total quality management 890 (1)

8/3/2019 Total Quality Management 890 (1)

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Quality Gurus

To fully understand the TQM movement, we need to look at the philosophies of notable individuals

who have shaped the evolution of TQM. Their philosophies and teachings have contributed to our

knowledge and understanding of quality today.

Walter A. Shewhart was a statistician at Bell Labs during the 1920s and 1930s. Shewhart studied

randomness and recognized that variability existed in all manufacturing processes. He developed

quality control charts that are used to identify whether the variability in the process is random or due

to an assignable cause, such as poor workers or miscalibrated machinery. He stressed that eliminating

variability improves quality. His work created the foundation for todays statistical process control,

and he is often referred to as the grandfather of quality control.

W. Edwards Deming is often referred to as the father of quality control. He was a statistics

professor at New York University in the 1940s. After World War II he assisted many Japanese

companies in improving quality. The Japanese regarded him so highly that in 1951 they established

theDeming Prize, an annual award given to firms that demonstrate outstanding quality. It was almost

30 years later that American businesses began adopting Demings philosophy. A number of elements

of Demings philosophy depart from traditional notions

Deming outlined his philosophy on quality in his famous 14 Points. These points are principles that

help guide companies in achieving quality improvement. The principles are founded on the idea that

upper management must develop a commitment to quality and provide a system to support this

commitment that involves all employees and suppliers. Deming stressed that quality improvements

cannot happen without organizational change that comes from upper management.

Joseph M. Juran After W. Edwards Deming, Dr. Joseph Juran is considered to have had the

greatest impact on quality management. Juran originally worked in the quality program at Western

Electric. He became better known in 1951, after the publication of his book Quality Control

Handbook. In 1954 he went to Japan to work with manufacturers and teach classes on quality.

Though his philosophy is similar to Demings, there are some differences. Whereas Deming stressed

the need

for an organizational transformation, Juran believes that implementing quality initiatives should

not require such a dramatic change and that quality management should be embedded in the

organization.

One of Jurans significant contributions is his focus on the definition of quality and the cost of

quality. Juran is credited with defining quality as fitness for use rather than simply conformance to

specifications. As we have learned in this chapter, defining quality as fitness for use takes into

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account customer intentions for use of the product, instead of only focusing on technical

specifications. Juran is also credited with developing the concept of cost of quality, which allows us

to measure quality in dollar terms rather than on the basis of subjective evaluations. Juran is well

known for originating the idea of the quality trilogy: quality planning, quality control, and quality

improvement. The first part of the trilogy, qualityplanning, is necessary so that companies identify

their customers, product requirements, and overriding business goals. Processes should be set up to

ensure that the quality standards can be met. The second part of the trilogy, quality control, stresses

the regular use of statistical control methods to ensure that quality standards are met and to identify

variations from the standards. The third part of the quality trilogy is quality improvement. According

to Juran, quality improvements should be continuous as well as breakthrough. Together with

Deming, Juran stressed that to implement continuous improvement workers need to have training in

proper methods on a regular basis.

Armand V. FeigenbaumAnother quality leader is Armand V. Feigenbaum, who introduced

the concept of total quality control. In his 1961 bookTotal Quality Control, he outlined his quality

principles in 40 steps. Feigenbaum took a total system approachto quality. He promoted the idea of a

work environment where quality devel opments are integrated throughout the entire organization,

where management and employees have a total commitment to improve quality, and people learn

from eachothers successes. This philosophy was adapted by the Japanese and termed company-

wide quality control.

