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Implementation Guideline for

5S-CQI-TQM Approaches in Tanzania

“Foundation of all Quality Improvement Programme”

May 2009

The United Republic of Tanzania

Health Services Inspectorate Unit

Ministry of Health and Social Welfare

TABLE OF CONTENTSAcronyms...........................................................................................................................................................................ivForeword.............................................................................................................................................................................vAcknowledgement.............................................................................................................................................................viExecutive Summary.........................................................................................................................................................vii

1.0 CurrentsituationofQualityImprovementactivitiesinTanzania........................................................12.0 5-SExpansionPlan.........................................................................................................................33.0 BasicConceptof5S-CQI-TQMConcepts.......................................................................................7

3.1 Quality and Safety in Health......................................................................................................................7 3.1.1 Introduction.............................................................................................................................73.1.2 Safety........................................................................................................................................73.1.3 Highly Reliable Organization (HRO)......................................................................................8

3.2 Strategic Management................................................................................................................................83.2.1 Definitions................................................................................................................................83.2.2 Current situation......................................................................................................................93.2.3 Why do we have to manage our work?....................................................................................9

3.3 CQI-“KAIZEN”...........................................................................................................................................103.3.1 What is CQI?..........................................................................................................................103.3.2 The first challenge in CQI.......................................................................................................103.3.3 How can you arrange the user-friendly and convenient work environment......................103.3.4 What is KAIZEN?...................................................................................................................103.3.5 Health Services and KAIZEN.................................................................................................11

3.4 Point of KAIZEN (CQI) is 5-S Principles..................................................................................................113.4.1 What is a 5-S principle?.........................................................................................................113.4.2 What is 5-S?...........................................................................................................................123.4.3 5-S for health institutions.....................................................................................................143.4.4 Lean Thinking.........................................................................................................................15

4.0 Implementationof5S-CQI-TQM......................................................................................................164.1 Implementation of 5S-CQI-TQM activities.............................................................................................16

4.1.1 Introduction...........................................................................................................................164.1.2 5S-CQI-TQM Implementation Phases..................................................................................174.1.3 Implementation steps of 5-S activities.................................................................................204.1.4 From 5-S to KAIZEN (CQI) process.......................................................................................264.1.5 Total Quality Management (TQM).......................................................................................294.1.6 How to deal with resistance and implement KAIZEN (CQI) activities...............................30

4.2 The 5S-CQI-TQM as a Foundation of all other QIPs...............................................................................32

5.0 5-Stoolsforactualimplementation.................................................................................................335.1 5-S Tools....................................................................................................................................................33

5.1.1 Alignment...............................................................................................................................335.1.2 Numbering/Alphabetical cording..........................................................................................335.1.3 Red Tag...................................................................................................................................345.1.4 Safety signs.............................................................................................................................345.1.5 Colour cording........................................................................................................................355.1.6 Signboards/ Mapping.............................................................................................................355.1.7 Labeling..................................................................................................................................355.1.8 Symbols...................................................................................................................................365.1.9 X-Y Axis...................................................................................................................................365.1.10 Zone........................................................................................................................................375.1.11 5-S Corner...............................................................................................................................37

5.2 Usage of 5-S Tools for enhancement of visual control.............................................................................385.2.1 What is visual control?...........................................................................................................385.2.2 What are potential benefits of visual control?.....................................................................385.2.3 Practicing of visual control....................................................................................................38

6.0 MonitoringandEvaluationof5S-CQI-TQMactivities.......................................................................406.1 Introduction..............................................................................................................................................406.2 Tanzanian 5S-CQI-TQM Logical Framework..........................................................................................416.3 Monitoring and Evaluation by QIT..........................................................................................................426.4 Monitoring and Evaluation by WITs.......................................................................................................436.5 Envisioned M&E information flow system.............................................................................................43

Annex1: 5S-CQI-TQM activities monitoring sheet.................................................................................................44Annex2:Action Plan format.....................................................................................................................................47Annex3:KAIZEN activity checklist format.............................................................................................................49Annex4:KAIZEN Progress Report format..............................................................................................................50Annex5:Example of 5-S activities (before and after).............................................................................................53

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ACRONYMS

AAKCP Asia-Africa Knowledge Co-creation ProgrammeBMC Bugando Medical CentreCHMT Council Health Management TeamCD Capacity developmentCMO Chief Medical OfficerCQI Continuous Quality ImprovementDAP Directorate of Administration and PersonnelDHS Directorate of Hospital ServicesDHR Directorate of Human Resource DevelopmentHCWM Health Care Waste ManagementHIC Health Improvement CollaborativeHPAT Hospital Performance Assessment ToolHR Human resourceHRO High Reliable OrganizationHSIU Health Service Inspectorate UnitHSSP Health Sector Strategic PlanIPC Infection Prevention and ControlJICA Japan International Cooperation AgencyJIT Just In-TimeKCMC Kilimanjaro Christian Medical CentreMDGs Millennium Development GoalsM&E Monitoring and Evaluation MMAM Mpango wa Maendeleo ya Afya ya Msingi (Kiswahili abbreviation for Primary Health Services Development Programme)-PHSDPMNH Muhimbili National HospitalMoHSW Ministry of Health and Social WelfareMRH Mbeya Referral HospitalPHSDP Primary Health Services Development ProgrammeQA Quality AssuranceQC Quality ControlQI Quality ImprovementQIA Quality Improvement Approach (es)QIP Quality Improvement ProgrammeQIT Quality Improvement TeamRH Regional HospitalRHMT Regional Health Management TeamSBM Service Based ManagementSOP Standard Operational ProcedureTOT Training of TrainersTQIF Tanzania Quality Improvement FrameworkTQM Total Quality ManagementURC University Research CompanyWIT Work Improvement TeamZTC Zonal Training CentreZRC Zonal Resource Centre

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Foreward

Health services provided in health facilities in the country leave much to be desired in terms of quality. In adequate funding; shortage of human resources and other key health resources; poor infrastructure; piecemeal quality improvement programme (QIP); inadequate coordination and more concentration on the technical aspects of quality have been the stumbling blocks. To this end, it has been understood that, successful quality improvement in health services depends mostly on the ability to create and sustaining a foundation to QIPs.

Japanese Government through its International Cooperation Agency (JICA); noted this need in African Countries. Using the experience gathered in Asian countries, JICA promoted a knowledge creation avenue for quality improvement to several African countries including Tanzania. This knowledge sharing is called: Africa – Asia Knowledge Co-creation Programme (AAKCP). The approach advocated is 5S – CQI – TQM using 5-S principles (sort, set, shine, standardize and sustain) as entry point.

Pilot implementation of the 5S – CQI – TQM in Mbeya Referral Hospital (MRH) and later to Muhimbili National Hospital (MNH) has proved to be effective. Basing on these results the Ministry decided to scale-up the approach to other hospitals as a foundation of other QIPs. The scale-up process of this approach has taken a zonal approach; one hospital from each of the eight Zonal Training Centres (ZTCs) was invited to bring Trainer of Trainers (TOTs) to a training held at MNH from June 30 to July 05, 2008. The TOTs will scale-up training in their hospitals. The selected hospitals are expected to be showcases in their respective zones.

This guide has come in timely as the Ministry prepares to embark on a Primary Health Services Development Programme (PHSDP); which in Kiswahili it is called “Mpango wa Maendeleo ya Afya ya Msingi (MMAM)”. It is important to stress here the need of continuous quality improvement (CQI) strategy to strengthen capacities at these Front-Line Health Facilities (FLHFs). Achievements in the fight against Malaria, HIV/AIDS, TB and other communicable diseases; as well as provision of appropriate management of non-communicable diseases; depends much on the strengths and capacities of these FLHFs; utilizing rationally available resources.

For successful implementation of 5S – CQI - TQM, health workers of all cadres working with facilities and programme should fight the greatest enemies to them. These enemies are “cynicism” and “indifferent attitude”. Positive attitude (mind-set change) is the cornerstone for successful implementation of 5S – CQI – TQM and other QIPs.

This document will be a guide to all hospitals and other health facilities and vertical programme in implementing QIPs. It will help all facilities to build a strong foundation onto which other QIPs will step-on during design and implementation of their QI approach (es). The Ministry therefore recommends the day-to-day use of this guide by all health workers and other stakeholders; to achieve quality improvement in health services.

Blandina S.J.Nyoni

PERMANET SECRETARY

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Acknowledgement

Development of this guide marks an important milestone in the efforts of the Ministry to ensure quality health services are provides to all Tanzanians consistently and all the time they need. Its use is expected to add value to the way scarce resources are utilized in our health services system.

This document is also a symbol of the good working relationship between the Ministry of Health and Social Welfare, and Japan International Cooperation Agency (JICA), through its HRH Planning Advisor, Mr. Hisahiro Ishijima at the Chief Medical Officer’s office.

The developmental process has been participatory and sharing. Inputs were received from the staff in the Ministry’s Health Services Inspectorate Unit (HSIU); Mbeya Referral Hospital QIT; Muhimbili National Hospital Quality Improvement Team; Other Directorates of the Ministry; and from Trainers of other implementing hospitals.

I would like to extend my sincere gratitude to all those who have contributed in making the development of this guide, become a reality. However, it should be noted that its achievement is embedded in the commitment of health facilities leadership, health workers, and other stakeholders.

Dr. Deo M. Mtasiwa

CHIEF MEDICAL OFFICER

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Execut�ve Summary

BackgroundIn Africa, it has often been pointed out that the management of the hospital services provision system has some challenging aspects. Under the chronic shortage of medical resources, the challenge to be tackled is a matter of management of this system for delivering obtainable best hospital services. Asian countries also faced same kinds of challenges in the hospital services provision. To improve the situation, some Asian countries took action to improve quality of health care using 5-S (Sort, Set, Shine, Standardize and Sustain) principles, which were developed in Japanese manufacturers such as Toyota to improve quality of their products and customer satisfaction, in collaboration with Japan International Cooperation Agency (JICA)

In 2006, based on the observation of Asian countries movement, JICA planed to conduct a training course for supporting African developing countries to gain skills and knowledge for TQM for better hospital services. The course is named as Asia-Africa Knowledge Co-creation Programme (AAKCP). AAKCP aims to provide the forum where Asian and African countries share knowledge and experiences, and thereby facilitate each participating country to create its own method of development that suits best to each country’s contexts.

Several African countries were informed about the opening of AAKCP training course, and eight (8) African countries (Eritrea, Kenya, Madagascar, Malawi, Nigeria, Senegal, Tanzania, and Uganda) participated. The Ministry of Health and Social Welfare (MoHSW) selected Mbeya Referral Hospital (MRH) as the AAKCP pilot project hospital.

OfficialAdoptionof5S-CQI-TQMapproachesAAKCP Initial Seminars were conducted in March 2007 followed by AAKCP field workshop in Sri Lanka in July 2007. A total of four senior officers from MRH were trained in those workshops. After the two workshops, MRH started to implement 5S-CQI-TQM activities since August 2007. The workshop’s feedback provided to Chief Medical Officer (CMO) in August 2007. CMO decided to share 5S-CQI-TQM concepts with other Ministry of Health and Social Welfare officials and Hospital Management Team of Muhimbili National Hospital (MNH) and MNH started to implement 5S-CQI-TQM approaches since October 2007. Some hospitals in the Southern zone also started implementation in December 2007.

