of the various actions/activities set out in the plan.

Once the plan meets your satisfaction, you proceed to the “Do” phase. The do phase is where you implement the actions and activities set out in your plan. Make sure to have a baseline documented. This should be obtained at the planning phase, but if that is not done, it ought to be the first part of the do phase. The baseline tells you where you were before any of your interventions was implemented as is a necessary reference point.

Once the activities are implemented, you proceed to the “Study/Check” phase. Is the projected impact being witnessed? What was our baseline when we started? Where are we now? Is it an improvement? The result of the study phase will inform the next phase. During Study, you may find that the intervention results in a worse situation, no change, modest improvement, or a marked improvement. A key component of the study phase is the root cause analysis. When a result is not as expected or projected, a root cause analysis is carried out to understand what factors resulted in the deviation from the expected. The idea is to modify the root cause to have better outcomes. This ushers us to the Act phase. In the event of deficiencies being observed, remedies as can be made based on the findings of the RCA. Bear in mind that acceptable actions may include rolling-back the changes and perhaps doing away with the project altogether. This however requires courage and humility, neither of which is easy to find.

There is no limit to the number of times PDSA cycles that can be implement. Indeed this should be the routine baseline.


An improved version of PDSA is the OPDSA. “O” stands for observation: observe the prevailing situation before you make plan. That sounds good, right?


An separate improvement model is DMAIC from six sigma – Define, Measure, Analyze, Improve, Control. There are important differences in the two processes but they are not mutually exclusive. Indeed all the steps in the two models are useful.

Model for improvement components

What are the critical components required to implement the model for improvement?

  1. The political will to improve and allocate resources towards improvement
  2. Problems that can be solved by improving processes in a measurable way.
  3. People to carry out the interventions designed in the PDSA cycles
  4. Pragmatic interventions that can be implemented within the resources allocated to the improvement process
  5. Measurement tools that can be used to determine the baseline as well as assess progress.
  6. Time. Remember to set timelines to all improvement processes at the time of planning.


The model for improvement can be implement in a wide range of scenarios: from improving your own daily habits or routines, to improving productivity in a small scale business, to improving quality and outcomes in healthcare to achieving one of a country’s big four agenda. The process is simple but rarely applied, perhaps because the model is not well known across board.


A few years ago, to address the matter of congestion in Nairobi, the ministry of Transport banned 14 seater matatus and replaced them with bigger capacity buses: 25 seater and above. Did this intervention follow the model for improvement? How would you apply the model for improvement to this issue if you were the one in charge of policy? Leave your response in the comments section and Look out for my blog post on this very matter for us to compare notes.

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I have contributed to healthcare in Kenya in many areas. I was a co-founder and first chairman of the doctors’ union (KMPDU). I participated in the development of the patient charter and the Health act 2017 amongst many initiatives. I pushed for and was a key player in the “Musyimi” task-force report on strengthening healthcare delivery in the public sector. However, of these achievements, the one that I single out for mention is the GIERAFS model.

Patients seek two things from health workers: healing and a sense of being heard and cared for. Patients want to attain cure and recover from their illnesses. However, they also want to be treated with respect and feel that they have been listened to. In fact, a quack with tremendous patience, humility, attention and an overdose of “compassion” is likely to get better reviews than a haughty doctor.

Client experience is an area of focus in private institutions. However, even here it remains a struggle. In our public facilities, there are those health workers who try to extend a positive experience, but their efforts are often drowned by an unsupportive, broken system or a majority who, for one reason or the other, do not try anymore.

In 2016, an administrative colleague of mine (Sr. Felistas King’ori, of the Sisters of Mercy Kenyan Province) and I shared a concern on this very matter. Then one morning in 2016, in my office at the Mater Misericordiae Hospital,  in a discussion with Sr. Felistas,, it occurred to me that perhaps the missing link was a set structure that would provide proper guidance to well meaning health workers.  As a result of this discussion and by the end of this one meeting,  the GIERAFS model had been born as a simple, easy to remember, easy to apply, yet effective model to guide the interaction between all health care workers and their clients.

