Strategic Management and Continuous Quality …...Str.Man.KAIZEN(CQI)-5S I A short manual as an...

Str.Man.KAIZEN(CQI)-5S I

A short manual as an entry point for better management

Strategic Management and Continuous Quality Improvement (CQI) using 5-S Principles

A tool for non-stop quality management and project implementation at your workplace in line with strategic planning

A Custom made Manual for Health Personnel Prof. HANDA Yujiro Dr.med.dent.,Dr.med.sc.(Jpn), F(Hon)Pcoms [email protected] [email protected] Assigned as: Project Formulation Advisor (Health Planning, Hospital Management, Health HRD, M&E) JICA Regional Support Office for East / South Africa (JICA-ReSOESA) Nairobi, Kenya Moses SINKALA MD, MPH Director, Lusaka District Health Management Team Assist. Professor-OBGYN, University of Alabama at Birmingham, USA [email protected] and Naphtali N. AGATA M.B. Ch.B, MPH, Cert. Epid Public Health Specialist Consultant (Health) Regional Support Office for Eastern and Southern Africa Nairobi, Kenya

JICA PHC Project (Lusaka) and JICA – ReSOESA (Nairobi)

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mailto:[email protected]



Str.Man.KAIZEN(CQI)-5S II

Strategic management and Continuous Quality Improvement (CQI) using 5-S principles: A tool for non-stop quality management and project implementation at your workplace in line with strategic planning

A Custom made Manual for Health Personnel

Copyright: JICA Primary Health Care Project (Phase II), Lusaka District Health Management Board, Lusaka,

Zambia Contact address: 1012/58m Church Rd., Rhodes Park, Lusaka , Zambia,

TEL: (+260) 1 251 474, FAX: (+260) 1 255 907 OR

Lusaka District Health Management Board Plot 5231 Makishi Road, Box 50827, Lusaka, Zambia Phone: 260 (1) 2355554, Fax: 260 (1) 236429

Compiled in 03/JUN – 18/JUN/2004 in Lusaka JICA-PHC Project (Phase II), Zambia and modified in May, 2005 and July 2008 at Regional Support Office for East / South Africa (JICA), Nairobi, Kenya

Compiled by Prof. HANDA Yujiro Dr.med.dent., Dr.med.sc (Jpn), F(hon)Pcoms Senior Advisor, JICA* <Health Planning, HRD, Hospital Management and M&E> Contact Address.......…….JICA Regional Support Office for East / South Africa Rahinmtulla Tower 17F., P.O. Box 50572-00200, Nairobi, Kenya TEL…+254 20 272 4871/152, FAX…+254 20 272 0190

Email: [email protected] [email protected]

Mobile: (+81) 90 9676 1344 (Japan), (+94) 72 2244 898 (Asia, Africa, Europe) (+254) 724 262 380 (Kenya)

* JICA: Japan International Cooperation Agency

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Contents

Executive Summary Foreword 00…Preface 01…Introduction ……………………………………………………………………………………………………………………………. 02…Objective of this manual 03…Timetable for using this manual in training 04…Headache of health personnel, who are expected to manage the work:

Case documents and managers’ song 05…Our Enemy 06…Everybody has to change something for the better. ……………………………………………………………………………………………………………………………. PART 1…Strategic Management 07…What is “Management”? What is CQI? 08…Who is a “ Manager”? 09…Why all health personnel have to manage their work? 10…What will happen if there is no management? 11…What is “Strategy”? 12…Why “Strategy” is important in Management? 13…What is “Strategic Management”? 14…How should the process (steps) of the strategic management be organized? 15…What is “Strategic Analysis”? 16…What is “Strategic Choice”? 17…What is “Strategic Control”? …………………………………………………………………………………………………………………………… PART 2…Continuous Quality Improvement 18…The first challenge in Continuous Quality Improvement toward “Quality of Service” 19…KAIZEN (CQI) will never stop. 20…Entry point of KAIZEN (CQI) is 5S Principles 21…What are the targets (objects) of 5S activities in health services? 22…How can we organize 5-S activities in our respective workplace? 23…Managers’ song 2 …………………………………………………………………………………………………………………………. 25…For further reading

