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III…Methodologies

III-1…5S <Five S> Principles and the activities III-1-1…Definitions 5S is the principles of work environment improvement derived from the Japanese words seiri, seiton, seiso, seiketsu, and shitsuke. In English the five Ss are respectively described Sort, Set Shine,

Standardize, and Sustain. This principles focus on effective work place organization starting from physical environment and gradually to functional aspects, which are influential to 5S simplifies your work environment, reduces waste and non-value activity while improving quality efficiency and safety. 5S is Key activities of the TQM and describe basic philosophy of KAIZEN. 5S Principles are your reliable instruments to make a break-through in improving your work environment and staff attending various types of jobs in your Project or Institution. This is not only a concept but also a set of actions which have to be conducted systematically with the full participation of staff serving in the Project or Institution. 5S activities are practiced in a real participatory movement to improve the quality of both the work environment and service contents delivered to your clients. 5S is literally 5 abbreviations of Japanese words with 5 initials of S. These are 1 - Seiri, 2 - Seiton, 3 - Seiso, 4 - Seiketsu and 5 - Shitsuke. Convenient translation to English similarly provides 5 words with initials of S. …………………………………………………………………………………………………………… 1 - Sort: Remove unused items from your venue of work; and reduce clutter (Removal / organization)

2 - Set: Organize everything needed in proper order for easy operation (Orderliness)

3 - Shine: Maintain high standard of cleanness (Cleanness)

4 - Standardize: Set up the above three Ss as norms in every section of your place (Standardize)

5 - Sustain: Train and maintain discipline of the personnel engaged. (Self-Discipline)

……………………………………………………………………………………………………………

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Five steps of Sort-Set-Shine-Standardize-Sustain are a sequence of activities to improve your work environment to as convenient and comfortable a level as possible and thereby to improve your service contents with regard to preparedness, standardization, timeliness and communication. Health personnel are technology oriented, since its delivery is based on application of specific techniques. 5S activities are the tools to prepare the best obtainable stage for them to make maximal use of their skill and knowledge. Two different grades are identified in the standard of 5S activities in the service sector particularly in the health service. 5S has been used not only to make <White belt> physical work environment better, but also for the <Black belt> software matters such as: --Job sequence and contents, --Time management, --Communication system such as meetings and briefings The entry point of the <Black belt> 5S will be the active utilization of 5S tools, such as; a…Orderly arrangement of items based on the objective-oriented way of thinking, for instance, using alphabetical order, chronological order, and numerical order Pharmaceuticals at emergency room are good examples. Those items should be arranged at specific places with a system, which is recognized by all staffs, who have to handle on demands. b…X-axis and Y-axis arrangement Posters and notices on the notice board, for instance, should be arranged based on this concept avoiding messy situation and unintended oblique angles in hanging up. c…Check lists

141

s+s+s+s+s= 5-S

Seiri （整理）

Seiton（整頓）

Seiso （清掃）

Seiketu（清潔）

Shituke （躾）

Sort

Set

Shine

Standardize

Sustain

5-S Principles

Seiri (Sort, Séparer )

Seiton (Set, Systématiser )

Seiso (Shine, Salubrité)

Seiketsu (Standadize, Standardiser )

Shitsuke (Sustain, Se discipliner)

139

s+s+s+s+s= 5-S

Seiri （整理）

Seiton （整頓）

Seiso （清掃）

Seiketu （清潔）

Shituke （躾）

Sasambua

Seti

Safisha

Sanifisha

Shikilia

Swahiri

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S+S+S+S+S=5S

Seiri （整理）

Seiton （整頓）

Seiso （清掃）

Seiketu（清潔）

Shituke（躾）

Clasificar

Organizar

Limpiar

Estandarizar

Mantener

Spanish

144

s+s+s+s+s= 5-S

Sort

Set

Shine

Standardize

Sustain

Arabic

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Five S activities, particularly of Standardization (Seiketsu) level, should always be monitored by the 5S practitioners at each venue. For this purpose simple check lists can be developed and put them into their practice. Periodical guidance by Quality Improvement Team (QIT) can be done to the Work Improvement Team (WIT) can be supportively conducted based on the check lists. III-1-2…5S activities and actual sequence of the works III-1-2-1…Sort (Seiri in Japanese language, S1) Sort: Remove unused items from your venue of work; and reduce clutter (Removal / organization)

Important 1st step of 5S Without ―Sorting‖, you cannot have the next step of putting appropriate order in your work places. There are several steps for realizing venues without unnecessary items and clutters. For commencing this important first step of 5S, it is mandatory for the hospital to install WIT at each work unit or department. The WIT is a team organized by each work front-line unit for conducting 5S in the beginning and later KAIZEN, the front-line based participatory problem solving for betterment of work process and the service contents. Each WIT is an actual body to plan, implement, and monitor the process of 5S. Unwanted Items’ Store Quality Improvement Team (QIT), the superior organization established under the hospital director for leading 5S activities, is to announce the commencement of ―Sort‖ step with an extremely important activity. This is opening up ―Unwanted Items Store‖ or ―Condemning Store‖. This store is used to collect unwanted items from all work units or departments after commencing ―Sort‖ step of 5S. Each unit actively removes unwanted, unnecessary, unworkable items from their venues and brings them to the store. Since those items are all government property, the hospital cannot discard them immediately. Due to this nature, the items have to be kept for a while until the permission is granted by the authority. At the store, the items should be further classified into several subgroups. Functioning, broken but reparable, irreparable, and clatter are the sub-categories. Red Tag and the tagging Unwanted items should be identified during the routine work. If those are found, red color tags or labels should be given to the items with proper explanation on the problems. This procedure will be the first step of the colour coding system of the hospital. The system in this stage is standardized yet, maybe. It is a good opportunity for QIT to look into the future colour coding system applicable variety

198Discarding unnecessary items in “Sort” of 5S

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of purposes in this stage. From indoor to outdoor The ―Sort‖ step of 5S maybe started from the various rooms and spaces under the roof within the hospital. The activity is then extended to outer space of the building structure. The indoor spaces both of health service front-lines and the backyards are the primary targets of this activity. Among indoor spaces in the hospital, there are no place, where is excluded from the activity. The priority can be set due to the seriousness of disorganization, visibility as a pilot successful place and urgent demands in functional betterment. In the mean time, works are advanced to reach a point to modify physical structure of the room, wall, door etc. It incurs some costs, which maybe elaborated by the top management of the hospital to find out the fund for the remodeling. In case, gardening and re-arrangement of the trees and fences appears as the targets of ―Sort‖. Step-by-step approach should be taken to do the job with consideration of the expense. Decision-making and leadership Decision-making is important as well as the leadership. The division head and /or WIT leader should make vigorously make a decision in removing big items and large amount of clutters with obtaining consent from the staffs. Each staff is, then, encouraged to check designated spaces such as desk and cupboard for removing unwanted items gradually without enforcement. First step to improve waste management system of the hospital Solid waste management system for the entire hospital premises should be, in this stage, discussed among QIT members and the hospital top management group. It is not, however, necessary to make a large scale activity with radical change of the existing practice. Promotion of segregation of the solid waste at each work unit can be proposed and put into practice without using large scale fund but with utilizing the existing resources. Initiation of “Reduce, Reuse, Recycle Concept” with “Sort” step of 5S Waste management can educate staffs for mind-set change. Reducing clutter and piled up unnecessary documents and paper make the staffs happy with additional spaces and cleaner environment. The moment, when WIT leader and/or division head detect a small change in physical environment of the workplace, is the time for introducing the new waste management trial. a…Simple separation of solid wastes into

(1) Medical wastes including infected items / materials and (2) Normal wastes without possibility of infection

b…Further separation of the category (2) into

(2-1) Items, which can be provided to the safe recycling process, for instance, inner wrapping paper of disposable surgical gloves, glass bottles of i.v. antibiotics and so force,

(2-2) Items, which can be collected for selling to outside recycling companies, for instance, PET bottles and other plastic materials.

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The above-mentioned challenge is an example of the activities, which connect the ―Sort‖ process to the later ―Standardize‖ process. In addition to that, ―Sort‖ will be a useful initiation opportunity in refinement of the existing waste disposal management system. “Big cleaning day” should be timely set for “Sort” A specific half day in a month may be used for hospital-wise day for ―Sort‖ activity. QIT have to announce the time/date of this special day, in advance, to all WITs and departments. If the Saturday is an official working day, one half day session of ―Sort‖ can be used for removing unnecessary things from all corners of the hospital. ―Unwanted Items Store‖ will be the busiest area in the hospital to accept items transported from various divisions. Discarding performance, for instance, burning unnecessary document at final garbage collection site in the hospital premises can be demonstrated to all hospital staffs. At the same time, it will be a good chance to make the collection site can be cleaned up and re-organized for avoiding risks related to infected disposals and also birds, animals and insects.

III-1-2-2 …Set (Seiton in Japanese language, S2) Set: Organize everything needed in proper order for easy operation (Orderliness)

“Set” based on perfection of “Sort” ―Set‖ is the second step of 5S and is namely a process to put orderliness in every workplace for better work efficiency and visualization for all workforces, which have to collaborate as a team for achieving a specific target. The process has to be commenced under the perfection in removing clutter and other unnecessary items for the work from their workplace.

202A site for dumping disposals before “Sort”, “Set”

203A site for dumping disposals in the process of

improvement

75

Sort Set

Unwanted items’ storage

76

20 minutes 20 seconds

Work Environment Improvement by 5S

Searching a file

Sort Set

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Set the target place of “Set” It is recommendable to select the prioritized portions and/or functions related to the important services that should be delivered by the team for the internal and external customers. Taking an example of clinical venues in the hospital, ―Emergency Cupboards‖ containing drug and medical devices will be the impactful targets of ―Set‖. If those places are ―set‖ with perfection in orderliness and the orderliness is perfectly recognized by the team members, the work process itself can be improved instantly just with betterment of time factor. In case that emergent situation is happened, whatever the reason, the time factor for retrieving necessary items and drugs is a key issue, in case, for life-saving.

131

After Sort and Set at a maintenance workshop

132After Sort and Set at a maintenance workshop

133

Your drawer is

also Sort / Set

target!

221Drug storage at Pharmacy

Set

222

Common use drug at ward is kept with labeling.

Set

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Step by step in “Set” Recognizing the improvement and workload reduction by ―Set‖ at important portions within respective workplace, WIT and the members are highly recommended to guide themselves to expand the target of ―Set‖ to all areas of the work venue. It should be done with checking the existing work processes, reviewing the experienced constraints. Five S tools, which were already mentioned in the former column, should be actively utilized for achieving better work environment. It is vital for the staffs to begin ―Set‖ activities making maximal use of the existing system and resources without altering the existing set up. It is not necessary to achieve the drastic change. Neatness and convenience are the most expecting situation. Recycled boxes and hand-made containers are the symbol of these ―Set‖ activities. If the basic ―Set‖ condition is achieved, small ideas to maintain the ―Set‖ condition and prevent so-called ―Set-Back‖ should be considered among WIT members. QIT has an active role to guide WITs to encourage the front-line staffs to maintain ―Set‖ works within routine works. The routine works and the demands from customers are the mother of improvement.

Work efficiency is positively affected by “Set” Priority areas for commencing ―Set‖ are the places with functional importance, which can demonstrate changes within a short period. Emergency cupboards accommodating drugs, medical materials and devices will be a good example of the prioritized and useful location, which has impact both to work efficiency and work process as the foundation of work environment. Recognition on the ―change‖ and removing unnecessary workload due to disorganization should be the encouraging factor to gear up the team for continuing the step of ―Set‖ throughout the work venue. Locations on furniture, machines, instruments, devices, documents, should be arranged likewise seeking perfection in the orderliness. Those are all influential hardware to the work process and the time factor. “Set” is an onset for the centralization of supply system in the hospital Central Sterilization and Supply Department (CSSD) and Linen Department incl. laundry service are the two vital areas as the target of ―Set‖. If the hospital already installed those centralized system as a mode of material supply to various work units of the hospital, the ―Set‖ processes can make further development in those functions. In the other hand, still, there is a tendency that those services are rather neglected as a fringe backyard jobs allocated both to nursing staffs and non-professional staffs. In addition, the jobs are often conducted as a scattered manner at each place requiring those services. This situation negatively affects the work efficiency. If it is so, the hospital managers and QIT will be able to encourage WITs to assess the existing problems in the supply and advice them to apply ―Set‖ activities for the betterment of the existing work environment without major change of the work system. After achieving ―Sort‖ and ―Set‖, you will have a high time to discuss the centralization of those practices step by step.

213Unused information…It was a mess.

(Before “Sort” and “Set”

215Medical record room after “Sort” and “Set”

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Tagging and labeling starts from setting up board for each room Name tag, board and symbols development and installation are namely symbolic activities of ―Set‖ process. Each work venue has specific objective for the use. Identify names of the room and install a simple board for the benefits of staffs and visitors. In the beginning of this activity, it is recommendable to avoid making permanent boards before having certain test period by means of the boards with printed paper. In this test run time, the hospital managers can re-consider the room usage and the names for efficient and effective use of the spaces. As touched upon in the description on ―Sort‖, unwanted items store is a key area for 5S activity. In this stage of ―Set‖, there is a possibility to ―set‖ the space utilization and manage to have an additional room, which you can provide for the unwanted items store, in case. “Set” kick off improvement of inventory system Inventory system of various equipment, instruments and devices can be reviewed during the ―Set‖ period. Tagging and labeling should be nicely done with consideration on standardization. In conjunction with this activity, you can review and improve the existing inventory system. Specific locations for the items, arranging workable instrument sets, storage of those sets, and colour coding system for easy handling are all useful topics, which can be handled during ―Set‖ activity.