Philip B. Crosby is another recognized guru in the area of TQM. He worked in the area of quality

for many years, first at Martin Marietta and then, in the 1970s, as the vice president for quality at

ITT. He developed the phrase Do it right the first time and the notion ofzero defects, arguing that

no amount of defects should be considered acceptable. He scorned the idea that a small number of

defects

is a normal part of the operating process because systems and workers are imperfect. Instead, he

stressed the idea of prevention. To promote his concepts, Crosby wrote a book titled Quality Is Free,

which was published in 1979. He became famous for coining the phrase quality is free and for

pointing out the many costs of quality, which include not only the costs of wasted labor, equipment

time, scrap, rework, and lost sales, but also organizational costs that are hard to quantify. Crosby

stressed that efforts to improve quality more than pay for themselves because these costs are

prevented. Therefore, quality is free. Like Deming and Juran, Crosby stressed the role of

management in the quality improvement effort and the use of statistical control tools in measuring

and monitoring

quality.

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Kaoru Ishikawa is best known for the development of quality tools called cause-and-effect

diagrams, also called fishbone or Ishikawa diagrams. These diagrams are used for quality problem

solving, and we will look at them in detail later in the chapter. He was the first quality guru to

emphasize the importance of the internal customer, the next person in the production process. He

was also one of the first to stress the importance of total company quality control, rather than just

focusing on products and services. Dr. Ishikawa believed that everyone in the company needed to be

united with a shared vision and a common goal. He stressed that quality initiatives should be pursued

at every level of the organization and that all employees should be involved. Dr. Ishikawa was a

proponent of implementation ofquality circles, which are small teams of employees that volunteer to

solve quality problems.

Dr. Genichi Taguchi is a Japanese quality expert known for his work in the area of product design.

He estimates that as much as 80 percent of all defective items are caused by poor product design.

Taguchi stresses that companies should focus their quality efforts on the design stage, as it is much

cheaper and easier to make changes during the product design stage than later during the production

process. Taguchi is known for applying a concept called design of experimentto product design.

This method is an engineering approach that is based on developing robust design, a design that

results in products that can perform over a wide range of conditions. Taguchis philosophy is based

on the idea that it is easier to design a productthat can perform over a wide range of environmental

conditions than it is to controlthe environmental conditions.Taguchi has also had a large impact on

todays view of the costs of quality. Hepointed out that the traditional view of costs of conformance

to specifications is incorrect, and proposed a different way to look at these costs. Lets briefly look at

Dr. Taguchis view of quality costs. Recall that conformance to specification specifies a target value

for the product with specified tolerances, say 5.00 _ 0.20. According to the traditional view of

conformance to specifications, losses in terms of cost occur if the product dimensions fall outside of

the specified limits. This is shown in Figure 5-4. However, Dr. Taguchi noted that from the

customers view there is little difference whether a product falls just outside or just inside the control

limits. He pointed out that there is a much greater difference in the quality of the product between

making the target and being near the control limit. He also stated that the smaller the variation around

the target, the better the quality. Based on this he proposed the following: as conformance values

move away from the target, loss increases as a quadratic function. This is called the Taguchi loss

function and is shown in Figure 5-5. According to the function, smaller differences from the target

result in smaller costs: the larger the differences, the larger the cost. The Taguchi loss function has

had a significant impact in changing the view of quality cost. What characterizes TQM is the focus

on identifying root causes of quality problems and correcting them at the source, as opposed to

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inspecting the product after it has been made. Not only does TQM encompass the entire organization,

but it stresses that quality is customer driven. TQM attempts to embed quality in every aspect of the

organization. It is concerned with technical aspects of quality as well as the involvement of people in

quality, such as customers, company employees, and suppliers. Here we look at the specific concepts

that make up the philosophy of TQM.

Q. 2 Define and discuss the concept of Deming philosophy and its importance in TQM.

Critically discuss the 14 point of Deming philosophy and their main themes keep in view the

financial sector of Pakistan.

A core concept in implementing TQM is Demings 14 points, a set of management practices to help

companies increase their quality and productivity:

1. . Create a constant purpose toward improvement.

Plan for quality in the long term.

Resist reacting with short-term solutions.

Don't just do the same things better find better things to do.

Predict and prepare for future challenges, and always have the goal of getting

better.

2. Adopt the new philosophy.

Embrace quality throughout the organization.

Put your customers' needs first, rather than react to competitive pressure and

design products and services to meet those needs.