GIERAFS is a mnemonic detailing the basic components, in sequential order, of an interaction between a healthcare worker and his/her patient:

G – Greet the patient

I – Introduce Yourself

E – Explain what you would like to do

R – Request the patient’s permission to proceed

A – Ask whether they have questions and answer any questions they may have

F- Feedback to the client on your findings and plan

S- Smile. It helps. 🙂

Please try it out and let me know how it works. Good luck.

Dr. Victor Ng’ani

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The Thief

After 9 years of service, my job at the Mater Misericordiae Hospital came to an end at the end of March 2018. I opted to liquidate part of my pension and use the funds to set up income streams to sustain me through the subsequent season. I was pleasantly surprised to find out that the monthly payments had accrued quite an amount in interest. On this interest, I determined to pay my tithe to my local church back at home. I was quite excited to make this payment, imagining what it could be used for and how beneficial it would be to the church. I therefore set the money aside, in cash, before all else.

When I got home a few weeks later, one of the first things I purposed to do was submit the amount to the local pastor but alas, when I checked where I had put the money, 40% of it was missing! I searched everywhere but it was nowhere to be found. Where could it have gone?

The house I was staying in was largely locked. However, for a brief period earlier in the day, one of the two ladies hired to help my aging mum with house chores had been tasked to clean the house. She had been there by herself for quite sometime. This, to the best of our recollection was the only time the house had been unlocked and accessed by another adult. Turns out, this lady had acquired a dubious record with regards to accessing material things. There was a string of items that had disappeared over time that she had been suspected of taking and others reported to have been confirmed. After further inquiries, it became clear that she was the person most likely to have stolen the money from its hidden place. We went to find her at her house but only found her children despite it being night time. Where could she, or her husband have gone at such an hour leaving children alone? Somehow we managed to reach her on phone and demanded that she comes to our home, which she did, accompanied by her husband.

Of course, and as expected, whereas she acknowledged having cleaned the house by herself, she denied ever having taken or even seen the money. We confronted her with the past allegations against her and after quite sometime, she owned up to having taken some small kitchen items and some food occasionally but remained adamant that she had not taken the money. At some point the husband came in to defend the wife and stated that he was certain that his wife had not taken any such money. If she had, he would have known. He also owned up to the few items the wife had spoken of taking without permission earlier. Then my sister noticed it. In the dark. The t-shirt he was wearing had been hers. She inquired how he had come to be in possession of it. The couple was taken aback but then the lady regained her composure and explained that the clothing item had been rained on, and she had taken it home to dry (or some other unconvincing story like that about rain and drying). The husband on the other hand said it was the wife who had brought it, as Eve had brought the apple to Adam in the garden of Eden.

With this and the history, it was clear to everyone who the culprit was. People have been burnt for stealing items of much less value than the money lost that day. As you know, I am ardently opposed to murder in the name of “mob-justice.” (I consider it, and it is, evil several orders worse than theft). No one lay a hand on her, nor on her husband but we threatened to take them to the police, and had them enter a vehicle for this very purpose. All this while, despite the mountain of evidence, they pleaded their innocence and refused to confess. We probably would have forgiven them if they would just have owned up and returned whatever portion of the money they had not spent. Seeing that the police threat didn’t work either, we opted to let them go but that would be her last day as our employee. Meanwhile, I bemoaned the need to raise yet another amount to replace what had been stolen. In this instance, a cheerful giver I was not. I do pray for God’s forgiveness. I had no doubt in my mind that she was the one responsible for the loss. Nobody in the village doubted their guilt. I am however grateful that we did not harm her or escalate the matter to the police. I imagine that in some communities in Kenya today, despite the many relatives (or the very people) who engage in corruption and theft in their workplaces, these two could have been tortured, beaten till half dead, then set alight, all the while as the people, these self-righteous corrupt people who bribe or receive bribes so often, cheered.

My gladness that we did not do anything of the sort was multiplied a week later when I got back to Nairobi.

