Continuous Improvement Cycle Research Articles

Energy Efficient Dryer Operation—An Update on Developments

ABSTRACT Recent European legislation designed to limit carbon emissions and to reward the efficient use of energy will undoubtedly encourage dryer operators to reduce their fuel consumption. This article first describes such legislation, which includes the climate change levy, enhanced capital allowances for energy-efficient plant, emissions trading, and the integrated pollution prevention and control regulations. Techniques for measuring dryer performance, benchmarking the results, and analyzing different energy-saving options are then discussed. It is concluded that more stringent legislation coupled with technical improvements, and social, political and economic pressures will result in a cycle of continuous improvement in operating performance.

Redevelopment of a Consultation-Liaison Service at a Tertiary Paediatric Hospital

This paper aims to describe the way a multidisciplinary team set out to redevelop a consultation-liaison (C-L) service at a tertiary paediatric hospital. The activities and processes in which the team members engaged were documented within a continuous quality improvement cycle. These activities included literature review, analysis of referral patterns, consultation with extant services, survey of referral sources and consultation with other tertiary paediatric services. The outcomes of these initiatives were integrated into a re-formulated multidisciplinary team model dedicated to providing C-L services to the paediatric hospital. Significant challenges identified in the initial process were ongoing issues with caseload management and clarification of boundary demarcations. There has been a gradual acceptance of the new C-L service by medical staff. The structure has resulted in a focused and coordinated C-L team that has contributed to innovations in the C-L process within the hospital.

Redevelopment of a consultation-liaison service at a tertiary paediatric hospital

Objective: This paper aims to describe the way a multidisciplinary team set out to redevelop a consultation–liaison (C-L) service at a tertiary paediatric hospital. Method: The activities and processes in which the team members engaged were documented within a continuous quality improvement cycle. These activities included literature review, analysis of referral patterns, consultation with extant services, survey of referral sources and consultation with other tertiary paediatricservices. Results: The outcomes of these initiatives were integrated into a re-formulated multidisciplinaryteam model dedicatedto providing C-L services to the paediatric hospital. Signi?cant challenges identi?ed in the initial process were ongoing issues with caseload management and clari?cation of boundary demarcations. Conclusion: There has been a gradual acceptance of the new C-L service by medical staff. The structure has resulted in a focused and coordinated C-L team that has contributed to innovations in the C-L process within the hospital.

Clinical supervision.

The NHS Plan (DoH 2000) states that the modern National Health Service (NHS) will be driven by a cycle of continuous quality improvement. This will enhance the efficiency, productivity and performance of the NHS. The aim of this article is to examine clinical supervision as a quality assurance initiative. To achieve this, clinical governance and lifelong learning will be evaluated within a theoretical framework with the focus on clinical supervision.

A Note on New Product Project Selection Model

By focusing our attention on one particular scoring method which is used to evaluate R&D projects, this paper seeks to specify empirically the factors that discriminate successful projects from failed projects in the Japanese chemical industry. Our statistical analysis revealed that when projects are evaluated in this industry, three factors, marketability, technology, and synergistic potential, tend to be valued by practitioners approximately in a 3:2:1 ratio. Although the project evaluations in this research were conducted ex-post, the findings suggest that the results may also be applicable in the project selection stage. Built on our findings, we propose a Continuous Improvement Scoring Method (CISM) that contains continuous improvement cycles, which links ex-ante project selection with ex-post project evaluation.

Clinical Practice Guidelines: A Tool to Measure Variance

Objective: To outline plans of the RANZCP Quality Improvement Committee (QIC) for the implementation of the Clinical Practice Guidelines (CPG) into clinical practice in Australia and New Zealand, and provide views of the QIC on the role of CPG as a quality improvement tool. Conclusions: Clinical Practice Guidelines are of limited utility unless there is clinician buy-in and they are used as a tool to measure variance as part of a continuous quality improvement cycle. The QIC actively encourages debate regarding the content and development process of the CPG as well as methods for their use in routine clinical practice.