Be prepared for a major change in the way business is done. It's about leading,

not simply managing.

Create your quality vision, and implement it.

3. Stop depending on inspections.

Inspections are costly and unreliable and they don't improve quality, they

merely find a lack of quality.

Build quality into the process from start to finish.

Don't just find what you did wrong eliminate the "wrongs" altogether.

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Use statistical control methods not physical inspections alone to prove that

the process is working.

4. Use a single supplier for any one item.

Quality relies on consistency the less variation you have in the input, the less

variation you'll have in the output.

Look at suppliers as your partners in quality. Encourage them to spend time

improving their own quality they shouldn't compete for your business based on

price alone.

Analyze the total cost to you, not just the initial cost of the product.

Use quality statistics to ensure that suppliers meet your quality standards.

5. Improve constantly and forever.

Continuously improve your systems and processes. Deming promoted the Plan-

Do-Check-Act approach to process analysis and improvement.

Emphasize training and education so everyone can do their jobs better.

Use kaizen as a model to reduce waste and to improve productivity,

effectiveness, and safety.

6. Use training on the job.

Train for consistency to help reduce variation.

Build a foundation of common knowledge.

Allow workers to understand their roles in the "big picture."

Encourage staff to learn from one another, and provide a culture and

environment for effective teamwork.

7. Implement leadership.

Expect your supervisors and managers to understand their workers and the

processes they use.

Don't simply supervise provide support and resources so that each staff

member can do his or her best. Be a coach instead of a policeman.

Figure out what each person actually needs to do his or her best.

Emphasize the importance of participative management and transformational

leadership.

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Find ways to reach full potential, and don't just focus on meeting targets and

quotas.

8. Eliminate fear.

Allow people to perform at their best by ensuring that they're not afraid to

express ideas or concerns.

Let everyone know that the goal is to achieve high quality by doing more things

right and that you're not interested in blaming people when mistakes happen.

Make workers feel valued, and encourage them to look for better ways to do

things.

Ensure that your leaders are approachable and that they work with teams to act

in the company's best interests.

Use open and honest communication to remove fear from the organization.

9. Break down barriers between departments.

Build the "internal customer" concept recognize that each department or

function serves other departments that use their output.

Build a shared vision.

Use cross-functional teamwork to build understanding and reduce adversarial

relationships.

Focus on collaboration and consensus instead of compromise.

10. Get rid of unclear slogans.

Let people know exactly what you want don't make them guess. "Excellence

in service" is short and memorable, but what does it mean? How is it achieved? The

message is clearer in a slogan like "You can do better if you try."

Don't let words and nice-sounding phrases replace effective leadership. Outline

your expectations, and then praise people face-to-face for doing good work.

11. Eliminate management by objectives.

Look at how the process is carried out, not just numerical targets. Deming said

that production targets encourage high output and low quality.

Provide support and resources so that production levels and quality are high and

achievable.

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Measure the process rather than the people behind the process.

12. Remove barriers to pride of workmanship.

Allow everyone to take pride in their work without being rated or compared.

Treat workers the same, and don't make them compete with other workers for

monetary or other rewards. Over time, the quality system will naturally raise the level

of everyone's work to an equally high level.

13. Implement education and self-improvement.

Improve the current skills of workers.

Encourage people to learn new skills to prepare for future changes andchallenges.

Build skills to make your workforce more adaptable to change, and better able

to find and achieve improvements.

14. Make "transformation" everyone's job.

Improve your overall organization by having each person take a step toward

quality.

Analyze each small step, and understand how it fits into the larger picture.

Use effective change management principles to introduce the new philosophy

and ideas in Deming's 14 points.

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Q. 3 Discuss the concept customers feedback in continuous quality improvement. Critically

discuss the role of comments card and focus group in getting the customers feedback with

reference to the manufacturing organization

Serving your customers, whether they are internal or external to your organization, is central to your

success.

Some of the most important components of customer service are:

Customer satisfaction - a process that involves extending exceptional courtesy and service to

our customers.