Going through my things, I found out that in my hurry to get home, I had purposed but failed to combine the two tithe monies into one as I had planned. Indeed, the 40% was right in the coat pocket where I had initially kept it and there it had remained, even as we dragged through the mud, the reputation of our “thief.” My heart sank from terrible guilt for what I had done. We had treated the couple horribly. All this while, despite what we all believed, the dishonest sounding pleas of innocence from the couple, despite the history, despite the t-shirt, despite the food items, were actually the truth and I…we… with our 200% certainty, were actually wrong. So with tremendous shame and guilt, I picked up the phone and started the difficult process of setting the record straight. I had to call her, then the husband, then all my family members whom I had involved in the incident, and in that low moment, I apologized and confessed what I had found. I must say, they were quite gracious in their response and were quite forgiving.

But why this story?

Have you heard of “thieves” burnt because “alionekana?” Have you heard of villagers gathering the day after incidences to flush out gangs and perpetrators, extracting confessions, and relying on “eye-witness” accounts? Have you heard of people lynched because the murderers in the lynch mobs took the words of people who were cork sure that the lynched were guilty? How about of witchcraft? Turns out, in criminology, the least reliable and most error-prone type of evidence is the eye-witness account. First, we shouldn’t be burning or lynching anyone. The murderous evil capable of this is not fit for societal integration, and forms the basis of an evil, brutal society that cannot prosper. Secondly, there is a reason why the legal process is in place. The Chicken thief too is entitled to his day in court. Let the case be proven beyond reasonable doubt. Let not circumstantial evidence, as compelling as it may be (and was in my case) be the reason to destroy somebody’s life. Let not our faith in our correctness and infallibility be the basis for the death of a father, mother, brother, sister, daughter, son, for one thing is for sure: we often make mistakes. Let us not be thieves, stealing the well-being, freedom, or lives of innocent people in our often vengeful quest to blame somebody.

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Nancy and her husband did what they knew would protect them. They cooperated fully. The three man gang had entered their home shortly after 9 PM, guns in hand and had been there for nearly two hours. They had welcomed themselves to dinner. Watched the remainder of the 9pm news bulleting, and casually commented on the social stories that Nancy could not remember. They took their phones, and all the money they had in the house: all of thirteen thousand. All the while, they spoke jovially. For the two hours, one could almost image a humane face to the thugs. None of their neighbours knew what was going on.

Then it got worse. A lot worse. Shortly past 11pm, all of a sudden, the gangsters casually mentioned that it was now time to assault Nancy. It was part of their ritual, they said. With pain and tears in their eyes, their desperate pleas falling on deaf ears, the couple endured this horror: eternal scarring starting thus. “How do I live with this?” Mwangi lamented in Anguish, feeling that he had betrayed and failed to protect his wife. At the gate as they were on the way out, “Ah, you needn’t worry about that. You don’t have to live with that guilt. I am going to help you.” The young man said. Barely past his teenage years, he pointed his gun at Mwangi’s head and pulled the trigger twice. They hopped onto two motorcycles and sped off, their countenance not changing one bit, leaving the widow in disbelief, horror and shock.

“Huyo achomwe!” Mwangi had screamt two weeks earlier. Finally, one of the notorious phone snatchers had been caught. They had been running a smooth operation: one person knocks on the opposite car window two divert attention, and in that instance, his colleague reaches in and snatches the phone right from the seat. Gone in five seconds. This one had been the “knocker.” Quite unfortunate for him a group of football fans were trooping back in the vicinity and saw him. He never stood a chance.

He had endured half an hour of torturous beatings with everything heavy and hard thing that could be found on the road. His ribs were broken and so were several other bones on his body. He could barely see anything through the blood that had run over his face but he saw a blurry motion towards his face before another bout of searing pain engulfed the place where his mouth used to be. Someone had swung a heavy metal bar straight into his mouth with his head on the tarmac, breaking every single tooth that was left at the front. He would have loved to block the blow with his hands but they were mangled, broken, bloody and he couldn’t move them. All he felt was pain. The blow shattered his teeth. The pain was searing. He didn’t have enough time to cry as he felt a horrifying scream come out of his mouth amid gurgles of blood. Someone had lifted a huge construction boulder and let it on his mid shin, breaking the big bone in two… He had feared being burnt. Now it couldn’t come too soon. The torture was too much to bear. He imagined being burnt would be painful but it would end soon.