Kanji's Business Scorecard

The Balanced Scorecard was first devised by Kaplan and Norton (1992, Harvard Business Review , January-February, pp. 71-79) as a measurement framework that was expected to overcome some of the deficiencies of traditional performance systems. It gives a holistic view of the organization by simultaneously looking at four important perspectives (financial, customer, internal processes, innovation and learning). Apart from being a measurement framework, the Balanced Scorecard achieved recognition as a strategic management system. The new approach to performance measurement suggested in the Balanced Scorecard is consistent with the initiatives under way in many companies: cross-functional integration, continuous improvement, customer-supplier partnerships and team rather than individual accountability. In this sense, it fits well into the quality management philosophy, embracing some of the business excellence principles of Kanji's Business Excellence Model. Nevertheless, the Balanced Scorecard, as presented by Kaplan and Norton, is not without limitations. The causality links suggested among the four perspectives are particularly problematic and ambiguous. Additionally, it fails to recognize explicitly the contributions of important stakeholders, such as employees and suppliers. Taking into account the potentialities and limitations of the traditional Balanced Scorecard, we propose the development of a new framework integrating the elements of Kanji's Business Excellence Model and taking advantage of the strengths of its sound methodological support. The Business Scorecard may be improved by integrating the total quality management principles and critical success factors that constitute Kanji's Business Excellence Model. The Kanji's Business Scorecard we present in this paper is not only a conceptual model, but also a measurement model. Furthermore, Kanji's approach has the potential to give a deeper understanding of how achievements in the different areas feed each other to form a cycle of continuous improvement. Finally, the implementation of Kanji's Business Scorecard can help organizations to develop, cascade and implement a strategy for business excellence.

Facilitating best practice: transferring the lessons of the Clinical Support Systems Program.

The Clinical Support Systems Program (CSSP) includes the management of clinical practice using clinical and consumer pathways, outcome and performance indicators, clinical measurement and review in a continuous improvement cycle using the best available extant evidence. The Royal Australasian College of Physicians is testing the CSSP model through four consortia around Australia. There are 17 project sites in three States. The funded projects address major clinical problems including congestive heart failure and acute coronary syndromes, acute stroke management, and colorectal cancer care. There is some early evidence of the CSSP influencing change in areas beyond the bounds of the project settings and the College has developed a plan to promote wider adoption of best practice. This approach recognises the College's role in providing Fellows with the practical tools of quality improvement, the means to collect data and compare their practice to other clinicians, while traversing the appropriate educational framework.

Kanji's Business Scorecard

The balanced scorecard was first devised by Kaplan and Norton (1992, Harvard Business Review, Jan.–Feb., pp. 71-79) as a measurement framework that was expected to overcome some of the deficiencies of traditional performance systems. It gives a holistic view of the organization by simultaneously looking at four important perspectives (financial, customer, internal processes, innovation and learning). Apart from being a measurement framework, the balanced scorecard achieved recognition as a strategic management system. The new approach to performance measurement suggested in the balanced scorecard is consistent with the initiatives under way in many companies: cross-functional integration, continuos improvement, customer–supplier partnerships and team rather than individual accountability. In this sense, it fits well into the quality management philosophy, embracing some of the business excellence principles of Kanji's Business Excellence Model. Nevertheless, the balanced scorecard, as presented by Kaplan and Norton, is not without limitations. The causality links suggested among the four perspectives are particularly problematic and ambiguous. Additionally, it fails to recognize explicitly the contributions of important stakeholders, such as employees and suppliers. Taking into account the potentialities and limitations of the traditional balanced scorecard, we propose the development of a new framework integrating the elements of Kanji's Business Excellence Model (Kanji, 1998, Total Quality Management, 9, pp. 633-643) and taking advantage of the strengths of its sound methodological support. The business scorecard may be improved by integrating the total quality management principles and critical success factors that constitute Kanji's Business Excellence Model. The Kanji's Business Scorecard (KBS) we present in this paper is not only a conceptual model, but also a measurement model. Furthermore, Kanji's approach has the potential to give a deeper understanding of how achievements in the different areas feed each other to form a cycle of continuous improvement. Finally, the implementation of KBS can help organizations to develop, cascade and implement a strategy for business excellence.

