Q UA LI T Y P R O B LE M
S O LV I N G :
SCOPE AND PROSPECTS
GERALD F. SMITH, UNIVERSITY OF MINNESOTA
Total quality management (TQM) has come to embrace virtually
all organizational activities. While the TQM movement has his-
torically included a problem-solving component, quality problem
solving (QPS) is often viewed rather narrowly as finding and fix-
ing defects. This article proposes an expanded notion of QPS, argu-
ing that such is needed if TQM is to achieve its full potential. Five
major types of quality problems are identified and discussed, along
with problem-solving methods currently used by QPS practitioners.
While the techniques used by practitioners are valuable, they have
limited power and operationality. Case-based QPS, a new strategy for
developing strong prescriptions aimed at particular kinds of situations,
is proposed and illustrated. This strategy demonstrates how research
on QPS can contribute to the success of TQM.
Key words: case-based quality problem solving, problem solving,
total quality management.
INTRODUCTION
Total quality management (TQM) encompasses many
organizational activities, from certifying vendors to mea-
suring the cost of poor quality. One such activity, promi-
nent in books (Goodmeasure 1988) and training sessions,
is problem solving. This article is concerned with quality
problem solving (QPS); that is, TQM efforts aimed at
identifying and solving organizational problems.
Problems are traditionally defined as gaps between
the way things are and the way one wants them to be
(Reitman 1964, 282–315). A problematic gap must be
difficult to bridge or close, and it must be important
enough to motivate solution efforts (Agre 1982). Broadly
understood, then, a problem is any situation that bears
improvement. Problem solving is thinking done to effect
improvement. Problem solving can be viewed as a cogni-
tive activity consisting of psychological processes—rea-
soning, judgment, memory recall, and imagination. It
can also be conceptualized as the performance of func-
tions or tasks like problem identification, diagnosis,
alternative generation, and design.
QPS is currently construed as the identification, diag-
nosis, and correction of certain performance problems—
situations in which a system is not producing acceptable
outputs. It is often assumed that organizational products
and activities can be standardized. “Processes, such as
building automobiles, mixing chemicals, writing insur-
ance policies, and so forth, are conceptually set up to
make something in a standard way. Every operation is
planned down to the last detail” (Crosby 1989, 165).
Problem solving occurs when standards are violated; it is
a matter of finding and fixing defects. Because of the
standards, problem solving is relatively simple. One need
only compare actual performance with standards to iden-
tify discrepancies; one need only enforce standards to
correct the situation.
Indeed, the literature often adopts a disapproving
view of QPS. A problem is a failure of the system (Slater
1991). The way to handle problems is to prevent them
through process improvement (Ebel 1991; Walton 1990).
Slater argued that “piecemeal problem solving by its very
nature is an undirected ‘creeping convergence’ to some-
QMJ 94 Fall 25
 QUALITY PROBLEM SOLVING

thing uncertain” (p. 27). If TQM were totally effective, it
is claimed, QPS would be unnecessary.
Despite arguments on its behalf (Wilson, Dell, and
Anderson 1993), QPS is an underappreciated part of
TQM. Even when limited to finding and fixing defects,
QPS is an important, challenging activity. Case studies
demonstrate how difficult it can be to identify the causes
of unacceptable outputs. Every product and process is
infinitely detailed, having many attributes not covered by
specifications. In addition, some processes are immune to
proceduralization, making it impossible to identify fail-
ures as deviations from standards. Juran and his associates
dissent from the narrow notion of QPS ( Juran 1986; Juran
and Gryna 1988). They view problem solving as a vehicle
for continuous improvement, over and beyond fire-fight-
ing responses to sporadic problems. This article extends
Juran’s claim. Problem solving is the thinking that under-
lies all organizational efforts to improve process and
product quality. In addition to finding and fixing defects,
quality problem solving must be concerned with reducing
costs, improving processes, and designing products.
A foundation for scientific research on QPS is
developed in this article. In the next section, five major
types of quality problems are identified. This provides
the basis for an assessment of existing QPS methods.
Then, a new strategy for prescriptive QPS research is
proposed. This strategy — case-based QPS — analyzes
past instances of quality problems and problem solving to
has come to be seen as the prototypical quality problem.
Closer analysis suggests that TQM involves various
kinds of problem situations, calling for different problem-
solving methods. Figure 1 identifies five types of quality
problems. Three are performance problems—situations
in which an existing system is not performing acceptably;
and two are design problems—situations calling for the
design or redesign of some thing. Figure 2 defines each
problem type, indicating how each is usually identified
and the key problem-solving tasks that it poses.
Compliance Problems
This is the set of traditional quality problems, its label
being suggested by Schonberger (1986). In such situa-
tions, a structured system having standardized inputs,
processes, and outputs is performing unacceptably from
the standpoint of product users. When standards are
incomplete, the category shades into unstructured per-
formance problems. If compliance problems result from
systemic causes, they give rise to process or product
design problems.
Figure 1 Types of quality problems.
Quality
problems
Performance Design

develop useful problem-solving insights.

Effectiveness Efficiency
TYPES OF QUALITY PROBLEMS
Processes Products
Quality problems are a subset of managerial problems,
which include, for instance, co-workers who cannot get Standardized Nonstandardized
task task
along and investment decisions. TQM evidences little
analysis of quality problems or distinctions among prob- Compliance Unstructured Efficiency Process Product
problems performance problems design design
lem types. Almost by default, finding and fixing defects problems problems problems