The thought of his death brought a deep sadness, greater than that of the pain he felt. Not for him. No. For his younger siblings who depended on him for what to eat. Both their parents had died years ago leaving them with nothing. He had forfeited the chance of going to college as he couldn’t afford it. His siblings, 11, 8 and 6 didn’t have anyone else to take care of them. Work had been hard to come by. He would go to industrial Area every morning at 5am and wait outside the factory hoping to be one of the people who would be allowed to work that day. There were hundreds with him and he didn’t have money to bribe the supervisor. He had tried running a water mkokoteni but the water cartels had given him a serious beating. At least his 16 year old sister had gotten married. He doubted that her elderly alcoholic husband treated her well but at least she had something to eat. He felt saddened, worried and pained by the future his siblings faced without him. They still slept hungry a few times, but not as frequently as before.

His thought was interrupted by another bolt of pain in his already cracked ribs. He felt someone force him to sit up and place a band around him. It felt like a tyre. “Please! Nisamehe.” He mustered enough strength to whisper. No one seemed to hear it. He summoned all the effort left in his weakened, battered body. “Tafadhali! Nisameheni!” He screamed. A massive kick to the head. “Sisi ndio tulikwambia uibe?” Laughter. Then he felt the cool liquid on his skin all over him. It stung a little as it run over the many wounds. Suddenly he noticed that the one who was lighting the match was was the devil himself. He could see it clearly, but nobody else in the group seemed to notice. But the devil passed the match to another man to finish the act. The pain was excruciating…

And Mwangi went home a satisfied man. A good thing had been done. One less criminal in the city. He had narrated the story to his brother who had come to visit him to show him his newest vehicle.

His younger brother had a rough start life to adult life. He had gotten mixed up with the wrong group in high school and ended up performing far worse than had been expected. He missed out on University and dropped out of two middle colleges before finally finishing a diploma course. Fortunately, his aunt knew someone who new someone. The job interviews at the ministry of transport and infrastructure had been completed and the appointment letters were about to be issued. His parents had agreed to sell a piece of land and pay for a job for his son. It crossed their mind that they may get conned. Fortunately, that didn’t happen. The public officer that had been approached by the person who was known by the person who known by Patrick’s aunt, was a man of his word. Once he received the agreed amount, he randomly removed Monica Tanui’s letter from the pile that was to be sent to the successful applicants and made out a new appointment letter to Patrick. Neither Mwangi nor his brother Patrick, nor any other member of his family ever heard the name Monica, or what had happened in the background. None of them knew that even though she applied to hundreds of other jobs thereafter, she didn’t get another opportunity. She gave up trying after four years and ended up working as a house-help despite her college education.

But Patrick had done very well in his new job. It was a fairly low-level job but in three years, he had built a house for his parents and this was his second car. They both knew that his salary couldn’t pay for any of these things, but public service jobs had their ways.

“How does this politician manage to give so much money?” Patrick asked as they had watched news. “This is public money they must be stealing.” Mwangi’s neighbour George had joined them for the evening. “Why do you say that? Can’t the son of a sugarcane farmer work hard and earn money?” “But what is this work he has done to earn this much in 15 years?” Don’t you know he runs matatus, and owns a lot of real estate? He owns three beach resorts.” Mwangi interjected here, “Friends, to get to the matatus and real estate required lots of money in the first place. Besides, Safaricom is the best performing business in Kenya today. The returns from his matatus and real estate have to be better than Safaricom for this level of spending to make sense. No matatu business is that profitable.” They laughed. “Still, we admire his charisma and how he helps the poor. This EACC story is a witchhunt that is headed nowhere. I don’t see anyone unseating him from office any time soon. I think I’ll still vote for him.”