According to the monitoring and periodical evaluation of 5-S activities at MRH, MNH, and the four district hospitals in southern zone (Masasi, Newala, Nachingwea and Tandahimba), 5S-CQI-TQM approach was verified as a practical, cost effective and efficient approach for improvement of working environment that support the effective implementation of quality improvement approaches. Therefore, Ministry of Health and Social Welfare decided to adopt 5S-CQI-TQM concepts officially as a foundation of all quality improvement approaches, and to scale up this approach to other hospitals. Up to April 2009, 13 hospitals were already implementing 5-S activities.

5-SasanentrypointofallQualityImprovementProgrammes(QIPs)5-S is a management tool, which originated in Japanese manufacturing sector. It is used as a basic, fundamental, systematic approach for productivity, quality and safety improvement in all types of organizations.

Usually, improvement of work processes often is sustained only for a while, and workers drift back to old habits and managers lose the determination and perseverance. 5-S in contrast involves all staff members in establishing new disciplines so that they become the new norms of the organization, i.e., internalization of concept, and development of a different culture.

Although the 5-Ss originated in the manufacturing environment, they translate well to other work situations including hospitals, general offices, telecommunication companies, and etcetera. 5-Ss are

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abbreviations of the Japanese words Seiri, Seiton, Seiso, Seiketsu, and Shitsuke. In English, 5-Ss are translated as Sort, Set, Shine, Standardize, and Sustain. In Tanzanian context, Kiswahili words are more effective for people to understand easily thus, facilitators of 5S-CQI-TQM have translated 5-S English words into Kiswahili words and those are: Sasambua (Sort), Seti (Set), Safisha (Shine), Sanifisha (Standardize) and Shikilia (Sustain).

5-S is the initial step towards establishing Total Quality Management. There will be no conflict in the implementation of 5-S activities even though his or her organization is implementing other quality improvement approach. 5-S will support all quality improvement approaches to move forward.

Wayforward

The Ministry plans to:

• Scale-up the 5S-CQI-TQM concept and 5-S implementation to all consultant hospitals, regional referral hospitals and district hospitals. To achieve this, all consultant hospitals and regional hospitals will be trained. First TOT was conducted in June/July 2008, drawing participants from four consultant hospitals (BMC, KCMC, MRH and MNH) and three regional hospitals (Dodoma, Maweni, and Sokoine). In 2009, eight regional hospitals and three municipal hospitals will be trained and the rest of regional hospitals will be trained in 2010. Then, all regional hospitals will be able to train in district hospitals in their jurisdiction area.

• Using 5S-CQI-TQM as a foundation of all other quality improvement approaches

• Institute a regular M & E system reinforcing on the 5S-CQI-TQM logical framework for Tanzanian context

• Adopt and incorporate 5S-CQI-TQM into the Tanzania Quality improvement Framework (TQIF).

• Pushing for all hospitals implementing 5S-CQI-TQM, to ensure that mechanisms for sustaining it are put in place and adhered to.

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�.� Introduct�on Provision of quality health care is one of the top priority in the National Health Policy (1990; revised in 2002; and updated in 2007) and Health Sector Strategic Plan (HSSP) – II, 2003-2009. The quality improvement (QI) agenda will also feature well in the next HSSP-III, as we countdown to the Millennium Development Goals (MDGs) targets of 2015.

Ministry of Health and Social Welfare (MoHSW) established a unit called Health Service Inspectorate Unit (HSIU) in 1998, under the Office of Chief Medical Officer to take responsibilities on the following main functions:

• Conduct inspection of health care services,• Coordination of Supportive Supervision, • Coordination of Quality Improvement related training, • Coordination of Medical Audit and, • Collection and dissemination of all experiences, techniques, data and references in regard to quality

�.2 Steps taken by MoHSWThe first steps taken by the Ministry included the Health Sector Reforms of 1994 which have been progressively implemented. In 2004, HSIU developed “Tanzania Quality Improvement Framework” (TQIF). The framework has two main purposes; firstly, to encourage all health workers at all levels and other stakeholders in the sector to develop a culture of quality in health care; and secondly, to outline necessary actions for improvement and institutionalization of quality in health care. The Unit also developed infection prevention and control (IPC) guidelines as one of the crosscutting issues in healthcare provision in 2004; its pocket guide and Kiswahili version were developed in 2007. These aimed at improving the quality domain of safety of health care (to clients and providers) during services delivery. Training of health workers on IPC has been ongoing with some selected topics on QI and supportive supervision. More over, Directorate of Hospital Services developed “Hospital Reform Guideline at Regional and District level” in 2005 and Continuous Quality Improvement – Total Quality Management (CQI-TQM) approaches are emphasized to improve quality of hospital services1; and nearly 40 hospitals were trained.

� Referonpage�2and�3of“HospitalReformGuidelineatRegionalandDistrictlevel”in2005

Chapter �CURRENT SITUATION OF QI ACTIVITIES IN

TANZANIA

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�.3 ChallengesDespite all the efforts taken so far to improve the quality of health services provided, there has been little improvement in services rendered in the health facilities. Several reasons can be attributed to this situation such as: delay of the Quality Improvement (QI) training for hospitals; difficulty of changing attitude among health workers; shortage of human resources; and unreliable medical supplies. Another issue is that several QI approaches are introduced to health sector in Tanzania. However, those QI approaches are implemented as area-based (depend on the areas covered by donor(s)), focusing on technical issues only, and there is not unified approach (Nationally recommended approach).

�.4 New �mpetus to �mprove QI approaches �mplementat�onDue to the above –mentioned reasons, Quality Improvement Programme (QIP) are not showing good progress and satisfaction of users of health facilities remains low. To breakthrough the current situation, MoHSW reviewed the present QI approach implementation in the pilot hospital (Mbeya Referral Hospital) and decided to adopt 5S-CQI-TQM approach as the foundation of all QIP’s.

HSIU is currently working on integration of 5S-CQI-TQM approaches into TQIF and try to coordinate and harmonize all QI approaches for more effective and efficient health sector QIP in Tanzania.

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For the first step of 5-S rolling out, Ministry of Health and Social Welfare conducted Training of National Trainers on 5S-CQI-TQM from June 30 to July 05, 2008 in collaboration with Japan International Cooperation Agency (JICA).

After the Training of National Trainers, all trained personnel from seven hospitals (Muhimbili National Hospital, Mbeya Referral Hospital, Kilimanjaro Christian Medical Centre, Bugando Medical Centre, Kigoma (Maweni) Regional Hospital, Dodoma Regional Hospital, Lindi (Sokoine) Regional Hospital) and MoHSW were recognized as “National Trainers” and they were expected to implement 5S-CQI-TQM activities at their organization and hospital as a team to reinforce QI approach. Health Service Inspectorate Unit, MoHSW and HRH planning advisor, JICA/MoHSW will conduct consultation visits to make sure that all trained hospitals will appropriately practice 5-S.

Initially, MoHSW planed to formulate “5-S Showcases” in each zone (Zonal 5-S model hospitals) to scale-up 5S-CQI-TQM approach. However, alignment with Regional Referral Health Management system, and strengthen Regional Referral hospitals, MoHSW modified rolling out strategy, and all regional hospitals will be trained by June 2010. Full schedule of this roll-out strategy is shown in table-1 and 2.

Once 5S-CQI-TQM activities are implemented, and start showing improvement of work environment at trained hospitals, they will disseminate the 5S-CQI-TQM concepts to other hospitals within the region, and conduct trainings.

The concepts also will be disseminated to Regional Health Management Team (RHMT) and Council Health Management Teams (CHMTs). Knowledge and skills on 5-S will be used effectively whenever RHMT and CHMTs conduct supportive supervision which will always include a component of improvement of working environment.

Chapter 25-S NATIONAL ROLLING OUT PLAN

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Table 1: List of 5-S implementing hospitals (March 2009)

No. Hospitals Location (region) Started from

1 Mbeya Referral Hospital Mbeya Aug. 2007

2 Muhinbili National Hospital Dar es Salaam Oct. 2007

3 Tandahimba District Hospital Mtwara Dec.2007

4 Newala District Hospital Mtwara Dec.2007

5 Masasi District Hospital Mtwara Apr. 2008

6 Nachingwea District Hospital Lindi Apr. 2008

7 Kilimanjaro Christian Medical Centre Kilimanjaro Aug. 2008

8 Bugando Medical Centre Mwanza Aug. 2008

9 Maweni Regional Hospital Kigoma Aug. 2008

10 Dodoma Regional Hospital Dodoma Aug. 2008

11 Sokoine Regional Hospital Lindi Aug. 2008

12 Ligula Regional Hospital Mtwara Nov.2008

13 Mwananyamala Municipal Hospital Dar es Salaam Feb.2009

Table 2: List of TOT target regional hospitals

No. Hospitals Location (region) Year of TOT

1 Songea Regional Hospital Ruvuma 2009

2 Morogoro Regional Hospital Morogoro 2009

3 Tumbi Special Hospital Pwani 2009

4 Iringa Regional Hospital Iringa 2009

5 Sumbawanga Regional Hospital Rukwa 2009

6 Kitete Regional Hospital Taboara 2009

7 Singida Regional Hospital Singida 2009

8 Amana Municipal Hospital Dar es Salaam 2009

9 Temeke Municipal Hospital Dar es Salaam 2009

10 Mbeya Regional Hospital Mbeya 2009

11 Bombo Regional Hospital Tanga 2010

12 Mawenzi Regional Hospital Kilimanjaro 2010

13 Mount-Meru Regional Hospital Arusha 2010

14 Sekou-Toure Regional Hospital Mwanaza 2010

15 Musoma Regional Hospital Mara 2010

16 Manyara Regional Hospital Manyara 2010

17 Shinyanga Regional Hospital Shinyanga 2010

18 Kagera Regional Hospital Kagera 2010

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Diagram 1: 5-S National Rolling Out Framework

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Diagram 2: Location of 5-S implementing hospitals and TOT plan

Diagram 2: Location of 5-S implementing hospitals and TOT plan

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3.� Qual�ty and Safety �n Health

3.1.1 IntroductionWhile hospitals are performing a valuable service to the public, stakeholders, including the public it self, are unsatisfied and complaining. This is because the services provided are not focused on the customer’s expectations and the services are not attractively presented to the customer. To this end, customers remain with many un-met expectations.

Expectations that are not met include non-health expectations such as dignity, basic human needs, human rights, prompt attention in care and treatment, confidentiality, communication, autonomy, etc. Other unmet expectations are health expectations. Hospitals that fail to deliver these expectations express such failure as hospital accidents. These failures can be active failures when rules and procedures are violated at the site of treatment or action, or they can be latent failures created as a result of design failure, building failure and regulatory or policy failures.

3.1.2 SafetyReport of the Institute of Medicine2 stated that errors cause between 44,000 and 98,000 deaths every year in American hospitals and over one million injuries. The biggest killers include:

• Hospital associated infections• Drugs errors• Patients accidents• Communication problems• Disorganized work environment

The hospital industry is a hazardous industry. However, while the hospital industry has many employees of different categories, involved in risky procedures to save patients and with many conflicts, other hazardous industries tend to have fewer employees of fewer categories involved in risky procedures to make a product or provide a service and usually with less conflict.