26 QMJ 94 Fall
 QUALITY PROBLEM SOLVING

Figure 2 Problem identification and problem-solving tasks. problems, however, the system is
not well specified by standards.
Problem type/description Problem identification Key problem-solving tasks
Compliance problems: The absence of standards can
A highly structured system is Statistical process control; Diagnosing the causes of
performing unacceptably from user feedback unacceptable performance
reflect system immaturity or the
the standpoint of product users. need for flexibility in system per-
Unstructured performance problems:
A nonstandardized process is User feedback Determining user needs and formance. The system may face
producing unacceptable outputs diagnosing the causes of poor
from the standpoint of product performance
varying demands, so that its opera-
users. tions cannot be prespecified. The
Efficiency problems:
A system is performing Use of standards; Goal setting; eliminating activities of an expert woodworker,
unacceptably from the standpoint benchmarking; employee unnecessary activities
of its owners and operators. suggestions; accidents
for instance, are adjusted to the
Process design problems: grain and moisture content of the
A new process must be developed Self-assessment; occurrences Identifying process goals and
or an existing process redesigned. of performance problems; constraints; devising process wood. Service workers adapt their
initiation of new activities components and synthesizing
them into the whole behaviors to the preferences of
Product design problems: individual customers. Most knowl-
A new product must be developed Customer feedback; market Translating user needs and
or an existing product redesigned. research constraints into product edge work cannot be standardized;
specifications
there is no one right way, for exam-
Identification of compliance problems is aided by ple, of writing advertising copy.
the existence of standards. System inputs, processes, and The lack of standards strongly affects problem iden-
outputs can be compared with standards, with problems tification. Whereas compliance problems are usually dis-
being identified when variations are excessive. Problems covered before defective products are sold to customers,
can also be identified as a result of user feedback, although unstructured performance problems are likely to be iden-
this suggests a failing in quality control efforts. The tified through negative user feedback. The major challenges
major challenge or functional demand posed by compli- in solving this type of problem are determining customer
ance problems is diagnosis; that is, determining the cause needs and diagnosing the causes of poor performance.
of the nonconformity. Once this has been done, remedial Unlike compliance problems, customer needs are not
action can be simple: Return the system to its specified captured in product specifications. Needs are partially
performance routine. Diagnosis can be difficult owing to variable and, in service situations, must often be deter-
the complexity of actual products and processes. Standards mined as the service is being performed. Because of cus-
cannot address all characteristics of the system, and non- tomer variability, it may be difficult to determine why a
conformities can result from interactions between factors product was unacceptable: for example, what did the
that are individually acceptable. salesperson do wrong, or why weren’t a consultant’s rec-
ommendations adopted. TQM has stressed the need for
Unstructured Performance Problems organizations to maintain close contact with customers.
Situations of this type resemble compliance problems This helps identify unstructured performance problems
since they occur when a system’s outputs are not ade- and determine the unsatisfied customer needs that give
quate to user needs. With unstructured performance rise to such problems.

QMJ 94 Fall 27
 QUALITY PROBLEM SOLVING
Efficiency Problems
The third kind of performance problem adopts the per-
spective of system owners and operators. While outputs
may be unacceptable to users, system performance may
not achieve the goals set by these other parties. System
operations can be more costly than its owners desire, or
can pose unsafe or undesirable conditions for workers.
Such situations are termed efficiency problems, and cost
efficiencies are the most prevalent concern of this kind.
This category of problems reflects a stakeholder view of
quality (Smith 1993). Although product quality is usually
defined in terms of user needs, the concept can reflect
the interests of other parties. From a producer’s stand-
point, a quality product is profitable because customers
buy it at a price exceeding the product’s cost. Thus, low
cost is a quality attribute of a product from the producer’s
perspective. Similarly, workers prefer to make products that
can be produced safely and under favorable working condi-
tions. The stakeholder view of quality accommodates the
fact that many TQM activities have been oriented toward
reducing costs and improving working conditions.
Efficiency problems shade into product and process
design problems when needed changes require major
overhauling of the product or production process. Problem
identification is not customer driven. Due to competitive
factors, customers are insulated from, hence unconcerned
with, a product’s cost or the conditions under which it is
produced. Identification of efficiency problems can be
based on operator suggestions. These problems are also
identified by comparing system performance with cost
standards, its own history, or the performance of compa-
rable operations (benchmarking). Safety problems can be
identified from the occurrence of accidents or near-miss
safety incidents. Problem solving centers on identifying
and eliminating unnecessary activities and finding less
costly ways of performing needed functions.
28 QMJ 94 Fall
Process Design Problems
A process is an organized set of activities, a way of doing
something. Process design problems involve the develop-
ment of new processes and the revision of existing
processes. Process design has emerged as a major focus of
attention within TQM, and for good reason. Process
design underlies all organizational activities, determining
the efficiency and effectiveness with which things get
done. Many organizational processes have not been well
designed or have become obsolete with advances in
information technology.
Process design problems often entail the redesign of
existing processes, blending into performance problems.
Problem identification is prompted by recognition of
performance inadequacies. It can also result from self-
assessment: Can we do better? Process design is prompted
by the initiation of new activities. When a product is
introduced or a customer relations program is initiated,
related processes must be developed. As with any design
activity, process design requires that user needs and relevant
constraints be identified ( Jones 1981; Smith and Browne
1993). Devising process components and integrating
these into an effective whole are other key tasks.
Product Design Problems
The final type of quality problem involves the design of
products that satisfy the needs of internal or external
users. Product design is a major focus of attention in
TQM, reflecting the urge to push quality management
upstream to prevent problems before they occur. With
the exception of quality function deployment (QFD) and
Taguchi techniques, however, TQM has produced little
by way of product design methods. On the other hand, it
has developed ways of identifying customer needs. These
activities complement the traditional engineering orien-
tation of the product design function in organizations.
 QUALITY PROBLEM SOLVING

Although design work can be initiated as a result of
product performance failings, problem solving usually
occurs as a natural part of competitive life in a market envi-
ronment. Research and development units routinely initiate
new product design projects. A major challenge in product
design, addressed by QFD, is translating user needs and
constraints into product attributes and specifications.
QPS METHODS
This section reviews the most important problem-solving
methods used to address quality problems. An underlying
issue is whether these methods are adequate to the challenges
posed by an expanded notion of QPS. A method or tech-
nique is a way of doing something, a prescribed process. It
can be specified in varying degrees of detail; methods range
from informal heuristics to precisely defined algorithms. The
key issue is effectiveness. Effective heuristics can be more
worthy of use than sophisticated algorithms. In assessing a
method’s effectiveness, three criteria are pertinent; the first
two having been proposed by Newell (1969, 361–414).
1. Generality, the range of situations to which the
method can be usefully applied
thinking, some adopt a mathematical approach, and others
use diagrams. Methods vary in degree of comprehensive-
ness, from those addressing a particular functional
demand (for example, diagnosis) to those prescribing for
the entire problem-solving process. Methods can be
applicable to certain types of problems. Techniques
appropriate for negotiation tasks would not be used in
solving efficiency problems. Figure 3 organizes the major
QPS methods in a classification scheme based primarily
on problem-solving functions. Although often used in
QPS, generic research methods (for example, surveys and
experimentation) are not included in the figure. This
scheme guides the discussion that follows.
General problem-solving methods. This category
includes methods addressing the entire problem-solving
process. Such methods are common in the QPS litera-
ture, appearing as n-step techniques (Gaudard, Coates,
and Freeman 1991; Meyer 1990; M. Robson 1988). The
Figure 3 QPS methods.
General problem solving Alternative generation
PDCA cycle Brainstorming
Storyboarding Nominal group technique
Problem identification Force field analysis

