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BSNS 6351 Quality Management

Assignment Two

Investigation into quality management systems, techniques and tools in business situations

Prepared By: Kendal Johnson For: Jeffrey Marriot Date: 2nd June 2011

1.0 1.1 1.2 1.3 Quality Systems Defined ....................................................................................... 3 Quality System Training and Implementation ........................................................ 3 ISO9000, ISO1400 and TQM Systems ................................................................. 4 Quality Tools The Old Seven ............................................................................ 7 Cause and Effect Diagrams ............................................................................ 8 Check Sheets ................................................................................................. 9 Control Charts .............................................................................................. 10 Histograms ................................................................................................... 10 Pareto Charts ............................................................................................... 12 Scatter Diagrams .......................................................................................... 12 Flow Charts .................................................................................................. 13

1.3.1 1.3.2 1.3.3 1.3.4 1.3.5 1.3.6 1.3.7 1.4 1.5 2.0 2.1

Six Sigma ............................................................................................................ 14 Quality Awards, Baldrige Award Purpose and Role ......................................... 14 Hospital strives to restore faith in service ............................................................ 15 Quality Problems ................................................................................................. 17 Cannot Supply Demand ............................................................................... 17 Management commitment to get government resources .............................. 18 Management of Patients ............................................................................... 19 Staff Hiring and Training ............................................................................... 19

2.1.1 2.1.2 2.1.3 2.1.4 2.2

Quality Solutions ................................................................................................. 20 Plan, Do, Check, Act ................................................................................... 20 Quality Tools................................................................................................. 23 Technology ................................................................................................... 23

2.2.1 2.2.2 2.2.3

2.2.4 Quality of Management..................................................................................... 24 References: ............................................................................................................... 25

Examination of the various quality systems that are appropriate to New Zealand organisations


Quality Systems Defined

A quality system is the overall approach an organisation uses to carry out quality management. It contains guidelines on what is to be done and who is to do it. Its objectives are to satisfy customers, align the product or service with the organisations strategy and make continuous improvements. This can be more clearly defined by Goetsch & Davis (2011): The quality management system is composed of all the organisations policies, procedures, plans, resources, processes and delineation of responsibility and authority, all deliberately aimed at achieving product or service quality levels consistent with customer satisfaction and the organisations objectives. When these policies, procedures, plans and so forth are taken together, they define how the organisation work and how quality is managed. Using this concept there have been many people, organisations and collective groups that have developed and implemented a quality system of some sort. Some choose to adopt the principles used by theorists and successful organisations; others may choose to develop their own unique system that works for their specific organisation. The following will look into some of the quality systems that are appropriate for New Zealand organisations.


Quality System Training and Implementation

The New Zealand Organisation for Quality (NZOQ), which is a non-profit professional society, dedicated to providing leadership in the adoption of the principles of quality management and best practice in New Zealand. (NZOQ, 2011). Although it is not a Quality Management System, it is recognised as facilitating the education and promoting best practices for other New Zealand organisations to compete with world class business performance. It offers training in the following areas: Quality Assurance, Systems Auditing, Internal Auditor Training, Internal Auditor Online, Practical Quality Management Skills, Quality in Healthcare, Project Management, ISO 31000 Risk Management, ISO14001 Environmental Management, ISO9001 Management Briefing and Lean Six Sigma. (NZOQ, 2011). The NZOQ is one of many organisations that offer some form of training in quality management. Examples of other organisations involved

with quality training are; The Ministry of Education, New Zealand Qualifications Authority (NZQA), New Zealand Qualifications Framework (NZQF), Universities, Polytechnics and many others. It is important to recognise this aspect of the process because proper training allows organisations to implement quality systems with employees that are educated in the area of quality. Education promotes employee empowerment and puts them in a better place to take on decision making and autonomy of their role whatever level of the organisation they might be in. The training courses teach people how to use tools that are found in many quality systems e.g. charts, cause and effect diagrams, check sheets, histograms and many more. They learn not only how to use them but how to use them for decision making. In any situation if you are going to give someone tools to work with you must also give them training in how to use the tools. So how does an organisation know which quality management tools to use in order to create the optimal quality system for them? Ideally it will be a process of implementing tools and creating systems with an openness to change. It is reasonable to say that a quality system is developed with the intention to improve over time and direct all organisation resources towards attaining a product or service that meets customer requirements and continuous improvement. The organisation might not choose the right combination of tools to use from the beginning, however the system can be checked and changes made to improve it, also making sure that it complements the organisations mission and strategy. The size of the organisation also has a huge part to play in how large or detailed the quality system is. For smaller organisations there may not be the need or resources to focus much attention towards a quality management system e.g. a corner dairy or a stall holder at the local market. A larger company or one that has a product or service that has a unique design for each customer may need a more extensive quality system in place e.g. Pharmaceutical companies or law firms. The following will investigate some widely used quality systems that are appropriate for organisations in New Zealand.