Hospitals appear to be far behind other high-risk industries in ensuring basic safety. Highly Reliable Organizations (HROs) are organizations in which errors can have catastrophic consequences but which consistently avoid such errors. To accomplish this they conduct relatively error free

Chapter 3BASIC CONCEPTS OF 5S-CQI-TQM

2 TheInstituteofMedicine(IOM)releasedareportin�999entitled“To error is HIMAN: BUILDING A SAFE HEALTH SYSTEM”

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operations over a long period of time and make constantly good decisions resulting into high quality and reliability. Examples of such organizations include aviations and airlines, air traffic control, and nuclear power plants. Could hospitals become the same? The answer is “YES”, through proper organization of the work environment hospitals can achieve this.

3.1.3 HROshavethefollowingcharacteristicelementsi They frequently audit the processes and procedures to make sure that they are correct,

efficient, effective and pertinent.

ii They constantly do risk management by assessing the risk involved in all their undertaking and taking preventive and effective measures.

iii They avoid quality degradation by continuous quality improvement including adoption of new inventions.

iv They have a good system of command and control by having a system that assures good leadership, good decision-making process as well as effective monitoring and evaluation process.

v Employees are well motivated by the existence of a good rewarding system.

vi Migrating decision-making is made possible by the existence of clearly known protocols coupled with good communication system in the organization.

vii Back-up system is always in place and known to all pertinent employees in the organization.

viii Formal rules and procedures are in place and are observed. There is hierarch but this should be differentiated from the bureaucracy with negative implications.

Therefore to achieve such characteristics of providing high quality services has to be attained. Where symptoms of poor quality are seen, it is impossible to provide services with safety. To achieve high quality, systems used in implementation have to constantly be improved, for quality fails when systems fail. It is therefore important to note the following ranking order in problem solving:

• First order problem solving is to remove the immediate obstacle for patient care. But it has to be remembered that in doing so nothing removes the chances of problem(s) to occur again. Therefore, it is important to implement second order problem solving.

• Second order problem solving refers to system re-organization to prevent problem recurring.

3.2 Strateg�c Management

3.2.1 Definitions• Management: - In the sense of managing it is synonymous to; control, supervision,

manipulation, handling, directing, administration, government, conduct, governance, operation, running, superintendence, command, guidance, stewardship (Oxford Thesaurus 1990)

• Management is the ability to go from point A to point B despite of; small deviations, fixed obstacles, moving obstacles, moving target, distractions, possibility of dead in the water – no fuel, possibility of going in cycles – no plan or map.

• Management is the ability to start, change or stop.

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• Strategic: - Is an adjective synonymous to: tactical, key, crucial, principal, cardinal, and critical.

• Strategic management: - The most effective and efficient way to start, change or stop whatever we are or want to do.

Strategic Management can also be defined as a joint operation of intellectual activities of planning and continuing exercise of work environment improvement, which leads to quality services and high productivity.

• Total Quality Management (TQM): - A comprehensive & fundamental rule or belief for leading & operating an organization aimed at continuously improving performance over a long term by focusing on customers while addressing the needs of all stakeholders.

3.2.2 CurrentsituationsTo run health facilities resources are needed. These include financial, human and infrastructure resources. In government health facilities as well as non-governmental health facilities there is a short supply of these resources. There is a chronic shortage of government subsidy funds. Unavailability of sufficient health insurance cover to the population compounds the financial resource problem of the health facility. Cost recovery through cost sharing is insufficient. The number and skill mix of the health workers is insufficient. The infrastructure is dilapidated. All these chronic constrains lead to deterioration in efficiency & quality of services manifested by poor preparedness in the delivery of services, poor standards, poor or no increase of service packages, inequity in service provision and insufficiency in clients’ satisfaction.

Empowering people to fight against poverty could ameliorate the chronic problems of funding health services. But while the problems are persistent with us, we, health workers, cannot stop providing services to the people, nor can we leave the problems unattended. The answer to this lies with how we manage the available resources and work environment.

3.2.3 Whydowehavetomanageourwork?We manage our work so that we can enjoy life. But in order to achieve this, one has to have an active professional life through which he/she can reach his/her life aspirations. However, in order to reach a situation where one has an active professional life, one has to have confidence in one self that in turn is only possible if one is able to gain respect from his/her clients and fellow workers. Respect is achieved through professional competency. Professional competency is easily reached where the working environment affords minimal workload with maximal achievement, in a comfortable work place and a good teamwork.

Managing our work will lead to our enjoyment of life. One of the strategic entry points is the working environment improvement, which can easily be achieved by the implementation of the 5-S concept. The other strategic entry point is the implementation of the planning activities. These planning activities include strategic analysis, strategic choice, and strategic control. While there are various models of implementing the planning activities the most important and vital point is the need to always improve on what already exist leading to Continuous Quality Improvement.

Implementing working environment improvement together with intellectual activities of planning with CQI will lead to acquiring the TQM framework thus enabling the provision of quality services and high productivity.

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3.3 CQI –KAIZEN3

3.3.1 WhatisContinuousQualityImprovement(CQI)?It is a process to secure “Productivity” of a Project. This is a non-stop, day-to-day process to improve the standard of work, followed by all members of the workforce for achieving the best in outcomes (outputs) of service (including health) or products

CQI is a sequence of actions as mentioned above. In addition to that, it is a “Means of Monitoring” as well. CQI itself has a function to monitor the on-going work and task given to each cluster of the system. In a health institution, for example, CQI can monitor the performance of each section of the hospital ranging from hospital director’s office to patient wards. The major TOOL for the initiation of CQI process is 5-S, which is elaborated in Chapter 4.0 (implementation of 5S-CQI-TQM)

3.3.2 ThefirstchallengeinCQItowards“QualityofService”Betterment of your work environment is the first challenge in Continuous Quality Improvement (CQI). Without a well-organized venue for work, we cannot provide well- prepared, standardized, and timely services with proper communication with our client, which means that we cannot reach the standards of quality of service.

The entry point of CQI should be as follows:

Work environment is not an entity only with physical environment, such as building, equipment, and instruments. It includes functional aspects of your working venues, such as personnel team, meetings, recording/reporting system, time arrangement for work and communication system among staff and external counterparts.

Environment often defines the behavior of the people. Your workforce is not an exception. If the physical structure and other in-house facilities are comfortable to them, their muscular and mental stresses are much reduced. They fulfill their work easily and efficiently.

On the contrary, under unfavorable and inconvenient work environment, where they have to use extra energy to overcome the inconvenience, people’s willingness to the work naturally deteriorates.

3.3.3 Howcanyouarrangetheuser-friendlyandconvenientworkenvironment?Do you think that your work venues are good enough to promote motivation to work? Are you satisfied with the present condition? Are you sensitive enough to detect inconvenience to yourself and your staff?

There are so many questions, which have to be answered by you. The responsibility of a manager includes the arrangement of the obtainable best work environment for the teammates and staff. Now we have to discuss a feasible approach for us to uplift the work environment. One approach that we can employ is called KAIZEN in Japanese language or Continuous Quality Improvement (CQI). The instrument for the initiation of this approach is 5-S principles.

3.3.4 WhatisKAIZEN?KAIZEN is a process of Continuous Quality Improvement (CQI) by means of a non-stop process to uplift the standard of your work environment and services contents to the obtainable best condition and maintain it as user-friendly and convenient as possible.

3 Prof.HANDAYujiro,MosesSINKKALA.2005.“StrategicManagementandContinuousQualityImprovement(CQI)using5SPrinciples”

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CQI has to be practiced by all categories of staff including the management team. Top management is not an exception and should participate in the process. For top management of a Project or an Institution; and for activities, including community-based health services, it is crucial to make this process a “Movement or Campaign” within the organization as a management target.

KAIZEN (CQI) is an approach developed in manufacturing sector in Japan to improve the productivity. Imagine a factory manufacturing vehicles. There, over 2500 parts are prepared, standardized and supplied timely for the assembly process of one vehicle. Also there is a workable communication system among different sections and offices to control the production process. The production line is perfectly in order since they have to assemble the 2500 parts precisely on time having their outcome target of finalizing 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 at end products final evaluation. If there are many rejected items, the company looses money. It also negatively affects the quality of vehicles and finally loses in the competition in the market.

Quality of the end-product, which is handled by various groups of people (production units), cannot be maintained, if there is no mechanism, by which all production units seek higher quality of work throughout the on-going production process. It is this concept, which KAIZEN (CQI) seeks to achieve in the provision of health services in the hospitals and other health facilities.

3.3.5 HealthserviceandKAIZEN(CQI)Health service is also an outcome of a complex process, as in the case of car industry, requiring “Quality of Product”. This “Product” is “Health service” as you have already learnt in the previous chapters. Health service too is handled by various groups of people. Therefore, you, as managers of health service, are the persons who have to strengthen internal mechanism of your organization to involve all staff in the movement to promote Continuous Quality Improvement (CQI). This is KAIZEN.

Specific targets for KAIZEN (CQI) have to be given by top- and /or middle-level management staff to all divisions or implementation units at health facility or hospital set up. We need a situation, where every division always look into the potentiality of making the job easier, more effective and more efficient within the given circumstances by mobilizing their capacities to create new ideas. Small ideas sometimes initiate efficiency and effectiveness. Ideas from the workforce have to be considered by the top management (bottom to top uptake of ideas).

3.4 Entry po�nt of KAIZEN (CQI) �s 5-S Pr�nc�ples4

3.4.1 Whatis5-Sprinciple?5-S Principles are your reliable instruments to make a break-through in your work environment and staff attending various types of jobs in your institution. This is not only a concept but also a set of actions, which has to be conducted systematically with the full participation of staff serving the institution. 5-S activities are practiced in a real participatory movement to improve the quality of both the work environment and service contents, which are delivered to your clients using the improved environment. It is used as a basic, fundamental, systematic approach for productivity, quality and safety improvement in all types of organizations.

Targets of 5-S principles are:

• Zero changeovers leading to product/ service diversification• Zero defects leading to higher quality

4 Prof.HANDAYujiro,MosesSINKKALA.2005.“StrategicManagementandContinuousQualityImprovement(CQI)using5SPrinciples”

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• Zero waste leading to lower cost• Zero delays leading to on-time delivery• Zero injuries thus promoting safety• Zero breakdowns bringing better maintenance• Zero customer complaints, i.e., customer satisfaction• Zero red ink, i.e., betterment of organization’s image

Furthermore, introduction of 5-S is expected to instill team culture, increase morale and motivation and improve job satisfaction. They are simple but effective methods to organize the workplace (Hirano and Talbot, 1995). In the long-run implementation of the 5-S principles also help in creating positive altitude to the workforce.

3.4.2 Whatis5-S?5-S is literally five abbreviations of Japanese terms with 5 initials of S. These are (i) Seiri, (ii) Seiton, (iii) Seiso, (iv) Seiketsu, and (v) Shitsuke.