2. Power, the quality of results produced by the method Statistical process control
Benchmarking
when it is applied to situations within its range Data collection
Check sheet
3. Operationality, the extent to which prescribed activities Histogram
can be performed in a way that consistently yields Run chart
Problem representation
acceptable results Affinity diagram
Interrelationship digraph
Newell (1969, 361–414) noted the existence of a power- Data analysis
Stratification
generality trade-off: Powerful methods tend to have lim- Pareto analysis
Scatter diagram
ited ranges, and general methods tend to be weak. There
Concentration diagram
is an operationality-generality trade-off as well: General Matrix diagram
Diagnosis
methods often include activities (for instance, generate Design of experiments
Shainin techniques
options) that one may not know how to perform.
Cause-and-effect diagram
There are many ways of characterizing problem- Kepner–Tregoe method
Five whys
solving methods. Some methods rely on qualitative Root cause analysis
Process design
Flowchart
Process analysis
Systems thinking
Reengineering
Benchmarking
Product design
Quality function deployment
Design of experiments
Taguchi methods
Value engineering
Reliability engineering
Failure mode effects analysis
Simultaneous engineering
Evaluation and choice
Prioritization matrix
Glyph
Multivoting
Implementation
Tree diagram
Process decision program chart
Activity network diagram

QMJ 94 Fall 29
 QUALITY PROBLEM SOLVING
most influential is the Shewhart, Deming, or PDCA
cycle (Deming 1982), which consists of four steps—plan,
do, check, and act. While the cycle reflects a fundamental
heuristic action strategy, it illustrates the inadequacies of
general problem-solving methods. Despite the plaudits it
has received from practitioners, the cycle has little opera-
tionality. The plan step is the core activity, but the method
does not explain how planning is to be done. Storyboarding
(G. Robson 1991) and other general problem-solving
methods also include steps (for example, generate alterna-
tives) that an individual or group is expected to perform
with scant aid from the technique and no guarantee of
effectiveness. Such methods are quite weak.
Problem identification. Statistical process control
(SPC), a problem identification method, exploits the fact
that extreme observations, or low probability patterns, of
a variable signal the possible existence of problems,
understood as out-of-control conditions. SPC presumes
that variables can be measured often and accurately and
that extreme observations are problematic. These
requirements limit its generality. Benchmarking, a com-
plementary method, relies on comparisons with high-
performing organizations. After these, TQM only has
heuristic advice regarding problem identification. Some
heuristics are useful—looking for problems in the cracks
between departments and in comfortable business indices
(Bajaria and Copp 1988, 170–179). Because problem
identification is affected by the nature of the problem,
the prospects for developing strong general methods for
identifying quality problems are slim.
Data collection. These are methods for collecting
information concerning possible problem situations.
Data collection is often done as part of problem identifi-
cation or shortly thereafter. Because the situation is
poorly understood, collection methods should not make
strong assumptions about what is important. Information
30 QMJ 94 Fall
can be acquired by direct observations, interviews, or sur-
veys. The methods cited in Figure 3 are typically used to
record data collected by direct observation. Histograms
indicate the frequency with which different values of a
variable are observed. Check sheets provide frequency
information and can handle multivariate data. Run charts
allow the identification of time-dependent patterns in
the data. Qualitative verbal data are acquired by means of
interviews or surveys. These methods are widely used,
and they seem adequate to the needs of QPS.
Problem representation. Problem definition or repre-
sentation tries to clarify or depict the situation (Smith
1989). It is not a time-delimited phase of problem solving,
since an understanding of the situation evolves during
the problem-solving process. Verbal definitions, common
in practice, can be bolstered by diagrams. The key repre-
sentational issue is determining which elements and rela-
tionships to depict. Affinity diagrams encompass any
content, grouping it on the basis of general relatedness
(Brassard 1989). Interrelationship digraphs focus on cause-
and-effect relationships. Other elements (such as goals,
subproblems, constraints, and unknowns) and relationships
(such as time-sequence, part-whole, and means-ends) can
be important for understanding problems. Representa-
tions are partially problem dependent; certain kinds of
situations (for example, decision problems) lend them-
selves to certain kinds of diagrams (for example, decision
trees). Good methods do not merely record elements and
relationships comprising the situation; they evoke them as
well, aiding recognition of key problem features. Existing
QPS methods are weak in this regard.
Data analysis. This function effects a transition from
formulation (problem identification, definition) to problem
solving (diagnosis, design). It provides direction for subse-
quent thinking. Stratification is useful when a problem
consists of different failings that can be grouped in various
 QUALITY PROBLEM SOLVING
ways. Pareto analysis directs attention to the most promi-
nent groups. Scatter diagrams are used to detect correlation
between variables, this being a cue for causality. When
defects are physically localized on a product, concentration
diagrams help identify trouble spots. Matrix diagrams, the
most general of these methods, indicate relationships among
two or more elements of a situation (Brassard 1989). This is
a key juncture in problem solving; a false step will result in
lost time and effort. Although existing techniques are use-
ful, there is a need for problem analysis methods (Smith
1990); that is, ways of analyzing a situation to determine
its structure and appropriate problem-solving strategies.
Diagnosis. A major functional demand for compliance
problems—diagnosis—has been a primary target of QPS
activity. It involves the determination of causes. Diagnosis
includes the subtasks of generating causal candidates and
testing their validity, the former being more difficult and
important. Design of experiments is a mathematical
technique for efficiently testing hypotheses. Although
controversial among statisticians, Shainin’s heuristic
methods can be used to generate and test causal candi-