ISO9000, ISO1400 and TQM Systems

ISO is the International organisation for standardisation. It is the largest developer and publisher of international standards operating with a framework of 162 countries coordinated by a central secretariat in Geneva, Switzerland. ISO enables a consensus to

be reached on solutions that meet both the requirements of business and the broader needs of society (ISO, 2011). For many New Zealand organisations competing in the international market, having an internationally recognised and standardised system will be a competitive advantage. Having a widely recognised system or accreditation can give customers confidence that the product or service will arrive to them in the highest possible standard and at a low price since waste is minimised. The ISO9000 family focuses on what the organisation does to fulfil the customers quality requirements and applicable regulatory requirements while aiming to enhance customer satisfaction and achieve continual improvement of its performance in pursuit of these objectives. (ISO, 2011). This system is applicable to any organisation whether it is in the private or public sector. It can work for organisations of all sizes and applies to the facets of the organisation that can have an impact on the product or service quality. ISO 9001 is the only standard in the family against which organisations can be certified. It is based on eight principles from total quality management (TQM): 1. Customer Focus Understanding needs, meeting requirements and exceeding expectations 2. Leadership Establish unity of purpose and organisational direction. Promote employee involvement in achievement of objectives. 3. Involvement of People Take advantage of fully involved employees, utilise all their abilities to the organisations advantage. 4. Process Approach Things accomplished are a result of processes. Processes along with related activities and resources must be managed. 5. System Approach to Management Multiple interrelated processes that contribute to an organisations effectiveness are a system and should be managed as a system 6. Continual Improvement Should be a permanent objective applied to the organisation and to its people, processes, systems and products. 7. Factual Approach to Decision Making Decisions must be based on the analysis of accurate, relevant and reliable data and information. 8. Mutually Beneficial Supplier Relationships Both organisation and Supplier benefiting from each others resources and knowledge result in value for all. (Goetch & Davis, 2010)

A research undertaken by Canterbury University and NZOQ looked into the type size, spread and benefits of adopting ISO 9000 in New Zealand. They found out the key statistics showed why it is beneficial to implement the system. NZ ISO 9000 certified companies are motivated to get ISO 9000 certification because of improved quality, marketing benefits and improved corporate image. The benefits gained after the ISO 9000 certification seem to be largely of internal nature such as improved internal procedures and improved quality. NZ patterns of ISO 9000 certification are comparable with patterns identified in other developed countries such as US, Australia, France. (Castka, Balzarova and Kenny, 2006). No organisation is required by government to achieve ISO9001 accreditation. Some organisations may encourage or require their suppliers to be ISO 9000 registered to keep their own product under the system throughout the whole supply chain, however it is the choice of management whether to adopt ISO9000 or not. Management must be involved and support the system entirely as they lead the culture of this system feeding it right down through the whole organisation. It is important that managements motives to implement ISO 9000 are appropriate. Ideally management will adopt ISO 9000 as a way to make real improvements in the companys operations, service its customers in a more responsible way, and, as a result, be more successful (Goetsch & Davis, p.342). Implementing it to look good just for a marketing point of view will not work. TQM stands for Total Quality Management. This idea was created in Japan during the 1950s with the help of ideas from Dr. Walter Shewhart and Dr. W. Edwards Deming. Japan needed to recover their place in the international market after World War II and create a new confidence in their U.S. customers that their products were of high quality. The Plan, Do, Check, Act cycle was developed with a function to operate as a neverending loop of continual improvement. The cycle made its way to ISO 9000 and is said to be the operating principle of ISOs management system standards. (Goetsch & Davis,p.334). Total Quality Management came before ISO standards. They originated independently from each other at different times in different places in the world. ISO was developed in response to a growing need to harmonise dozens of national and international standards. The relationship between TQM and ISO 9000 is that they work in conjunction with each other but are not the same. The main point of difference being that TQM is concerned