“Mum, please don’t kill the mouse. It’s only looking for food that’s why it came to the house. Even the flies” the young girl smiled. Little children have a way about them that is simply charming. The mother put away the insect spray and hid the mouse trap away from view. Such an innocent, caring spirit these children have. “Where are you brothers?”

The young children had gone out playing. Topang’ ran to them breathless. “Quickly, come see what’s happening!” “What is it? ” “You come see.” They got there and stared in absolute horror at what they were seeing. They were all heartbroken and felt so much pity. They couldn’t imagine that human beings could be that cruel. “Who is it?” “It’s a thief!” They paused for a moment. “Shouldn’t he be taken to jail?” “My uncle told me that if you steal, you will get killed. Like this.” “Oh, this is so sad and painful.” “I feel sorry for him. Does he have children?” It is said that children can see clearly spiritual things that adults can’t. And there, clearly in the crowd, they could see two devilish creatures. The creatures noted that they were being watched and turned to the children. The children fled.

The children ended up moving to different areas thereafter. By the time they witnessed their third mob-justice over the years, the got accustomed to it and to expect it. They no longer saw the devil in it. Taking life no longer horrified them. It was no longer anything big. If anything, there were problems that could be solved thus.

What Nancy didn’t know is that that group of children defined her very night. One had grown to be a thug and taking life hadn’t meant much to him. As it turned out, he had been the mentor of the young man who shot Mwangi that night. One was Mwangi her husband, one was Patrick, her brother in law, one had grown to be a public servant, one had grown to be policeman, hunting and killing criminals. What she didn’t know is that over four decades, an evil culture had grown in her society and four generations had come to embrace a culture of theft and murder: a double standard as they would not touch the thieves in their own families, nor the thieves that are the leaders they voted for, but would light up with glee as they tied up, tortured and burnt the chicken thief. And no, the killers didn’t think of it as murder. They didn’t see the killing as worse than the chicken-theft. They justified it as a good thing. They didn’t see their people stealing from the public as a bad thing. They justified it.

A brutal and barbaric society breeds brutal and barbaric people. The children watch and learn from the actions of the adults. They learn life has no value and take it easily when they see adults take life, with glee, for stolen phones and stolen chicken. They learn stealing from the public is fine when they see their parents do it or glorify it. A brutal society breeds brutal adults: a brutal thug who kills the cooperating victim without provocation, the brutal member of public who can set alight another human being, the brutal citizen who can hack to death another because of difference in tribe and political opinion, the brutal policeman who can shoot and kill the surrendered suspect, the brutal public officer who can steal relief food from those dying in hunger, the brutal health worker who can steal medicine from people dying in hospital, brutal leaders who can steal wealth from a rich country and allow tens of thousands to die for various systeminc gaps that result from their theft, brutal husbands and wifes who can kill each other and set their children on fire, brutal politicians who will kill their opponents or arrange for supporters of their opponents to be hacked.

Wisdom spoke: “Look at this lost and perverse generation. while it is written “thou shall not kill,” “thou shall not steal” they spill blood every day and rejoice in it. They steal the very essence of what I have given them. Look at these sinners casting the first stones: crying for the police to shoot the arrested thief. Won’t they have stoned the woman caught in adultery? Won’t they have been in the crucifixion band? Yet their sins are dark and black. Who is without sin? Who can say they are better than the thief? They and their people have stolen more from their workplaces than the thieves they burn. They have bribed and stolen opportunities from deserving folk more than the thieves they want shot. They have stolen fathers from children, husbands from wives in the evil they call “mob justice.” They have stolen innocence from children, hardening their hearts against compassion and respect. They have stolen life that they don’t own. Their anthem speaks of a blessing yet they ask whether they are cursed, remaining backward despite the numerous resources. Will they be blessed? Only if they change their ways from the evil ways of theft and murder that they have allowed. Yet how many peoples were asked to change their ways in the good book?” Wisdom spoke. Evil didn’t like what wisdom said.

What will it take to change this vicious cycle that is killing our society?

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