dates (Bhote 1991). Qualitative methods provide cues
suggesting possible causes. Cause-and-effect diagrams
depict a hierarchy of candidate causes suggested by the
“five Ms”—men, machines, materials, measurements, and
methods—that inform diagram construction (Ishikawa
1989). The Kepner-Tregoe method (1981) asks problem-
solvers to look for changes explaining differences between
acceptable and problematic conditions. Imai (1986) cites
an example of a machine breakdown in which the five-
why technique—asking “why” five times in deepening
succession—led to the identification of the root cause. As
proposed by Wilson, Dell, and Anderson (1993), root cause
analysis includes barrier analysis and other techniques.
The variety of methods for generating causal candidates
reflects the nature of causality. Effects result from causes
in many different ways. Lacking a principled way of
identifying causal candidates, practitioners must resort to
heuristics. Existing diagnostic methods are impressive,
but there are assuredly yet-to-be-discovered ways of gen-
erating and testing causes.
Alternative generation. Creativity can be involved in
many aspects of problem solving; it is most pertinent to
the generation of solution alternatives. Being difficult to
define, creativity gives rise to airy discussions and ques-
tionable prescriptions. Techniques proposed in the TQM
literature, such as imagineering (Slater 1991), lack opera-
tionality. For the most part, QPS employs traditional
creativity methods, notably brainstorming and the nomi-
nal group technique. These rely on group interaction to
stimulate the flow of ideas and try to prevent social pres-
sures from inhibiting that flow. Force field analysis, based
on the social psychological theories of Kurt Lewin (1951),
suggests what is possible: By evoking factors that help or
hinder achievement of a goal, the method elicits alternatives
that exploit aiding factors or avoid hindrances. Effective
alternative generation methods must use an analysis of
the problem to evoke possibilities from memory.
Process design. These methods respond to process
design problems. The most fundamental technique is
flowcharting (Burr 1990). It depicts a process as a
sequence of activities. Most process analysis methods
augment flowcharts with heuristics for identifying
unnecessary activities, weak interfaces between activities,
and other inefficiencies (Harrington 1991; Melan 1985;
G. Robson 1991; Rummler and Brache 1990). Process
analysis can exploit systems thinking by examining inputs,
transformation processes, outputs, feedback, and control
points. Reengineering uses information technology and
heuristics, such as developing multiple versions of a
process and employing hybrid centralized/decentralized
operations (Hammer and Champy 1993). Benchmarking
QMJ 94 Fall 31
 QUALITY PROBLEM SOLVING
improves processes by borrowing ideas from others.
Poka-yoke (Shingo 1989) refers to mistake-proofing tech-
niques developed by the Japanese. Processes are designed
to prevent operators from making errors, a frequent cause
of poor quality. TQM is a leader in business process
design methodology. QPS methods evidence sound
strategies and useful heuristics. Further advances will
build on lessons learned from experience.
Product design. Addressing another type of quality
problem, product design methods promote identification
of user needs and translation of these into product specifi-
cations. The first task is aided by heuristics, notably those
discussed by Juran (1992). The latter calls on traditional
design methods as well as QFD, a Japanese technique
tailored to the design of consumer products (King 1989).
Design of experiments and Taguchi methods (Lochner
and Matar 1990) help determine optimal settings of
product parameters. Value and reliability engineering are
collections of heuristics for reducing a product’s cost and
increasing its durability. Reliability engineering encom-
passes failure mode effects analysis, which systematically
considers how a product might fail as part of improving
its design. Simultaneous engineering reduces product
development time by having design work performed in
parallel. Product design draws on the engineering design
literature, but can benefit from methods used in architec-
ture, urban planning, and other design fields ( Jones
1981). Again, most progress is likely to result by exploiting
lessons from experience.
Evaluation and choice. These functions are tradition-
ally addressed by decision-making techniques such as
decision and cost-benefit analysis. TQM, however, has
shown little interest in decision making. Brassard (1989)
proposed the use of prioritization matrices that rank
solution alternatives according to weighted criteria.
Gitlow (1990) discussed glyphs, a graphical means of
32 QMJ 94 Fall
comparing options on various dimensions of value, and
multivoting, a group voting process that converges on a
favored alternative. The latter is often misused, as when
group preference displaces reasoned argument in deter-
mining a course of action. TQM’s neglect of decision
methods is, in fact, justified. Quality problems are not
situations of preference-driven choice. The evaluation of
options does not hinge on which is most preferred, but
rather on which responds most effectively to the situation.
Structured arguments are likely to be of more use than
traditional decision methods.
Implementation. Owing largely to Mizuno (1988),
TQM has been introduced to a set of diagrammatic
methods for planning and implementing problem solu-
tions. Tree diagrams depict a hierarchical decomposition
of general goals into specific activities. Process decision
program charts help identify and plan for contingencies
that can affect a course of action. Activity network dia-
grams are a repackaging of PERT/CPM project planning
methods developed in operations research. While QPS
can entail the implementation of complex projects, there
is nothing unique about project implementation in a
quality context. The methods can be helpful, but the
greater need is to identify difficulties commonly encoun-
tered in TQM implementations, and to develop heuristics
and techniques responding specifically to those challenges.
These methods have limitations, as has been noted
in the TQM literature (Caroselli 1991; Scherkenbach
1986). Certain methods are overused, as practitioners
apply familiar techniques, especially cause-and-effect
diagrams, to problems outside their range (Nemoto
1987). These failings will only grow worse as QPS
addresses more varied and difficult problems. If practi-
tioners must recognize the limitations of existing methods,
researchers must develop powerful new techniques
addressing the full range of quality problems.
 QUALITY PROBLEM SOLVING