226CSSD stores items with colour coding. Blue implys “sterile”

Set

218“Set”, with systematic labeling

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Colour code system Simple and demonstrable colour coding should be made and applied to various items, which are essential for respective job and service in order to achieve work efficiency and mistake proofing. The attempts in ―Set‖ activity on this will be a foundation of future standardization and system development for the entire hospital. Tools useful to enhance “Set” activity XY axes, alphabetical and/or numerical order and slot allocation based on use frequency can be aggressively applied to various places, which are visible and functionally important. By using those ideas, neat and function-oriented arrangement of necessary items for every sort of hospital jobs can be achieved with future standardization in mind. Neat and well arranged notice boards in the hospital, for instance, are good indicators of the process advancement of ―Set‖ process.

Effective utilization of existing materials and goods Case of CHR Banfora, Burkina Faso

CHR Banfora has tackled 5S practices with utilizing existence materials and goods effectively same as Sri Lanka does. For instance, they purchased plastic baskets which are used for storing patient‘s belongings at bedsides. The baskets are much cheaper than any other medical bedside furniture, and then, it‘s easy to get at local market in Bandore. Also, patients in hospital keep dishes and kitchen pan in the basket. Likewise, used carton boxes are redesigned for storing documents and patient‘s files. The carton boxes are reinforced with transparent tape and describe the purpose. Instead of spending extra money, using carton boxes helps to save budget and to set the documents appropriately.

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“Set” activity as the precondition on patient triage at OPD Guidance maps and direction boards can be installed relevantly throughout the hospital premises for the convenience both of visitors and staffs. After testing temporary maps and direction boards in ―Set‖ stage, the hospital authority can develop a standardized style of those items. In addition to them, it is also possible to regard the patients and visitors coming to hospitals as the target of ―Set‖. Various zoning and classification methods can be used to avoid confusion, congestion and conflict. Waiting lounge at outpatient department (OPD) provides a good example on this topic. If the proper triage is made in the lounge by capable nursing officers, it is possible to classify the patients into two to three groups, such as patients with urgent attendance, on the first visit, and the patients seeking re-examination. The waiting list at OPD can be adjusted based on the mentioned patient administration practice. This comes to be realistic only after practicing ―Set‖ activities of the waiting lounge and the related amenities. III-1-2-3…Shine (Seisou in Japanese language, S3) Shine: Maintain high standard of cleanness (Cleanness) Participatory activity ―Shine‖ is the participatory activities for maintaining cleanliness at every work venue regardless the category and location in the hospital. All personnel in the hospital are allocated specific territory as his/her work venue. Regardless the category, rank and gender of the human resources, everyone is expected to join in the ―Shine‖ activity and control the work environment on cleanliness in conjunction with the ongoing ―Sort‖ and ―Set‖. Territories requiring professional attendance, in particular, cannot be cleaned up only by the efforts of cleaners. Also desk-top of executives‘ office cannot be touched casually by other people. The executive should take care of his or her territory by his / her own efforts. Only small efforts are needed. The efforts should, however, be sustained in a continuous manner. Functionally improving and beautifying your own work venue will be a reflection of your mind-set. The mind-set as a professional person in the society should be further strengthened based on your spiritual aspect of your capability. Periodical implementation of “Shine” Periodical implementation of ―Shine‖ is important. Daily, weekly, monthly and quarterly ―Shine‖ time can be set by QIT for promoting cleaner hospital based upon the ongoing ―Sort‖ and ―Set‖. If the periodical activity is stabilized, definitely ―Sort‖ and ―Set‖ are also further activated. Perfection of ―Sort‖, ―Set‖ and ―Shine‖ will be gradually achieved and the teams, so to say, WITs conducting those activities come to be more energetic and capable. Daily 10 minutes morning ―Shine‖ before starting routine work will help a lot to motivate the staffs to be sensitive on 5S activities.

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Cleaning staff and their work environment Cleaning tools are important particularly for the group of cleaners. This category of the staffs is, sometimes, treated in wrong way by other groups of hospital staffs due to the nature of the job, which is often misunderstood to be unimportant and disrespectful job. Investment is not relevantly made by the hospital to this area of work. Even in case of outsourcing, the work environment and amenity for the cleaning staffs are not properly arranged. This situation should be overcome by adopting 5S principles. Or conducting ―Shine‖ activity, the cleaning staffs are the core human resources. They should be given more attention by other staffs of the hospital. Interventions, such as cleaning tool renewal, tool storage space arrangement and provision of small office and better uniform for cleaning staffs will be encouraging factors for perfection seeking in cleanliness. “Shine” and equipment maintenance Medical equipment should be well protected from dust and dirt. During the ―Shine‖ activity, WITs and QIT will discuss how they can protect the equipment from dysfunction caused by unfavorable work environment and system failure of preventive and users‘ maintenance. Firstly the equipment should physically be protected from dust and dirt for instance by periodical and timely cleaning and appropriate cover and/or wrapping during resting time of the machines. If the ―Shine‖ is well and systematically done by the full participation of the staffs, WIT members will be able to create feasible ideas for sustaining sound operation of the equipment. Obviously, cleanliness of the work venue is the most influential enabling factor to longevity of life of medical equipment. Check list and supervision Cleaning check list should be systematically used in every work venue. This is not a bid burden to respective work team member to give mark just after conducting routine cleaning work before and after the work. Once the check list is applied, relevant supervision should be conducted maybe by QIT. For sustaining the check list utilization, the format should not be too complicated. Also, the guidance should be done by the middle class managers under no blame policy but under encouraging atmosphere. Hospital waste management and “Shine” activity Cleanliness issue can be well discussed during the activities together with ―Sort‖ process. Hospital disposal handling both of infectious and non-infectious wastes is an important topic for the environmental and functional betterment of the entire hospital. Prevention of Nosocominal infection is firstly achieved on the basis of reliable and safe waste management practice. ―Shine‖ should be applied perfectly to the waste separation, collection, storage, transport and final treatment system. The emphasis particularly goes to the damping site of the waste within the hospital premises. With or without modern incinerator, many hospitals in developing country setting have to make final treatment of the infectious solid wastes and biological wastes within the hospital premises. It is not easy to achieve perfection in waste management system due to uncontrollable external conditions and limitations of the civil service. ―Shine‖ activity is, however, extremely vital for the betterment of the waste management for every hospital. Cleaner damping site create better hospital safety. III-1-2-4…Standardize (Seiketsu in Japanese language, S4) Standardize: Set up the above three Ss as norms in every section of your place (Standardize) Making 3Sa a part of routine work ―Standardize‖ is an activity to develop standards for the three S activities. In addition to that, the ultimate goal of this step of 5S activities is to make ―Sort‖, ―Set‖, and ―Shine‖ important parts of all personnel‘s routine work at all work units in the hospital. For that purpose, challenges should be done by the hospital authority and QIT to standardize the key procedures of each step of S1-S3 based on the experiences and the assessment of pilot work units particularly of successful WITs. Dissemination of

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the standardized procedures, thereon, should be done by visualization and sensitization activities throughout the hospital.

Visualization of slogans Information, Education, Communication (IEC) tools for dissemination purpose should be formulated after compiling simple and workable guidance documents. Eye-catching ear-stimulating slogans and other key messages on 5S should be included in posters, stickers, and other public relation materials. The situation, where the terms and phrases related to 5S and quality of service are visible in every corner of the hospital, will be created and come to be influential to hospital personnel and visitors as well. The people in the hospital community including patients and visitors are gradually guided to respect the work environment, which was positively changed by the step by step practice of ―Sort‖, ―Set‖ and ―Shine‖. The hospital, particularly visible common spaces are occupied by the atmosphere, where no one can disturb the improved environment.

215

Visualization of the Principles

STANDARDIZE

Madampe Peripheral Unit, Sri Lanka

―Creative way of Trash box‖ Colour coding: Case of HOMEL in Benin.

It is a general 5S practice to identify color coding trash boxes based on the control level. According to the national health rules at Benin, HOMEL sets up color coded trash boxes at each section, for instance, black is general garbage, yellow is medical wastage, and red is organs and blood contaminated items. Moreover, at HOMEL, black trash boxes are indicated 5S principles not only Japanese version but also in French. Through this attractive trash box, 5S practice has been spread to hospital staff, patients, patient families and hospital visitors effectively. And this 5S activity tries to be delivered to out of hospital as well.

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A symbolic "Standardization" is colour coding system Colour code system is a good example of standardization. Various attempts of color code application, which was done during ―Set‖ activities at different work units, are compared and discussed by QIT and representative of WIT leaders for making a standard. Once the standard is formulated, it should be disseminated by IEC materials and through various meetings. Short but effective training opportunities should also be created by QIT particularly for WIT leaders for applying the newly established standard throughout the hospital. The color selection will be an interesting thing maybe for QIT members and WIT leaders, since each color has specific image. In CSSD, mentioned in the former column, blue color is normally used on sterile items and materials after sterilization, whereas red is allocated to unsterile items. Yellow will be suitable as a symbol of "infection". Infection Control Unit may wish to use this colour predominantly for demonstrating important procedures and drawing attention from the staffs and patients.

"Standardize" contribute to MIS through M/E Monitoring and evaluation (M/E) is another issue that should be highlighted in this "Standardize" activity of 5S. Also regular supervisory visit is essential activity to ensure the development of 5S toward perfection in conjunction with the mentioned M/E. for conducting routine M/E, the major role should be taken by QIT both on formal data collection and on informal site visit for encouragement. QIT should closely work together with WIT leaders for simplify and standardize various check lists, such as the lists for stock management, environment management and patient administration. Existing management information system (MIS) should then be well looked into for correlating the change or evolution through 5S to quality uplifting process of MIS information particularly to resource and financial management. Improvement of check lists here in "Standardize" process of 5S should contribute not only to the work processes but to the data collection system managed by administration office of the hospital. Encouragement should be prioritized in supervision activity Informal site visit for supervising ongoing S1, S2 and S3 processes is an essential mode of standardization. The supervision should not a process only to reveal shortcomings, mistakes, incorrect performance of WIT. Supervision should be an encouraging process of work environment improvement by 5S. In that meaning, supervisors, mostly QIT members plus top management, should be "good point finders". Based on the informal friendly communication, the supervisors firstly have to try to find the positive indications and praise the person in charge in front of WIT and other spectators. The shortcomings can be indicated in a constructive manner after discussing the positive indications with WIT members on site.

200

Colour coding system at Castle Street Hospital for

Women, Colombo, Sri Lanka

199Sterilized items stored clean with colour coding

Standardize

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III-1-2-5 …Sustain (Shitsuke in Japanese language, S5) Sustain: Train and maintain discipline of the personnel engaged. (Self-Discipline)

Self-discipline improvement with positive attitude Everything should be sustained in development. Hospital management is not an exception. "Sustain" here imply the activities for make further improvement of self-discipline of the personnel together with re-confirmation of mind-set change from cynical attitude to positive attitude, by which the hospital continue challenge to realize quality of services under the policy of maximal use of existing resources. Definitely conducting 5S is not a final goal of hospital services. Principles of 5S is an starting point of the long process for achieving goal of hospital services, represented by high employees' satisfaction, high customers' satisfaction, success rate of diagnostic / treatment services in diversified medical services. To be on the right truck, 5S activities should never have a set-back and withdrawal. Deterioration of cleanliness should never happen at the hospitals, where good leaders introduced this unique management tool originated in Japan. Introductory training should be started with nursing officers and midwives Introductory training is crucially important both for commencing and disseminating 5S Principles. It should be a sort of leadership training and a good exposure to a new concept of work. Maybe 1 hour lecture session can be organized for respective category of hospital staffs. Since hospitals are the place, where are served by various groups of staffs. Interests and knowledge level on management are quite different grout to group. It is useful to start the session with highly populated and influential human resource. This particular group is nursing officers and midwives. They are well organized under the matron and also educated both in technical and managerial subjects in their undergraduate training. They are the people, who are close to patients and visitors both in terms of communication and technical terms of reference. Also the duration of work in a day for them is rather long. Based on those reasons, they are already in good preparatory status to receive an idea to function as a breakthrough of managerial constraints at hospitals. The lecturer, maybe highly motivated hospital director or QIT chairperson should use the most suitable language, phrases and workings to touch their spirits to serve the people.

Doctors as well but not in the beginning Doctors, both medical and dental, except for the persons related to hospital management will be the last group to have this sort of session. After all other categories of staffs are exposed and started to work on 5S, maybe they will recognize a slight change of their work environment. The point of time is the high time to ask for them to join in the movement to improve the work environment. Doctors are normally just wish to concentrate their technical areas particularly of diagnosis and treatment.

