Recommendations for Improvement

Recommendations for Improvement

BUS 445: Total Quality Management

Recommendations for Improvement

In any organization, quality is crucial to its continuous success. If there is an issue, distinguishing the reason could go a long way to determine the problem. As indicated by Evans & Lindsay (2017), “measurement is the action of gathering information to calculate the values of goods, services, processes, and different business metrics. Measures and indicators allude to the numerical outcomes acquired from measurement” (sect. 8.1). Performance measurement systems permit organizations to foster key thoughts and assess results while keeping at the frontline the goals of the organization. While there are numerous approaches to achieve process improvements, the main goal is to identify the problem, create a practical solution, and effectively execute it. Through the Hallenvale Hospital Case Study and Chapter 9 Discussion Question 7 parts b, c, and g, we will evaluate the different process management tools that would be utilized to determine the best answer for issues that exists within them.

Hallenvale Hospital Case Study

The Hallenvale Hospital administrators were worried about how high the disease percentage rates were after medical procedures and needed to know whether different variables were causing them. For instance, in the third month, the percentage rate was demonstrated as 1.49%, and in the twelfth month, the percentage rate was at 1.76%. As indicated by Evans & Lindsay (2017), “The Joint Commission Accreditation of Health Care Organization (JCAHO) monitors and assesses health care providers as per strict standards and guidelines. Improvement in quality consideration is a chief concern. Hospitals are required to identify and monitor important quality indicators that influence patient care and establish “thresholds for evaluation” (TFE), which are levels at which special investigation of issues ought to happen. A logical method to set TFEs is through control charts” (Ch.8). To ensure that Hallenvale was within the threshold for evaluation (TFE), thirty-six months of data was collected and placed into a control diagram to accurately view the data.

A control chart is a tool usually utilized in quality management to show predictable behaviors over the time of a project. Control charts serve as a visual of how a procedure might change over time. A control chart has two horizontal lines; the upper control limit and lower control limit (UCL/LCL) lines. Once the control limits have been determined, distinguishing and deciding whether the procedure is in control would be a lot less complex.

Figure 1: Hallenvale Hospital Infection Data Control Chart

The 8,095 number of surgery procedures rather than the 55 number of infections shows an average infection of 0.690, which is demonstrated by the Mean on the chart. This number would be the control limit. To check whether a process is in control, there should be no points outside the upper control limit or lower control limits. The quantity of points over and under the line must be similar, and the points are not grouped or in clusters, with the most points lying near the centerline (Evans & Lindsay, 2017). In light of Figure 1, it ought to be deteremined that Hallenvale’s processes are within the restrictions of the threshold for evaluations (TFE). Thusly, there is no compelling reason to take any additional moves now. The hospital should keep on monitoring the infection rates after surgery in the months ahead to ensure that they remain within the limits of their thresholds for evaluations (TFE). While the control chart is successful in showing the information that the hospital was looking into, it is imperative to take note that the data is from a one-sided perspective since the number can’ t go below a zero percent. It would be essential for Hallenvale to conduct research and observe a sampling size, the occurrence rate, as well as other control limits too. If any of these values show a pattern, then the hospital should move to actualize changes that would create a new threshold for evaluation (TFE).

Chapter 9 – Question 7: Identify and discuss what would be the most appropriate tool to utilize to attack each of these problems.

B). The publication team for an engineering department wants to improve the accuracy of its user documentation but is unsure of why documents are not error free. In this situation, the process management tool suggested would be a variation of the Deming Cyle and creative problem-solving process which is known as the FADE process. FADE stands for Focus, Analyze, Develop, and Execute. These four steps are important to the success of an organization’s quality improvement which is a significant part of overall quality management. The four steps are efficient and simple to follow. The process can also be repeated on a progressing premise so different issues will constantly be perceived and resolutions are set in place. This also assists to facilitate the coherence of the business, and ensures everything will operate normally and easily. The FADE process would be a useful approach in this situation because the publication team would be able to assess and improve the accuracy of its user documentation. As per Davis (2000), “To focus, a team articulates an identified problem. To analyze, the team collects baseline data, the pre-test part of the project. To develop, means developing a plan to address the problem. Finally, to execute, the team puts the plan into action” (p.228).

C). A rental car agency is getting numerous complaints about the length of time that customers have to wait to obtain a car. They need to get a better handle of the factors that relate to the wait time. In this situation, the process management tool suggested would be the Deming Cycle or the PDCA cycle. The PDCA cycle stands for Plan, Do, Check, and Act. If the rental car agency utilizes this tool they are able to investigate the issue of why the wait times are occurring and how they can improve on reducing the customers wait times and complaints. There could be a number of reasons as to why wait times are long. For instance, it could be because the company is short-staffed, not enough cars on hand to meet customer demands, cars could be in service or any other operational and mechanical issues. Once the problem has been discovered, the agency is able to create a plan and act on it successfully. As per Trachenko (2018), “the Deming Cycle allows an enterprise to provide its processes with necessary resources, manage them, identify and implement on opportunities for their improvement” (p.252). The Deming Cycle is a continuous quality improvement process. The agency is able to implement its method, and from there they are able to determine the expected results from it.

G). 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. In this situation, the process management tool suggested to examine call volumes under the conditions that the travel agency is keen on would be for them to utilize a process capability study measurement. According to Winton & Suozzi (1999), “Process capability study is a systematic procedure for determining the capability of a process. Usually performed as part of a process certification effort or a process optimization effort” (p.3). This management tool is suggested because it allows the travel agency to compare its call volume levels at different points throughout the year for over several years to determine whether there is a pattern of higher call volume during specific times of the year. If there is a consistent pattern, the agency would be able to determine if it would be easier to hire temporary help that is needed to manage the high call volumes during that specific time, or if the staff workload should be reduced when business operation is slow.


In conclusion, applying the process improvements tools, for instance, the FADE process, the Deming Cycle, and the process capability study helps in gathering information about processes within various organizations. This data can be utilized to either reveal and address errors or check whether the process being utillized is productive and efficient, or if modifications and changes should be taken. While each process management tool has their strengths and weaknesses, they help to give an explanation to issues at hand, and offer answers so that the organization is better equipped in the future in handling situations that are similar and it rises again. Having the correct apparatuses that ensures that organizations can work all the more effectively in times to come.

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