IMPROVING QPS: Case-Based QPS

A CASE-BASED APPROACH
This section outlines an innovative approach for improv-
ing QPS. The proposed strategy responds to the central
dilemma of problem-solving methodology: General
methods tend to be weak and nonoperational. Problem-
solving methods achieve power by exploiting characteristics
of situations to which they apply. For instance, linear
programming is a powerful optimization method that
exploits the topology of a feasible region defined by linear
constraints. Stratification takes advantage of the fact that
the instances constituting certain problems can be unevenly
distributed when characterized in certain ways. Unfortu-
nately, no strong general principles define the set of quality
problems, hence no such principles can be exploited by
QPS methods. Like all real-world problems, quality
problems are incredibly varied (Smith 1992). There are
many different causes of failure, ways of reducing costs,
and products and processes to be designed. Many quality
problems, however, have features that can be exploited by
problem-solving techniques. What is needed is a general
problem-solving strategy that encompasses prescriptions
responsive to characteristics of particular problems.
Artificial intelligence researchers must often devise
prescriptions for use in domains that are not defined by
strong general principles. The methodology known as
case-based reasoning (CBR) has emerged in response to
this need. CBR is “a general paradigm for reasoning from
experience” (Slade 1991, 42). The solution to a problem
is derived from experiences with similar situations, rather
Case-based QPS, a strategy for solving quality problems,
resembles the approach adopted in CBR systems. Prior
experience is used to identify problem-solving insights
and solution alternatives. As depicted in Figure 4, expe-
riential learning occurs at various levels of generality
(Cohen and Feigenbaum 1982), with three levels repre-
sented in the figure. A situation can suggest high-level
general rules—such as, identify all possible causes—as
well as specific lessons applicable only to the case at
hand. The most useful insights occupy an intermediate
level of generality. When experiential knowledge is applied
in a new situation (the right side of Figure 4), the value
of intermediate generalizations becomes apparent. In
contrast to particularized, case-specific lessons, the gener-
alizations are applicable to situations other than those in
which they are learned. Unlike high-level generalities, the
case-specific lessons offer real problem-solving power.
Some useful lessons of experience will be more or less general
than others, but most will occupy this intermediate range.
Case-based QPS involves three activities. First, a
large and varied set of experiences of quality problems and
problem solving must be accumulated. Second, lessons at
a useful level of generality must be abstracted from these
experiences. Finally, the lessons must be organized to
make them accessible and usable by practitioners.
Figure 4 Learning from experience.
Levels of
generality Learning Application
High-level Generalities
general lessons aren’t powerful

than from general principles. CBR systems consist of Intermediate

level of Useful lessons
a database of cases and a procedure for retrieving cases generality of experience

pertinent to the task at hand. Such systems have been Situation- Specifics
specific lessons do not apply
Memory
developed for negotiation, planning, and design tasks,
Original Current
among others (Kolodner 1991). experience situation

QMJ 94 Fall 33
 QUALITY PROBLEM SOLVING

Performance of the first task is facilitated by the large lit-
erature of QPS cases; that is, published reports of
attempts to solve quality problems. Such reports can be
found in practitioner journals (for example, Quality
Progress) and in books (for example, Asian Productivity
Organization 1984). Reports can also be found in orga-
nizational records of activities by internal problem-solving
teams. Although some published QPS cases are not
detailed enough to permit the necessary analysis, many
satisfy the requirements for the second step. Here the
task is analytical, to think through each case in order to
identify lessons that could be applied in other situations.
Many cases offer no such insights, since their lessons are
either too situation specific or so general and obvious as
to go without saying. But some cases will yield notewor-
thy problem-solving insights to careful analysis. As these
findings accumulate, it becomes necessary to organize
them in a coherent manner, to make them communicable
to and understandable by QPS practitioners. The lessons
might be organized around problem-solving functions
(for example, problem identification or diagnosis) or the
five types of quality problems. They could also be
grouped in terms of topics, such as unnecessary materials,
excessive search time, and lack of standardized methods.
To demonstrate, case-based QPS will be applied to a
case reported by Walton (1990) and Larson (1990).
Case 1. Management at West Paces Ferry Hospital
in Atlanta believed that the percentage of births by
caesarean section could be lowered. C-section, a more
dangerous and expensive alternative to vaginal delivery, is
intended for use under special circumstances. At one
time, the procedure involved surgical incisions that made
it necessary for subsequent patient deliveries to also be by
C-section. However, improved surgical methods elimi-
nated the “repeat C-section” requirement. Nonetheless,
13 percent of the C-sections performed at West Paces
were repeat C-sections. As a problem-solving team dis-
covered, patients often requested the procedure due to
the mistaken “repeat C-section” assumption.
A number of lessons can be derived from this case.
It illustrates how technical advances are not always incor-
porated into existing practices. Neither the hospital nor
its staff had made a concerted effort to educate patients
as to the non-necessity of repeat C-sections. The case
also demonstrates that the customer is not always right.
Customers can be uninformed about how product/service
alternatives relate to their needs; and, when someone else
(for example, an insurer) is paying the bill, they may not
be motivated to make wise purchasing decisions. Finally,
the case demonstrates the need to ensure that inexpen-
sive processing alternatives are used whenever possible,
with expensive, special-purpose methods being restricted
to circumstances in which they are truly required. This
lesson applies wherever costly express delivery services
are routinely used to send materials that could have been
posted by first-class mail.
None of these lessons were cited by either of the
authors reporting the case. This is typical. The lessons
explicitly expressed in published QPS cases are usually
well-known generalities—for example, satisfy customer
needs. Authors leave it to readers to derive more substan-
tive conclusions. It is unlikely that readers are reliably able
to do so. Even if they could, the lessons are encountered so
sporadically as to be quickly forgotten and never integrated
into a durable understanding. Case-based QPS overcomes
these limitations.
While learning from experience is commonplace,
case-based QPS is an innovative means of developing
useful problem-solving prescriptions. The approach has
some precedents in the quality literature. Shingo (1987)