Convenient translation to English similarly provides five initials of S. (i) Sort (ii) Set (iii) Shine (iv) Standardize (v) Sustain. These are explained briefly below:

………………………………………………………………………………….....………

(i) Sort:Remove unused stuff from your venue of work; and reduce clutter (Removal/ organization)(ii) Set:Organize everything needed in proper order for easy operation (orderliness)(iii) Shine:Maintain high standard of cleanness (Cleanness)(iv) Standardize: Set up the above three Ss as norms in every section of your place (Standardize)(v) Sustain: Train and maintain discipline of the personnel engaged. (Discipline)

To make 5-S principle more familiar with workers at health facilities in Tanzania, translation and dissemination of 5-S into “Kiswahili” is important. Kiswahili version of the 5-S is as described in the box below:

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K�swah�l� translat�on of 5-S

i. Sasambua(Sort) Ondoavifaavyotevisivyotumikaofisinikwako.

ii. Set�(Set) Wekakatikautaratibumzurivifaavyakoilikurahisishaupatikanajiwakatiwakutoahuduma.

iii. Safisha(Shine) Dumishausafiwahaliyajuu,pamojanavifaavyakazikatikasehemuzotezakutoleahuduma.

iv. San�fisha(Standardize) Kusasambua,kuseti,nakusafishakwakiwangokinachokubalikaiweniutaratibuwakilasehemuyakutoleahuduma.

v. Sh�k�l�a(Sustain) Fundishanadumishatabianjemayawatoahudumayautekelezajiwakusasambua,kuseti,kusafishanakusanifishailiiweendelevu.

Five steps of Sort-Set-Shine-Standardize-Sustain is a sequence of activities to improve your work environment to as convenient and comfortable as possible and thereby also improve your service contents with regard to preparedness, standardization and timeliness. Health personnel are technology oriented, since everyone lives on health service, which is based on specific technique. 5-S activities are the tools to prepare the obtainable best stage for them to make maximal use of their skill and knowledge. The 5-S conceptual framework is shown in diagram 3.

Diagram 3: 5-S Conceptual framework

Two different grades are identified in the standard of 5-S activities in service sector particularly in health services:

• Grade 1: This refers to the physical environment • Grade 2: This is refers to software matters such as:

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--Job sequence and contents, --Time management, --Communication system such as meetings and briefings,--Standardization of patients care procedures

If the guidance of a health facility management is strategic, it will be able to reach the standard on the above grade-2 and tackle your technical aspects of the work (health care) for the betterment.

3.4.3 5-SforhealthfacilitiesHospitals and other health facilities and hospitals are the typical targets of 5-S, since these systems are rather complicated and difficult to maintain for delivery of various services in the obtainable best condition. There are divisions, as implementation units (clusters), which need to have respective objectives, as an essential functional component of the institution. Table 3 gives some examples on divisions and expected outcomes.

Table 3: Examples on divisions and expected outcomes

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 are all in good function

PharmacyDrugs 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 WardInpatients receive treatment under comfortable environment.

Delivery roomNormal deliveries are conducted in a safe, clean and efficient system

Operation TheatreSurgical care is given under a safe, clean and efficient system

CSSDSupply 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 officeOffice works as the management Centre for nursing/ auxiliary staff

Hospital Doctor’s OfficeOffice works as the centre for decision-making and management.

The above is an example of the target setting for clusters (implementation units) at a health unit. To have a tangible outcome, each division is required to fulfill the task in the obtainable best working condition avoiding excessive workload to the staff 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 many clients, too much paper works and too much complexity in the reporting system is often seen in workplaces.

These are all targets of 5-S activities. By the continuous actions of Sort-Set-Shine-Standardize-Sustain you can; reduce your workload; make maximal use of given working hours to provide

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services to the clients; and in addition, you will be able to have an extra cup of tea in the tea time, because your system becomes lean and maximally efficient. You sorted necessary and unnecessary things at your workplace and discarded unnecessary items. Then you set nicely the essential items in the best order for the convenience of your operation. You 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 this KAISEN (CQI) and 5-S movement to sustain and improve the “Quality of Service” of the health facility or hospital. Attainment of lean service system and better quality of service is illustrated in diagram 4.

Diagram 4: 5S-CQI-TQM Frameworks

3.4.4 LeanThinking5

Lean methods create a continual improvement based on waste-elimination culture that involves workers and operators at all levels of the health facility.

Management team of health facility should have “Lean Thinking” for appropriate health resource management. “Lean Thinking” forces on three objectives:

• Reducing production resource requirement by minimizing inventory, equipment, storage, service space, and materials.

• Increasing service provision velocity and flexibility

• Improving quality and eliminating defects

Eliminating waste is the basic principle of Lean Thinking. Lean Thinking looks at the total value chain and asks: How can things be structured so that the health facility does nothing but add value, and do it as rapidly as possible. It is important to have Lean Thinking when you conduct 5S-CQI activities.

5 ICOMIA.2008.“ONLEANTHINKINGANDTHEENVIRONMENT”

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4.� Implementat�on of 5S-CQI-TQM act�v�t�es

4.1.1 IntroductionIn this chapter, actual implementation of 5-S activities is explained in details. Implementation condition of 5-S activities is believed to reflect moral and management level of an organization. If the sense of belonging of staff to the organization is high, work place will be automatically well organized, clean and systematic. However, change management of a system is bound to be difficult and complex in any organization. Implementing a quality improvement system often face difficulties due to deficiencies in leadership, support and motivation of management and staff, information management, organizational structure, and culture (e.g. team work, learning orientation)

It is necessary to create good working environment to make health workers and service users satisfied. However, top to bottom approach only will not be able to improve working environment, as sense of belonging of health workers to the health facility is not going to change easily. Therefore, big attitude change and mutual effort by both management and other health workers are necessary to improve working environment. This can be achieved through utilization of a mixture of top to bottom and bottom to top approaches shown in diagram 5 “ 5-S implementation structure”

Diagram 5: Implementation structure

Chapter 4IMPLEMENTATION OF 5S-CQI-TQM

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Implementation of 5-S activities should not be onetime or short-term event. It is better to make it a habit of health workers so that sustainability of 5-S activities will be high. To make 5-S as a habit of health workers, it is necessary to clarify how work place and environment should be, and share that image to all staff. Here are the key factors for successful implementation of 5-S activities:

1. Thereshouldbecontinuedcommitmentandsupportbytopmanagement

2. 5-Simplementationstartswitheducationandtrainingofallhealthworkers

3. Therearenoobserversin5-S,everyonemustparticipatein5-Sactivities

4. Practice5-Scycle(Sort-Set-Shine-Standardize-Sustain)dailyinordertoachieveahigherstandard

Note that what we need in implementing 5-S principles is: little knowledge, little hard work, little dedication and a very big positive attitude!

4.1.2 5S-CQI-TQMImplementationPhases5-S is usually implemented gradually - often over a one- or two-year period of time. The following implementation phases and duration of each phase are recommended for effective and efficient implementation of 5S-CQI activities. Preparatory phase – three months, Introductory phase – six months, Implementation phase – two years, and Maintenance phase – ongoing indefinitely. The details are shown in table 4 and diagram 6.

Table 4: Phases of 5-S implementation

Phases Approximate time period Example of activities

1 Preparatory phase Three monthsDissemination, Management level training, QIT formulation, Situation analysis, Target area(s) selection

2 Introductory phase Six monthsStaff level Training, WIT formulation, Sorting-Setting-Shining activities

3Implementation phase

Two years On going monitoring, Standardizing activities

4 Maintenance phase On going Refresher training, Awarding,

The implementation phases should be considered carefully at the time of development of action plan. Inserting many activities in the first two phases will delay the implementation process. Selection of few target areas and prioritization of activities for each targeted area according to the implementation phase leads to successful implementation of 5-S.

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Diagram 6: 5S-CQI-TQM implementation phases

The phases of implementing 5S-CQI-TQM activities have a total of ten (10) steps. Preparatory phase has five (5) step; Introductory phase has three (3) steps; Implementation phase has one (1) step; and Maintenance phase has one (1) step. In each step there are many activities that need to be done to accomplish it. The 5S-CQI-TQM activities flow chart is illustrated in diagram 7.

The Maintenance phase is an on-going phase hence has no time limit. However, it is expected that within three (3) years of entering this phase all the necessary structures and accountability systems be in place. All health workers (staff) will be shaped to follow workplace rules and habits. S1-S4 will be the culture of all staff and the facility management.

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Diagram 7: 5-S Implementation Flowchart

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4.1.3 Implementationstepsof5-Sactivities

Preparatory Phase

In this phase, aims to make managers and staff understand and adopt 5S-CQI-TQM concepts. It is also important to know “where and how you are” by conducting situation analysis. Time required for this phase is approximately three (3) months.

Step-1:Dissemination(Sensitizationofstaff)of5S-CQI-TQMconceptsAs stated in the above, 5-S activity starts with ”education”. All staff in your health facility can be targeted for dissemination of 5S-CQI-TQM concepts. At the time of dissemination/ sensitization, true meaning of 5-S must be conveyed to the staff. 5-S is often incorrectly characterized as “standardized cleanup”, however it is much more than cleanup. 5-S is a philosophy and a way of organizing and managing the workspace and work flow with the intent to improve efficiency by eliminating waste, improving work-flow and reducing process unreasonableness.

The following points should be emphasized during the dissemination/sensitization session:

(i) 5-S implementation helps is to improve working environment for smooth implementation of quality improvement activity (foundation of all QIP)

(ii) 5-S is not in conflict with any other quality improvement approaches that are already introduced in Tanzania Health Sector

(iii) 5-S is not a one time event. It should be practiced day by day and make 5-S as a culture of the health facility. Periodical training is necessary for both management and department/section level for sustainability.

Step-2:TrainingforManagementlevelstaffOne of the key factors for successful 5-S implementation is “strong leadership and commitment”. Therefore, training for management level staff is essential in order to implement 5S-CQI-TQM activities. In this training, the concepts of 5S-CQI-TQM must be well understood and adopted by managers and the steps of 5S-CQI-TQM activities implementation should be lectured logically. It is better to focus on the following contents in the management level training;

• 5S-CQI-TQM concepts• Situation analysis methodology for health facility• How to establish Quality Improvement Team (QIT) and its roles and responsibilities• Action plan6 development• How to establish Workplace Improvement Team (WIT) and its relationship with QIT• Monitoring and evaluation of 5-S activities• Training methods with teaching material development for staffs

It is important to develop 5S-CQI-TQM Action Plan (version 0) at the end of the training.

Step-3:FormulationofQualityImprovementTeam(QIT)After the training of the management level, it is recommended to establish a team taking lead to implement quality improvement activities, called Quality Improvement Team (QIT).

6 SeeAnnex2:FormatofActionPlan

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Member of QIT should be selected from Hospital Management Team members. The team that includes top and middle management has to coordinate initial planning and implementation. This helps to improve the speed of decision-making and increase commitment for quality improvement in the hospital.

Main roles of QIT are as follows:

• To train hospital staff on 5S-CQI-TQM • To conduct situation analysis• To implement 5S-CQI activities for common problems of the hospital• To conduct periodical monitoring and provide technical advice to WIT• To record all QI activities conducted in the hospital• To review situation and the action plan• To provide necessary input for 5S-CQI-TQM activities• Provide progress report quarterly to HMT, MoHSW-HSIU and CHMT&RHMT

Step-4:ExecutionofSituationAnalysis

“KAIZEN” - Continuous Quality Improvement (CQI) is a problem solving process for Total Quality Management (TQM). Therefore, it is necessary to conduct situation analysis to find problems, cause(s) of problems and come up with possible solutions.

After the management level training, Quality Improvement Team (QIT) should be established within Hospital Management Team. Usually, members of Hospital Management Team are aware of problems within the hospital. Therefore, it is easy for them to identify problems and its cause(s) together with possible solutions.