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They seldom pay attention how their professional work is supported systematically by the hospital system including backyard services and logistics. When they noticed the positive change in their well supported work environment, doctors should be invited to join in 5S activities as leaders. They definitely comes to be good leaders and provide various ideas guiding the respective work venue to betterment of safety and quality of services Proper training done in regular WIT meeting Proper training programme should be in place for creating universal positive attitude toward work environment improvement. The main focus of this training during 5S activities should be the front-line personnel particularly of WIT members, regardless the category and rank of the staffs. Periodical short time meeting for example bi-weekly briefing of each WIT on progress of 5S activities should be a venue of training. The meeting should be done within working hour for avoiding feeling of enforcement and additional task. The duration of the meeting should not be long. After quick review of the ongoing 5S activities, constraints of the work process, timeliness and workplace safety should be informally talked for exchanging experiences and ideas. Democratic atmosphere should be created to provoke the people to make comments and suggestion freely. This sort of 30-45 minutes regular meeting is a venue, where WIT leaders and QIT members can grasp the responsiveness of the staffs to the ongoing 5S activities. Also QIT can expect to receive good suggestions from the work front-lines. Short but practical learning process in WIT meeting "One-topic training" can be added in the above-mentioned regular meeting. Out of various topics related to quality issues, one message short presentation can be done by an invited QIT member to WIT meeting. The topic should be practical not too much theory and conceptual explanation. It will be a good idea to share the information on, for instance, a newly introduced parking system of stretchers and wheel chairs, which is intended to improve the work efficiency of intra-hospital transport of patients. There are various topics that can be informed and taught through this small classroom at every WIT meeting. Stimulation to WITs Monthly or bi-monthly short lecture can be planned as the part of "Sustain" activity for category-based large group of personnel. Top management and/or QIT chairperson can organize such a lecture session maybe having outside lecturer for exposing the hospital personnel to the different angle of work environment improvement and the problem-solving process, which will be systematically handled in KAIZEN process in the later stage. People involved in a movement of such king tend to feel boring, when they are familiar to the processes after getting them into the routine work. Stimulation is often necessary to wake them up for tackling higher targets. Positive competition is a stimulant too Positive competition is useful mode of stimulation to all WITs, both for active and inactive work groups. I t is not rare to have situation, where some are extremely active, exceeding the expectation of QIT but majority of WITs remains still in low gear. Competition of 5S outcomes at 6 months after the commencement, may work as a stimulant to vitalize the entire activities. It is obvious that a few selected model work units are in progress. Other units, however, take a chance to catch up to those model units and, in case, some units shows creativity and efforts to overtake the model units. The competition can be organized by QIT together with appropriate assessment score format of 5S. QIT appoint neutral judges from inside and outside of the hospital. It is then important to have a ceremony in front of all hospital personnel and praise the successful groups granting prizes and small tokens. The prizes are, of course, not going to individuals but groups. Monetary incentives are not basically recommended to use in this context, since this competition is a mode of encouragement to all involved people. In any cases, receiving a prize in front of colleagues is a stimulating and pleasant occasion for the work group, such as WIT, if the team has been united for common objective.

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III-1-2-6…Safety issues and 5S activities Without implementation of 5S activities, you cannot guarantee hospital safety. The safety is an extremely wide area to cover from inside issue of each medical service package to physical facility-related safety. In this column, discussion is limited only to work environment related dimension. Patients, visitors and staffs are all should be safe, when they are in the hospital premises. Any kinds of accidents, medical and non-medical ones, should be avoided. For that purpose, structural and systematic enforcement, based on the improved work environment, should be a pre-condition for any safety promotions within the hospital. Various pro-safety ideas should be incorporated to the procedures of 5S. During Sort and Set, in particular, physical structures, which might cause inconveniences of mobility of staffs and various lines of work flow, should be meticulously checked in participatory manner. Safety promotion is then automatically realized if the staffs come to be sensitive to the work environment and its influence both to clients / patients and the workforces. Slippery corridor, car park without control, slope without safety sign or tiger mark are good examples of unsafe common spaces in the hospital. In addition to the outer environment of clinical venues, there are various observation and improvement points related to physical facilities, hospital equipment for safety promotion. Electric wiring should be regularly monitored and in case any risks are detected, the hospital should prioritize the repair or re-wring works. Likewise, fire extinguishers are essential items, which are periodically and strictly checked up on the expiring date and devices' function. Clinical safety is a big issue for any type of health facilities. The details will be taken up in other chapters. Here, the readers are requested to pay your attention to the fact that the foundations of clinical safety are "Work Environment" and "Communication". Obviously, WEI by 5S is essential for safety. Also "Safety" is an important idea behind continuing encouragement to the front-line health staffs for strengthening capacity in conducting 5S activities. Definitely, we cannot separate safety issues from WEI and KAIZEN. Through 5S processes, particularly of "Standardize" step, QIT, in collaboration with WITs, can challenge to formulate a simple by effective reporting system related to accidents and/or incidences of the occasions, where the staffs felt risky or terrified at situations which might cause accident and / or dangerous events to patients and/or to staffs. If the mentioned system is in place and functioning, each work unit led by and middle manager automatically monitor the safety through the reporting. Also the collected reports are provided to the discussion table of the superior management group including QIT and the steering committee to plan the countermeasures for further promoting safety. This is a typical progressive managerial activity, which often encourages the "Sustain" process and at the same time to prepare the incoming KAIZEN phase, where there are various problem solving process on the ground of diversified hospital services. III-2…Navigation process of 5S from kick off to stabilization In every work venue, a work unit in charge of a specific task needs to look into their work and work environment from the point of view of 5S application, although the team is a group of personnel, who are well trained and familiar with the task. There are some important questions that are often asked in the process of 5S implementation. Q1--Are there any unnecessary items or clatters? (Sort) Q2--Are the essential items for the work properly given a workable arrangement both in placing and the line work flow? (Set) Q3--Are the venue, equipment and consumables arranged in the obtainable cleanest condition? (Shine) Q4--Are the processes of Sort, Set and Shine are the part of routine work in all areas of the work

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venue? (Standardize) Q5--Are the personnel managing and working on the specific task well disciplined, based on periodical learning opportunities, to serve the clients? (Sustain) The situation, where the above questions are positively used by all personnel for their routine works of the hospital, will be called as the stabilized implementation condition of 5S. The following description is typical sequences, which top and middle managers will follow at the introduction phase of 5S Principles to a hospital. III-2-1…Implication of 5S Principles to objective of respective work unit Service systems of health facilities, particularly of hospitals are rather complicated and difficult to maintain in the obtainable best condition. There are various divisions, as the work units, which have specific objective. The following chart is describing typical features of front-line or district level hospital. …………………………………………………………………………………………………………… Divisions Expected outcomes of routine work --Security guard office --The facilities are protected from outside environment. --Kitchen, --Foods supplied to in-patients are safe, nutritious and tasty. --Maintenance technician‘s office, --Equipment is all in good function. --Pharmacy --Drugs are well managed and delivered to the clients precisely. --Laboratory --Standardized and quick laboratory tests are available. --OPD --Outpatients are nicely treated with minimum waiting time. --Patient Wards --Inpatients receive treatment under comfortable environment. --Delivery room --Normal deliveries are conducted in a safe, clean and efficient

system. --Operation Theatre --Surgical care is given under a safe, clean and efficient system. --CSSD --Supply and sterilization system supports the safety and

cleanliness. --Room for doctors --The utility provides staff relaxation and readiness to work. --Administrative office --Office is functioning as the management centre. --Matron‘s office --Office works as the management center for nursing/ auxiliary

staff. --Hospital Doctor‘s Office --Office works as the centre for decision-making and

management. …………………………………………………………………………………………………………… To have a tangible outcome, each division is required to fulfill the task in the obtainable best working condition avoiding excessive workload to the staffs in charge. The workload should be moderate under the stimulating working condition to allow the staff to be innovative in developing various ideas or proposals for the betterment of the jobs and the outcomes. It is, however, not easy to realize the above situation, in reality. Too much clients, too much paper works and too much complexity in the reporting system are often seen in workplaces. Above-mentioned outcomes are all, at the same time, targets of 5S activities. By the sequential activities of 5S, the staffs can reduce their workload and make maximal use of given working hours for the clients and, in addition to that, they will be able to have an extra cup of tea in the tea time, because the work system becomes lean and maximally efficient by 5S. The staffs sorted necessary and unnecessary things at their workplace and discarded unnecessary items. Then they set nicely the essential items in the best order for the convenience of the operation. They always make the venue shining by daily cleaning and also standardize the process of Sort-Set-Shine successfully. In the process of the standardization, you acquired good attitude to be in driver‘s seat of incoming KAISEN process and continuation of 5S activities to be ready to tackle the ―Quality of Service‖.

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III-2-2…Navigation process for introduction and stabilization of 5S activities A distinctive approach to mainstream 5S activities in routine managerial process is necessary at hospitals. The following sequence will be the most common and useful for your hospital, in which you introduce this intra-organizational social movement. Health Centre or Front-line Hospital as well as large scale general hospital will be able to apply this sequence for establishment of the implementation structure of 5S. Large scale organizations, such as ministry offices are not exceptions. Regardless the size of the project or institution, you can make use of the following strategies and the sequence of work. Top management and middle managers are both highly expected to obtain the following tips to success. III-2-2-1…Decision-making of the top management Top management has to firstly learn 5S Principles by him or herself. The starting point of 5S activity introduction is to have strong will and determination to improve your organization. Improving your work environment by yourself is the first action that you have to take, if you want to be a more powerful leader with high potentiality of further development. Just decide to practice 5S and move forward. III-2-2-2…Exposure and training for the staff Exposure and empowerment seminars for your executive staff (limited attendance of under 10 in number) is the second step after you achieve a little by your own efforts in improvement of your territory (for e.g. your own desktop or office). You are the only able person to guide your core staff members toward 5S. Hopefully you arrange a small 2-3 hour seminar on 5S, inviting a lecturer and/or moderator form outside. III-2-2-3…Trial and making showcase or pilot area for advertisement of 5S You may choose a limited number of offices or divisions for making showcases for the rest of staffs to make them interested on the process and outcome of 5S. The executives or core staffs, who attended the 5S seminar, have to work together with you for this step. Maybe your office will also be a good place for the demonstration purpose. In addition to the above arrangement, you can choose the most neglected categories, both with the attention of people and funding as a part of pilot areas of 5S. In most cases, the suitable target will be the Classified Day Employees (CD) and their territories. Cleaning work will be one of the most useful target jobs for 5S. You can make small financial input and improve the 5S practices of them, for example, by replacing old and broken cleaning tools with the new items (Sort) and the installation of toolboxes or rockers (Set). This, definitely, is an opportunity to improve the working environment for CD. If the top management directly shows his or her interest on CDs‘ job by encouragement or instruction, the quality of their work will definitely improve with the implementation of 5S activities. This is the second of the points / areas to expand your movement to other parts of the organization. III-2-2-4…Appointment of 5S Manager as future Quality Improvement Team (QIT) Leader Appoint one person out of your core staff members as the responsible post for the entire process of 5S activities. If you are a hospital director or an equivalent, do not be the Manager by you. You have to create the organization, where 5S manager is totally authorized by you to control everything on 5S. You need to set a situation, where he can assess your territory, such as office or file system; and in later stages to check whether or not the continuing efforts on 5S were properly made. This is a

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strategy to construct the sham-flat-organization under the given cadre system or ladder of human resource. Flat-organization is the utopia, where you can work on 5S and KAIZEN most efficiently. It is, however, very difficult to eliminate the borders between ranks and sections. Sham-flat-organization is the compensation for this but is very useful. III-2-2-5…Exposure to middle-level management personnel 5S Pilot areas: A precondition of Work Improvement Team (WIT) formulation A gathering of middle-level managers of technical and administrative sections is necessary to endorse the information and support the guidance on 5S directly from 5S Manager and the top management. Request them to do something on Sort and Set just after this meeting. One hour meeting is quite enough just to explain the objective and methods of 5S activities and expecting outcomes in a statement, such as ―you can enjoy one more cup of tea in the afternoon after organizing your work venue. Your headache of the workload too will be gradually well controlled by 5S.‖ Important thing is to have such meetings several times using working hours. Do not organize big meetings in the post- or pre-working hours. This sort of extra duty makes them lose their interests. The small successes of the 5S pilot areas should be demonstrated to the middle level managers. These people will be leader of WITs after getting new experiences and knowledge. III-2-2-6…Declaration of 5S activities to all staff in the first 5S Day or Festival 5S activities should not be a stress to your staff. You can make it enjoyable. People have to enjoy the process aimed to achieve the best work environment. You could identify one convenient date and arrange an enjoyable festivity in lunchtime for example. The purpose is to make official announcement from top management that this organization will adapt 5S activities as the official movement for Quality Improvement of Work. If you have a small fund, you can treat your staff with refreshment or lunch and accommodate entertainment such as singing or dancing, in which you may incorporate the message on 5S. 5S Manager will be officially introduced by you but in an enjoyable manner. You can prepare a special costume or cap to symbolize his or her role. This festivity will be definitely memorized among your personnel as a milestone in the long process of improvement. After several years, if you are in the same position, you will find the visible outcomes of 5S and recall this date of orientation and initiation. III-2-2-7… Daily 10 minutes 5S activities and in-service training for middle-level management personnel The top management and the 5S manager announce that a specific time in the working hours, in most cases, the first 10 minutes of morning, working hours is called as ―Daily 10 min. 5S time‖. This special time frame has to be used only for 5S activities. If you have an in-house broadcasting system, you may release announcement every morning. At the same time, 5S Manager should be given a small freehand on scheduling of his or her routine work and go around all the units managed by middle-level managers, on and off. 5S manager has to nicely push the middle-level managers and staff to mobilize the Sort-Set-Shine-Standardize system. In addition to that, the 5S manager looks for the good candidates for 5S committees representing respective cadre or job categories. III-2-2-8…Quality Improvement Team (QIT) and Work Improvement Teams (WITs) are established. QIT should be formulated. This committee consists of representatives from each cadre or job group and is chaired by the 5S manager. He or she is now officially called as "QIT leader". Important thing is to grant authority to make assessment of the achievement in 5S activities done by each