34 QMJ 94 Fall
 QUALITY PROBLEM SOLVING
illustrated a general problem-solving method with analyses
of specific situations. Benchmarking uses the experiences
of others to improve organizational performance. The case
method of teaching is often employed in management,
law, and other applied fields. But in such applications,
cases are used to illustrate rules and lessons that were
identified by other means. With case-based QPS, the
cases themselves are the origins of insights to be learned.
Cases are the recorded experience from which problem-
solving knowledge can be derived.
The research areas closest to case-based QPS are
offspring of artificial intelligence, these being expertise/
expert systems research and, as noted earlier, work on
CBR. Studies of expertise try to identify the methods
that domain experts use to achieve outstanding levels of
performance. These can then be taught to domain novices.
Unfortunately, it is unlikely that there are true QPS
experts; that is, people proficient at solving the full range
of quality problems. Consequently, the expert strategy for
developing useful knowledge is inapplicable in the QPS
domain. Case-based QPS is similar to CBR in that it
relies on cases, not experts, as a source of knowledge. But
whereas CBR is implemented as a computer program,
case-based QPS is operationalized in natural language, as
a set of verbal prescriptions. And unlike CBR systems
that generate descriptions of situations similar to the task
at hand, case-based QPS provides explicit prescriptions,
not cases, that apply to the current problem. Thus, while
this methodology is not unprecedented, it exhibits a sig-
nificant degree of originality.
Illustrations
To demonstrate what case-based QPS can achieve, results
from a research project will be reported. This ongoing
project had, at the time of this writing, analyzed 629
cases drawn from 203 sources. Obviously, due to space
limitations, only a few of the findings can be reported.
The discussion will illustrate how case-based QPS can
both broaden and deepen QPS practice. The following
case evidences a common process design inadequacy.
Case 2. A Toyota worker was responsible for time-
stamping employee suggestions to indicate when they
were received. This practice dealt with the possibility of
multiple workers submitting suggestions on the same
topic during the same day. Over the years, however,
simultaneous submissions of this kind had never
occurred. (Nemoto 1987)
In this case, an activity is performed to protect against a
rare event. But unless the event is catastrophic, preventive
activities are not worth doing. The case’s lesson can be
described at different levels of generality: Don’t perform
unnecessary activities; don’t perform activities that guard
against rare but noncatastrophic events; and don’t time-
stamp employee suggestions. As suggested by Figure 4, the
first is too general to be useful and the last too specific to be
broadly applicable, while the second is an intermediate-
level prescription that has value in many situations.
Multiple lessons can be drawn from a single case,
and the same lesson can be evidenced by multiple cases.
Consider the following:
Case 3. A manufacturer planned to purchase addi-
tional polishing machines because its six existing machines
could not keep up with the workload, despite extensive
overtime. Each polishing operation required 11 passes.
Investigation revealed that the preceding milling operation
was leaving excessive stock to avoid overcuts. By control-
ling the milling operation more precisely, the amount of
excessive stock was reduced so that only three polishing
passes per item were required. The number of polishing
machines was reduced from six to two. (Shingo 1987)
QMJ 94 Fall 35
 QUALITY PROBLEM SOLVING
Case 4. An auto screw machine for turning bolts was
experiencing 69 percent rejects. The bolt diameter speci-
fication was 0.250
0.000 inches/ 0.003 inches.
Believing the machine inadequate for the job, management
considered buying a new one. A frequency distribution of
bolt diameters indicated clustering around the upper
specification limit. Operators aimed at that limit to avoid
scrap: Oversized bolts could be machined down; under-
sized bolts were lost. After operators were told to aim for
the midpoint of the tolerance range, rework vanished.
(Prasad 1982)
Case 3 illustrates the need for precise control of opera-
tions, a tendency for upstream processors to allow them-
selves slack at the expense of downstream efficiency, and
the need to use the most efficient operation for a function
(milling removes stock more efficiently than polishing).
The last lesson was also drawn from case 1, concerning
C-sections at a hospital. Moreover, cases 3 and 4 are
both situations in which operators created extra work by
trying to avoid losses. The cases illustrate a trade-off
between over- and undercosts, between doing too much
of something and not doing enough. The same trade-off
commonly leads people to make too many copies of
handouts for a meeting.
Case-based QPS can be used to elaborate concepts
that play important problem-solving roles and to identify
ways in which such concepts show up in real situations.
For instance, the notion of cause, central to diagnosis
tasks, has been expanded by cause-and-effect diagrams,
which identify men, machines, materials, measurements,
and methods (the five Ms) as generic causes. Case-based
QPS allows further development of this kind. Cases
indicate that the men category includes failings due to
perceptual difficulties, inattention, lack of training, and
inadequate motivation. Material causes include the use of
36 QMJ 94 Fall
shoddy materials, yield loss, impurities, materials han-
dling, and inefficient waste processing.
Or consider the concept of slack, made famous by
the rocks-in-the-river analogy often cited in arguments
for lean inventory production methods. Inventory is but
one form of slack, one way in which people and processes
are insulated from the consequences of mistakes. The
Tennant Company learned that space is a form of slack.
When it eliminated plant floor space for machines await-
ing rework, the volume of defective machines declined
significantly (Hale, Hoelscher, and Kowal 1989).
Milliken Contract Carpets created slack through a liberal
customer allowance policy for off-quality product.
Manufacturing performance only improved when the
mill was forced to deal with substandard carpeting it had
produced (Williams 1992). Slack allowances can be
designed into a product, as with the bumper shims that
Ford used to aid bumper alignment on new cars. Since
Japanese cars didn’t include such allowances, parts had to
be manufactured with less variation (Peterson and
Hillkirk 1991). Slack is also evidenced by case 3, in