When QIT conducts the analysis, QIT must be equipped with digital camera and photographs of work place must be taken to record the current situation prior to 5-S implementation. These are useful for comparison and to measure the progress (before-after) of activities.

Pictures of hospital environment such as entrance, parking, waste dumping point, garden, patient waiting area, should be taken first. Then, pictures of OPD, examination rooms, laboratory, X-Ray, pharmacy, laundry, medical record section must be taken. Finally, move to wards to take pictures of bed arrangement, in side of medicine cabinet, nurse station, and toilet. Note that positions of photographing must be recorded for the next visit to monitor progress of 5-S activities. Observation and interview from staff are also important methods for the analysis. All pictures should be shared with management and department staff. This will help them to understand “how your working environments are”.

The analyzed result should be used to modify the action plan (version 0) for proper understanding of situation and development of action plan (version 1) to start 5-S activities.

Step-5:SelectionofTargetarea(s)

Selection of “target area(s)” is highly recommended for successful implementation of 5-S activities. Proper implementation of 5-S activities at targeted area(s) is to make “showcase” (model of 5-S), which helps to make staff understand “what is 5-S about” (seeing is believing!)

When select the target(s), DO NOT select sections or departments that are facing lots of problems as it will take long time to solve the problems and difficult to make them as a “showcase”. Number of target(s) can be decided according to the capacity of QIT and other resources. Criteria of target selection are described in the box below.

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Cr�ter�a of target select�on w�ll be:

• ThereissomeonewhohascommitmenttoimplementQIProgramme,inthesection;

• Situationofsection/departmentneedtobeimprovedforbettercustomercare;and

• Section/Departmentisfacingfewerproblemsortheproblemsareeasytotackle.

Once 5-S is successfully introduced to the targeted area(s) and mechanism to sustain the activities is in place, expansion of target area(s) can be executed.

Introductory Phase

In this phase, aims to make staff understand and adopt 5S-CQI-TQM concepts. It is also important to know “How to do” with 5-S activities. Time required for this phase is approximately six (6) months.

Step-6:TrainingallStaff

As noted before, one of the key factors for successful 5-S implementation is “everyone’s participation”. Therefore, training of all staff at targeted area(s) is essential. During the training, the following contents should be focused:

• 5S-CQI-TQM concepts• Situation analysis method for department/section level• 5-S tools• Establishment of Work Improvement Team (WIT)• Development of action plan for department/section• Self monitoring and evaluation

Step-7.WorkImprovementTeamEstablishment

A team is defined as a group of people working together to achieve a common goal for which they share responsibility. It can also be defined as a high performing task group whose members are interdependent and share common performance intent.

Workplace improvement teams (WITs) are essential employees-based small group activities. Their aim is to provide staff with opportunities for meaningful involvement and contribution in solving problems and challenges. The teams meet regularly to identify, analyze, and solve problems and improve their outputs of their work unit. They also implement improvement measures or recommend them to management. The bottom line outcome includes higher quality outputs and improvement productivity. Formation of WITs essentially necessitates pursuing several steps that are: forming, storming, performing and closing. The norms of the team generally consist of:

• Close relationships developed and the team demonstrating cohesiveness• Team group rules and boundaries agreed • Cooperation• Team identify and member enjoy camaraderie (fellowship/peer consciousness) with one another and • Commitment to work out differences and giving constructive feedback

High performing team usually establish urgency and direction, pay particular attention to the meeting, set some clear rules for behavior, spend a lot of time together, exploit the power of positive feedback, recognitions and rewards. The team meeting should be conducted regularly as per schedule and minutes

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of the meeting including the attendance record of the participants should also be kept properly and appraised regularly (see diagram 8 on how WIT operates).

Throughout WIT regular meetings, the tips are usually underlined. Some of the tips of effective team meeting take into account: meeting agenda prepared in time and distributed to the members, time management and maintain focused discussion, encourage and support participation of all members.

Amongst the areas which WITs seek to effect qualitative improvement includes; services to the customer /public, workflow, efficiency use of resources, work environment and safety.

The workplace improvement team leader, members of the WITs are obliged to take their roles and in addition to be familiar with the importance of the team facilitator and the position of the steering committee in their hospitals.

Benefits of working as a team comprise sharing of the knowledge, skills and experiences of different members which builds confidence among the members and collective decision making, sharing responsibility, tackle issues in synergistic manner and there is also mutual support and cooperation between team member thus in the end accomplish quality improvement.

Teamwork is vital in achieving continuous quality improvement and is at the heart to improve quality. Usually the teams take a problem as an opportunity and the team members’ support each other. One big tree does not make a forest!

Diagram 8: How does a WIT operate

Step-8.PracticeofSort,SetandShine

Practice of Seiri (Sort) is starting from identification of unwanted items in the work place. It has to be initiated by disposing all that are no longer needed after identification of unwanted items through red tagging (see Chapter 5.0: 5-S tools).

Simple way of Sorting is to categorize all equipment, machines and furniture into three (3) categories by using colours. These categories are; Unnecessary (not need it), May/May not be necessary (May not needed it), and Necessary (Need it) as depicted in diagram 9.

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Unnecessary (Not need it): Unnecessary items should be discarded, if the item is not repairable. If the item is repairable, repair it and stored as it may be needed by other department/sections or other hospitals.

May be necessary/May not be necessary (May need it/May not need):May/May Not Necessary items mean that the items are not used often (probably only once a month) or it is functioning but not used in current workflow. This kind of items should be stored in sub-store of department/sections so that it can take out quickly when it is needed.

Necessary (Need it):Necessary items should be organized properly according to current workflow. This will be explained in “setting” activities

Diagram 9: How to Sort materials/items/tools

Remaining items have to be arranged and stored according to frequency of use. All areas including floors, cupboards and tabletops have to be organized. The changes made have to result in more efficient work than before.

When unwanted items are collected from various departments/sections, the following things must be recorded and filed for smooth discarding procedures:

1) Name of items 2) Inventory number, 3) Where it was,4) Where it will be stored

“Unwanted item store” should be established and all unwanted items properly stored in until complete discarding process. If sizes of unwanted items are large and not repairable, space for unwanted items should be created within hospital compound with safe storing measures. Rules for regular disposal have to be established.

Practice of Seiton (Set) emphasizes on proper orderliness of things in the work place. Signboards are set at the entrance for easy access of various services locations in the health facility. All locations are named or numbered. Every item has to be labeled with an inventory number (discretely) and assigned a location. The assigned location is marked on the item and at the location. Visual controls including colour coding are practiced. Files and cupboards are indexed. X-axis-Y-axis alignment is practiced in the positioning of items (see chapter 5.0 on 5-S tools). Items are placed to facilitate easy access and to optimize workflow.

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Practice of Seiso (Shine) is the cleaning stage. All the items including floors, walls, windows and equipment are cleaned. Appropriate cleaning tools, methods and materials are identified and practiced. Waste bins are made available at required places. Cleaning maps and schedules are developed for continuous practice of cleaning. Waste bins colour coding must follow the national standard colour coding in the healthcare waste management (HCWM) policy, standards, and guidelines; as well as the National Infection Prevention and Control guidelines of the MoHSW.

Note that since 5-S tasks appear minor, staff may not concentrate on 5-S after the initial implementation. Inspections through monitoring teams and continuous evaluations of all work units are essential to keep track of 5-S programme.

Implementation Phase

In this phase, the aim is to practice S1 to S3 properly and generate maintenance system for S1to S3. Time allocation for this phase is approximately two (2) years.

Step-9.ProperpracticeofS1toS3(Sort,Set,andShine)togenerate maintenancesystem,developstandardsandregulations

Seiketsu (Standardization) establishes regular and continuous practice of maintaining tidiness, orderliness, and cleanliness (first 3-Ss). All processes and procedures of the organization are standardized to reduce the cycle time, to reduce waste, to improve safety and to improve outcome. Thus, the following kinds of activities are implemented in this phase:

• Development of Standard Operational Procedures (SOPs), • Development of Standard Operational Manual• Display marking of safety signs• Garbage typing collection system (infectious/non-infectious, recyclable), following the Maintenance Phase IPC/HCWM guidelines• Colour cording for linen system• Zoning for storing/parking equipment

“Checklists” should be developed for each activity/service area and utilize it for the standardization.

Heijyunka (Equalization) is important for reducing variability. Variability is the cause of creating needless work in the workflow. Therefore, consider equalizing the followings:

Another important things is to equalize the following during this phase:

• Individual capacity, • Quality, Productivity and Safety, • Information • Staff’s mindset towards KAIZEN activities.

These aspects can be equalized using various tools as mentioned below:

• Individual capacity: • Information sharing and development of Standard Operational Procedures,

• Quality, Productivity and Safety: • Use of Standard Operational Manual and Standard Operational Procedures

• Staff ’s mindset towards to KAIZEN activities: • Fair performance evaluation and awards to good practice, equal opportunity of training to all staff,

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• Information: • Sharing among staff of policy and strategy for quality improvement and current situation of KAIZEN activities

Note: Standard Operational Manual (SOM), which is developed by MOHSW or relevant authority that is unchangeable as to keep national standards. On the other hand, Standard Operational Procedures (SOP) are developed at field, which can be modified according to situation of department/ward

Maintenance Phase

In this phase, aims to maintain people to follow well work habits and keep workplace rules and regulations. To make 5-S activities as a part of your organization culture, it takes long time and need to be repeated. There is not time allocation of this phase as it is ongoing process.

Step-10.Making5-Sactivitiesacultureofyourfacility

Shituske (Sustain) is about disciplining to maintain consistent practice of 5-S. Training programme is carried out for employees. Competitions are organized and good practices are rewarded. Authoritarian rule is not practiced and employees are motivated to internalize 5-S. Training should include organization-wide meetings where management and employees announce their results. This acts as an incentive to motivate staff and to practice benchmarking.

Care should be taken not to get into a routine with 5-S activities. Once again, since 5-S tasks appear minor, staff may not concentrate on 5-S after the initial implementation. Inspections through patrol teams and continuous evaluations of all work units are essential to keep track of 5-S Programme. The following activities are expected be conducted in this phase:

• Periodical training of staff • Periodical monitoring by both patrol team from management and departmental monitoring team. • Quality competitions and awarding for good practice• 5-S poster development and display• Establishment of 5-S corner within department/section • Display of 5-S progress chart, table, and graphs

4.1.4 From5-StoKAIZEN(CQI)processAfter this step, KAIZEN (Continuous Quality Improvement) process starts to meet client’s satisfaction. Productivity and safety must be considered in the process of KAIZEN. However, even though step up to KAIZEN process, 5-S activities must be continued to maintain the foundation of quality improvement. The CQI framework is illustrated in diagram 10.

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Diagram 10: CQI Framework for health services

Kaizen teaches individual skills for working effectively in small groups, solving problems, documenting and improving processes, collecting and analyzing data and self-managing within a peer group. KAIZEN activity must deal not only with improving results, but also more importantly with improving capabilities to produce better results in the future.

Work Improvement Team was mentioned in Step-7. WIT is the main actor of KAIZEN (CQI) activities. As mentioned before, WIT is established in department/section to discuss problems within the department/section, and find solution or improvement measures against the problems.