Customer Feedback and Research - a process that requires an organization to consistentlysolicit feedback from its customers in order to improve services and products.

Continuous Quality Improvement - a process of continuous learning in order to help

organizations work to improve their services and products.

Individual Responsibility - a process that acknowledges that each person in the organization

is responsible when it comes to customer service.

COMMENT CARD

A carefully planned and well-written customer comment card allows the customer to express their

opinion and provide valuable feedback. This form of store evaluation not only helps measure

customer satisfaction, but also shows the retailer what areas of operation may need additional

resources.

The customer comment card is a great way to collect testimonials. It can also be a great tool for

receiving complaints.

Disgruntled customers generally need an outlet to express their dissatisfaction. A conveniently

placed customer comment card could prevent the unhappy customer from complaining to a third-

party. Now the retailer can receive the complaint and act quickly to resolve the issue. Not only do we

get to keep that customer, but it may also prevent any negative word-of-mouth.

Customer Comment Card Tips:

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In order to encourage people to take part in a longer online survey you can offer them a ten-dollar

gift certificate for completing it. This helps you out in multiple ways. Not only do you gain

additional information from your customers, but you can help ensure theyll keep coming back in.

Another bonus of using color printing to hand out survey cards is that it shows people that you care

about what they have to say. People like to know that a company cares about what they think, and

this will generate more interest in your store.

If you think about it, this is the best means of gathering research about your customers that you could

hope for. These are the very people youre trying to market to telling you what they most want.

Use this information to tailor your color printing material to an advertisement that will appeal

specifically to them.

The costs of getting survey cards printed along with the cost of having a website set up for the survey

is well worth the marketing benefits youll gain. Now youll never have to worry that people are only

going to stick around until they find something better. If people can see a business willing to listen to

their advice and change to keep them happy, theyll be much more likely to stick around for years.

FOCUS GROUP

Market research: Small number of people (usually between 4 and 15, but typically 8) brought

together with a moderator to focus on a specificproduct ortopic. Focusgroupsaim at a discussion

instead of on individualresponses to formal questions, andproducequalitative data(preferences and

beliefs) that may or may not berepresentative of thegeneralpopulation

Using Focus Groups Effectively

Focus groups are managed like any other project; they require defining the objectives, creating a

work plan, conducting the group discussions and, most important, completing insightful analysis and

developing recommendations. There are several lessons-learned, namely:

Complete detailed background research on what you need to learn from the groups. The

facilitator must understand the group participants to be able to draw out the essential

information the client needs to learn and understand.

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Involve the end-user in the design of the group so he/she can verbalize and visualize

success. This is an opportunity to expose the end-user to the process and to discuss what they

should expect.

The physical layout needs to encourage participants to feel free to express themselves and

interact with each other. Free dialogue starts with the arrangement of chairs and tables.

Assigned seating with first-name tags can encourage discussions.

Follow-up a week after the event allows the facilitator time to think over what he/she

experienced and to draw better conclusions. It is important to leave a period-of-time for the

wonderment of focus groups to wear off.

Q. 4 Define and discuss the term team in the view of Total Quality Management. Critically

discuss the role of teams in the continuous quality improvement process with reference to

commercial organization.

WHAT ARE THE STEPS IN THE CONTINUOUS QUALITY

IMPROVEMENT PROCESS?

Step 1 Identify a need/issue/problem and develop a problem statement

Step 2 Define the current situation - break down problem into component parts, identify

major problem areas, develop a target improvement goal

Step 3 Analyze the problem - identify the root causes of the problem and use charts and

diagrams as needed.

Step 4 Develop an action plan - outline ways to correct the root causes of the problem,

specific actions to be taken, identify who, what, when and where

Step 5 Look at the results - confirm that the problem and its root causes have decreased,

identify if the target has been met and display results in graphic format before and after the

change

Step 6 Start over - go back to the first step and use the same process for the next problem

WHAT IS THE CONTINUOUS QUALITY IMPROVEMENT TEAM STRUCTURE?