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Executive Summary Strategic management The Strategic Management model outlined in this manual is intended for both professional and non-professional health personnel who are in-charge of supervising or in control of routine programmatic and project activities. The process of strategic management can be characterized into three phases: Analysis-Choice-Control. These three phases are composed of the following steps as the logical link in managing a program, a project, or a health institution. Strategic analysis is the phase in which various analytical steps are followed to formulate the conceptual framework of a project, starting from defining Vision-Credo-Mission. This is followed by the steps for recognizing and understanding the environmental factors related to the project. Internal (step 2) and external environments are systematically analyzed and the information obtained from this phase is used to make right choices or generate alternative solutions in the next phase i.e. Strategic Choice. Strategic Choice has to be made by top management and the team based on the results of strategic anaysis. The management team has to concentrate in scrutinizing the networking (Step 1) system with outside organizations, and also with internal implementation units (clusters). Since health services are the products of a project or a health institution, the service content that should be delivered to beneficiaries should be organized in accordance with demand and internal capacity. Cluster formation (Step 2) is the next step required to organize the implementation units to deliver the said services and catalyze the upgrading of these services to a higher level of efficiency Over all diagnosis and finalization of risk assessment. (Step 3) is made during this phase. Strategic Control is the implementation phase of the project. In this phase, the management team sets the targets with time frame into respective implementation units (Step 1). For this purpose, the results of the analytical phase should again be maximally used. The quality of the services delivered by respective clusters should be well controlled in the best achievable condition to maximize resource utilization. Quality Control is the target of this step (Step2). In this phase, KAIZEN (Continuous Quality Improvement) and 5S Principles are critical tools that will enable the organization deliver the best services optimally under a lean system (limited funding, personnel and equipment). Strategic control enters the final stage (Step 3) by mobilization of built-in Monitoring and Evaluation system. KAISEN (CQI) and 5S Principles This is a core issue in the phase of Strategic Control. The production system to ensure delivery of quality Services or Products can only be realized when the work environment is the best obtainable. It is also imperative that service contents and the mechanism for delivery be in the best arrangement in terms of preparedness, standardization, timeliness and communication. The processes employed in pursuing these conditions are called KAIZEN in Japan, where this principle was first created. When this principle was introduced to the Western World it was referred to as Continuous Quality Improvement (CQI). A powerful tool for achieving KAIZEN (CQI) is the 5S Principles (Sort-Set-Shine-Standardize-Sustain). Sort is a step to classify used and unused items in the work environment and discard the unused. The step of Set then follows to give proper order and location for the essential items in the work environment. It is also mandatory to make the work venue productive by the Shine step, in which all staff have to clean their respective work areas to realize the cleanest and dustless work environment. These 3S (Sort-Set-Shine) are all customized and normalized in all places and at all times through a process of Standardization. In the final stage, the emphasis is on positive attitude development of the staff through continuing education and training (Sustain). This activity of 5S can be organized by the decision-making of the top management of the project or institution. It is a participatory process of all staff including top management. Implementation structure and process of 5S activities should be carefully constructed with specific purpose to involve staff of all cadres and job categories. The target of 5S was originally the production line. The movement expanded to office environment and service sectors. It is definitely applicable to health services not only for work environment for health service delivery but also to service contents, and software matters such as time allocation and communication.

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Foreword Health service is one of the most important sectors of the social service of any country. A healthy workforce is critical for national productivity, hence the significance of public and private health services. Under the present context of national health financing, it is also vital to achieve rationalized health resource allocation and maximal utilization of financial and human resources. Management is an art to run the system and maximize output from the smallest possible input with sustainable growth of the system. It is inevitable for health service delivery system to achieve the best obtainable managerial practice with focus to vulnerable groups in the society as core beneficiaries of the public health service. With increased demands from other priorities including Malaria, HIV/AIDS, TB and other communicable diseases, recourses remain limited. Continuous quality improvement in service delivery is vital when specifically targeting highly populated urban settings. Promotive, preventive and curative services are key to sustaining front line health services. It is obvious that health personnel cannot avoid responding to immediate health problems that confront them them inspite of the constraints they face since they are dealing with issues that touch on human security. In this context, management improvement provides a break through to an otherwise complex situations. This manual is a guide for health care providers to strengthen management of health systems at their levels. 5S principles are a simple but crucially important instrument of management which can be used widely by various cadres in the health service. I sincerely hope that this manual will be actively used by all involved in the delivery of health services in order to improve managerial practice for the benefit of users including vulnerability population groups. In conclusion, I express my deepest gratitude to our counterpart organizations in Zambia, Tanzania and Kenya for their endeavors that realized the development of this manual and its utilization for training in KAIZEN (CQI) and 5S. God bless you. Mr. Yoshihide TERANISHI Resident Reporesentative JICA - ReSOESA Nairobi, Kenya