Re-engineering the design and construction processes for in situ concrete frames

This paper summarises the aims and objectives of the European Concrete Building Project and sets into context the construction and research on the in situ concrete building which has been completed to date. The in situ building was the focus of a business process re-engineering study during its design and construction. The primary output from the process research studies on the in situ concrete building is a series of short punchy Best Practice Guides. These are intended to be a stimulus for change, helping eliminate outdated practices and providing designers and contractors with the techniques and tools upon which a longer term cycle of continuous improvement will be based. Review of the design of the in situ building to Eurocode 2 carried out by Buro Happold has highlighted potential areas for improvement. Details of the performance research projects completed to date are summarised and plans for further projects explored. The application of the findings from the research undertaken has the potential to revolutionise current methods of working, practices and procedures with dramatic benefits in terms of efficiency. However, this will require commitment from the industry at large to be open-minded and critically review the way things are done at present. This project has met the Egan challenge of reducing capital costs and construction time by 10% per annum. It is now planned to demonstrate these savings on a selection of practical projects implementing some of the innovative thinking developed in this programme.

Re-engineering the design and construction processes for in situ concrete frames

This paper summarises the aims and objectives of the European Concrete Building Project and sets into context the construction and research on the in situ concrete building which has been completed to date. The in situ building was the focus of a business process re-engineering study during its design and construction. The primary output from the process research studies on the in situ concrete building is a series of short punchy Best Practice Guides. These are intended to be a stimulus for change, helping eliminate outdated practices and providing designers and contractors with the techniques and tools upon which a longer term cycle of continuous improvement will be based. Review of the design of the in situ building to Eurocode 2 carried out by Buro Happold has highlighted potential areas for improvement. Details of the performance research projects completed to date are summarised and plans for further projects explored. The application of the findings from the research undertaken has the potential to revolutionise current methods of working, practices and procedures with dramatic benefits in terms of efficiency. However, this will require commitment from the industry at large to be open-minded and critically review the way things are done at present. This project has met the Egan challenge of reducing capital costs and construction time by 10% per annum. It is now planned to demonstrate these savings on a selection of practical projects implementing some of the innovative thinking developed in this programme.

Control de calidad del seguimiento del embarazo normal en atención primaria

GENERAL: to increase the quality of mother-baby care in our population. SPECIFIC: to improve by at least 10% the record of activities with poorest compliance at the first evaluation on the quality cycle.Quality cycle of the normal pregnancy monitoring programme in primary care (PC). The scientific-technical dimension of quality was the one studied. There was a retrospective, crossed evaluation, on internal initiative, about the clinical records of the pregnant women. SEQUENCE: first evaluation of pregnancies in 1994-95; application of corrective measures in 1996; second evaluation of pregnancies in 1997-98.Primary care.All the pregnancies monitored by our PC team during the periods described.CRITERIA EVALUATED: care activities of the programme for monitoring normal pregnancies in Area 10. First evaluation (n = 54): 11.5% overall non-compliance. The criteria with under 80% compliance were: folic acid supplement, counselling, diagnosis of pregnancy diabetes and attendance in the month after delivery. Second evaluation (n = 69): 6.3% overall non-compliance. All activities surpassed 80% compliance except obstetric examination on the first visit, attendance a week after delivery and attendance a month after delivery.After introducing certain simple corrective measures, we achieved overall improvement of over 40% and increased compliance in most activities, except for attendance after delivery and obstetric examination on the first visit. We think a continuous cycle of quality improvement needs to be maintained in order to achieve adequate mother-baby care.

Development of integrated ecological standards of sustainable forest management at an operational scale