with transforming every function and level of the organisation from top to bottom to adopt teachings of Deming, Juran, Ishikawa, and others with criteria defined by Demings fourteen points, Jurans ten steps to quality improvement and the Malcolm Baldrige National Quality Award, it is more pervasive and demanding (Goetsch & Davis, p.340). ISO 9000 is more specific being concentrated on quality management systems alone. ISO 9000 can be part of a larger total quality management environment but it can also be implemented on its own in organisations that have not adopted TQM. ISO 14000 is worth mentioning as it is concerned with Environmental Management. Its aims are to minimize harmful effects on the environment caused by its activities, and to achieve continual improvement of its environmental performance (ISO, 2011). This is beneficial for New Zealand environment but also impacts the view that the employees, external stakeholders and the community have on an organisation. This is appropriate for many New Zealand organisations who like to portray an image of being environmentally responsible. Some problems that may occur when TQM and other quality systems are implemented are; Lack of co-ordination between systems, differences in philosophy of different systems (cant ensure systems are followed), multiple audits for multiple systems audit fatigue and lots of resources being expended maintaining various systems (CQA, p.5.24, 2006). As stated earlier, creating a quality management system is a process of change. Being open to problem solving, trying new ideas and where possible seeking simple solutions. Teams work to reduce, eliminate and prevent quality deficiencies through continual improvement. This is where we can examine some quality tools used in the quality management field.


Quality Tools The Old Seven

Dr. Kaoru Ishikawa, a professor of engineering at Tokyo University, believed that there were seven basic tools of quality that were indispensible. They support a management by facts approach, where every decision or solution to a problem is carefully analysed using appropriate analysis of relevant data, rather than making quick decisions based on gut feelings and experience. (Goetsch & Davis, 2010). These tools are appropriate to any New Zealand organisation and used correctly embrace the implementation of quality management systems. They are commonly known as; 1) Cause and effect

diagram (also called Ishikawa fishbone chart, 2) Check Sheets, 3) Control Charts, 4) Histograms, 5) Pareto Charts, 6) Scatter Diagrams and 7) Flow Charts.

1.3.1 Cause and Effect Diagrams

Invented by Dr Kaoru Ishikawa, it is sometimes referred to as the Ishikawa Diagram or Fishbone Diagram, since its shape resembles the skeleton of a fish. This is used by teams as a kind of brainstorming template to identify and isolate root causes of a problem. Below is an example of a cause and effect diagram used by the American Society for Quality (ASQ):

These diagrams produce a picture of the processes that make up the system creating the product or service. It enables you to easily see the relationships between the possible major and minor causes of a problem. The spine points to the effect, which in this diagram is iron in product. The ribs represent causes are assigned to what are considered major factors leading to the effect. The minor factors leading to the effect, branch off the ribs. As seen above the major causes can be broken into six categories; measurements, materials, methods, machines, manpower and the environment. As stated by Goetsch & Davis (2010) The key to the diagrams usefulness is that it is very possible that no one individual had all that knowledge and information. That is why cause-and-effect diagrams are normally created by teams of people widely divergent in their expertise. Teamwork is the idea behind Demings 9th point which is to break down barriers between staff areas. It is good practice for any organisation to utilise the skills

of all their employees and encourage departments to work together. Quality management promotes the wisdom of many over the knowledge of one.

1.3.2 Check Sheets

Check sheets are used primarily to collect data. They can take on many forms and the only requirements are that data entry only requires a check mark and the data must be easily translated into useful information. Manually collecting the data is usually the responsibility of the operator. If this collection is a part of managing the business or improving quality, something more organised can not only increase the reliability of the data, it can also save time in creating data and charts that are immediately useful (Syque, 2011). Below are some examples of different check sheets retrieved from Syque Quality (2011):


Tally Chart

Location Deciding what sort of data you need isPlot first step in designing a form that fits the type the of data to be collected and suits the people that have to use it. Check sheets must be tested by someone else that was not involved in the design of the sheet. Revise the

sheet as necessary and finally design a tally sheet to summarise the data from individual forms (if necessary). (Goetsh & Davis, 2010)

1.3.3 Control Charts

Control charts are made of data plotted on graphs to record or show how a process changes over time. It has a line in the centre representing the average. It has an upper line marking the upper control limit and a lower line marking the lower control limit. These lines are created using historical data and are used to monitor the current process to ensure it stays within the specified control limits. Similar to this is a Run Chart, which also displays trends in data over time except a run chart does not have upper and lower limits. The usefulness of having the upper and lower limits in a control chart is being able to detect the special causes from the common causes. It also sends a signal that something is wrong if the line penetrates either of these limits or has several points in a row above or below the average line. This gives you a better chance to prevent the problem from occurring rather than detecting it afterwards. An example of what a control chart looks like:

Source: Washington Interactive Training Guides (2011)

1.3.4 Histograms
A histogram shows frequency distributions. That is how many over what spread. The shape of the distribution conveys important information about the data. This statistical method of displaying data usually requires some form of training or at least a basic

understanding in statistics to interpret. According to the American Society for Quality (ASQ) 2011, histograms are used: When the data are numerical. When you want to see the shape of the datas distribution, especially when determining whether the output of a process is distributed approximately normally. When analyzing whether a process can meet the customers requirements. When analyzing what the output from a suppliers process looks like. When seeing whether a process change has occurred from one time period to another. When determining whether the outputs of two or more processes are different. When you wish to communicate the distribution of data quickly and easily to others. An example of a Histogram used in a New Zealand Banking Organisation is from the Westpac Banking Corporation, 2009:

The histograms are a useful tool to determine when a market price is statistically stretched, and therefore more likely to revert towards the mean. It can indicate useful contrarian market signals but the distribution should have a normal, or bell shape, so that statistical inferences have validity. (Westpac Banking Corporation, 2009)

1.3.5 Pareto Charts

The Pareto Chart is named after Italian economist and sociologist Vilfredo Pareto who had the insight to recognise that in the real world a minority of causes lead to the majority of problems. (Goetsch & Davis, p.352). The theory suggests that hat 80 percent of the problems stem from 20 percent of the causes. The purpose of a Pareto chart is to show the organisation where to put its resources by identifying the significant few causes of problems from the trivial many. It sorts the data in the form of a bar graph from largest to smallest so that the biggest problems can be identified and addressed first. It often has a line indicating the cumulative percentage.

Source: (2008) This tool saves organisations wasting valuable resources and keeps cost to a minimum so that the product or service can be delivered to the customer at a competitively low price.

1.3.6 Scatter Diagrams

This is the simplest of the seven tools and is used to determine the correlation (relationship) between two variables. One variable is labelled on the x axis and one on the y axis. If there is a obvious linear relationship (straight line) it means it is very likely that there is a correlation between the variables. If the scatter plot is spread out over the graph it indicates there is little or no correlation. The closer the data points get to forming a straight slope, either upward or downward the stronger the relationship between the two variables. Here is an example from the New Zealand Ministry of Education (2010): The actual weights and self-perceived ideal weights of a random sample of 40 female university students enrolled in an introductory Statistics course at the University of Auckland are displayed on the scatter plot below.

This graph shows a positive linear correlation. As actual weight increases so does ideal weight.

1.3.7 Flow Charts

Flowcharts are a graphic representation of a process and have been promoted by both Deming and Juran. Creating a flowchart is a necessary step in improving a process. It can be revealing to ask several different team members to flowchart the process and identify any difference in the understanding of the process as this could be a significant problem. Another strategy is to ask them to flow chart the current process and then flowchart how they think it should be. This can help identify causes of problems and suggest improvement possibilities (Goetsch & Davis, 2010). Flowcharts use an internationally recognised set of symbols to represent the various actions, inputs and outputs. Flowcharts can be as simple or complex as needed. The following is a very simple flowchart created by Biosecurity NZ (2010) illustrating the process for when a member of the public has a suspected Didymo find:


Six Sigma

Introduced by Motorola in the mid 1980s, the purpose of this innovative concept is to improve process performance to the point where the defect rate is less than 3.4 per million. (Goetch & Davis, 2011). It is a widely used quality tool, however is more appropriate for manufacturing rather than service industries.


Quality Awards, Baldrige Award Purpose and Role

National Quality Awards have been created to motivate and encourage organisations in both the private and public sectors to adopt a quality culture. Quality awards recognise organisations that demonstrate exemplary performance in the way they run their business; the quality of their goods and/or services and the delivery of ever-improving value to customers resulting in improved marketplace performance (CQA, p.7.1, 2006). The Baldrige Award is named after Malcolm Baldrige who was the Secretary of Commerce and an advocate of quality management as a key to U.S. prosperity and sustainability in the early 1980s. He was killed in a rodeo accident in July 1987, Congress named the Award in recognition of his contributions (NIST, 2010). The Baldrige Award and TQM are similar in the fact they depend on ideas from Deming, where it is essential for managers to develop profound knowledge of quality. The Baldrige Award and ISO 9000 are similar where they are both orientated to customer, process and continuous improvement. Other Quality Awards that are applicable to New Zealand organisations are the New Zealand Business Excellence Awards (NZBEA) and the Performance Excellence Study Awards (PESA). When the Criteria of the Baldrige Award changes so do both of the New Zealand awards (CQA, 2006) Although the primary purpose of quality awards is to educate organisations in the practices of quality, it can also be motivation to strive to become the best they can be. As Chris Leavy, Plant Manager at the Toyota Thames Assembly Plant (Winner of the NZ Quality Award 1993), Stated: ISO certification is like getting a licence to drive but it does not necessarily make you a good driver. It is only a starting point (CQA, p.7.3, 2006). This is where benchmarking can be useful. Its objectives are to majorly improve the organisations performance by focussing on processes. This is done between consenting organisation by comparing with a best-in class performer. (Goetsch & Davis)

Applying appropriate Quality Tools to a New Zealand Organisation with Quality Problems