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implementation unit. This committee should hold meetings every month to discuss and make decisions immediately on the unsolved issues related to 5S. For example, you can imagine that there is rubbish in the common space of the hospital. This rubbish cannot be removed due to the uncleanness of the responsible division. The Team comes to see the site and immediately makes suggestions to do this job. This QIT is not a body just to discuss the matters but the authority to make decision on the implementation actions of 5S. The informal groups, which have been working on 5S at each work unit, are now officially called as WITs with appointment of WIT leaders. In each work unit or division of the hospital, WIT was equipped finally. The entire hospital is ready to scale up the 5S activities to the organization-wide activities. III-2-2-9…Continuing education on 5S for all the personnel to "Sustain" improvement You may promote a scheme to educate all categories of staff on 5S, every two weeks or every month. This scheme can be organized by the QIT with the initiative of QIT leader in consultation with the Top management. One hour in-depth leaning on the actual methods on 5S from other successful WITs should be organized by QIT. Later, QIT should praise those successful WITs in front of all other WITs. Their efforts and outcomes should be presented maybe on the notice board for promoting more interests of the people. The meetings should not be long. Punctuality too should be learnt by all staff. In addition to the above educational opportunities, each WIT is encouraged to hold periodical short meeting on 5S and the outcomes together with the persistent problems still existing even under 5S Principles. The staff meeting of each division, led by WIT members, is expected to share the information on ongoing 5S processes and the needs for further improvement of work flow, on which the smoothness was disturbed due to disorganized physical environment. Regardless the rank and category of the personnel, every meeting participant is invited to speak for the sake of better environment. The WIT leader is requested to handle the discussion topics with care to promote comments and ideas from the staffs, which actually know the reality both of the workload and work system. III-2-2-10...Monitoring activities and "Suggestion Scheme" Simple reporting system can be developed in line with the existing management information system (MIS). It is not necessary to build up a new and separate reporting system specifically for 5S. It is useless and just increases the paper work of your staff. Conduct 5S on the existing MIS of the hospital. If the existing MIS is an inconvenient system and a sort of burden to your workforce, you can try to reform it to a lean and efficient system, taking the introduction of 5S as a chance to do so. The effects of 5S can be assessed by a simple check list of 5S steps. Work outputs, for instance, the number of patients, who was undertaken blood sampling within a set timeframe at the hospital laboratory, will be a visible change after practicing 5S even without drastic change of the work process and without introducing modern equipment. Those demonstrable changes can be detected, if the top and middle managers come to be more sensitive to work environment and the strengthened teamwork in conducting 5S activities. You may carefully observe those changes on MIS. This practice leads you to the Black-belt 5S activities, which are 5S for standardization using several managerial tools and regulatory mechanism, such as alphabetical order alignment, emergency cart arrangement, mistake proofing. Suggestion scheme, herewith, is defined as the mechanism to raise suggestions from the work front-line, regardless the categories, to the middle and top management positions on the needs in improving work environment and some work processes. Official request from the top management to the work front-lines should be made for collecting suggestions from each work unit. The collected suggestions are scrutinized at QIT meeting periodically for setting priorities. The prioritized issues related to the work environment and its countermeasures will receive a small scale funding by the top

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management for completion of 5S and also to proceeding to positive change of the work process and the service contents, if necessary. The mentioned change can be regarded as an attempt of KAIZEN, which is related to work environment. Even within the stage of 5S, which is originally focused only to work environment, eruption of problem-solving of the work process can be seen, if the "suggestion Scheme" is functioning and well utilized both by top management and the front-line work units. III-2-2-11…Bi-annual award of 5S for the best performance WIT People have to be praised if the performance is excellent. QIT will make objective assessment on the progress of 5S using direct observation and check lists and identify the best division or work unit (job group) for the 6 months duration. It is quite useful to motivate people to actively join the positive competition on 5S practice. Small awards can be granted with a small token to the job group. If small amount of cash was given, the money can be managed by the QIT and that can allow them to purchase items, with which they can improve their working environment. It is also possible to make use of funds for their amenity such as a table for tea or utensils. It is a monetary incentive for a non-monetary purpose, granted to a team and not to an individual. The usage of money is for common interests. This is genuine. In 5S activities, incentives can be used only for the improvement of 5S activities. III-2-2-12…5S-festival for showing up the achievement Evaluation from outside of the organization could be the best incentive for the staff. The 5S Festival should be arranged as a day for publicity on 5S, for the people outside the institution. If the photo materials are collected during the past 12 months, you may demonstrate the ―change‖ by visual material to the guests. It is useful to demonstrate the situations both before and after the application of 5S. Same as the first festivity for initiation of 5S, you may organize the event to make it enjoyable for all people. Then your management cycle will return to the beginning. As you know, top management is always like this. You are on the upward spiral of development line. Even if you are a bit tired, you have to continue this movement. This guarantees lots in terms of your development of managerial skill at the same time.

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III-3...KAIZEN III-3-1…Definition Origin of the term, KAIZEN is a Japanese word implying "Change for the better" or "Improvement". In management, it, generally, means "continuous cost reduction" and "improving quality and safety" by reducing delivery time. As mentioned above, KAIZEN is a team-based improvement activity, in which every process can and should be continually monitored and improved. Nobody knows everything but everybody knows something. So working together minimizes the weakness of individual and enhances the strength of each individual as well as the team. If KAIZEN is applied to a workplace, the activity on site comes to be a process for continuous improvement involving everyone regardless the difference in position or rank, manager or worker. KAIZEN is originated in manufacturing sector but now not limited to manufacturing systems only. It can be applied to service industry including health care. III-3-2…Objective, implications and the effects Objective of KAIZEN is ―Work Improvement‖, whereas the core objective of 5S is ―Work Environment Improvement‖. The difference between 5S and KAIZEN is the difference of target and process. The most important achievement of 5S is "employees‘ satisfaction (ES)" as the result of improvement of work environment. In other words, ―Easy to Work‖ is the visible outcome of 5S. The main achievement of KAIZEN is, however, not only ES but also "organization‘s satisfaction" through improvement of work processes leading to high quality and safety. The target area and procedures of 5S are mostly standardized. WIT is the engine for promoting 5S activities as bottom-up approach under the commitment of top management. In KAIZEN, on the other hand, the aim is problem-solving, which may not be defined clearly in the beginning. To define the problems, some Scientific Quality Control (SQC) tools were developed in Japanese industry. The tools are now applicable also in service sectors including hospitals. Failure in continuing KAIZEN is a life-threatening issue in manufacturing sector. You can imagine a factory making vehicles. There over 10,000 parts are prepared, standardized and supplied timely for the assembly process of one vehicle. Also there should be a workable communication system among different sections and offices to control the production process. The production line should be perfectly in order since they have to assemble the 10,000 parts precisely on time having their outcome target of finalizing, for example, 5,000 vehicles per day. Each assembly process and maneuver of workers should be in the achievable best level. The issue is to reduce the number of products, which are rejected as end products at final evaluation. If there are many rejected items, the company loses money. It also negatively affects the quality of vehicles and finally loses in the competition in the market. Health service is also an outcome of a complex process same as the above car industry, which have to always seek ―Quality of Product‖. It is often said that hospital is the most complicated service creation and delivery system. One unique feature of "hospital" is the segregated groups of specialized human resources sustaining the function of health services. Doctors, nurses, various technologists are the technical workforces, which are supposed to be well supported both by administrators and other non-professional staffs. Autonomy is granted to the professional decision-making of doctors in terms of health care needs and intervention. Doctors often prioritize medical issues putting managerial issues aside. IN addition to that, most of large scale hospitals are managed with multiple human resource management channels. For instance, management lines of doctors and nurses are normally separated. Doctors are managed by department head and the nurses are controlled by matron's office. Decision-making process in hospitals therefore tends to be complicated and slow. Multi-disciplinary

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team approach in hospital is easy to talk but extremely difficult to practice partly due to those reasons. Managers in health service are the persons, who have to strengthen internal mechanism of your organization to involve all staffs under different categories to the movement promoting participatory problem-solving process being conducted at every work unit in a participatory way. This process is KAIZEN. If the real, workable team is in place in every work unit, we can overcome the above-mentioned complexity of management in hospitals. If the multi-disciplinary teams are functioning in solving technical and managerial problems in respective work venue, we are entitled to be on the upward spiral of development. In the former chapter, it was clearly mentioned that 5S activities for WEI also work as a mode of team building. During the sensitization of the staffs to work environment, WIT and its leader reinforce the capacity and sensitivity of WIT members and other work unit members to look into the work environment as an important determinant factor affecting work processes, the efficiency and also the quality of services. KAIZEN process, a participatory problem-solving process followed by job groups, comes into reality during or after Black-belt 5S period, when WIT vigorously work on perfection of 5S. Complaints in workplaces raised by the workforces, such as "hard to do", "incomprehensible", "complicated", "annoying", "bothering", "out of my job" and so on, are all the seeds of KAIZEN. There are at least three different solutions when you detect a specific complaint in a workplace under your management. The first solution is just to stop working on the job related to the complaint. There is no point to continue the work, since the work does not create any values. The second is to change the process or system related to the job. The third and the worst solution are to add the work for solving the problem. If you do that, you will have just an additional tasks and additional problems on them. As mentioned in the above second solution, the core concepts of KAIZEN are to visualized problems, to define the required quality, to simplify the working process and system and to continue the improvement. III-3-3…Phasing and the logic III-3-3-1…Gemba KAIZEN: Managers should visit work front-line frequently.

Gemba is a Japanese word meaning ―real place‖ – now adapted in management terminology to mean the ―workplace‖ – or that place, where value is added. In manufacturing, it usually refers to the shop floor. Gembutsu the tangible objects found at gemba, such as work pieces, rejects, jigs, tools, and machines Go to gemba is first principle of gemba kaizen. This is a reminder that whenever abnormality occurs, or whenever a manager wishes to know the current state of operations, he or she should go to gemba

right away, since gemba is a source of all information In many service sectors, gemba is where the customers come into contact with the services offered. In the hospital sector, for instance, gemba is everywhere: in OPD, ward, dispensary, operating theatre, laboratory etc. In the hotel business, it is in the lobby, the dining room, guest rooms, the reception desk, the check-in counters, and the concierge station. Most departments in these service companies have internal customers with whom they have inter-departmental activity, which also represents gemba.

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To start kaizen in gemba, muda offers a handy checklist and mura and muri offers a handy reminder for this purpose. MUDA is a Japanese word meaning ―waste‖ which, when applied to management of the workplace, refers to a wide range of non-value –adding activities. But this word carries a much deeper connotation. Work is a series of processes or steps, starting with raw material and ending in a final product or service. At each process, value is added to each activity, and then sent on to the next process. The resources at each process – people and machines – either do add value or do not add value. Muda refers to any activity that does not add value. Muda in gemba has seven deadly wastes. Seven deadly wastes Waste is so often in front of us that we do not always see it ―The greatest waste is the waste we do not see‖

1. Overproduction: Blood draws done early to accommodate lab. Lab investigations not taken to the BHTT and idling in nurse‘s lockers.

2. Transportation: Moving patients to tests unnecessarily. Sending two or more ambulances for the same clinic due to lack of planning in the hospital.

3. Excessive Processing: Asking patient the same information multiple times. Nurses drawing the drug chart, observation charts rather than spending time on patient care.

4. Waiting: Inpatients waiting in X-Ray rooms, ECG rooms etc for investigations, especially during emergency.

5. Inventories: Keeping the items, which are unnecessary for the unit, condemning items, and irrelevant items for the unit, and excessive items in a unit.

6. Movement: Looking for missing charts or equipment, searching an item for more than 30 seconds, unnecessary movements to perform a work.

7. Defects: medication errors. MURA (Irregularity) Whenever a smooth flow of work is interrupted in an operator's work, the flow of parts and machines, or the production schedule, there is mura .For example, during an emergency in labour room (Post Partum Haemorrhage), each person from VOG , MOO, Nursing Officers to LR attendant are performing more than their capacity to recover the patient. But the one who goes to blood bank may take her own time to return to LR without any consideration about the emergency. Therefore everybody‘s work in the labour room must be adjusted to meet the slowest person‘s work. Looking for such irregularities becomes an easy way to start gemba kaizen. MURI (Strenuous work) Muri means strenuous condition for worker and machines as well as for the work processes. For instance, if a newly appointed nursing worker is assigned to assist a veteran surgeon without sufficient training, the job will be strenuous for her, and chances are that she will be slower in her work and may make many mistakes, creating muda. To avoid this, the managers should follow LUCK principle i.e. Labour Under Correct Knowledge. Muri can occur when operating a machine. For instance if the trolley is not properly maintained in the hospital, a minor staff may feel difficult to push it when taking a patient. This causes strain on him meaning that abnormality has occurred. Golden Rules of Gemba management

• When a problem (abnormality) arises go to gemba first; • Check the gembutsu (relevant objects);

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• Take temporary countermeasures on the spot; • Find the root cause; and • Standardize to prevent recurrence

Ten basic rules for practicing KAIZEN in gemba

1. Discard conventional rigid thinking about production / service; 2. Think how to do it, and not why it cannot be done; 3. Do not make excuses. Start by questioning current practices; 4. Do not seek perfection. Do it right away even if for only 50% of target; 5. Correct mistakes at once; 6. Do not spend money for kaizen; 7. Wisdom is brought out when faced with hardship; 8. Ask ‗Why?‘ five times and seek the root cause; 9. Seek the wisdom of ten people rather the knowledge of one; and 10. Remember that opportunities for Kaizen are infinite.