The Department of Children & Family Services/Office of Community Services' Continuous Quality

Improvement process involves two levels of teams. There is a state level Continuous Quality

Improvement team and a Continuous Quality Improvement team in each region statewide. The teams

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include staff from all levels within the agency representing all programmatic service areas as well

as community stakeholders.

WHAT ARE CONTINUOUS QUALITY IMPROVEMENT TEAM ROLES?

Chair/Facilitator - facilitates Continuous Quality Improvement meetings, champions the

Continuous Quality Improvement process and coordinates input and feedback to staff.

Scribe - takes detailed meeting minutes, schedules meeting room.

Member - participates in review of issues referred to the Continuous Quality Improvement

team; provides feedback to peers, stakeholders and consumers

Implementing total quality management: role of team management.

Introduction

Globalization in the business theater is driving companies toward a new view of quality as a

necessary tool to compete successfully in worldwide markets. A direct outcome of this new emphasis

is the philosophy of total quality management (TQM). In essence, TQM is a company-wide

perspective that strives for customer satisfaction by seeking zero defects in products and services.

The TQM Philosophy

Implementing a total quality management system has become the preferred approach for improving

quality and productivity in organizations. TQM, which has been adopted by leading industrial

companies, is a participative system empowering all employees to take responsibility for improving

quality within the organization. Instead of using traditional bureaucratic rule enforcement, TQM calls

for a change in the corporate culture, where the new work climate has the following characteristics:

An open, problem-solving atmosphere;

Participatory design making;

Trust among all employees (staff, line, workers, managers);

A sense of ownership and responsibility for goal achievement and problems solving; and,

Self-motivation and self-control by all employees.

The TQM approach involves more than simply meeting traditional rejection rate standards. The end

result of TQM is the efficient and effective use of all organizational processes in providing consistent

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quality at a competitive price. The TQM philosophy is a long-term endeavor that links people and

processes in a system that alters the corporate culture to become one where quality is the core aspect

of business strategy.

The effective use of quality improvement teams, and the TQM system as a whole, can be reinforced

by applying basic principles of motivation. In particular, the recognition of team accomplishments as

opposed to those of individuals, and the effective use of goal setting for group efforts, are important

in driving the TQM system. The HR department is in a position to help institutionalize team

approaches to TQM by designing appraisal and reward systems that focus on team performance.

For many companies, the philosophy of TQM represents a major culture shift away from a traditional

production-driven atmosphere. In the face of such radical operational makeovers, a determined

implementation effort is vital to prevent TQM from becoming simply platitudinal and the team

approach just another management fad. Senior management must take the lead in overt support of

TQM.

Senior Management and TQM

To be successful, a TQM system must be wholeheartedly accepted by top management, who, in turn,

must convey their commitment to all organizational members.(9) The policy for implementation and

maintenance of the TQM system should be set forth in writing and incorporated into the

organization's mission and goals statements. The key elements of senior management's role in

implementing TQM are:

* Institutionalizing the TQM structure as established by stated goals and formal policies and

procedures; and

* Providing leadership as demonstrated by top management's explicit expectations and behavior in

everyday activities.

In summary, top management's responsibilities in the TQM implementation process include:

1. Initiating agreement on goals and measures that cascade throughout the organization;

2. Providing the agreed resources (people, money, training, machines, etc.);

3. Assigning authority and establish deadlines to put resources into motion;

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4. Monitoring progress in achieving goals, not to apportion blame, but to aim for improvement; and,

5. Measuring improvement and reward both the achievement of goals and the ways they are achieved

Obtaining cooperation from other departments in the use of surveys largely depends on their

perception of HRM's role in the survey process. The challenge is to establish that HRM is not

usurping departmental prerogatives, but is instead a helpful collaborator assisting each department in

making their own quality improvements. Emphasizing HRM's collaborator role can be accomplished

in the participative spirit of the TQM philosophy by involving other departments in the development

of the survey instrument itself. This involvement begins the process of helping each department own

the TQM program which will follow. Thus, using a corss-functional TQM survey development team

provides an early opportunity for HRM to exemplify the TQM team philosophy and dispel territorialfears about how survey results will be used.