Hospital strives to restore faith in service

North Shore Hospital is trying to restore faith in its services following a spate of medical horror stories. In early May 2011 60-year-old grandmother Shirley Curtis died at the hospital after a nurse gave her 10 times the prescribed dose of a beta blocker. Waitemata DHB admitted the dosage was wrong but it is waiting on investigations to determine the cause of death. However the case prompted other potentially fatal mistakes to come out of the woodwork (TVNZ, 2011). On Saturday May 14th (2011) North Shore Hospital admitted to TVNZ ONE News the nature of many other serious problems that had occurred with patients in their care:

1. Graeme Griffiths was gravely ill with cancer and passed without the dignity he deserved. He was soaked up to the chest in urine and the nursing staff would say that they changed him when they clearly hadnt. His medication was forgotten, he was starved while awaiting tests one day and on another occasion left unattended in the shower for 30 minutes. The staff found him unconscious in the shower and thought he had died. He eventually died at age 65 in may 2010. When the family complained, North Shore Hospital sent an apology letter back admitting the care was substandard. 2. Tony Ciora was admitted in November 2008 with a fractured back. He was given Panadol, a gastric injection in the stomach, an intravenous antibiotic and a blood thinner. But all this was actually another patient's prescription. He was getting his own medication at the time so ended up with a double dose. Cioras family spoke to the nurse who seemed shocked and admitted to a mistake being made, letting them know they were within their rights to complain. When the family pursued this complaint it was dismissed because no incident report was made at the time. The family took it to the Health and Disability commissioner who suggested mediation. The family were stunned by the fact the mistake was covered up.

A report carried out by the health and disability commissioner in 2007 uncovered many more quality problems in its service, in particular elderly patients. The following complaints were revealed (Health and Disability Commissioner, October 2007): 1. Ms A was 82 when she was admitted to North Shore Hospital ECC (Emergency Care Centre) from her rest home on 1 April 2007, with gastric bleeding. She spent 36 hours in ECC. The complaint from her partner was about her care, the lack of communication and support when she was discharged, and two days after her discharge, it was discovered that she had a fractured right hip. Ms A was readmitted to North Shore Hospital on 6 April for surgery to repair the fracture. She died eight days later. 2. Mrs B (81 years) was admitted to the ECC on 6 July 2007 after being airlifted from the United States where she had spent a month in hospital after a severe stroke. She had also suffered a heart attack. Mrs B was transferred to ward 11 with breathing difficulties and in heart failure on the afternoon of 6 July, and died there on 14 July 2007. Her son, a doctor, complained that his mothers deteriorating condition and his requests for medical assessment were not given the necessary priority. 3. Mrs C (85 years) was referred to North Shore Hospital on 25 September 2007 by her GP for assessment and treatment of heart problems. After four hours in ECC she was transferred to ward 10. Two days later her condition deteriorated. Her family raised concerns that this was caused by the codeine she had been given. She died on the ward on 28 September 2007. 4. Mr D was 73 when he was admitted as a self-referral to the ECC on 20 September 2007, with hyperventilation, anxiety and a heart condition. He had been diagnosed and treated for lymphoma earlier in the year. Mr D was transferred to ward 11 after six hours in ECC. His family were anxious about his breathing problems and reluctance to eat, and the lack of care. They thought he was dying and were frustrated by a lack of communication about his condition and that the doctors believed he could be rehabilitated. On 18 October, Mr D was discharged to a private hospital at the familys request, but stayed there only hours before being transferred back to North Shore Hospital with an exacerbation of his heart condition. He died in the ECC on 19 October 2007. 5. Mrs E (79 years) was referred to North Shore Hospital on 17 October 2007 by her GP, with possible pneumonia. She spent about 12 hours in ECC where she experienced delays in calls for assistance to get to the toilet. Mrs E was transferred to ward 10. She experienced delays in nursing responses to her calls for assistance, and a lack of hygiene in the ward. Mrs E was discharged home on 19 October 2007 and made a good recovery.

The stories are raising the question of how there could apparently be such frequent systems failures around patient care and administration of medications.


Quality Problems

Quality problems are a result of a failure in the system. In an interview on Close Up, may 18th 2011, the WDHB chairman, Dr Lester Levy, said the paradox of modern health systems is that they are very good but not perfect, and that tiny gap is a place of absolute heartbreak because it can cause devastating impacts; and we have seen one of those in recent times. He was being interviewed after the incident of Shirley Curtis being given 125ml of Beta Blocker instead of 12.5ml. Ultimately the person reading the dose prescribed failed to either notice or see the decimal point. In good quality management, when something goes you should never blame the person, you blame the system. Dr Levy was asked by Close Up if a case like this can be accepted as the odds of human error, he replied: No, if we accept some of these things we will become complacent. We have to battle to reduce and ultimately we have to believe that we can eliminate. The problem being, every time there is a patient, a system and a healthcare professional intercept there is a moment of truth. Healthcare is very routinised and unless healthcare workers take every moment as a new moment of truth, error will happen. Watching this interview it appears the chairman has the right approach to quality, but is this culture feeding down throughout all the staff members at North Shore Hospital? When there are problems occurring, we need to look at the problems in the system and find solutions to make continuous improvement. The following will investigate further into the problems that are occurring.

