Hallenvale Hospital Recommendations for Improvements

Hallenvale Hospital Recommendations for Improvements

BUS445: Total Quality Management

Threshold’s for evaluations (TFEs) “provide a means of focusing attention on nonrandom errors (that is, special causes of variation). A logical way to set TFEs is through control charts” (Evans & Lindsay, 2017, Ch. 8). Hallenvale Hospital will evaluate how well the hospital can monitor patient care and decrease any infections that may happen after surgeries are performed.

Improvements should be made, but the hospital must perform an analysis to see why some of the patients are getting infections after some surgeries. “Performance measurement and improvement systems play key roles in developing strategic plans and evaluating organizational objectives” (Alomar & Pasek, 2014, p. 629). This paper will evaluate different scenarios and provide recommendations and how to implement changes based on the information from the text of Managing for Quality and Performance Excellence by authors James Evans and William Lindsay, 2017.

Hallenvale Hospital must monitor and evaluate why some patients are getting infections and must meet the standards set by “The Joint Commission Accreditation of Health Care Organization JCAHO) monitors and evaluates health care providers according to strict standards and guidelines” (Evans & Lindsay, 2017, Ch. 8). Hallenvale must identify and establish “thresholds for evaluation” (TFEs), by using control charts. The control chart will find the average percentage of infections, determine the upper and lower control limits on the control chart. There shall be recommendations made based on the chart as to what measures should be taken if any.

Based on the sampling received, statistically, the infection rate is under control; however test should be administered on a more regular basis to get more accurate results. The control chart shows that there was an extreme spike in infections but was then lowered, and no spikes were over the UCL. Velury (1997) concludes that the information received on control charts are “fairly accurate and that the chance of being wrong in identifying these out-of-control conditions is as low as 5 percent” (p. 32).

The publication team for an engineering department wants to improve the accuracy of its user documentation but is unsure of why documents do not error free(Ashford University, 2019).

The engineering department can use flowcharts, which are used “as design tools, enables management to study and analyze processes before implementation in order to improve quality and operational performance” (Evans & Lindsay, 2017, Ch. 5.3). This process can be used to get an understanding of how the process of creating documents works. The engineering team can use the technique called “backward chaining” which starts “with the outputs, or customer requirements, and move backward through the process to identify the key steps needed to produce each output; stop when the process reaches the supplier input stage” (Evans & Lindsay, 2017, Ch. 5.3).

A rental car agency is getting numerous complaints about the length of time that customers must wait to obtain a car. They need to get a better handle on the factors that relate to the wait time” (Ashford University, 2019).

Since many factors can cause wait time for a customer, the rental car agency may consider using the “Fishbone Diagram,” which takes into consideration the cause and effect of a situation.

The cause-effect chart (the Fishbone Diagram) is a method for the analysis of complex problems that present several interrelated causes. The method uses a combination of visual representation (branches) and brainstorming techniques for obtaining the causes. To create a fishbone chart, we use arrows or branches primary branch: represents the effect; -major branch: corresponds to the primary cause; -minor branch: corresponds to the causative and more specific factors (Loredana, 2017, p. 99).

Once the rental agency determined what the root problem is based on the fishbone diagram, recommendations can be made to resolve the issues.

A travel agency is interested in gaining a better understanding of how call volume varies by time of year in order to adjust staffing schedules” (Ashford University, 2019).

The travel agency could use a process called run charts. Run charts provide “data such as production volume, cost, and customer satisfaction index and display the data over time” (Evans & Lindsay, 2017, Ch. 9.4). Run charts will determine why call volumes vary by the time of year to see when the fluctuation occurs and then adjust schedule the necessary staff to cover the massive volume of calls coming in.

With the use of process improvement tools such as control charts, run charts, and other performance measurement tools, it is easier to implement tests to perform analyses and make changes to improve the quality and performance of the process in question.


Alomar, M., & Pasek, Z. J. (2014). Linking Supply Chain Strategy and Processes to Performance Improvement. Procedia CIRP, 17(Variety Management in Manufacturing), 628-634. doi:10.1016/j.procir.2014.01.144. Retrieved from the Ashford Library.

Evans, J. R., & Lindsay, W. M. (2017). Managing for quality and performance excellence (10th ed.). Mason, OH: South-Western Cengage

Loredana, E. M. (2017). The Analysis of causes and effects of a phenomenon by means of the “Fishbone” diagram. Analele Universităţii Constantin Brâncuşi Din Târgu Jiu : Seria Economie, (5), 97. Retrieved from http://search.ebscohost.com.proxy-library.ashford.edu/login.aspx?direct=true&db=edsdoj&AN=edsdoj.0a2b34f129a4b289601a263f8ea5774&site=eds-live&scope=site

Velury, J. (1997). Statistical thinking in problem solving. IIE Solutions, 29(10), 30. Retrieved from http://search.ebscohost.com.proxy-library.ashford.edu/login.aspx?direct=true&db=f5h&AN=9710192540&site=eds-live&scope=site