TQM and Training and Development

In general, HRM is responsible for providing training and development. With their background, HR

departments are well-positioned to take the leading role in providing such programs consistent with

the TQM philosophy. HR managers have an important

Beyond communicating the TQM philosophy, the specific training and development needs for

making TQM a practical reality must be assessed. Basically HR professionals must decide the

following: What knowledge and skills must be taught? How? What performance (behaviors) will be

recognized, and how will we reward them? HRM has faced these questions before and can best

confront them in the TQM process. Training and development that does not fit within the realm of

these questions will more than likely encounter heavy resistance. However, training and development

does fall within the realm of these questions probably will be accepted more readily.

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Q. 5 Discuss the different improvement strategies used in continuous quality improvement

management. Critically discuss the primary improvement strategies with examples in the light

of business organization. Which one strategy is better in your view and why?

Quality Improvement Strategies

More than 40 years ago, Donabedian proposed measuring the quality of health care by observing its

structure, processes, and outcomes. Structure measures assess the accessibility, availability, and

quality of resources, such as health insurance, bed capacity of a hospital, and number of nurses with

advanced training. Process measures assess the delivery of health care services by clinicians and

providers, such as using guidelines for care of diabetic patients. Outcome measures indicate the final

result of health care and can be influenced by environmental and behavioral factors. Examples

include mortality, patient satisfaction, and improved health status.

Twenty years later, health care leaders borrowed techniques from the work of Deming in rebuilding

the manufacturing businesses of post-World War II Japan. Deming, the father of Total Quality

Management (TQM), promoted constancy of purpose and systematic analysis and measurement of

process steps in relation to capacity or outcomes. The TQM model is an organizational approach

involving organizational management, teamwork, defined processes, systems thinking, and change to

create an environment for improvement. This approach incorporated the view that the entire

organization must be committed to quality and improvement to achieve the best results.

In health care, continuous quality improvement (CQI) is used interchangeably with TQM. CQI has

been used as a means to develop clinical practice and is based on the principle that there is an

opportunity for improvement in every process and on every occasion. Many inhospital quality

assurance (QA) programs generally focus on issues identified by regulatory or accreditation

organizations, such as checking documentation, reviewing the work of oversight committees, and

studying credentialing processes. There are several other strategies that have been proposed for

improving clinical practice. For example, Horn and colleagues discussed clinical practice

improvement (CPI) as a multidimensional outcomes methodology that has direct application to the

clinical management of individual patients . CPI, an approach lead by clinicians that attempts a

comprehensive understanding of the complexity of health care delivery, uses a team, determines a

purpose, collects data, assesses findings, and then translates those findings into practice changes.

From these models, management and clinician commitment and involvement have been found to be

essential for the successful implementation of change. From other quality improvement strategies,

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there has been particular emphasis on the need for management to have faith in the project,

communicate the purpose, and empower staff.

Quality improvement is defined as systematic, data-guided activities designed to bring about

immediate improvement in health care delivery in particular settings A quality improvement

strategy is defined as any intervention aimed at reducing the quality gap for a group of patients

representative of those encountered in routine practice Shojania and colleagues developed a

taxonomy of quality improvement strategies , which infers that the choice of the quality

improvement strategy and methodology is dependent upon the nature of the quality improvement

project.

The lack of scientific health services literature has inhibited the acceptance of quality improvementmethods in health care, but new rigorous studies are emerging. It has been asserted that a quality

improvement project can be considered more like research when it involves a change in practice,

affects patients and assesses their outcomes, employs randomization or blinding, and exposes

patients to additional risks or burdensall in an effort towards generalizability Regardless of

whether the project is considered research, human subjects need to be protected by ensuring respect

for participants, securing informed consent, and ensuring scientific value

Plan-Do-Study-Act (PDSA)

Quality improvement projects and studies aimed at making positive changes in health care processes

to effecting favorable outcomes can use the Plan-Do-Study-Act (PDSA) model. This is a method that

has been widely used by the Institute for Healthcare Improvement for rapid cycle improvement. One

of the unique features of this model is the cyclical nature of impacting and assessing change, most

effectively accomplished through small and frequent PDSAs rather than big and slow ones, before

changes are made systemwide.