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Work Environment

Improvement (WEI)

5-S

Sort, Set, Shine,

Standardize, Sustain

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262Outcomes of KAIZEN (CQI)

A pharmacist, who achieved

this KAIZEN through WIT

and suggestion scheme

This KAIZEN at

dispensary was

achieved based on

5S outcomes at

pharm. storage

263Outcomes of KAIZEN (CQI) improving

service contents

Improvement in system reducing workload and time cycle

Svc-providers’

satisfaction

Clients’

satisfaction

Safety promotion

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III-3-3-2…PDCA cycle Gemba KAIZEN is a basic philosophy for KAIZEN mind. In the hospital, there are a lot of Gemba KAIZEN points and you have to tackle to solve the problems or constrain as soon as possible utilizing present resources. We need systematic approach how to manage KAIZEN continuously? When you manage KAIZEN, the following four steps are important. Step 1; Plan, preparing how to implement KAIZEN Step 2; Do, Implementing KAIZEN activities Step 3; Check, Reviewing the result of KAIZEN activities Step 4; Act, taking countermeasures based on the review in Step 3 (Back to Step 1 for new KAIZEN activities)

This step wised method ―Plan – Do – Check – Act‖ cycle (PDCA cycle) is the core concept of managing KAIZEN activities and also called ―Deming Cycle‖. In the four steps, ―Do‖ step may be intended more important than the other steps because ―Check‖ and ―Act‖ steps are not implemented if it is not done. In business, however, it is the saying that ―80 % of Success is decided by proper planning‖ and ―learning from failure is the gate of the success‖. Planning is able to be identified three components as ―To know‖, ―To Understand‖ and ―Able to‖. It means knowing ourselves and the present situation broidery first, then understanding issues in the present situation deeply second and finally considering the solution what we are able to. If the plan is designated appropriate procedures as mentioned, 80% of success may be secured. Since PDCA cycle consists of four steps only, the cycle may be stopped at ―Act‖ often. Kaizen aims to raise the standard of our workplace, productivity, quality and safety in a continuous upward spiral through rotating PDCA cycle, reflecting on achievement of KAIZEN and taking action to improve the way for next KAIZEN.

Golden Cycle for Improvement

Planning is • To know• To understand• Able to

PlanPlan

DoDo

StudyStudy

ActAct

At first, We have to know ourselves At first, We have to know ourselves

before planning!!!before planning!!!

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Points of each step in PDCA cycle are followings. 1 Step 1; Plan, preparing how to implement KAIZEN - Clarify the objectives and decide on the control characteristics (control items) - Set measurable target - Decide on the methods to be used to achieve the target Step 2; Do, Implementing KAIZEN activities - Study and train in the method to be used - Utilize the method - Collect the measurable data set up on the plan for decision-making Step 3; Check, Reviewing the result of KAIZEN activities and achievements - Check whether the results of implementation has been performed according to the plan or standard - Check whether the various measured values and test results meet the plan or standard - Check whether the results of implementation match the target values Step 4; Act, taking countermeasures based on the review in Step 3 - If the results of implementation deviate from the plan or standard, take action to correct this - If an abnormal result has been obtained, investigate the reason for it and take action to prevent it recurring - Improve working system and methods III-3-3-3…KAIZEN Suggestion To propel PDCA cycle in the hospital, you have to consider how to make a plan for KAIZEN by each WIT. The solution of your consideration is KAIZEN Suggestion. KAIZEN Suggestion is an entry point of KAIZEN and brings valuable opportunities for work unit members' self-development as well as for interactive communication in the workplace. KAIZEN Suggestion makes employees' KAIZEN - consciousness and provides opportunities both to health and non-health staffs to speak out with their managers as well as among themselves. KAIZEN Suggestion, which is the first process of KAIZEN, encourages staffs to generate a great number of suggestions. Having these opportunities, they work hard and consider how to implements the job, which are suggested and created by them. The top management has to prioritize the submitted KAIZEN suggestions based on the relevance, effectiveness and efficiency, and also gives the recognition to employee's efforts for improvement. An important aspect of KAIZEN Suggestion is that each suggestion, once implemented, has potentials to lead the entire work process to an upgraded standard. The American-style suggestion system stresses the suggestion's economic benefits and provides economic incentives. However, the Japanese-style KAIZEN Suggestion stresses the morale boosting benefits of positive employee participation. In KAIZEN Suggestion, there are three Stages as followings. 1. Encouragement In the first stage, top manager and QIT should make every effort to help all staffs, who provided suggestions. No matter how primitive those suggestions are, the top management group has to handle them for the betterment of the work flow, the workplace and visitors‘ satisfaction. This will help the

1 Source; [the QC problem solving approach] by Katsuya Hosotani 1992

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staff look at the way they are doing their jobs. 2. Education In the second stage, manager and QIT should stress employee education so that employees can provide better suggestions. In order for the staff to provide better suggestions, they should be equipped with skills to describe the problem objectively and the backgrounds. 3. Efficiency Only in the third stage, after the staff is both interested and educated, the top management should be concerned with the management improvement through the suggestions. Example of major subjects for KAIZEN Suggestion as followings, - Improvement in one's own work - Savings in energy, material, and other resources - Improvements in medical equipment and facility - Improvements in medical supply, medicine and other goods - Improvements in work process - Improvements in quality of service packages and / or products - Improvement in non-medical customer services and customers relations KAIZEN ideas, related to the above topics, should be well scrutinized in a participatory approach and group work. The before and after KAIZEN should be quantitatively and/or qualitatively compared using workable indicators. Also it is important both for the staffs and managers to be able to confirm what they learnt through the KAIZEN process.. After receiving various KAIZEN ideas, top management group and /or responsible persons of QIT have to make decision promptly on the prioritization among the ideas.

Example of KAIZEN suggestion Sheets

Kaizen Idea Suggestion Form Date Team member Team leader

Target process(es) Target product(s)

Picture of current condition Picture of target condition

Description of current condition Description of target condition

Team leader / manager to complete

Estimated impact What we learned as by implementing this idea

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III-3-3-4…Quality Control (QC) Story: A standardized KAIZEN process Submitting KAIZEN suggestions, job group members led by WIT are supposed to look into how to improve the situation where they have constraints. They may, then, tackle to solve invisible problems such as work process or time consumptions. Under these circumstances, QC tools, several applicable methods to KAIZEN process, are provided to quantify the existing undesirable situations. To analyze the causes using cause-effect relationship and to select the feasible solutions are both essential in KAIZEN especially of invisible problems. The entire process, mentioned above, is so to say, a visualization process of the invisible causes. Based on PDCA (Plan-Do-Check-Action) cycle, KAIZEN process is established as a sequential process of events, so-called ―QC (Quality Control) story‖. QC story is a basic procedure for solving problems scientifically, rationally, efficiently and effectively. At the same time, it is a fundamental problem solving tactics, which allows any staff or group to solve even persistent problems in a rational and scientific way. QC story consist seven basic steps. Certain time-frame is normally set for the problem-solving process, since consciousness of time is really vital in the real work front-line. It is recommendable that one QC story has to be finalized within around six months. If the QC story is shorter than six month, the work unit members involved in the process cannot cope up with each step and cannot utilize the QC tools properly. If QC story is longer than six months, the members will be boring and discouraged in tackling problem-solving. The most prioritized topic for problem-solving should be selected for respective work unit conducting KAIZEN. As already mentioned above, the solution should be achievable within six months. The 7 basic steps are as follows; Step 1; Select Topic, Describe Problem Step 2; Understand situation and Set Target, Analyse problems and Specific objectives Step 3; Planning Step 4; Analyze causes Step 5; Plan and Implement countermeasures Step 6; Check Result Step 7; Standardize and Establish control Step 1; Select Topic, Describe Problems Areas of priority concerns Since members of WIT will work together on KAIZEN for six months, it is important to select a challenging and attractive topic. WIT has to notify the problem, which is expected to be removed through KAIZEN, to the top management via QIT. For doing the above, the followings are useful in identifying existing undesirable conditions. - Check the KAIZEN suggestion which should be solved by the team - Check the roles and job descriptions of each staff and department - Check the policies and objectives assigned to the work unit and department - Conduct study visit to the work venues suffering from problems - Formulate reporting using Video/photos, if possible Check points for selecting appropriate KAIZEN topic

The topic is

- a common issue for all work unit members - highly necessary and relevant in the work unit and the venue - manageable in the work venue by the job group - challenging but achievable - appearing with no negative influence

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- linked to hospital policies and objectives - potential to develop new capacity of work unit members including WIT members.

Topic examples for KAIZEN in hospitals

- Reduction of waiting or idle time within job sequences at reception, pharmacy, laboratory,

administration office and so forth, - Reduction of the number of missing drug orders at dispensaries, - Prevention of failure in maintaining temperature of hospital meals prior to serving, - Reduction of expenditure for electricity and water usage - Reduction of preparation time of instruments and the consumables for emergency cases Step 2; Understand situation and Set target, analyse problems and specific objectives 2-1…Analyse problems and identify Important Key Areas for improvement At the first step in analytical process, WIT member should collect data related to the selected topic. Both quantitative and qualitative data should be in his or her hands. The data collection methods, used here, are expected to be standardized in advance for better reliability of the collected data. Reliable data can be obtainable, if the personnel, handling the data, effectively calibrate the information on the existing situation among the job group. The term ―situation‖, used here, implies the conditions related to the topic in the past, and the existing present one. In addition to that, various influential factors to the "situation" should also be well considered by the job group. Understanding the unfavourable present situation should be accomplished by scrutinizing how unsatisfactory it is and, at the same time, how it was bad in the past. 2-2…Useful check-up actions for understanding the situation -To collect time line data and visualize them on charts or graphs -To check work process flow and visualize them on charts or graphs -To collect events, which gave influence to the positive and negative change of the situation

-To analyze linkages between the problems in the work flow by demonstrating the work flow with data by stratification

2-3…Specific objectives, the expected results and the mile stones The objectives for problem-solution shall be decided by balancing the ideal conditions and constraints on the determinant factors, such as duration, cost, and human resources. The expected results of problem-solving should, thereon, be indicated clearly based on the following criteria.

What -Specific character of the topic How much -Quantitative target value of the topic How well -Qualitative target value of the topic By When -Time limit of QC circle activities to solve the topic To whom -Target beneficiaries related to the topic Where -Target area related to the topic

Step 2, above touched upon, aims to expose what to be wrong, what to tackle and how to proceed. If the Step 2 is not taken properly, the forthcoming steps will be in the foggy atmosphere with difficulties. It will be undoubtedly hard for the job group to reach expected goal. Step 3; Planning The WIT, handling KAIZEN topic, are required to draw up the plan as a team and allocate the roles,

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tasks and responsibilities for each job group member. All members are supposed to share fairly allocated responsibility of the KAIZEN activities with respect to their skills and responsibilities in the work area. All activities in KAIZEN should be drawn up on a chart with time line and indications on in-charge members. The chart is essential to monitor the gap between planned and actual situations. Step 4; Analyze causes This step is the most important step in KAIZEN using QC story. Accurately identifying the true causes show various hints for creating solution measures. If the WIT and job group members can not identify the causes of visible problems, the countermeasures, planned by the group will not be practical. Analyzing causes is actually an investigation process using the logic of "Cause-Effects relationship". Root causes, which maybe crucial ground causes of various visible problems, can be identified in this analytical process. Ideas for necessary actions, which should be taken as the countermeasures, are automatically created, in a later stage, through the brain-storming. QC Tools, which can be applied to this analytical process, are followings. The details will be opened up in the latter chapter. Here in this portion of the explanation on KAIZEN process, the readers just touch upon the names with good imagination on the contents. -Fish Bone (Cause – Effects) Diagram or Problem Tree -Pareto Diagram -Graphs -Check sheets -Histogram -Scatter diagrams -Control Charts The sequence of this analytical process can be summarized as follows: -Brainstorming to identify problems -Sorting the problems in "Cause – Effects Relationship" -Rating the causes and finding root causes -Analyzing one of the root causes -Drawing the results of analysis -Analyzing another root cause and again -Selecting prioritized target causes for solution Step 5; Plan and Implement countermeasures 5-1…Plan countermeasures The WIT and the job group members look into possible countermeasures as many as possible with paying attention to the following sequences related to the nature of the targeted problem. The process for participatory work are (1) considering the problems from all angles, (2) collecting ideas from the related parties and stakeholders in upstream and downstream segments of the work system, (3) discussing the topic in open-mind and avoiding critics for critics. For collecting wide-ranged ideas from multiple groups of the concerned people, the following several ways of thinking are available, if the job group led by WIT wish to be in a higher status both in efficiency and effectiveness of brain-storming and the group work. Strategic ways of thinking for idea generation in brain-storming2 -Elimination -Reversal 2 Source; [the QC problem solving approach] by Katsuya Hosotani 1992, P96