KAIZEN focuses on:

• Moving rapidly from planning to implementation• Making continued progress rather than waiting to find the perfect solution;• Worker involvement and teamwork;• Addressing the root causes of problems; and• Process improvement from at systems perspective.

The following steps should be taken for KAIZEN activities. Here are the steps of KAIZEN activities:

i. Selecting KAIZEN Topic (where/what to improve)ii. Sharing views on the importance of the selected topic in the WIT

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iii. Situation analysis and feasibility check-up (how is it at the moment and what is the root causes of the problems)

iv. Objective setting for improvement (how it should be)v. Objective analysis for identifying measures (how to improve)vi. Alternative analysis and selecting approach (what kind of method can be apply)vii. Formulating a plan of operation with 5W1H; Why, What, Who, Where, When and How (plan how

to do it, by when, who will….)viii. Installing monitoring mechanism with indicators (how is the plan going)ix. Building in measures for sustainability and preventing set back (how we can keep it)x. Building in measures for impact creation for other parts of the organizationxi. Summarizing experienced constraints during the activity and suggestions to top management

KAIZEN activities should be implemented with a designated timeframe for maximizing teamwork and work efficiency.

Note that WIT members may suggest many issues/problems to be improved. Number of suggestions made by WIT members must be recorded. However, does not need to take improvement actions for all the suggestions. Pick up the issues that are common to all WIT members and clients first and take improvement actions. For the issues that are not common to all, try to integrate them with other issues to be improved.

Diagram 11: Example of KAIZEN Memo 7

As showing in diagram 11, all KAIZEN activities must be recorded using “ KAIZEN” memo. It is important to keep record on “what kind of KAIZEN measure was taken”. It is recommended to make memo rather than report as report making and reading consumes lots of time and may confuse readers. Simple memo like Diagram 11 is easy to make and clear “what is improved”.

This kind of memo should be shared with all health workers in the hospital to create more wisdom among health workers. It is also used for awarding, such as selection evidence of “good 5-S practices”.

7 DukeRohe,Powerpointpresentantion“Kaizen Sessions”

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4.1.5 TotalQualityManagement(TQM)Total Quality is a description of the culture, attitude and organization of a health facility that strives to provide clients with services that satisfy their needs. The culture requires quality in all aspects of the facility’s operations, with processes being done right the first time and defects and waste eradicated from operations.

Total Quality Management (TQM) is a method by which management and employees can become involved in the continuous improvement of the services. TQM is a health service management strategy aimed at embedding awareness of quality in all organizational processes as shown in diagram 12.

Diagram 12: From 5-S to TQM

The above diagram indicate what health facility management team should consider. At the beginning, consider creating good working environment to enable health workers to be competent towards to provide high quality of services. Then, consider clients satisfaction to improve clinical and non-clinical (responsiveness) issues with CQI activities. Then, other related issues such as financial, human resource management should be considered. Considering quality in all services, in all departments and sections is called Total Quality Management.

TQM processes are divided into four sequential categories: plan, do, check, and act as illustrated in the PDCA cycle diagram 13. In the planning phase, people define the problem to be addressed, collect relevant data, and ascertain the problem’s root cause; in the doing phase, people develop and implement a solution, and decide upon a measurement to gauge its effectiveness; in the checking phase, people confirm the results through before-and-after data comparison; in the acting phase, people document their results, inform others about process changes, and make recommendations for the problem to be addressed in the next PDCA cycle.

Actual implementation of TQM at health facility, all staff should get training on PDCA cycle to equip them for problem-solving process within their work place. WIT should use PDCA cycle for KAIZEN practice.

30

Diagram 13: PDCA cycle8

Further explanation of PDCA cycle is as follows:

PLAN Establish the objectives and processes necessary to deliver results in accordance with the expected output. By making the expected output the focus, it differs from what would be otherwise in that the completeness and accuracy of the specification is also part of the improvement.

DO Implement the new processes.

CHECK Measure the new processes and compare the results against the expected results to ascertain any differences.

ACT Analyze the differences to determine their cause. Each will be part of either one or more of the P-D-C-A steps. Determine where to apply changes that will include improvement. When a pass through these four steps does not result in the need to improve, refine the scope to which PDCA is applied until there is a plan that involves improvement.

4.1.6 HowtodealwithresistanceandimplementKAIZEN(CQI)activitiesChange management of a system is bound to be difficult and complex in any organization.

It is often seen slow down or stop KAIZEN (CQI) activities. There are few characteristics observed behind the organization that slow down or stop KAIZEN (CQI) activities. These include:

• Management of the organization prioritize “profit” over customer satisfaction• Management of the organization has weak leadership and hesitate to “change”• Copy KAIZEN (CQI) methodology and implement without proper understanding and adoption of the concept.• Management of the organization does not recognize the importance of user-friendliness

Even management of the organization has strong leadership and 5S-CQI-TQM concept is well adopted by managers, there are some organizations that slow down or stop KAIZEN (CQI) activities. In this case, “resistance to changes” among workers is often the cause.

“Un-cooperative staff or resistant to changes” in your organization affect “cooperative staff” to have negative thinking and attitude on KAIZEN (CQI) activities.

8 Wikipedia“PDCAcycle”

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Often observed that those “Un-cooperative staff or resistant to changes” are senior staff of institution and usually those personnel are well experienced and skilled. Un-involvement of experienced and skilled personnel into KAIZEN activities is inexpedient as skills and knowledge of those personnel are very effective for quality improvement. Therefore, it is necessary to change mindset of “un-cooperative staff or resistant” on successful implementation of KAIZEN (CQI) activities. Here are the hints (box bellow) for how to change mindset of un-cooperative or resistant staff:

H�nts for how to change m�ndset of res�stant workers

• Showexampleandexplaineffectiveandnecessityof5-Susingdata,picturesetc.

• Remove“unnecessarywork”fromcurrentworkflow,

• Removevariabilityofwork(Equalization/Leveling)

• MakeworkprocedureclearanddevelopStandardOperatingProcedures,

• Explainwhatwecandoif5-Sisintroduced.

Once resistance to “change” is reduced, managers should aim to build mutual understanding and communication mechanism between management and other workers. As previously mentioned, QIT and WIT are very important for development of this mechanism. To run the communication mechanism, it is important to respect humanity and hash out until you have consensus between management and other workers.

For successful implementation of 5S-CQI-TQM and other QIPs, changing the attitude of all health workers is cornerstone. Staff should be encouraged to perform 5-S in their mind and brain as summarized in the box bellow.

T�ps for successful 5-S �mplementat�on (b)

“5-S of the bra�n”

• Sortinyourbrainistoclarifyyourworkonwhat/forwhom/whatpurpose/howandbywhen

• Setinyourbrainistoprioritizeyouwork

• Sh�neinyourbrainistomanageyourworkonebyone

• Standard�zeinyourbrainistoremovebarriersofmanagingyourwork

• Susta�nofyourbrainistosolveproblemsandexecuteyourworkcontinuously

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T�ps for successful 5-S �mplementat�on (a)“5-S of the m�nd”

5-Sisusuallyusedfor“things”,however,itisimportanttoimplement“5-Sinyourmind”forpracticing5-Sactivitiesappropriately:

• Sortyourmindtoconcentrateonyourwork

• Setyourmindtoorganizeyourwork

• ShineandStandardizeyourmindtoenjoyyourworkandmaintainyouwayofworking

• Sustainyourmindtocarryoutyourworkactivelyandmaintainyourworkquality

Doing 5-S of the mind and brain is very important for changing your attitude in positive way and accelerates 5-S implementation appropriately

4.2 The 5S-CQI-TQM as Foundat�on of all QI ProgrammeImplementation of 5S-CQI-TQM will serve as a foundation of all other QIPs. The photographic baseline assessment is a yardstick to show other hospital staff the real situation. This also will stimulate the hospital staff towards an urge to reject the status quo. From this point, the 5-S principles are implemented starting with few targeted areas and use the results from these areas; to win support from the remaining areas to implement the 5-S principles. On improvement of the work environment from 5-S implementation; then other QIPs can now come in to improve various aspects of quality in health services, including the technical issues. Re-assessment is done using the 5-S active monitoring checklist (Annex 1) to maintain the practice, and also other tools like the Hospital Performance and Self Assessment Tool (HPSAT) can be used as a more comprehensive tool covering the technical issues.

It is important for all health workers to note that 5S-CQI-TQM, should continue to be implemented, as other QIPs are introduced. This will facilitate quick realization of outcome and impact of other QIPs introduced in health services provision. The implementation of relationship between 5S-CQI-TQM and other QIPs is shown in diagram 14.

Diagram 14: 5S-CQI-TQM as a Foundation of all other QIPs

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There are several 5-S tools that will help you to practice 5-S activities. Those tools are usually used for practice of S1 (Sort), S2 (Set) and S4 (Standardize). 5-S tools can be combined for sorting, setting and standardization practice. All tools require an agreed set of rules. The rules have to be known by all staff in the health facility and everyone must follow the rules. The 5-S tools that will be described in this chapter are; Alignment, Numbering/Alphabetical cording, Red tag, Safety signs, Colour cording, Sign board/Mapping, Labeling, Symbols, X-Y axis, Zone, and 5-S corner.

5.�: 5-S tools

5.1.1 AlignmentThis is used for “SET” activities to organize files, equipment, materials and other things in order to improve orderliness and beautification. The two pictures below give a case example of alignment in one of the hospitals in Tanzania implementing 5-S.

5.1.2 Numbering/AlphabeticalCordingThis is used for S2 “SET” activity. This is to organize files and other items by numbers / alphabets (see the two pictures below from one hospital in Tanzania. It helps users to find necessary things or information quickly and easily. It is very useful for practice of “Can See-Can Take Out – Can Return” principle. It requires an agreed set of rules, or a central coordinator to maintain system.

Chapter 55-S TOOLS FOR ACTUAL IMPLEMENTATION

34

5.1.3 RedTagThis tool is used for ”SORT” activities. When some items are difficult to decide, whether it is necessary or unwanted items during Sort practice. Put Red Tag on undecided items and observe for a month. If you didn’t move or use it for a month, it means these items are “may be necessary” OR “unnecessary” for the current workflow. You need to decide on its category by ticking on the options on the tag (® necessary; ® may be necessary; OR ® unnecessary) as illustrated bellow:

5.1.4 SafetysignsThis tool is used for “SET” and “STANDARDIZE” activities. This is used to warn visitors and workers to pay attention on hazardous items. Majority of hazardous items, which are commonly used in health facility, has international/national standardized safety signs. Therefore, it is recommended to use common safety signs. If you may not find or have access to common safety signs, you may develop your own safety design. The picture below shows some examples of common safety signs.

35

5.1.5 ColourcordingThis tool is used for “STANDARDIZE” activities. This tool is used for making facility users understand the meaning of something by using different colours. It is often used for collection of garbage, medical waste, and linen by type. It can also be used for categorization of areas/zones, identification of gas cylinders (full or empty) and so on. You should refer to the National IPC Guidelines and HCWM standards, policy and guidelines for the accepted national colour coding for different types of wastes.

Colour cording for waste dumping point Colour corded disinfectant buckets

5.1.6 Signboards/MappingThis tool is use for “STANDARDIZE” activities. This is used for identifying the location of places and guiding facility users to the place where they want to visit. Use common languages that are understood by all; in this case Kiswahili and English are acceptable.