which milling operators created inefficiencies by allowing
themselves excessive room for error. By demonstrating
the many ways in which a concept like slack can be
instantiated, case-based QPS can help practitioners use
the concept effectively.
Cases illustrate alternative solutions to common
concerns. Consider the problem of managing a resource
(for example, tools or blueprints) needed at different
times by different parties. One approach is to establish a
central location for the resource and a checkout system
allowing users to take items to their work areas. This has
been augmented in some companies by end-of-the-day
policing that ensures items are returned to the central
store. Taking a daily inventory can be aided by tool
boards and visual displays that indicate if something is
 QUALITY PROBLEM SOLVING
missing. Deleting unneeded items from the pool increases
the efficiency of resource management; adding high-use
items increases operating efficiency. Employees at
Firestone Tire and Rubber did a study to determine the
optimal number of machine cranks to provide and where
to position them among the plant’s 84 machines (Filley
1982). When the resource is information, a silver bullet
technological solution may be available: The IRS
replaced printed job announcements with an electronic
version that allowed many applicants simultaneous access
through computer terminals (Curry and France 1990).
The same solution would work in a medical center that
was having trouble scheduling patients in a single
appointment book (Lange 1991, 125–131).
Often there are two or more standard solutions to a
problem that apply under different circumstances. Case-
based QPS can help identify the situations in which each
solution is most effective. A classic issue in job design is
the degree of task specialization: Should an operator per-
form one task many times or a series of related tasks a
number of times? The issue is important in service oper-
ations, where handoffs between specialized service
providers often result in reduced customer satisfaction.
Hammer’s (1990) account of how the processing of
insurance applications was reengineered at Mutual
Benefit Life supports a process in which each operator
handles all requirements for a customer or case. On the
other hand, Wright (1992) describes a situation at
Schlumberger in which such an approach led to increased
errors: Some operations required skills that most workers
could not easily acquire. Thus, the benefits of repetition-
based expertise should not be ignored. On the other hand,
when tasks are relatively simple but there are serious infor-
mation losses and coordination costs if multiple specialists
are used, it is best to have operators handle more of a
product or customer transaction.
Prospects
Case-based QPS is not a problem-solving technique in the
traditional sense. It is not an n-step method specifying a
prescribed problem-solving process. As argued earlier, it
is unlikely that traditional methods can be both general
and powerful. Rather, case-based QPS offers a compre-
hensive set of prescriptions having varying degrees of
generality. Organized into a coherent framework, these
lessons will be accessible to QPS practitioners and
researchers alike. Practitioners can add their experiences
to the emerging body of cases. Researchers can identify
areas that lend themselves to improvement through
scientific investigation.
Case-based QPS promises a significant advance over
the existing state of practice. Currently, the lessons of
experience go largely unrecognized. Whatever conclusions
are drawn are not validated against each other or inte-
grated into a common framework. An invaluable body of
experiential knowledge remains undeveloped, at the level
of anecdote. Owing to resource limitations, traditional
scientific research programs cannot develop a complete
set of problem-solving prescriptions. Case-based QPS
provides an alternative methodology. It is a scientifically
legitimate means of developing useful knowledge from
the readily available raw material of experience.
Case-based QPS can be used to develop relatively
specific accounts of problem solving, say, at a company or
process level. Some organizations have taken steps in this
direction. After Hewlett-Packard decentralized customer
support activities in the early 1980s, a study revealed that
support employees were repeatedly solving the same cus-
tomer problems. Thus, Hewlett-Packard established two
nationwide response centers, backed by sophisticated
communications and tracking systems. As a result, a solu-
tion to one customer’s problem is instantly available to
QMJ 94 Fall 37
 QUALITY PROBLEM SOLVING
any other customer, anywhere, who has the same problem.
Hewlett-Packard estimated that this system generated
savings of $12.5 million over three years (Young 1990).
It may also be possible to implement case-based
QPS in a knowledge-based system, much like case-based
reasoning. Such a system would elicit a description of the
current problem and respond with case-based prescrip-
tions. It might also cite specific cases that illustrate how
its prescriptions are applicable. The key challenge in
developing a CBR system is devising an indexing scheme
that allows the system to identify cases relevant to the
situation at hand (Kolodner 1993). This challenge is
even more daunting for case-based QPS, owing to the
much larger range of problems that such a system would
address. The task of devising a conceptual scheme for
characterizing past cases and current problems is indeed
formidable. Nonetheless, the eventual development of
intelligent case-based QPS systems can be anticipated.
SUMMARY AND CONCLUSIONS
This article has identified quality problem solving as a
major component of TQM. While TQM has supported
problem solving, it has often viewed it too narrowly as a
matter of finding and fixing defects. An expanded notion
of QPS was developed around five types of quality prob-
lems. Each type poses characteristic demands regarding
problem identification and solving. Existing QPS methods
connect to different problem types and functions. A
review of these methods indicated that they often sacri-
fice power and operationality for generality. To remedy
this deficiency, case-based QPS was proposed and illus-
trated. It is a general methodology that achieves power
by extracting useful insights and prescriptions from
analyses of past cases. The methodology exploits the siz-
able published literature of QPS cases. It provides a
38 QMJ 94 Fall
means of formalizing and integrating the lessons that
QPS practice has to offer.
REFERENCES
Agre, G. P. 1982. The concept of problem. Educational
Studies 13, no. 2:121–142.
Asian Productivity Organization. 1984. Quality control
circles at work. Tokyo: Asian Productivity Organization.