Within Canada, and internationally, an increasing demand that forests be managed to maintain all resources has led to the development of criteria and indicators of sustainable forest management. There is, however, a lack of understanding, at an operational scale, how to evaluate and compare forest management activities to ensure the sustainability of all resources. For example, nationally, many of the existing indicators are too broad to be used directly at a local scale of forest management; provincially, regulations are often too prescriptive and rigid to allow for adaptive management; and forest certification programs, often based largely on public or stakeholder opinion instead of scientific understanding, may be too local in nature to permit a comparison of operations across a biome. At an operational scale indicators must be relevant to forest activities and ecologically integrated. In order to aid decision-makers in the adaptive management necessary for sustainable forest management, two types of indicators are identified: those that are prescriptive to aid in planning forest management and those that are evaluative to be used in monitoring and suggesting improvements. An integrated approach to developing standards based on an ecosystem management paradigm is outlined for the boreal forest where the variability inherent in natural systems is used to define the limits within which forest management is ecologically sustainable. Sustainability thresholds are thus defined by ecosystem response after natural disturbances. For this exercise, standards are proposed for biodiversity, forest productivity via regeneration, soil conservation and aquatic resources. For each of these standards, planning indicators are developed for managing forest conditions while forest values are evaluated by environmental indicators, thus leading to a continuous cycle of improvement. Approaches to developing critical thresholds and corresponding prescriptions are also outlined. In all cases, the scale of evaluation is clearly related to the landscape (or FMU) level while the stand level is used for measurement purposes. In this view the forest should be managed as a whole even though forest interventions are usually undertaken at the stand level. Key words: sustainable forest management, criteria and indicators, biodiversity, regeneration, soil conservation, aquatic resources, landscape level evaluation, planning and monitoring

Cycles of continuous improvement

This paper aims at increasing the understanding of the processes and dynamics of CI implementation. The paper presents findings from a longitudinal case study of how the organization is renewed by the embedding of quality‐related managerial ideology. It approaches CI from the perspective of organizational renewal, and looks at implementation as a managerial ideological change process. The paper draws on multi disciplinary concepts. The concept of ideology from political science is applied. Ideology is viewed as a force of organizational renewal, in other words, as a means that exerts influence on managerial thinking and practices. The ideological perspective provides new conceptual ideas and practical insights into CI implementation. The case study shows that CI implementation is cyclical and reveals company‐specific cycles. These cycles imply a challenge to management: the progress in developing CI capabilities is embedded in a rooted managerial ideology through which inimitable competitive advantages can be realized.

A workload balancing procedure for product design processes and its application

Many world manufacturers are trying to refine their product development function in terms of business process reengineering through concurrent engineering, information infrastructure enrichment, and traditional improvement activities, as one of the effective activities to cope with the recent volatile market environment. To support these efforts, this paper proposes a prototype procedure of workload balancing for product design processes, which consists of operations network analysis, simulation-based improvement and traditional PDCA continuous improvement cycles. Relevance of the proposed procedure is investigated and evaluated through case studies of engineering-to-order manufacturing companies.

Building Healthcare Quality: If the Future Were Easy, It Would Be Here by Now

Dr. Eugene Nelson's article has provided us with a seductive vision of a healthcare future that works. The image is compelling-small primary care microunits working to apply standardized protocols in a data-driven environment as part of iterative cycles of continuous quality improvement (CQI). We are presented with anecdotal reports of two practices in Florida and New Hampshire that are just now beginning to operate along these lines. But when one realizes that some of these concepts are already a generation old, it is natural to ask why they have not been more widely adopted. Cohen et al. (1986) and Goldberg et al. (1987) first described the introduction of small primary care units (a.k.a. firms) at an academic medical center in 1986. The reorganization served to enhance clinic productivity by 20 percent, while decreasing patient flow (the time spent in completing visits) by 15 percent. Unscheduled walk-ins declined by 39 percent because each unit's nurse practitioner was available to provide just-in-time cross-coverage. Because each firm staffed its own ward and clinic, tightly integrated care could be provided to a defined population of patients. Shifting of care from the inpatient to the outpatient setting decreased total charges by 27 percent. Neither is the notion of standardizing care a new one. In 1973, Sox reported that by following algorithms for 11 acute medical complaints, physician assistants would have accurately evaluated 45 percent of 3,024 patients seen without direct physician involvement (Sox, Sox, and Tompkins 1973). Two years later, Grimm et al. (1975) documented that the application of a symptom-oriented pharyngitis protocol had decreased the ordering of white-cell counts by 37 percent and the prescribing of antibiotics by 63 percent. The answer to why healthcare practices evolve relatively slowly is that curbing longstanding clinical habits is simply hard to do. This is especially so if implementing change initially consumes, rather than saves, resources. During the last decade, much effort was expended on the development and dissemination of clinical practice guidelines (Audet and Greenfield 1990; VanAmringe and Shannon 1992). It was at first believed that physicians and health systems would be easily persuaded to move practice into compliance with the best available scientific evidence. Rigorous reports, however, were later surprisingly consistent in demonstrating that guidelines in isolation had failed to promote voluntary change in practice patterns (Kosecoff et al. 1987; Hill, Levine, and Welton 1988; Lomas et al. 1989; Lomas 1991). Analogous to the experience with guideline implementation, the early literature supportive of clinical CQI teams has remained largely anecdotal (Kaluzny 1996). At least one rigorous trial is now at hand, however, and it suggests that a future where CQI principles are a routine part of mainstream practice is not quite ready for prime time. We recently published results from the first multicenter randomized controlled trial of the use of CQI teams in chronic disease care (Goldberg et al. 1998). Eight teams at two academic and two HMO clinics in Seattle worked for a year to improve guideline compliance and clinical outcomes regarding the primary care of hypertension and depression. A trained CQI facilitator instructed teams in the use of the Shewhart cycle of activities popularly referred to as plan, do, check, act (PDCA). Teams invested a considerable amount of time, with each holding 13 meetings and spending a total of 212 hours on average. Yet across all sites, no positive effects were demonstrated for either disease condition. At only one clinic was an outcome actually improved, a 17-percentage-point increase in the number of hypertensives adequately controlled. The reasons for these negative results were multiple. Some teams experienced difficulty in collecting timely data. The number and type of process changes selected varied greatly. …