2.1.1 Cannot Supply Demand

The North Shore Hospital has been put under pressure by a demand for its services far greater than it is built for. This creates longer waiting times for patients, crowded facilities and puts staff under great amounts of stress. Longer waiting times can put patients at risk or distress, crowded facilities carry the risk of cross-contamination or having to turn patients away that are not high priority and adding to this stressed staff are more likely to make mistakes. The report by the Health and Disability Commissioner has identified some key statistics on the subject. Hospitals operate most efficiently when they are, on average, at 85%. In the Auckland region, hospitals are typically at between 95% and 110% occupancy in winter. When a hospital is full, there is a backlog effect, creating overcrowding in the emergency department. This increases risk to

patients. Decreasing the occupancy rate is also important for infection control, to prevent cross-infection and multi-drug-resistant organisms. There is evidence that when emergency departments are more than 90% full, it can result in unnecessary harm to patients and reduced staff morale and retention. (2009, p.7) The North Shore Hospital is under the Waitemata District Health Board (WDHB). The only other hospital in this region is the Waitakere Hospital, which for adults the he ECC is open from 8am to 10pm seven days a week for walk-in patients. After 10pm patients are directed to North Shore Hospital's ECC, or to the Lincoln Rd White Cross Clinic. For children (under 15): 24 hours, 7 days per week (WDHB, 2010). This means ambulances collecting adult patients in the Waitemata region are also directed to North Shore after 10pm.This comes down the the problem of insufficient resources.

2.1.2 Management commitment to get government resources

Up until now, there seems to have been a lack of resources for the North Shore Hospital to upsize in order to meet its increasing demand. Hospitals receive funding through a population based funding formula which is based on the demographical makeup of the area it services. Waitemata DHB has long believed that this formula is inequitable because it gives too much emphasis to the relative wealth of its North Shore population and insufficient recognition to unmet need in Waitakere and the additional costs of serving the rural population in Rodney. It believes it has been (and continues to be) underfunded for the size and demographic make-up of its population and that this is getting worse. (Health and Disability Commissioner, 2009). Insufficient funding means there is a lack of financial resources to make necessary improvements to the quality of service. Quality improvement requires management commitment, so why have they not looked to other revenues in order to get the resources they need. Other hospitals such as Christchurch Hospital and Greenlane Hospital, have cafeterias and gift shops that bring extra revenue. If quality of service is being jeopardised by a lack of financial resources, commitment from top management is needed to solve the problem by finding ways to come up with the necessary money to improve facilities in order to provide a better quality service.

2.1.3 Management of Patients

The hospital has systems in place to direct the flow of a patient through its services. Its efficiency relies on the ability of staff in different departments working cooperatively together whilst competing for limited resources; this in itself is a contradiction. How a patient arrives to the hospital determines the path they follow through the hospital. All patients are seen by a triage nurse on arrival who allocates a code that reflects how
urgently they need to be seen by the ECC medical team. There are four zones in North Shore Hospitals ECC: the Resuss Zone for patients requiring resuscitation or immediate assessment and treatment; the Monitored Zone for those requiring urgent medical attention and/or close nursing monitoring; the Acute Zone where all acute presentations are initially assessed and treated; and the Observation Zone for patients needing short-term, continual care. Patients assessed as needing a hospital bed for 18 hours or less, are kept in the Observation Zone. (Health and Disability commissioner, p.10)

Patients needing a hospital bed can only have one ordered by a member of the relevant specialist team. This would increase their waiting times in ECC if they are always waiting upon another team to arrive and make the decision. It seems there is either a lack of expertise or autonomy with the staff in the ECC department on decisions relating to patient flow through the hospital. This is also compounded often by the fact that there may be no available beds in a ward that a patient needs to be treated in. In this case they are put in another ward and are called outliers, receiving poorer treatment. The house officer is responsible for monitoring the progress of the patients, and their treatment and discharge. The registrar oversees the house officers and provides clinical advice. When there is no house officer for a team, a trainee intern or fifth-year medical student covers the house officer duties. The house officers may cover for other teams if they are a doctor short. There are 5 wards which have between 34 and 36 beds, which can
mean that the on-call house officer is responsible for the welfare of 140 patients (Health

and Disability Commissioner, 2009). That is a lot of responsibility for one person.