Bajaria, H. J., and R. P. Copp. 1988. Quality improve-
ment: In front of live problems. In ASQC quality con-
gress transactions. Milwaukee: American Society for
Quality Control.
Bhote, K. R. 1991. World-class quality: Using design of
experiments to make it happen. New York: AMACOM.
Brassard, M. 1989. The memory jogger plus+. Methuen,
Mass.: GOAL/QPC.
Burr, J. T. 1990. The tools of quality. Part I: Going with
the flow (chart). Quality Progress 23, no. 6:64–67.
Caroselli, M. 1991. Total quality transformations:
Optimizing mission, method, and management. Amherst,
Mass.: Human Resource Development Press.
Cohen, P. R., and E. A. Feigenbaum. 1982. The hand-
book of artificial intelligence. Vol. 3. Los Altos, Calif.:
Walter Kaufmann.
Crosby, P. B. 1989. Let’s talk quality. New York: Penguin.
Curry, M., and J. France. 1990. Meeting the quality
improvement challenge with teamwork. Journal of
Quality and Participation ( July-August): 42–45.
Deming, W. E. 1982. Out of the crisis. Cambridge, Mass.:
MIT Center for Advanced Engineering Study.
Ebel, K. E. 1991. Achieving excellence in business: A practi-
cal guide to the total quality transformation process.
Milwaukee: ASQC Quality Press.
 QUALITY PROBLEM SOLVING
Filley, R. D. 1982. IEs help companies plan and imple-
ment better methods, more productive systems.
Industrial Engineering (May): 56–72.
Gaudard, M., R. Coates, and L. Freeman. 1991. Acceler-
ating improvement. Quality Progress 24, no. 10:81–88.
Gitlow, H. S. 1990. Planning for quality, productivity, and
competitive position. Homewood, Ill.: Dow Jones-Irwin.
Goodmeasure, Inc. 1988. Solving quality and productivity
problems: Goodmeasure’s guide to corrective action.
Milwaukee: ASQC Quality Press.
Hale, R. L., D. R. Hoelscher, and R. E. Kowal. 1989.
Quest for quality. Minneapolis: Tennant Company.
Hammer, M. 1990. Reengineering work: Don’t automate,
obliterate. Harvard Business Review ( July-August):
104–112.
Hammer, M., and J. Champy. 1993. Reengineering the
corporation. New York: HarperCollins.
Harrington, H. J. 1991. Business process improvement.
New York: McGraw-Hill.
Imai, M. 1986. Kaizen: The key to Japan’s competitive suc-
cess. New York: McGraw-Hill.
Ishikawa, K. 1989. Introduction to quality control. London:
Chapman & Hall.
Jones, J. C. 1981. Design methods. New York: John Wiley
& Sons.
Juran, J. M. 1986. The quality trilogy: A universal
approach to managing for quality. Quality Progress 19,
no. 8:19–24.
———. 1992. Juran on quality by design. New York: Free
Press.
Juran, J. M., and F. M. Gryna, Jr., eds. 1988. Juran’s quality
control handbook. 4th ed. New York: McGraw-Hill.
Kepner, C. H., and B. B. Tregoe. 1981. The new rational
manager. Princeton, N.J.: Princeton Research Press.
King, B. 1989. Better designs in half the time: Implementing
QFD—Quality function deployment. Methuen, Mass:
GOAL/QPC.
Kolodner, J. L. 1991. Improving human decision making
through case-based decision aiding. AI Magazine 12,
no. 2:52–68.
———. 1993. Case-based reasoning. San Mateo, Calif.:
Morgan Kaufmann.
Lange, W. B. 1991. System analysis can improve quality of
health care. In 45th annual quality congress transactions.
Milwaukee: American Society for Quality Control.
Larson, K. 1990. Hospital trustees lead quality efforts.
Quality Progress 23, no. 4:31–34.
Lewin, K. 1951. Field theory in social science. New York:
Harper & Row.
Lochner, R. H., and J. E. Matar. 1990. Designing for
quality. White Plains, N.Y.: Quality Resources.
Melan, E. H. 1985. Process management in service and
administrative operations. Quality Progress 18, no.
6:52–59.
Meyer, M. 1990. Solving chronic quality problems. Quality
Progress 23, no. 5:37–42.
Mizuno, S. 1988. Management for quality improvement:
The seven new QC tools. Cambridge, Mass.:
Productivity Press.
Nemoto, M. 1987. Total quality control for management.
Englewood Cliffs, N.J.: Prentice Hall.
Newell, A. 1969. Heuristic programming: Ill-structured
problems. In Progress in operations research, edited by J.
Aronofsky. Volume 3. New York: John Wiley & Sons.
QMJ 94 Fall 39
 QUALITY PROBLEM SOLVING
Peterson, D. E., and J. Hillkirk. 1991. A better idea.
Boston: Houghton Mifflin.
Prasad, C. R., ed. 1982. Statistical quality control and
operational research. Calcutta: Indian Statistical Institute.
Reitman, W. R. 1964. Heuristic decision procedures:
Open constraints and the structure of ill-defined prob-
lems. In Human judgment and optimality, edited by
M. W. Shelly and G. L. Bryan. New York: John
Wiley & Sons.
Robson, G. D. 1991. Continuous process improvement.
New York: Free Press.
Robson, M. 1988. Quality circles: A practical guide. 2d ed.
Aldershot, England: Gower.
Rummler, G. A., and A. P. Brache. 1990. Improving per-
formance. San Francisco: Jossey-Bass.
Scherkenbach, W. W. 1986. The Deming route to quality
and productivity. Washington, D.C.: CEE Press Books.
Schonberger, R. J. 1986. World-class manufacturing. New
York: Free Press.
Shingo, S. 1987. The sayings of Shigeo Shingo: Key strategies
for plant improvement. Cambridge, Mass.: Productivity
Press.
———. 1989. A study of Toyota production system from an
industrial engineering viewpoint. Cambridge, Mass.:
Productivity Press.
Slade, S. 1991. Case-based reasoning: A research para-
digm. AI Magazine 12, no. 1:42–55.
Slater, R. 1991. Integrated process management. New York:
McGraw-Hill.
40 QMJ 94 Fall
Smith, G. F. 1989. Defining managerial problems: A
framework for prescriptive theorizing. Management
Science 35, no. 8:963–981.
———. 1990. Heuristic methods for the analysis of man-
agerial problems. Omega 18, no. 6:625–635.
———. 1992. Towards a theory of managerial problem
solving. Decision Support Systems 8, no. 1:29–40.
———. 1993. The meaning of quality. Total Quality
Management 4, no. 3:235–244.
Smith, G. F., and G. J. Browne. 1993. Conceptual foun-
dations of design problem solving. IEEE Transactions
on System, Man, and Cybernetics 23, no. 5:1209–1219.
Walton, M. 1990. Deming management at work. New
York: Perigee.
Williams, M. 1992. Wall to wall commitment. TQM
Magazine 4, no. 5:315–318.
Wilson, P. F., L. D. Dell, and G. F. Anderson. 1993. Root
cause analysis: A tool for total quality management.
Milwaukee: ASQC Quality Press.
Wright, A. 1992. Quality assurance in cell assembly.
Quality Forum 18, no. 3:138–144.
Young, J. A. 1990. Focused on quality. Journal of Quality
and Participation ( January-February): 36–39.
Gerald F. Smith is an instructor in the Information and Decision Sciences
Department at the Carlson School of Management, University of
Minnesota. He earned a doctorate in decision sciences at the Wharton
School, University of Pennsylvania. Smith may be contacted at the
Information and Decision Sciences Department, Carlson School of
Management, University of Minnesota, 271 19th Avenue South,
Minneapolis, MN 55455; 612-624-9806.