Six Sigma

Six Sigma, originally designed as a business strategy, involves improving, designing, and monitoring

process to minimize or eliminate waste while optimizing satisfaction and increasing financial

stability. The performance of a processor the process capabilityis used to measure improvement

by comparing the baseline process capability (before improvement) with the process capability after

piloting potential solutions for quality improvement. There are two primary methods used with Six

Sigma. One method inspects process outcome and counts the defects, calculates a defect rate per

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million, and uses a statistical table to convert defect rate per million to a (sigma) metric. This

method is applicable to preanalytic and postanalytic processes (a.k.a. pretest and post-test studies).

The second method uses estimates of process variation to predict process performance by calculating

a metric from the defined tolerance limits and the variation observed for the process. This method

is suitable for analytic processes in which the precision and accuracy can be determined by

experimental procedures.

Six Sigma and PDSA are interrelated. The DMAIC methodology builds on Shewharts plan, do,

check, and act cycle. The key elements of Six Sigma is related to PDSA as follows: the plan phase of

PDSA is related to define core processes, key customers, and customer requirements of Six Sigma;

the do phase of PDSA is related to measure performance of Six Sigma; the study phase of PDSA is

related to analyze of Six Sigma; and the act phase of PDSA is related to improve and integrate of Six

Sigma.

Toyota Production System/Lean Production System

Application of the Toyota Production Systemused in the manufacturing process of Toyota cars

resulted in what has become known as the Lean Production System or Lean methodology. This

methodology overlaps with the Six Sigma methodology, but differs in that Lean is driven by the

identification of customer needs and aims to improve processes by removing activities that are non-

value-added (a.k.a. waste). Steps in the Lean methodology involve maximizing value-added

activities in the best possible sequence to enable continuous operations. This methodology depends

on root-cause analysis to investigate errors and then to improve quality and prevent similar errors.

Factors involved in the successful application of the Toyota Production System in health care are

eliminating unnecessary daily activities associated with overcomplicated processes, workarounds,

and rework involving front-line staff throughout the process, and rigorously tracking problems asthey are experimented with throughout the problem-solving process.

Root Cause Analysis

Root cause analysis (RCA), used extensively in engineering and similar to critical incident technique,

is a formalized investigation and problem-solving approach focused on identifying and

understanding the underlying causes of an event as well as potential events that were intercepted. The

Joint Commission requires RCA to be performed in response to all sentinel events and expects, based

on the results of the RCA, the organization to develop and implement an action plan consisting of

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improvements designed to reduce future risk of events and to monitor the effectiveness of those

improvements.

RCA is a technique used to identify trends and assess risk that can be used whenever human error is

suspected with the understanding that system, rather than individual factors, are likely the root cause

of most problems. A similar procedure is critical incident technique, where after an event occurs,

information is collected on the causes and actions that led to the event.

Due the breadth of types of adverse events and the large number of root causes of errors,

consideration should be given to how to differentiate system from process factors, without focusing

on individual blame. The notion has been put forth that it is a truly rare event for errors to be

associated with irresponsibility, personal neglect, or intention, a notion supported by the IOM.4,

Yetefforts to categorize individual errorssuch as the Taxonomy of Error Root Cause Analysis of

Practice Responsibility (TERCAP), which focuses on lack of attentiveness, lack of agency/fiduciary

concern, inappropriate judgment, lack of intervention on the patients behalf, lack of prevention,

missed or mistaken MD/healthcare providers orders, and documentation error may distract the

team from investigating systems and process factors that can be modified through subsequent

interventions. Even the majority of individual factors can be addressed through education, training,

and installing forcing functions that make errors difficult to commit.

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