Interpreting Profiling Data in Behavioral Health Care for a Continuous Quality Improvement Cycle

Six examples, drawn from the experience of a number of behavioral health care programs since 1994, illustrate how outcome data can be used to guide and test changes that will effect improvements over current practices. Example 1: Problem identification is one of the most obvious and immediate applications of outcome data relative to a quality improvement process. Data were presented at a meeting of the hospital medical staff; the data showed that one clinician had significantly poorer outcomes in treating bipolar patients. A review of the medical records for bipolar patients treated by this clinician indicated that this clinician was changing medications too rapidly, a problem that was quickly and easily corrected-with improved outcomes. Example 6: Data revealed that patients who were treated in accordance with the critical pathway showed a greater degree of improvement, even though these patients entered treatment with a 10% greater level of symptom intensity. Each example provides a sample of variability in outcomes and therefore an opportunity to study the reasons for the variability and institute changes.

Achieving baby friendly through a quality management approach

In 1994, The Royal Women's Hospital became the first public hospital in Australia to achieve Accreditation to the UNICEF Baby Friendly Hospital Initiative. The 10 Steps to Successful Breastfeeding, effectively created standards against which an organisation can be assessed on their ability to provide women with consistent advice, access to education and support. The application of the Continuous Quality Improvement cycle of Pland, Do, Check, Act, was successful in assisting maternity staff to assess their practice, implement improvements and evaluate against the 10 Steps. Ongoing monitoring ensures that the high standard is maintained by the hospital.

Learning to learn ‐ from facts to knowledge

Discusses Shewhart’s control charts and how they have been confined traditionally to the shopfloor in manufacturing industry. Contends that now practitioners are leading a growing interest in the charts’ wider application in areas such as sales, marketing, customer service, and inventory management. Shewhart discovered that variation in a process can result either from common causes (part of the process) or special causes (not part of the process). Shewhart’s charts enable us to learn about processes and improve them with the aid of his plan‐do‐study‐act continuous improvement cycle. Research conducted in Japan showed that companies which won the Deming Prize consistently outperformed the averages in financial measures for the industry.

Tight coupling in high performing teams

This article considers the development of work groups that need to be tightly coupled—that is, have highly sychronized performance that is achieved over time as the team and its leader work together. Such groups impose demands for coordination and learning as the team develops. The article argues that tight coupling and self-reinforcing cycles of continuous improvement occur when learning modes and communication patterns match task requirements at various transition points in the group's evolution and when process intensity matches situational demands and task interdependencies. Implications for research, human resource development, and group facilitation are discussed.