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Preface Everybody has the capability to do something for the betterment of others. This is the nature of human beings living on planet earth. People live together in a country, province, district, division, community and family as a group, large or small, seeking a better life and environment. There are, however, conditions where human beings disagree, or face constraints to do something together for the benefit of the group. People, therefore, have to make adjustment for the group members’ desires and also try to establish consensus. Sometimes they have to face the risk of separating the group or retaining inactive, uncooperative subgroup within the group. This is a risk as it weakens the capability of the group to get along with the outer environment, which sometimes may threaten the security of the group members. Now “Management”, the actions or processes of organizing and controlling the work, system or team becomes critical as an important tool regardless of the size of the group. It is obvious that health and service delivery systems of the country, at the macro-level is the target of “better management”, which enables even the most vulnerable groups in society to benefit by equitably distributed promotive, preventive, curative and rehabilitative health services. The reality is, however, not so easy and simple. National health systems are large and complex, being always exposed to the external and internal environments which pause a threat to the maintenance of the system. Financial resources envelope may be one of the most serious issues that can hinder autonomous development of the system. In both developing and developed countries, health systems are confronted with problems in financing. Each health personnel, regardless of his/her category should work as a manager, since everyone has his/her own working territory that has to be controlled by himself/herself. Management is an on-going concern aimed at making day to day work better in terms of outcomes and working conditions. It includes planning to orient and organize the system and mechanisms under which each person is given a role to play. As you may understand, this is a typical two- way job not one way from top to down. It is ideal to have a situation where top management, mid-level managers and work team members are all in a single communication circuit in the day-to-day managerial practices. To empower the beneficiaries of this manual, 5-S principles and activities are highlighted as the entry point for the managerial improvement and new system development. A set of 5 practices: 1 - Sort, 2 - Set, 3 - Shine, 4 - Standardize and 5 - Sustain were originally developed in the Japanese manufacturing sector in the process of product quality control in 1960s. They contributed much to establish the fame and quality of the products, although these were often referred to by consumers in the world as cheap and of low quality before World War II. The 5Ss were verbally called 1 - Seiri, 2 - Seiton, 3 - Seiso, 4 - Seiketsu, and 5 - Shitsuke in Japanese language. The enemy in management improvement is the cynicism and indifferent attitude of the people concerned. We should all be ready for change which should first occur within us. If our mind-sets allow the system or job to stay where these are without solving problems or removing obstacles confronting the system, then the challenge is not these problems and obstacles but ourselves. This manual is not intended to provide you with technology or new knowledge but just to provide an opportunity to think over your work environment and how you can best relate to it. We share in the manual ideas and perceptions, which definitely exist within your mind-set but which are submerged somewhere due to your daily busy lives. Prof. HANDA Yujiro 06 Jun 2004 Lusaka

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01…Introduction The Health system is a major component in the social service sector of a country. It is comprises the government (public sector) and private sectors. These two different health services co-exist in most countries, regardless of whether it is in a developed or developing country. Although public and private health services share the common spirit to serve the people, the financing mechanism is totally deferent. Mostly the government directly finances public health services. Tax, collected from the general public, is the usual source for these finances. Some countries are running government funded health insurance schemes through which government subsidizes health care cost particularly in curative care. The beneficiaries of the schemes also contribute to the financing through payment of insurance premiums. Private sector health services totally depend on the fee paid by the service purchasers. This health care service is business oriented and focuses on curative and some promotional services and not on preventive or environmental health. The latter entity is totally left for the government or municipal office to provide. In any case, health care is not free. The cost of health care will fall on someone. In the context of developing countries, the government struggles to fund public health services. It is, however, not easy for governments alone to cover the cost for all aspects of promotive, preventive, curative and rehabilitative services. Development partners work together with governments to sustain the health system while the private sector continues to play an important role. Health is an important asset of the people and health personnel, whether professional or non-professional, are in the front-line for improving delivery of health services. The health staff are actually in the battle fighting against various threats to the people’s asset. These fighters (health staff) unfortunately cannot control anything about the above-mentioned so-called macro-issues. Despite their incapacity to improve the macro-system and mechanisms, which sometimes affect them directly as uncontrollable negative factors particularly the shortage of resources, these genuine people have to continue to fight against diseases, malpractices in health behaviours and sometimes even against natural disasters. Health personnel need additional armament to fight in a better way and achieve their goal of serving the people in the best achievable conditions under the given circumstances. Definitely this is an issue that has to be looked into by all of us who are sharing both the achievements and constraints with front-line health personnel. Managerial capacity is one of the areas we can make further improvement in and provide additional armament to protect routine activities from collapse and disorganization. It must be well recognized by the users of this manual that “Management” should not remain just a concept that you acquired by intellectual training but should be a combination of “Concept” and “Practice”.. Otherwise no changes can come about. For the entry-point of non-stop management practice, KAIZEN (Continuous Quality Improvement: CQI) is introduced in this manual together with 5S Principles as the practical management instrument to initiate KAIZEN. This concept was developed in Japanese manufacturing sector after World War II, when Japan lost everything but the spirit to soldier on and live. After the success of industries in Japan, this concept has been widely accepted in the service sector and also in various businesses in many countries. This is the time to learn something from this concept and apply to public sector health services. We handle multi-factorial issues in health. A creative mind is, therefore, necessary to modify the learnt management tools to meet the demand of our front-line challenges.