5.1.7 LabelingThis tool is used for “Set” activities. This is used for identification of each item and organizes them properly. This is especially useful for filing and storing items in cabinet/store shelves. It is important to note that where there are many electrical switches must be labeled to identify which switch is for what (lights/equipments). Where a switch is hidden (even if one), a label to direct its location must be put on the wall to guide staff working on that area or new entrants.

3�

5.1.8 SymbolsThis tool is used for “Set” and “STANDARDIZE” activities. This is used for making everyone to understand the meaning of something by marks/symbols without or minimum explanation.

5.1.9 X-YAxisThis tool is used for S2 “SET” activity. This is used for improvement of orderliness and beautification; this is especially used for display and Poster display. It is important to remove old/outdated posters from notice boards regularly to keep it tidy.

Poorly arranged notice board Well arranged notice board following X-Y axis

X

Y

3�

5.1.10ZoneThis tool is used for “SET” and “STANDARDIZE” activities. This is used to identify or recognize the proper location or storage of items. This helps people to understand “Where it is supposed to be”

5.1.115-SCornerThis is effective for “SUSTAIN” activities. Utilize existing notice board or establish new notice board apart from existing notice board. There are three type of 5-S corner:

• Type 1: 5-S corner for all hospital staff at administration block• Type 2: 5-S corner for visitors (patients, care taker etc) at OPD waiting room, corridor• Type 3: 5-S corner for all departments/wards staff at each department/ward

On the 5-S corner, the following information is displayed:

• 5-S posters, • Pictorial progress report, • Implementation progress chart/table• Monitoring and Evaluation information (target areas, schedule, method)• Training information (target personal, schedule, venue, topics)• QIT/WIT Meeting information (schedule, venue, agenda)• Mission statement on quality improvement• Information on waste bin colour coding and type of waste

This table clarifies what kind of information should be displayed on which type of 5-S corner:

Table 5: Clarification of 5-S corners

Information on 5-S cornerTypes of 5-S corner

Administration OPD Waiting/Corridor Dept./Ward5-S posters Y Y YPictorial progress report Y Y YImplementation progress chart/table Y NA YEvaluation information Y NA YTraining information Y NA YQIT/WIT meeting information Y NA YMission statement on quality improvement Y Y YInformation on waste bin colour coding and type of waste Y Y Y

Y: necessary to display NA: Not applicable

3�

Example of 5-S corner at Administration Example of 5-S corner at department/ward

5.2: 5-S tools for enhancement of v�sual control

5.2.1: Whatisvisualcontrol?Visual control is means, devices, or mechanisms that were designed to manage or control our operations (process) so as to meet the following purposes: Make the problems, abnormalities, or deviation from standards visible to everyone and thus corrective action can be taken immediately:

• Display the operating or progress status in a easy to see format.• Provide instruction.• Convey information.• Provide immediate feedback to people.

5.2.2: WhatarepotentialbenefitsofvisualcontrolImplementing visual control in the hospital would help health workers in exposing abnormalities, problems, deviations, waste, unevenness, and unreasonable to facility users, thus corrective actions can be taken immediately to:

• Correct the problems,• Reduce operational costs,• Reduce possible waste,• Shorten services lead-time and thus keep the delivery of services on time.• Reduce inventory.• Ensure a safe and comfortable working environment.

5.2.3: PracticingofvisualcontrolThe main purpose of visual control is to organize the working area such that facility users can tell whether things are going well or are amiss without the help of expert. Visual control can be implemented using either the actual or analog items.

Actual items:

• Designate a location (position) for each item.• Indicate quantity (or maximum level of inventory)• Distinguish item from each other.• Specify form (document).

3�

Analog items:

• Colours• Shapes (contour)• Symbols • Characters (verbal)• Numbers• Graphs/tablesThe following table shows the example of usage of 5-S tools that will help to enhance visual control within a health facility. It is reminded that all tools require an agreed set of rules. Often colour cording and symbols have international rules or regulation that are well known by people. In that case, it is better to use rules that are adopted by majority of people.

All the rules must be informed to all staff in the health facility and everyone must follow the rules. Display the rules on 5-S corner or notice board is helpful for everyone to remind the meaning of colours or symbols. Table 6 shows how 5-S tools can be used for visual control.

Table 6: Example of usage of 5-S tools for visual control

Analog items 5-S tools Example of usage Actual items

Colours1. Colour

cording

1.1 Waste bin for infectious and general waste

1.2 Disinfectant containers (IPC guideline)

1.3 Linen system

1.4 Oxygen tank storage ( full-blue, empty-red)

Distinguish item from each other

Shapes 2. Zoning

2.1 Marking of stretcher/wheel chair parking,

2.2 Car parking

2.3 Position of waste bin

Designate a location

Symbols 3. Symbols

3.1 Indication of stretcher/wheel chair parking,

3.2 Toilet,

3.3 No smoking area

3.4 Dangerous areas (high voltage, incinerator

Distinguish item from each other

Characters

4 Alphabet cording

5. Labeling

6. Signboard

4.1 Open registry files keeping,

5.1 Store/stock management for medical supplies

6.1 Direction to facilities in hospital

6.2 Identification of facilities in hospital

Designate a location

Numbers 7. Numbering 7.1 Medical records keeping,

7.2 Administration files keepingDesignate a location

Graphs/

tables

8. Checklist

9. X-Y Axis

8.1 Progress report, evaluation result

9.1 Notice, poster display on notice boards/5-S corner

Specify form (Document) and indicate quantity

40

�.� Introduct�onMonitoring and evaluation (M & E) is an integral component of quality improvement in health services. Health managers, in-charges of hospitals/departments, programme managers/staff, and other health workers; they need to know about M & E. In this case they need not to be experts of it but just the basics of M & E are adequate; including data collection, processing, analysis, and use.

The knowledge about M & E helps health workers in the health sector to effectively monitor and evaluate their health facilities or programme; and hence strengthens the performance. This chapter aims at highlighting the M & E essentials for the implementation of 5S-CQI-TQM, as a foundation of all other QI approaches in the country.

6.1.1 WhatisMonitoringandEvaluation?

(a) Monitoring refers to an on-going activity to track progress in implementation of activities in a health facility or programme, against planned tasks. Data are systematically collected, analyzed and used to provide information to policy makers, health managers, directors, in-charges, programme managers and others (including stakeholders), for use in planning and management.

(b) Monitoring aims at providing regular feedback and oversight of implementation of activities in relation to plans, resources, infrastructure, and use of services by the community served.

Evaluation represents a set of procedures and analytical tools to examine how health interventions or programme are implemented; their level of performance; and whether they have the impact they were intended to have. Evaluation helps to assess the effectiveness, relevance and impact of a health intervention/programme towards achievement of the set goals.

6.1.2 ImportanceofMonitoringandEvaluationM & E is crucial in QI programme / approaches. It is particularly so due to the fact that it:

• Assists health managers, directors, in-charges, programme managers/staff, and others in he health sector in performing the day-to-day management of health facilities and programme.

• Provides information for strategic planning, design and implementation of health interventions and programme.

• Assists in making informed decisions on the prudent use of meager resources available.

Chapter �MONITORING AND EVALUATION OF 5S-CQI-

TQM ACTIVITIES

4�

• Helps to improve performance by identifying those aspects that are working according to plan, and those aspects, which need a mid-course correction.

• Tracks changes in services provided and in the desired outcomes.

• Assists to better the human condition in terns of safe working environment, and improved health status.

• Puts up a system for transparent accountability.

6.1.3 Interactionbetween5S-CQI-TQMimplementationandM&EThe diagram 15 shows the phases of 5S-CQI-TQM implementation and how the M & E comes in. Two things depicted here, which need to sit at the back of the mind of health workers is that; firstly, M & E is a continuous process; secondly, the 5-S activities are never onetime implementation. They should be done on daily basis.

Diagram 15: Interaction between 5S-CQI-TQM and M&E

5-S monitoring sheet in annex-1 should be used to monitor 5-S activities. The result of monitoring should be shared between QIT and WIT for further improvement. QIT should use “Action plan” and see “how many activities are achieved out of the target”. Once you move to KAIZEN process, number of KAIZEN memo and achievement of KAIZEN plan will also be used for evaluation of QIPs.

�.2 Tanzan�an 5S-CQI-TQM Log�cal FrameworkLogical framework is a diagram, which visualizes the factors that drive an intervention. The framework links the 5S-CQI-TQM approach to the desired impact (i.e. QI in health services). It incorporates some key contextual factors for successful implementation of 5S-CQI-TQM as shown in diagram 16.

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Diagrame 16: Tanzania 5S-CQI-TQM Logical Framework

�.3 Mon�tor�ng and Evaluat�on by QITQIT has responsibility of conducting monitoring and evaluation of 5-S activities within the hospital. QIT should monitor and evaluate their own performance and visit the section(s) or department(s) that is practicing 5S-CQI-TQM activities periodically. This kind of visit and exchange opinions with WIT is important to find problem(s) and have ideas of solutions. Provide technical support/advice, mentoring or coaching, if necessary. Points of monitoring and evaluation are as follows:

• Organizational leadership and ownership• Strategy development• Performance of Sort, Set, Shine, Standardize and Sustain activities• Performance of WITs

Note that organizational leadership and ownership and performance of Sort, Set, Shine, Standardize, and Sustain activities are evaluated by using the sheet attached in annex-1. If 5-S activities are in place and became a culture of the health facility (maintenance phase), consider going for next step and monitor and evaluate the issues for TQM achievements. Indicators vary from hospitals to hospital. Thus, select indicators that much with your health facility:

43

• Hospital health care delivery system• Health care result such as “coverage of a health intervention”, “hospital mortality and

morbidity rate”• Financial result such as “cost performance”• Human resource result such as “retention rate”

�.4 Mon�tor�ng and Evaluat�on by WITWIT has responsibility for conducting monitoring and evaluation of day-to-day 5-S practices and KAIZEN activities that are suggested and executed within their work place. Process of 5-S +KAIZEN activities must be documented and share the results within the department/sections. WIT will also communicate the results to the hospital QIT. WIT should develop their own checklist to suit their work environment.

�.5 Env�s�oned 5S-CQI-TQM M & E Informat�on - Flow SystemInformation flow and sharing is an essential component of M & E. The management structure at regional level (RHMTs) is given a critical role of coaching and supervising the CHMTs and regional hospitals. They will also ensure quality data from lower levels are available and communicated to the national level coordinating unit. Consultant and specialized hospitals will directly communicate to the national coordinating unit. The national coordinating unit will also from time to time communicate directly to the regional hospital QITs. The information flow system is illustrated in diagram 17.

Diagram 17: Envisioned M & E information flow in 5S-CQI-TQM implementation

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ANNEX 1: 5-S activities Monitoring sheet

MONITORING AND EVALUATION SHEET FOR THE PROGRESS OF 5-S ACTIVITIES

Hospital & Section/Department’s Name

( )( )DATE: / /

DESCRIPTION Very

po

or

Poor

Fare

Good

Very

good

AWARD

MARKS

1 5S LEADERSHIP OF THE CEO & MANAGEMENT

Role & Commitment of Top Management, Sustainability of 5-S activity, Training Programme for Middle

Mgt., Setting up 5-S Committees, 5-S Campaigns.

1.1 5-S knowledge/Understanding/Awareness of Executive &

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 review meeting Minutes & Audits by Patrol

teams, etc.