2.1.4 Staff Hiring and Training

Insufficient staff numbers at the hospital are a result of a failure in the recruiting process and succession planning. The system used to employ staff should alert managers long before there is a shortage that has an impact on the quality of patient service. Management should have plans in place for when key staffs leave. In the 2007 and 2008 North Shore Hospital had 340 budgeted nursing positions but 59 vacancies, representing a 17%

vacancy in the inpatient wards of the Adult Health Services. Occupancy at North Shore Hospital was at 100% over much of this period. During the winter months and at other peak times in 2006/2007, it was common for average staffing levels in the wards to be one nurse to six to seven patients (or more) during the day and 12 patients at night. (Health and Disability Commissioner, 2009). Inadequate staff means the workload and pressure increases on the remaining staff adding to the drop in morale, risking their health and possibly driving them to find work in better conditions.


Quality Solutions

No quality system, criterion or philosophy will provide the single solution to an organisations quality problems. A sound quality programme can be implemented by an organisation using ISO9001, the Baldrige award with its criteria and TQM only if it actually makes the effort to use the elements and their associated tools to create, maintain and continuously improve real quality (CQA, p.7.2, 2006). North shore hospital can have solutions suggested to improve its quality, the managers can acknowledge their deficiencies in the quality of its service and verbalise their intentions to improve quality but it will require commitment to change which is a thorough process requiring action and consistent follow-up. It demands the North Shore Hospital has a culture change spreading to every staff member in every department. Finding solutions is not just about restoring public image, failure in quality has resulted in people losing their lives; it is a number one priority to take solutions seriously. This means every employee understanding the possible impact they could have if they choose not to follow the procedures and processes put in place.

2.2.1 Plan, Do, Check, Act

This is one of the main two models for solving and preventing problems. Originated by Dr. Walter Shewhart and promoted by Dr. W. Edwards Deming, it is a continual improvement model in the form of a cycle, it keeps going. The second cycle will begin and take into consideration everything that is learned from the first cycle; then there will be a third, fourth etc. (Goetsch & Davis, 2010). For the problems that have occurred in the North Shore Hospital, solutions need to be long lasting and eliminate the possibility of reoccurrence. Using this cycle allows an organisation to get continuous improvements and become closer to meeting the customers expectations every time. The desirable outcome would not only be a safer hospital but also to have people

leaving feeling they had the best possible care while there. Goetsch & Davis (2010) explain the cycle as follows taking the liberty to replace act with adjust: 1. Plan If corrective action is to be taken, a number of activities should be undertaken. Problem must be defined, relevant information gathered, root cause of the problem identified, possible solutions developed and considered, and the best alternative selected for implementation. All of this needs to be done by people carefully selected on the basis of their association with the process involved and their special relevant skills, experience, and so on. 2. Do Implement the solution chosen as best the one most likely to produce the desired result. 3. Check Monitor the implemented solution and gather data relevant to the original problem and any other areas that might be of concern e.g. unintended consequences of the solution. Analyse the data to determine whether the solution eliminated the problem (or made it much less likely to occur). 4. Adjust If the check step confirmed that the problem has been eliminated and that it is not likely to recur, then the job is done. If it was found that the solution has not accomplished the intended result or that there is still a possibility of recurrence, then an adjustment will need to be made to the implemented solution. This can also mean discard the implemented solution and try a different approach. Whether the implemented solution has failed completely or does not quite measure up to expectation, the conceptual adjustment will be carried forward to the plan step of another PDCA cycle. Repeat this as many times as necessary until the problem is solved. Maybe go back and look at the original problem with the insight you have gained prom the process. Looking at the Shirley Curtis case where the wrong dosage of medication was given, the PDCA could be applied as follows. 1. Plan The problem has been defined above as incorrect translation of prescribed medication. The information gathered above in the case stories found the doctor prescribed 12.5ml Beta Blocker and the nurse administered 125ml. To define the root cause of the problem a team or specialists will have to be involved, such as the doctor and nurse involved, specialists that deal with that particular medication and a few more angles of insight by other nurses that work