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-Normal and Exceptional -Constant and Variable -Expansion and Contraction -Combination and Separation -Collection and Dispersion -Addition and Subtraction -Changing Order -Same and Different -Sufficiency and Substitution -Parallel and Series Consideration to 4M components of sustaining productivity and quality -Manpower (Human resources) -Machines (Physical facilities, equipment and other hardware) -Materials -Methods The 5W1H closely related to operational plan -What -Who -When -Who -Where -How Prioritization of countermeasures will be conducted after the above-mentioned identification process. The three keywords, effectiveness, feasibility and efficiency, are useful in putting priority onto the various candidate countermeasures. This process is a sort of alternative analysis based upon the practical way of thinking respecting the said three keywords. The selected countermeasures for implementation should be reconfirmed and agreed upon among the team members. 5-2…Implement the countermeasures Prior to implementation of the countermeasures, recording the present situation with constraints is essential activity for the convenience of the future monitoring and evaluation processes. For visualization purpose and also for easiness in demonstration of changes, photo and/or video-takings are highly recommendable. The each step of the countermeasure implementation should be properly recorded, with summary, in documents. It is expected that this procedure comes to be a part of routine administrative practice in wider range in the entire hospital. The changes after latter stage in problem-solving should be objectively and jointly evaluated by QIT and WIT. The outcomes are shared by the entire job group with the fact that they found workload reduction and improvement of work efficiency. In case, they detect some positive feedback both from internal and external clients. Step 6; Check Results The WIT and the job group members check the results of the countermeasures implemented in the previous step. The following processes are important. -Collect the data of improvement results by workable indicators

57

-Compare ideal situation and actual result -Identify benefits by the countermeasures -Analyze reason of success / failure (if necessary) The indicators, mentioned above, are measurement instruments, which should be professionally formulated and set in appropriate places in the work sequence. The following conditionality is normally given to the workable indicators. -Which target should be measured? -What extent of change is expected? -Where should it be measured? -When should it be measured? -Who does measure it? -How should it be measures? Step 7; Standardize and Establish guidelines The WIT and the job group members consider the means to prevent backsliding and to expand the results to other part of the organization using new standards of procedures, which are formulated based on the outcomes and evidences in KAIZEN process. For prevention of setback, consideration to the external uncontrollable conditions, which might affect negatively to the improved condition by KAIZEN, should be carefully looked into and incorporated to the plan for assuring sustainability. In case, setting rules, regulations and responsibility sharing among the concerned groups are necessary. Standardization of the work process is one key issue to sustain the effects of KAIZEN together with the dissemination of the new form of work improvement throughout the organization. The following actions are, generally, necessary for the standardization -Clearly spell out all the key points of new method -Obtain the agreement of relevant work areas -Obtain the approval of superiors -Follow the official guidelines of the organization when standards or guidelines have to be established and also revised In case of the revision, the facts, related to the reasons, time/date and responsible posts, should be clearly inserted to the designated portion of the documents. The revision should be widely announced together with the advocacy programme of the updated version of standards / guidelines. III-3-4…Organizational issues and the resource necessary for the activities To commence KAIZEN activities, the commitment of top management is important as emphasized at introduction of 5S activities. In critical situation, the most of top managers complains that ―It is not my fault‖ or ―I do my best but nobody work enough‖, and neglects the voice of frontline staffs. The top management, if they wish to be capable managers, shall recognize that ―crunch is chance to change‖, ―blaming problems creates nothing‖. It is also obvious that the workforce serving in the frontline listen to the voice of patients more than the top management. Under these circumstances, KAIZEN activities will improve the situation in hospital, if the top management shall promise the following commitments. - To describe the clear directions and objectives - To share the directions and objectives with all staff through continuous communication - To make decisions based on the evidences

58

- To select measurable evidence for decisions making - To measure the evidence by the staff of the workplace - To trust the staff - Not to be afraid the change and challenge Based upon the above, the top management shall keep in mind that KAIZEN (improvement of productivity) will be attained based on employees‘ satisfaction. If you attained the productivity by the sacrifice of employees‘ satisfaction, it is NOT KAIZEN (improvement) and it is only TRANSACTION (EXCHANGE) between productivity and employees‘ satisfaction. KAIZEN activities will implement by small teams called QC circle or WIT. The team is a small group consisting of first-line employees, who continually control and improve the quality of their network, products and services. These small groups operate autonomously, utilize quality control concepts and techniques and other improvement tools, and promote self- and mutual-development. Activities of WIT or QC Circle are periodical activities around a half year. When a QC Circle, once, attained the purpose in the period, new target of KAIZEN would be selected based on the directions and objectives of the organization. KAIZEN will be attained through continuous QC Circle activities. QC Circle activities are core activities for the improvement of productivity and quality, and also aim to develop members' capabilities, to achieve self-actualization, to make the workplace more pleasant, vital and satisfying, to improve customer satisfaction, and to contribute to society. Executives and managers ensure that QC Circle activities contribute to improving the health of the enterprise by treating QC Circle activities as an important part of employee development and workplace vitalization, personally practicing company-wide improvement activities such as TQM, and providing guidance and support for total participation while respecting the humanity of all employees. At the first step, WIT should upgrade into QC Circle and a Quality Improvement Team (QIT) should be upgraded also. Even though name of WIT is remaining, the function of WIT should upgrade into QC circle. WIT aims to promote 5S activities in several workplaces, to collect the voice of frontline staff, to define the problems, to train the principle of 5S, to monitor 5S progress and so on. The functionally upgraded new QIT or, so-called Quality Secretariat is the command unit of KAIZEN in the hospital and full-time staff shall be assigned. "Quality Secretariat" aims to promote KAIZEN activities in whole hospital, to describe periodical KAIZEN direction and objective, to organize QC circle, to train the member of QC circle, to facilitate QC circle, to train the staff for QC tools, to support QC circle activities, to monitor the progress of each QC circle, to advocate the QC circle activities and to conduct the exhibition of KAIZEN process and outcomes. Capacity of full-time staff of Quality Secretariat is not much enough to promote KAIZEN activities in hospital wide. The leader of QC circle shall understand the QC process (QC story) well, attach the proper skill of QC tools and adequate capacity as leader, such as guiding, communicating, medicating, fascinating, coaching, facilitating, energizing, and so on. Japanese industry takes a lot of effort to facilitate the QC circle activities and, as touched upon in previous sections of this book, there is a lot of methodology for QC circle. You can utilize the experience of Japanese industry in your hospital easily. III-3-5…Valuable Hints for practicing KAIZEN To implement KAIZEN, there are a lot of good and bad examples at industry in Japan. However, the starting point of KAIZEN shall be considered how to reduce the unnecessary work called ―Three Ms‖ in Japanese; ―MURI = Strenuous work‖, ―MURA = Irregularity‖, ―MUDA =waste‖ as mentioned before. The followings are the hints for better KAIZEN from the experience in Japan.

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Change the Process

-to reduce effort too much -to avoid taking care too much -not to check too much -to implement naturally -to consider cutting corners with employees‘ satisfaction, productivity, quality and safety

Plan with Implementation

-to consider feasibility of the plan -to avoid negative effect by the implementation

In addition to the above, there are many useful phrases describing key to success of KAIZEN. These contain trustworthy ideas for better implementation and outcome of KAIZEN. -There is no usual work without implementation -Sharing usual work through standardizing -Implementation will make work usual -Challenge from pity success -The fail is the egg of the further success -But big fail make you discourage -The success make you encourage even if it is small -Looking the Reality -Continuous measuring will take a time -Calculation will induce the mistakes -To consider necessary function to attain the objective as minimum as possible III-4... TQM III-4-1…Definitions and the annotations Total Quality Management (TQM) is a comprehensive and participatory management comprised with several kinds of systematic and scientific approaches, with which "quality of products or services" are specifically emphasized with the purpose to ensure managerial successes also in productivity enhancement, cost control, delivery effectiveness improvement, safety promotion and moral establishment both of personnel and organization. TQM is, at the same time, characterised with the team approach at every work unit or function in the management ladder and with enabled bi-lateral managerial vectors of top-down and bottom-up. In the context of public sector hospital management, TQM is logically explained as a three-step-approach of;

(1)…Work Environment Improvement (WEI) using 5 S Principles (2)…KAIZEN practice for problem-solving in work processes and service contents at all work

front-lines (3)…TQM for adjusting decision-making in full utilization of reliable evidences provided from

KAIZEN processes, which were continuingly carried out by the workforces In ISO 8402 official documents, definition of TQM is described as follow.

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―Management approach of an organization, centered on quality, based on the participation of all its members and aiming at long-term success through customer satisfaction, and benefits to all members of the organization and to society‖

When you ask what TQM is, you can find several answers in books and web sites. In business management, TQM is described as the final result of the forth revolution, demonstrated schematically in the following illustration, for enabling quality management.

There are several other important terms related to quality management. Useful definitions are here just cited for the sake of better understanding from ISO 8042. Inspection Activity, such as measuring, examining, testing or gauging one or more characteristics of an entity and comparing the results with specified requirements in order to establish whether or not conformity is achieved for each characteristic. Quality Control Operational techniques and activities that are used to fulfill requirements for quality Quality Assurance All the planned and systematic activities implemented within the quality system and demonstrated as needed to provide adequate confidence that an entry will fulfill requirement for quality. TQM is given a higher position in categorization of different managerial approaches than the summit of stone building with other modalities as shown in the illustration below. Obviously, 5S is in the bottom layer due to its nature with ―Basic Education‖. ―Standardization‖ is, then, in next layer, since it should be done based on the improved work environment. KAIZEN, equivalent to Continuous Quality Improvement (CQI), is located in the shown position with interlinking to all other modalities in the figure.

Total Quality

Management

QualityAssurance

Four Evolution Model

From “Managing Quality “third edition by Barrie G. Dale

Quality Control

Inspection

SalvageSorting, grading, reblendingCorrective actionIdentify sources of no conformance

Quality SystemAdvanced Quality PlanningQuality CostFMEASPC

Policy DeploymentInvolve Suppliers and CustomersInvolve All OperationProcess ManagementPerformance MeasurementTeamworkEmployee Involvement

Quality ManualProcess Performance DataSelf-inspectionProduct testingBasic Quality PlanningBasic StatisticsPaper Work Control

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TQM implies an organization-wide management of quality. "Management activities" include various dimensions of planning, organizing, directing, control, and assurance. The term "Total" of TQM here represents two crucial dimensions of "Quality". The first dimension is quality issues connecting satisfaction levels of clients. The second one is obviously the direct meaning of quality of products or services. Based on those definitions, any organizations practicing TQM are required to maintain certain standards in all aspects of production processes or processes for creating and delivering services. Wastes and defects are, of course, supposed to be reduced to the possible most minimal level. In industrial sector, TQM approach is, often discussed, citing various examples from "TOYOTA production system", "Lean methodology", "Six Sigma" or "Theory of constraint". It is possible to summarize that the core concept of TQM is to adjust the entire production system meticulously for preventing over-productions and also preventing shortage of the end-products in the manufacturing process. In health sector, however, particularly in public sector hospital services, TQM should be understood to be an approach promoting maximum utilization of limited resources and an approach seeking elimination of non-productive activities. In hospitals, every client or patient wishes to be taken care under smooth implementation of hospital services all the venues from the entrance to the exit III-4-2…TQM is macro-level optimization of resource usage and investment Only after achieving organization-wide work environment improvement and organization-wide continuing implementation of KAIZEN, the top management group is entitled to proclaim that TQM is implemented with evidence-based decision-making for realizing macro-level optimization of resource usage and investment. Whereas KAIZEN is a mean of optimization in work process and the outcomes at each work front-line in division / department level, TQM is an approach to optimize the entire organization by resource utilization and additional financial inputs. For this purpose, top management group should have sufficient capability to analyze the collected evidences from each work unit. As repeatedly touched upon in previous chapters and paragraphs, WEI and 5S contribute to construct the managerial foundation for implementing KAIZEN by strengthening sensibility and capacity of respective work unit or team during implementation process of 5S activities.

QC QC Model in Industry SectorModel in Industry Sector

5S Basic Education

KAIZENISO 9001

Standardization

AdvancedScientific Statistics

TQM,ISO 9004 6TQM,ISO 9004 6σσ

GOAL SettingGOAL SettingDeming AwardDeming Award / / MaMaｌｌcomcom BoldridgeBoldridge AwardAward

Toyota Way! to Health Sector

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TQMTQM

Macro Maximization

MissionValue

５S

Leadership(reality)

WorkEnvironment

Work Process

ProductivityQualitySafety

Objectives of Improvement

StaffStaff

TargetTarget

GroupGroup

HospitalHospital

Black belt ５S

KAIZENsuggestion

KAIZEN（QC Circle）

KAIZEN culture

ChangeMindset

CommunityCommunitySocietySociety

PolicyPolicyGovernmentGovernment

Hospital

5S5S--KAIZEN TQMKAIZEN TQM

5S5S

KAIZENKAIZEN

TQMTQM

Work place

Work place

Work place

Work place

Work place

Employee

Hospital HospitalWork place Work

placeWork place Work

place

PatientCommunity

Mission

It is obvious that functional harmonization among different jobs is a precondition of rationalized working condition in hospitals. Well-coordinated handling of diversified jobs in backyard, logistics and the service front-line should be realized, if the hospital wishes to be called as a centre of excellence. Mission, credo and vision of the hospital are well documented and disseminated to all personnel as well as to other stakeholders including the catchments. Micro-level optimization of the work process and outcomes can be realized within a relatively short period by perfection of KAIZEN activities in one work venue of the hospital. It is, however, not enough to guarantee the macro-level optimization, if the latter work processes are not well adjusted and /or optimized to meet the needs. In the hospital, where TQM is maintained, every pass connecting different jobs are optimized both in efficiency and effectiveness. In addition to that, all job groups are extremely sensitive to safety, timeliness and equity in service delivery.