1 2 3 4 5

1.4 5-S Manual developed with many relevant details 1 2 3 4 5

1.5 Evidence of Training conducted for Management Staff 1 2 3 4 5

TOTAL Full mark 25

2 SEIRI – (SORTING) “Sasambua”

Clutter free Environment in Premises, Inside Offices, Work Place, etc. Evidence of removal of unwanted

items should be evident all around.

2.1 Outside & Inside areas of the premises free of clutter 1 2 3 4 5

2.2 Unwanted items removed from Premises, Offices, Work Places,

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, pictures 1 2 3 4 5

2.5 Notice Boards – Current Notices with removal instructions 1 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 with

Mechanism to reduce paperwork, stocks, etc.

1 2 3 4 5

TOTAL Full mark 35

3 SEITON – (SETTING / ORGANISATION) “Seti”

Ability to find whatever is required with the least possible delay, evidence of eliminating the waste of time

throughout the Institute/Organization.

3.1 Photographic evidence of Pre 5-S Implementation and afterwards 1 2 3 4 5

3.2 Visual Control methods adopted to prevent mix-up 1 2 3 4 5

3.3 Directional Boards to all facilities from the Entrance onwards 1 2 3 4 5

3.4 Factory/Stores, etc., have Grid References clearly marked 1 2 3 4 5

3.5 All machines/Rooms/Toilets have identification labels 1 2 3 4 5

3.6 All Equipment/Tools/Files, etc., arranged according to ‘Can See’,

‘Can Take Out’ & ‘Can Return’ principle

1 2 3 4 5

3.7 X-axis, Y-axis alignment is evident everywhere 1 2 3 4 5

3.8 Visual Control methods for defects/Rework/Files/Equipment & to

prevent mix-up

1 2 3 4 5

3.9 Gangways clearly marked with Passageways/Entrances & Exit

Lines/Curved door openings/Direction of travel

1 2 3 4 5

3.10 Switches, Fans Regulators, etc., labeled 1 2 3 4 5

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3.11 Maintenance methods of SETTING established 1 2 3 4 5

TOTAL Full mark 55

4 SEISO – (SHINING / CLEANLINESS) “Safisha”

The Cleanliness all round the Institute/Organization should have been carried out according to the 5-S

Concepts.

4.1 Floors, Walls, Windows, Toilets, Change Rooms in working order

& clean

1 2 3 4 5

4.2 Daily self cleaning (3 min./5 min.) is practices 1 2 3 4 5

4.3 Cleaning responsibility Maps and Schedules displayed 1 2 3 4 5

4.4 Waste bin strategy is implemented 1 2 3 4 5

4.5 Use of adequate cleaning tools is evident 1 2 3 4 5

4.6 Storage of cleaning tools – Brooms/Maps/Other equipment 1 2 3 4 5

4.7 Machines/Equipment/Tools/Furniture at a high level of Cleanliness

& maintenance schedules displayed

1 2 3 4 5

4.8 General appearance of cleanliness all round 1 2 3 4 5

TOTAL Full mark 40

5 SEIKETSU – (STANDARDIZATION) “ Sanifisha”

High level of Standardization in all activities carried out in SEIRI, SEITON and SEISO and the evidence

of such standards being practiced all around.

5.1 5-S procedures adopted & standardized on Check lists & Labels 1 2 3 4 5

5.2 5-S procedures adopted & standardized in Corridors/Isles &

Gangways

1 2 3 4 5

5.3 Orderliness in the use of Corridors/Isles/Gangways by Pedestrians 1 2 3 4 5

5.4 Visuals on Danger/Open & Shut directional Labels on

Valves/Doors, etc.

1 2 3 4 5

5.5 Standardized Visuals on Oil/Lubricant Containers & Fire

Extinguishers, etc.

1 2 3 4 5

5.6 Innovative Visual Control methods implemented 1 2 3 4 5

5.7 Maintenance/Storage of Files/Records in Offices/Workplaces, etc. 1 2 3 4 5

5.8 Standardization/Orderliness in Keeping Furniture/Equipment 1 2 3 4 5

5.9 Standardized check lists for common Administrative Procedures 1 2 3 4 5

TOTAL Full mark 45

6 SHITSUKE – (SUSTAIN / SELF DISCIPLINE) “Shikilia”

Evidence of an disciplined approach to all 5-S activities through proper Training & Development, which

shows the sustainability in the long term.

6.1 Evidence of regular training Programmes for all categories of

Employees

1 2 3 4 5

6.2 Evidence of 5-S group Activities & promotion of Kaizen Schemes 1 2 3 4 5

6.3 Evidence in carrying out Internal Audits by Patrol Teams 1 2 3 4 5

6.4 Self discipline amongst workforce/Good & Bad Point Stickers, etc. 1 2 3 4 5

6.5 Evidence of 5-S Slogan & Poster Competitions among Employees’

Families

1 2 3 4 5

6.6 Evidence of Self Discipline among visitors to the Institution 1 2 3 4 5

6.7 Evidence of Self-Discipline in the overall Institution 1 2 3 4 5

TOTAL Full mark 35

GRAND TOTAL Full mark 235

NAME : …………………………………… SIGNATURE: ………………………………

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ANNEX 2: Action Plan Format

Quality Improvement Action Plan with 5S-CQI-TQM

For

(Name of your institution/hospital)

Developed by……………………………

Date…………………………….

1. Issues and challenges of the Region/District

2. Institutional Analysis

Overall situation of the facility:

Areas/Sections/Depart

ments

Problems Expectation of service users

3. Problem Statement

4. Goal

5. Objectives

Outputs Indicators Means of Verification

6. Target area(s) for implementation of 5-S

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7. Action Plan

Time Frame

20…. 20….

Ph

ase

of

imp

lem

enta

tio

n

Act

ivit

y f

or

imp

rov

emen

t

Ta

rget

Res

ou

rces

inp

ut

1 2 3 4 1 2 3 4

Res

po

nsi

bil

ity

Mea

ns

of

Vv

erif

ica

tio

n

Pre

pa

rato

ry P

ha

se

Act

ivit

ies

that

are

imp

lem

ente

d i

n f

irst

th

ree

mo

nth

s

Intr

od

uct

ion

Ph

ase

Act

ivit

ies

that

are

imp

lem

ente

d i

n n

ext

six

mo

nth

s

Imp

lem

enta

tio

n P

ha

se

Act

ivit

ies

that

are

imp

lem

ente

d i

n n

ext

two

yea

rs

Ma

inte

na

nce

Ph

ase

Act

ivit

ies

that

are

im

ple

men

ted

an

on

go

ing

bas

e to

mai

nta

in t

he

pre

vio

us

ph

ases

4�46

ANNEX 3: KAIZEN activity checklist format

KAIZEN (CQI) Activity Checklist

Department/Section: ………………………………………….

WIT Leader: …………………………………………………

Month & Year :………………………………………………….

Act

#

KAIZEN Activities Deadline

date

Responsible

persona

Status on the

deadline dateb

Status on the

New deadline

date

Objective:1

Target:

/ / Done

Partially done

Not at all

New deadline

/ /

Done

Partially done

Not at all

Reason

Objective:2

Target:

/ / Done

Partially done

Not at all

New deadline

/ /

Done

Partially done

Not at all

Reason

Objective:3

Target:

/ / Done

Partially done

Not at all

New deadline

/ /

Done

Partially done

Not at all

Reason

Objective:4

Target:

/ / Done

Partially done

Not at all

New deadline

/ /

Done

Partially done

Not at all

Reason

Objective:5

Target:

/ / Done

Partially done

Not at all

New deadline

/ /

Done

Partially done

Not at all

Reason

If the activities are not completed on the day of new deadline, the activity must be review and reset

objectives and target.

a Put name of WIT leader or suggested person

b If the status is “Not at all”, set new deadline

4�47

ANNEX 4: Example of Progress Report Format )

5S-CQI-TQM Progress Report Format

Date of entry: / / 200 Entered by

Hospital:

1. 5S-CQI Training activities conducted in the past 6 months

Fill training activities related 5S-CQI-TQM with the information of whom you targeted and how many staff

participated

Type of training Date Target group # of Participants

2. Activities of Quality Improvement Team Here, reports what kind of 5-S activities are conducted by QIT for improvement of overall hospital environment

such as establishment of 5-S corner, hospital map display, sign board display and so on. Moreover, reports what

QIT did for supporting departmental 5-S activities

Activities Area(s) Timeframe Changes

3. 5-S Implementation ProgressAccording to your action plan, reports, which phase are you now. In the row of “Target area” fill all

departments you are targeting to implement 5-S. If the targeted department formed Work Improvement Team

(WIT), check box of “WIT formed”. Then use “5-S activities Monitoring Sheet” to mark the progress of

activities to complete this section. For example, if total “leadership” score is 35 out of 75, it will be 35÷75×100

= 46.66 = 47%

Phase □Preparatory, □Introductory, □Implementation, □Maintenance

□WIT formed

Leadership( %), Sort ( %), Set ( %), Shine ( %)

Standardize ( %), Sustain ( %)

□WIT formed

Leadership( %), Sort ( %), Set ( %), Shine ( %)

Standardize ( %), Sustain ( %)

Target area

□WIT formed

Leadership( %), Sort ( %), Set ( %), Shine ( %)

Standardize ( %), Sustain ( %)

5048

□WIT formed

Leadership( %), Sort ( %), Set ( %), Shine ( %)

Standardize ( %), Sustain ( %)

□WIT formed

Leadership( %), Sort ( %), Set ( %), Shine ( %)

Standardize ( %), Sustain ( %)

□WIT formed

Leadership( %), Sort ( %), Set ( %), Shine ( %)

Standardize ( %), Sustain ( %)

4. Challenges

In the row of “ challenges”, fill the issues that QIT and HMT need to work on for implementation of QI activities.

In the row of “ actions planned to be taken”, fill the countermeasures for the challenge, followed by who is

responsible of the action and necessary inputs to take the action.

Challenges Actions planned to be

taken

Responsible unit Necessary input

5. Pictorial records: Paste photos of improvement. Pick good example of 5S-CQI-TQM activities’

photographs

Before After

Before After

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Before After

Before After

52

ANNEX 5: Successful �mplementat�on of 5-S act�v�t�es (Before and After)

MbeyaReferralHospitalMedicalRecord

Before (Aug.2007) Mid.year ( Feb.2008) After 1 year (Aug.2008)

MbeyaReferralHospitalOfficeofMedicalRecordsection

Before (Aug.2007) Mid.year ( Feb.2008) After 1 year (Aug.2008)

53

MbeyaReferralHospital,CentralStore

Before (Aug.2007) Mid.year ( Feb.2008) After 1 year (Aug.2008)

MbeyaReferralHospital,OpenRegistrysection

Before (Aug.2007) Mid.year ( Feb.2008) After 1 year (Aug.2008)

54

MuhimbiliNationalHospital,Waste-dumpingpoint

Before 5-S After 5-S

MuhimbiliNationalHospital,Wardmedicinecabinet

Before 5-S After 5-S

TandahimbaDistrictHospital,OPDImmunizationroom

Before 5-S After 5-S

55

Good example of well organ�zed work�ng places

Mbeya Referral Hospital Pediatric ward, APCU & ward store

Newala District Hospital Pediatric ward

Tandahimba District

Hospital Laboratory

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