in similar roles and maybe someone from the organisation that has experience in dealing with documentation and improvement to forms and other communication tools that were used in the process. To find the root cause the team could use root cause analysis in way of the Ishikawa Diagram (Explain earlier in 1.3.1). Breaking the system down into its main factors that affect the outcome and then from there brainstorming the more minor factors that may lead to the incorrect medication dose being given. They need to ask why, why, why, why, why. Making the best use of this planning stage and the precious time these staff have together to address this lots of questions need to be asked to help fill up the Ishikawa diagram maximising the brainstorming process. Once the root cause or causes have been identified solutions can be developed and considered. One suggestion I had was to have upper and lower control limits written next to every medicine that is to be administered. This may mean changes to documentation so they are easier to read, maybe even a way to eliminate the doctors hand writing all together and have it digitally compiled. Check sheets could be made where the medication gets checked not once but by two other staff on a check sheet that needs to be signed and dated for accountability, encouraging them to be through. These are only a few ideas but with a team comprised of specialist people and people that work with the processes every day, Im sure they would have many suggestions on how to improve the process to eliminate the chances of a patient getting the wrong dose of a medicine. 2. Do Implement the solution the team chose. For example with the check sheets stating an upper and lower limit of safe dosages clearly printed in red either side of a box where the doctor can prescribe the medicine for the patient. Or maybe like banks have a form with pre printed decimal places to make it clearer to read. Doctors handwriting is notorious for being untidy. 3. Check Are the check sheets getting used properly, is there enough staff to double check doses are correct. A possible consequence that may have come up is putting more demand on an already overloaded team. However if is it looking like the problem is eliminated or less likely to occur then well done. 4. Adjust; Check if the process has been followed and review its effectiveness to solve or reduce the problem. Can any more changes be made? Is this the right solution?

As this example above has been done, it can be used to investigate and implement solutions for every problem the hospital comes across.

2.2.2 Quality Tools

The North Shore Hospital management should make use of all the 7 Quality tools discussed earlier in this report. Collecting more information and data on the problems that the Hospital is facing is essential. This can be done by; putting up customer comment boxes throughout the hospital, sending patients home with questionnaires about the service to return, asking volunteer staff such as St John Workers who spend a lot of time with patients, asking staff, creating quality circles, looking into historical data on incidents and more. This information can be interpreted into Histograms and Pareto charts which will highlight the areas they need to focus on first. Cause and effect diagrams will help quality teams to identify what the root causes of many problems are. With the problem of ECC staff waiting for specialists to come and book beds for patients in the wards, maybe ECC staff could do this themselves with the help of flowcharts. If the flowcharts are designed by a team with the right expertise they should be able to follow the chart to work out which ward is best for their inbound patient. Then it would only be a case of using a telephone to ring and check availability or use an electronic bed allocating system. Control charts are useful for Hospitals; they get used to monitor patients heart rates blood pressures and levels of substances they can be tested for. The Shirley Curtis case is still under review so there is no information on whether a control chart was supplied to monitor the dosage she was given. I suggest they are implemented for all medicines, since this seems to be one of the most common errors occurring.

2.2.3 Technology
The possibility of finding the solutions might lie in modern technology by taking more of the human component out of the process. In an article published by ONE News, on May 22 2011, says a new electronic medicine checker could prevent deaths. It states: "We haven't released the full results ... but we know that in comparison we've reduced errors by well over 90%," internal medicine specialist Dr Andrew Bowers told ONE News. The actual number is 98%.Currently, doctors and nurses up and down the country use a paper chart, but all too often the writing can be illegible,

the dosages can be miscalculated and sometimes the charts have to be retranscribed up to three times. With the new electronic system, none of those problems are likely to occur. It has multiple prompts to ensure the wrong dose cannot be accidentally calculated, as well as fail-safe measures to eliminate other errors. "In fact, it even rounds the dose down to the correct vial size so the nursing staff have a very specific instruction on how to complete this," said Bowers. "The nurse is incapable of administering medications at the wrong time and the wrong date." Staff can be trained to apply the system in two weeks. He said the system is so efficient the nurses already using it have indicated there would "be a riot" if the system was shut down. (TVNZ, 2011) It is now Managements responsibility to drive the implementation of these new machines, provide staff training and follow up on the success or failure of the new computerised systems.

2.2.4 Quality of Management

In summary, quality management is all about the quality of management. Chairman of the WDHB Lester Levy was only appointed 15months ago and promotes himself as already making significant improvements and is leading upgrades to the hospital this year totalling $126 Million (TVNZ, 2011). Watching the interview with him on Close Up, it is easy to see that he understands the philosophy behind quality. The quality of North Shore Hospital service is the responsibility of all its employees, and organisation culture must be lead from the top down to encourage a philosophy of striving to attain the highest possible standard of care at every point of contact they have with their patients. Using the 8 points of TQM covered at the beginning of this report; customer focus, leadership, involvement of people, process approach, systems approach to management, continual improvement, factual approach to decision making and mutually beneficial supplier relationships, management can begin to adopt total quality. It is managements responsibility to make sure they have adequate resources to make this happen. North Shore Hospital has a good chance to restore faith in its service quality.


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