Reception

MedicalRecord

OPD

CSSD

Kitchen

Wastemanagement

Lab

Maintenance

X-rayWard

Operation

Pharmacy Casher

Warehouse

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Majority of the people in developing counties rely on government-run health facilities for receiving curative and rehabilitative health services. Even though the existing chronic resource shortage, the government cannot stop the public sector hospital-based health service. Government, regardless central or local, is obviously responsible to protect people‘s lives through their public services including health services. There are absolute needs and demand among general public. Under the above circumstances, quality of services at government-run hospitals becomes controversial. Direct measurement of the quality is not easy, since the issues are complicated involving various stakeholders including care-providers and beneficiaries. It is mandatory to involve the third parties in neutral positions in the measurement and evaluation. For realizing macro-level optimization of resource usage and investment, TQM is a sole approach to vitalize the entire management ladder from the top to front-line work unit level. ―Team Building‖ involving all stakeholders, regardless the internal or external customers are essential activities, which should be continuously and repeatedly conducted by the hospital. III-4-3…Phasing and the steps The core group including, chief administrator, senior consultants (doctors), matron and senior technologists are regarded as the core management group. Obtaining their collaboration, hospital director, as the top management of the organization, has to take major risk in decision-making. The common TQM process, which is directly connected to his or her decision-making, is the followings. This process is called ―Mission Deployment Management‖.

1…Top management has to identify and formulate the statements of ―mission, credo and vision‖ of the hospital. Logical coherence should be maintained between the above policy

Quality forSupply side

Quality forDemand side

PatientCustomer TQMTQM for

Hospital services

ThirdParties

AuditAccreditationCertification

ClinicalQuality

ManagementQuality

Quality forSociety

CommunityGovernment

5S5S--KAIZENKAIZEN

Team BuildingTeam Building

Productivity Quality safetyEmployee satisfaction

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statements and the short- and mid- term objectives of the organization. 2…Top management encourages mid-level managers including all department heads to formulate departmental short term objectives maintaining consistency with the policy statements.

3…The departmental objectives set by the mid-level managers have to be approved by the top management and notified to all staff members of each department. Five (5) S and KAIZEN activities have to be accordingly carried out by each department to attain the departmental objective.

4…The mid-level managers, responsible for departmental objectives, maintain periodical monitoring and reporting with reciprocating information with the top management. Top management gives proper instruction or guidance to the mid-level managers upon necessity.

5…Top management analyzes the monitoring results to find out determinant factors of successes and failures.

6…Top management notifies the analysis results to the department to reflect them to the next process of short-term objective setting.

Continuing education and training is important elements of TQM approach. In business sector in Japan, for instance, different training courses are developed respecting the demand in respective segment of managers. Leadership, team building, communication, planning, monitoring / evaluation and training / coaching methodology are all included in the training schemes. TQM cannot be applied to hospitals in developing countries as a copy of TQM, which has been functioning in developed world. In the government-run hospitals in the third world, the cultural and economical background, accepting a new managerial approach, is totally different from them of the hospitals, coping up to market economy and universal protection of health insurance system. In addition to that, learning opportunities on TQM in African continent, for instance, are not sufficiency available due to shortage of training institutes and the trainers in societies. Managers and front-line

Policy DeploymentMissionMission

VisionVision

LongLong--term Planterm Plan

MidMid--term Planterm Plan

Annual PlanAnnual Plan

PlanningPlanningCommitteeCommittee

General General ManagersManagers’’

PolicyPolicy

ManagersManagers’’PolicyPolicy

Operational PlanOperational Plan

President President PolicyPolicy BoardBoard

PolicyPolicy

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workforce in government-run hospitals is, therefore, unable to develop sufficient capacities to commence bottom-up activities both of 5S and KAIZEN. Top down initiative is now crucially important to maintain the organization-wide KAIZEN. Standardization of KAIZEN process should be achieved throughout the organization for ensuring reliability of the collected evidences, which have to be taken into consideration in top level managerial decision-making. For this standardization, periodical training for mid-level managers are institutionalized within the organization. Managing managers across the management ladder of the organization is responsibility of the top management. Directly under top management office of the organization, an office for TQM promotion and its TQM Promotion Team (TPT) can be installed for handling various managerial issues related to TQM. Quality Improvement Team (QIT), which was previously mentioned as a coordinating office of 5S and KAIZEN, should maintain information exchange with TPT. In every step of TQM, human resource management is a key process, since human hands mainly create the core value of the hospital service. The managerial targets ranges from management of their salaries, positions to capacity, motivation, work-life balance, and their will to work. In relation to human resource management, award system in 5S-KAIZEN-TQM activities is one of the best systems to encourage enrolled workforces to TQM. Positive competition among work units regardless the categories are promoted with expectation to enhance effectiveness of team work and its outcome. You can establish your own award system in hospital. The Malcolm Baldrige National Quality Award is a famous award in USA. Also Quality of Health Care Award was, later, established in Japan at 2004. It is recommendable that Ministry of Health in developing countries establishes a suitable award system for quality management of health care. . III-4-4…Example of TQM process in Castle Street Hospital for Women

Implementation

Introduction

Expanding

Preparation

Sustaining

Quality

Phase 1

Phase 2

Phase 3

Phase 4

Phase 5

Road Map for Quality Improvement

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Phase1; Preparation Learn about 5S, Kaizen, Productivity and Quality Situation Analysis (Kaizen Diagnosis Team, photos/ Video) Integrate and align ‗Quality Goals‘ into the hospital plan Determine how transfer initiative will be integrated with other processes and initiatives already in the

organization Select resource persons Address financial issues Identify 10 key areas for improvement Phase2; Introduction Establish infrastructure - Quality Management Unit - Steering committee - Work Improvement Teams Develop and begin implementation of the communication plan - Internal - External Establishment of objectives Develop Kaizen Improvement activity programme. Training of middle level managers and dissemination of objectives Study visits Phase3; Implementation Train staff members and disseminate objectives Conduct pilot projects Form WITs Start with implementing 5S (No cost, Low cost activities) Support and monitor projects Measure and review programme Customer and employee satisfaction surveys Review lessons learned Make decisions Involve consultants Phase4; Expanding Modify original plan based on lessons Expand to other units and additional training Communicate success of pilot and on-going projects Establish and communicate objectives to all staff members Measure, review and inspect Customer and employee satisfaction surveys and disseminate to middle level managers Phase5; Sustaining Conduct audit and take appropriate actions Continue to assess culture and act on gaps Customer and employee satisfaction surveys and disseminate to middle level managers Stay focus on the customers and bottom line Strategic goals for the organization must include measurable, stretch goals related to such areas as customer loyalty, service performance, competitive performance, costs of poor quality, and internal

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quality culture Upper managers must personally review and audit progress towards quality goals All employees must be trained to know what is expected of them, know how they are doing with respect to those expectations, and have the skills, tools, and authority to regulate their work to meet expectation Training – on the job, competitions (Essay, Posters, quiz) Apply for awards

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IV…Monitoring and Evaluation (M&E) for 5S-KAIZEN-TQM approach

IV-1…M&E is the basis of managing your business Monitoring is a process to assess the advancement and constraints of work process. It should be conducted in a regular manner with standardization. Various check lists can be utilized for this purpose. The information obtained from the monitoring is provided to the decision-making of process amendment and/or adjustment of the resource input for the smooth implementation of the work. Evaluation is, generally, an activity to review the entire process of the work for extracting lessons learnt both on positive and negative outcomes. The outcomes are thereafter analyzed to formulate better plan of action in the forthcoming phase of the work. In the context of hospital management, in general, quarterly review of the management targets, such as productivity, quality of service, cost control, delivery of services, safety issues and morale of the workforce, is considered as the evaluation activities. A hospital functions as a complex of diversified services ranging from backyard services, logistics and front-line services, where health staff directly contact with patients and the caretakers. As repeatedly touched upon in this textbook, work environment improvement (by 5S) and KAIZEN practices should be routinely conducted at all work units in backyard, logistics / central services and the clinical front-lines. Standardization both of 5S and KAIZEN activities should be realized after proper training of the middle managers and the work unit members. This situation allows the top management to communicate directly and/or indirectly to the workforce through the work environment improvement and problem-solving processes, which are maintained by each WIT. Of course the role of QIT will be extremely important to systematize the information collection particularly of S4 (Standardization) and S5 (Sustain) first in order to grasp the capacity and willingness of each WIT to detect and solve the problems, on which the workforce was suffered. Also KAIZEN process should be well learnt by WIT leaders first and thereafter by the entire workforce. Team work is then further enhanced based on the team‘s experience on 5S toward the implementation of problems-solving using the standardized KAIZEN process preceded by KAIZEN suggestions. The above is a quick review of so-called ―Transitional phase from 5S to KAIZEN‖. Now, what is the implication of ―monitoring‖ in the above-mentioned context of 5S-KAIZEN processes, through which a hospital challenges to achieve TQM? The monitoring activities are actually the extremely important process both for the top and middle managers of a hospital. Monitoring is a mandatory task for all managers. If the managers are not properly conducting the monitoring on the work being done by the workforce, no one can call him or her a competent manager with leadership. Top management of an organization should always pay attention to outcomes produced by 5S and KAIZEN activities and interlink them with his or her management targets. This can only be a measure for rationalizing resource control with prioritization in investment. For this purpose, each step of 5S and KAIZEN should be carefully monitored through the function of QIT. Top managements‘ wise and logical decision-makings can be done only with full function of QIT, which supervise and energize all WITs, the actors of 5S and KAIZEN. IV-2…Basic model Traditionally, there are two approaches to evaluate health system program; one is Donabedian evaluation model and the other one is Project evaluation model. Donabedian evaluation model consists to ―Structure‖, ―Process‖ and ―Outcome‖. In terms of the evaluation of 5S- KAIZEN- TQM approaches, Structure is mainly improved by 5S, Process is mainly improved by KAIZEN and improvement of Outcome means proper TQM implementation.

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Project evaluation model consists to ―Target‖, ―Objective‖ and ―Goal‖ in the logically designated plan. One of the most common planning frames is called ―Logical framework‖. There is ―means and end‖ relationship among them. In terms of the evaluation of 5S- KAIZEN- TQM approaches, Project Purpose is same as purpose of 5S, KAIZEN and TQM, Target is same as target area of 5S, KAIZEN and TQM activities and Overall Goal means system of continuous 5S, KAIZEN and TQM activities.

5S5S--KAIZENKAIZEN--TQM approach and M&ETQM approach and M&E

5S

ProductivityImprovement

Quality & SafetyImprovement

TotalQuality

Management

Leadership 1.5yrs

1.5yrs

1.5yrs

Building PositiveBuilding PositiveMind SetMind Set

KA

IZEN

Structure Process Outcome

Physical Condition

WorkProcess

ValuesES、PS、CI

Logical Framework(Project Design Matrix)Project Name Duration: Target Area Target group

Narrative Summary ObjectivelyVerifiableIndicators

Means ofVerification

ImportantAssumptions

Overall Goal

Project Purpose

Outputs

Activities Inputs

Preconditions

Ver. No.

Date

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IV-3…Evaluation Framework: Evaluation is assessing and judging the value of work of an organization. Its main purpose is to help an organization reflect on what it is trying to achieve, how far it is succeeding and identifying the required gaps. Generally, there are two dimension of the evaluation, formative and summative. Formative Summative Objective Reflect process

Help Improvement Check Achievement Probe Impact

Evaluator Self or Advisor Third party Method Can be qualitative Preferably quantitative objective Baseline Baseline data Necessary Baseline data essential

Formative evaluation is a process of ongoing feedback on performance. The purposes are to identify aspects of performance that need to improve and to offer corrective suggestions. Summative evaluation is a process of identifying larger patterns and trends in performance and judging these summary statements against criteria to obtain performance ratings. IV-4…Objectives of monitoring and evaluation for 5S-KAIZEN-TQM approach As mentioned above, the objective of the monitoring and evaluation is to minimize the gap between desired and actual status of the progress and / or performance of the project. For the health sector, the monitoring findings mainly describe the relevance of the process for service provision and the evaluation findings prove a real impact for ensuring the quality and safety for the hospital. The evaluation on the program of Quality Improvement of Health Services by 5S-KAIZEN-TQM is to be viewed in the following three aspects: To evaluate the progress of 5S-KAIZEN-TQM in hospitals Firstly, it should be identified that the unique feature of the 5S accomplishment in the workplace of the hospital is to make initiation of the KAIZEN process. Secondary, it should be evaluated that the improvement of the output, such as productivity, quality, const control, safety, service delivery and morale of the staff, is accomplished though KAIZEN activities. Finally, it should be reviewed the improvement of the outcome, such as clinical performance, employee satisfaction, patient satisfaction and the contribution for National Health Plan, is monitored toward the center of excellence with TQM. To disseminate 5S-KAIZEN-TQM policy through the regulatory authority of that country Monitoring and evaluation performances of the implementing authority especially Ministry of Health and pilot hospitals are mandatory for accommodating the relevance, efficiency and effectiveness of 5S-KAIZEN-TQM approach. The evaluation findings should be a policy input for the Ministry of Health for adopting right policy direction through strategic plan and guidelines and budget allocation for implementing the quality improvement of Health Services through 5S-KAIZEN-TQM. To organize supporting system of 5S-KAIZEN-TQM at hospitals Supporting system should be the part of evaluation. To encourage the activities in the field not to criticize /discourage their ongoing activities and to input necessary knowledge and skills are the most important roles of the supporting body. Mapping out whole supporting system and what is the function of each and how often what they do act and what expect to do. Supporting structure-instruction, information delivery of the field should be provided in right way and better to chalk out the time table/schedule of the whole supporting system.

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IV-5…Target of Monitoring and evaluation for 5S-KAIZEN-TQM approach

(1) 5S

The target of 5S is Work Environment Improvement (WEI). Taking photo before the implementation and after the implementation is basis for the monitoring and evaluation. Since it is mainly physical improvement, changing better situation is easy to identify visually. The implementation of minimum requirement in 5S is confirmed by check sheets at first, and the performance or output by 5S is also confirmed by check sheet and the other indicators if possible.

(2) KAIZEN The target of KAIZEN is Output of the hospital though changing working process by KAIZEN, such as Productivity, Quality, Safety, Cost control, service Delivery and Morale of the staff. Also the KAIZEN process should be confirmed to clarify relationship between the improvement of Output and KAIZEN activities, such as WIT performance and empowerment of the staff.

(3) TQM The target of TQM is Outcome by the hospital such as Clinical Indicators, Employee satisfaction and Patient satisfaction. If the hospital has the other tasks such as research, education and policy deployment, there are also the target of TQM.

IV-6…Feedback The result of a process activity, output or outcome as evaluative response should be shared among the stakeholders. Periodical Meetings and 5S festivals are good opportunity to share the result and drawing the results on the graphs and tables and posting on the notice boards are effective. The contents of the results consist not only the data and negative sounds but also good practice, recommendation and lessons learned. The monitoring and evaluation should be navigators toward further improvement by 5S-KAIZEN-TQM approach. IV-7…Monitoring and evaluation for the Ministry It should be a policy input for the Ministry of Health for adopting right policy direction for ensuring quality and safety in the hospital. The findings in the monitoring and evaluation should be treated as show window in Center of Excellence for the hospitals whole country. The employees of hospital from all over the departments and the Ministry of Health as a regulatory authority are viewed as real audience for this Center of Excellence. And also tasks of the Ministry for 5S-KAIZEN-TQM approach should be evaluated. The first is degree of the support to the hospitals where 5S-KAIZEN-TQM approach has been installed and the other one degree of the dissemination of the approaches into whole country. The check points of supporting activities by the Ministry are followings

- Delegation for 5S activities at the pilot hospital - Budget allocation for 5S activities at the pilot hospital - Human resource allocation for 5S activities at the pilot hospital - Announcement of the approach - Political Commitment for dissemination of 5S activities

To evaluate the dissemination of the approaches, the process of the dissemination has to be confirmed

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first. The steps of the dissemination of the approaches are followings. 1) Assignment of 5S activities at the pilot hospital 2) Administrative support for the implementation of 5S activities at the pilot hospital 3) Advertisement of 5S activities at the pilot hospital 4) Drafting the dissemination plan of 5S activities in country 5) Adaptation in health policies 6) Dissemination

The Ministry shall collect the information from the hospitals how the approach is going on and advertise the performance of each hospital to the other hospitals to make good peer groups for 5S-KAIZEN-TQM approach.

IV-8…Methodology Monitoring and Evaluation are opportunities for 5S or KAIZEN activities to examine how well it is implementing its activities towards results and to formulate lessons learned. Our broad goal should be defined which reflects overall aim of the evaluation. There are many methods for evaluation. According to for 5S-KAIZEN-TQM approach, we recommend five methods for monitoring and evaluating with the qualitative point of view; Daily Monitoring / Periodical Meeting, Self evaluation by Check list, Time survey, Employee satisfaction survey and Patient satisfaction survey. (1) Daily monitoring / Periodical Meeting Periodically meetings, for example monthly or bi-weekly with WIT leaders are effective not only to review the progress of the activities but also to input necessary support into WIT as well as internal meeting by WIT members. It is useful to provide the templates to review the progress of the activities and to record the points of the consultation by QIT for smooth implementation of the meeting. (2) Self evaluation by Check list Through a periodical monitoring for hospital activates by check sheet, the activities by each WIT are able to be compared based on the same points of views and QIT and monitors are also able to strengthen mentoring capacities of supporting activities for WIT activities.

1) Objectives of the self evaluation - To grasp the progress of 5S activities objectively and to share the result of the monitoring into

whole staff in the hospital - To improve the skill of the director and the member of QIT (5S committee) for supervision

regarding 5S activities

2) Team formation for the evaluation The hospital director or the acting director and the member of QIT should involve as the member of the evaluation team. Total number of the team is recommended three to five persons. Team leader should be selected through the discussion among the member when the evaluation team is formed.

3) Preparation

i) Setting date and time of the evaluation Since the evaluation team will order self evaluation by all departments in the hospital before the evaluation, the date and time of the evaluation shall be set at least two weeks before the implementation of the evaluation.

ii) Setting route of the monitoring

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The evaluation team decides the route of the evaluation. Since the member of QIT and the hospital director must understand everything in the hospital, the target departments for the evaluation are all departments include non-pilot department of 5S activities. Especially the department where minor staff is working must visit during the evaluation.

iii) Photocopy of the monitoring check sheet (attached file) for the member of the monitoring team and the self evaluation by the all departments.

iv) Notice of Monitoring Week

Only the week of the implementation of the evaluation (ex; 21st to 24th September) is informed to the target departments one week before the evaluation.

4) Training for Self evaluation and distribution of check sheets

A week before the commencement of the evaluation, small training session for the self evaluation by WIT and / or chief of the department shall be conducted. Especially, WIT and the chief of the department have to understand how to fill the evaluation check sheets. After the training, WIT or the chief of the department will be done self evaluation using the check sheets. The evaluation team distributes the monitoring check sheets. The points of the training are followings. - Significance / Purpose of 5S: Work Environment Improvement for the staff. - Purpose of the evaluation: Sharing the progress of 5S activities among all staff in the

hospital - Procedure of the evaluation; following this paragraph. - Procedure of the self evaluation by all departments; Filling the check sheets by WIT leader

and member or chief and member of the department. The evaluation team explains the definition of the each content in the check sheets and evaluation criteria.

- Question and answer session; confirming the participants‘ understandings.

5) Implementation of the evaluation The evaluation team shall record the starting time and ending time of the evaluation at each department. Though each member brings the check sheets, the member checks the overall progress of 5S activities in the target department instead of checking one point by one point according to the check sheets. The evaluation team shall consider praising mind rather than scolding mind even if the team finds any improper situations. The check sheets filled by the WIT or chief of the department as self evaluation shall be collected at same time.

6) Summary of the evaluation results

Rating of the check sheets shall be summarized on one check sheets of the hospital. Rating of the check sheets shall be decided in the meeting of the member of the evaluation team at same day. Based on the evaluation criteria, the evaluation team discusses the points of each subject on the sheets referring the check sheets by self evaluations and the team leader must decide the points of all subjects with the consensus of the members. If monitoring is not finished one day, tentative rate shall be set at first day and the tentative rate shall be amend by the result of the evaluation of rest of the days.

7) Feedback of the evaluation results

The evaluation team shall input some comment not only negative one but also positive one, to the result of self evaluation by all departments and the result of the evaluation and inform the result of the self evaluation by the notice board and / or conducting seminar to all staff and visitors in the hospital.

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Example of Check list (3) Time survey

Through 5S –KAIZEN- TQM activities, there is a lot of improvements in the hospital. However, some improvements are invisible and hard to confirm the achievement in the routine works in the hospital.

HOSPITAL:

DESCRIPTION Ver

ypo

orly

Poor

ly

Fare

ly

Wel

l

Ver

y w

ell

AWARD MARKS

1.1 5-S knowledge/Understanding/Awareness ofExecutive & Supervisors 1 2 3 4 5

1.2 5-S Involvement & Commitment of Executives & Supervisors 1 2 3 4 5

1.3 5-S Monthly progress meeting Minutes & Audits by Patrol teams, etc. 1 2 3 4 5

1.4 5-S Manual developed with many relevant details1 2 3 4 5

1.5 Evidence of Training conducted for Management Staff1 2 3 4 5

TOTAL 00

2.1 Outside & Inside areas of the premises free of clutter1 2 3 4 5

2.2 Unwanted items removed from Premises, Offices, WorkPlaces, etc. 1 2 3 4 5

2.3 Tops and insides of all cupboards, shelves, tables, drawers,etc. free of unwanted items 1 2 3 4 5

2.4 Walls are free of old posters, calendars, pictures1 2 3 4 5

2.5 Notice Boards – Current Notices with removal instructions1 2 3 4 5

2.6 Rules for disposal with Red Tags, etc.1 2 3 4 5

2.7 Maintenance/Prevention of Sorting Projects established withMechanism to reduce paperwork, stocks, etc. 1 2 3 4 5

TOTAL 00

Acquired marks / 25 x 100 =

2

1 5S LEADERSHIP OF THE CEO & MANAGEMENTRole & Commitment of Top Management, Sustainability of 5-S activity, Training Programme for Middle Mgt., Setting up 5-S Committees, 5-S Campaigns.

Full mark 25

SEIRI – (SORTING) “Sasambua”Clutter free Environment in Premises, Inside Offices, Work Place, etc. Evidence of removal ofunwanted items should be evident all around.

Full mark 35Acquired marks / 35 x 100 =

MONITORING AND EVALUATION SHEET FOR THE PROGRESS OF 5-S ACTIVITIESDate: 　 / / (D / M / Y)

DEPARTMENT:

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The time survey is good tool to describe the process improvement easily and simple tool to measure the working process by the hospital staff. The hospital staff also is able to identity whether her / his work is efficient or not。 We hope the hospital to implement the time survey periodically to make sure the level of improvement of your hospital and to benchmark the performance of the improvement to the other hospitals. The examples are shown as following occasions.

1) Time survey for ―Waiting time‖

i) Reception The receptionist gives a patient who just arrived at the reception the paper which was written the arrival time. The paper will received to hospital staff at the consultation room when the patient will come to the consultation room. The hospital staff writes the time of collection on the paper and calculates how much time was spent from arriving to the hospital to taking consultation.

ii) Laboratory test

At the consultation room, laboratory test request paper is issued with the issuing time. The laboratory technologist writes the time of issuing the result of laboratory test on the paper and gives the patient the result paper with request paper. The request paper and result paper are collected at consultation room when the patient come again to the consultation room and the hospital staff calculates how much time was spent from test request to receiving the test result and consultation again.

iii) Payment

The account staff gives a patient who just arrived at the accounting section to pay money the paper which was written the arrival time. The paper will be collected to hospital staff when the patient will pay money. The hospital staff writes the time of collection on the paper and calculates how much time was spent from arriving to the accounting section to paying money.

2) Time survey for ―Work hours‖

i) Patient record The surveyor measures the time by stop watch from ordering to the patient record room to taking the proper patient record. (Try more than ten times and calculate average time)

ii) Pharmacy

The surveyor measures the time by stop watch from ordering to the pharmacy to taking the proper medicines. (Try more than ten times and calculate average time)

iii) Central Sterilize and Supply Department (CSSD)

After the sterilization, the surveyor measures the time by stop watch from starting packing the operation tools to completion of the packing. (Try more than ten times and calculate average time)

iv) Linen supply

The surveyor asks to the line staff to drawing bar-chats regarding the process and times of line supply such as collection of dirty linen, laundry, iron, setting on the shelves.

(4) Employee satisfaction survey Initial target of 5S-KAZIEN-TQM approach is to change the mind set of the employees through providing the appropriate environment for professional works of medical and non-medical staff. The most useful indicator to justify the changing mind set is degree of the satisfaction of the employees in

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terms of non-monetary incentives. The employ satisfaction survey deals with workplace issues, such as benefit, commitment to work, amenity, conformability, effective communication and so on. And the survey helps paint a portrait of their attitudes, complain and suggestions. There are several types of template of employee satisfaction survey (also called job satisfaction survey). You can choose suitable one for your occasion or develop yourself based on the templates if you need not issues the result in academic fields as the evidence of the effectiveness of 5S-KAIZEN-TQM approach. (5) Patient satisfaction survey The overall goal of 5S-KAIZEN TQM approach is to deliver necessary medical services timely with adequate cost as well as the aim of the hospital. To justify the performance toward the aim of the hospital objectively, the degree of appropriateness of the services might be evaluate by customers. One of the most important customers for the hospital is the patient because the hospital was established for patients. The patient satisfaction survey also gives us the opportunity to know honest patients‘ feeling and to improve the hospital more and more if the survey has been implemented properly and fed back to the QIT and WIT promptly. There are also several types of template of patient satisfaction survey (also called customer satisfaction survey). You can also choose suitable one for your occasion or develop yourself based on the templates if you need not issues the result in academic fields as the evidence of the effectiveness of 5S-KAIZEN-TQM approach.