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02…Objective of the Manual The manual is meant to enable participants to review the conceptual structure of “Management” and to know how health personnel are capable of improving their present managerial practices. At the same time, the participants will be inspired to commence something useful to gain the best obtainable working environment and conditions without large scale (but with minimal ) financial input. With this in mind, top and middle-level management in the health sector at front-line health institutions will be motivated to mobilize their resources maximally to take their teams towards Continuous Quality Improvement activities. Everybody is a manager and everyday is a day for improvement. The manual may be used for conducting

the timetable outline proposed below. seminars on TQM and 5S following 03…Timetable Outline 0820-0845…Registration 0846-0859…Participants get seated. 0900-0910…Opening remarks 0911-0915…Opening Prayer or song PART -1 0916-0930…Objective of this seminar 0931-0940…We have to change something. Background and “Headache” 0941-1000…Preconditions and definitions related to “Management” and CQI 1000-1030…Review of Strategic Management: Analysis, Choice and Control

--What is “Strategic Management? --How should the process (steps) of strategic management be organized? (Cycle) --What is “Strategic Analysis”? --What is “Strategic Choice”? --What is “Strategic Control”? --What should be done in the step of “Strategic Analysis”?

Orientation of the Project (Vision-Credo-Mission) External environment and the Project Internal capacity of the Project

--What should be done in the step of “Strategic Choice”? Networking with external environment Your Service contents as “Products Cluster, as strategic implementation units Overall diagnosis on the prioritization of actions

--What should be done in the step of “Strategic Control”? Setting specific objective for the Project *Kaizen* (Continuing Quality Improvement: CQI) and 5-S Principles Resource mobilization, allocation and effective utilization Monitoring and Evaluation, guiding you to the next phase of the Project

1030-1045…Tea break PART 2 1046-1055…We can start even today. What and how??


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1056-1115…What we can start from this moment is KAIZEN (CQI) and 5S principles --KAIZEN (CQI) with 5-S Principles will never stop.

1116-1135…What is 5 S? --What are 5S principles? --What are the targets (objects) of 5S?

1136-1200…How can we organize 5-S activities in our respective workplaces? --5S Manager --5S Declaration ceremony --5S Committee meeting --5S Group as a cluster for implementation --5S Evaluation and rewarding --5S Reporting 1201-1215…First actions should be taken by leaders to conduct 5-S activities as non-stop KAIZEN (CQI) 1216-1235…How to monitor 5-S activities --Weekly visits of 5S committee members to every cluster unit --Reporting to top management and visualization of results and outcomes to all staff 1236-1400…Lunch Break PART 3 1401-1415…Gap between intellectual work (Planning) and actions should be minimized.

Plan should be implemented at the obtainable best working condition sustained by highly motivated personnel.

1416-1515…Q/A, Discussion session

--Are 5-S activities useful for community activities? --Are 5-S activities useful for GMP+? --Are 5-S activities useful to all health personnel regardless the job categories? --Can we make further improvement of management capacity by 5-S activities?

1516-1530…Wrap up and Closing Song

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PART 1….Strategic Management 04…Headache of health personnel who are expected to manage the work: case documents 4-1…Managers’ love song …………………………………………………………………………………………………………………………….

Call me irresponsible

Call me irresponsible Tell me unreliable Growing undependable too Do my foolish alibi for you Well I’m not too clever I just adore you

Call me unpredictable Tell me just unpractical Rainbow I’m inclined to pursue (You go ahead) Call me irresponsible Yes I’m unreliable But it’s undeniably true That I’m irresponsibly mad for you

……………………………………………………………………………………………………………………………. 4-2…Headache of health professionals (case statements) This is a short story in a developing country in Asia. An attendant of a health centre located in the outskirts of the capital, is a faithful person who wishes to work hard for the health centre. His major work as one of the supporting staff of the centre is to clean the corridors and various rooms used as clinical areas and common rooms for staff. He is not happy about the partly damaged cleaning tools and the shabby uniform and also about the space given for the storage of his tools. A clerk in the administrative office is not so busy in a district hospital in the city centre. There are various files and documents around him, since his office is the only office to manage the hospital records except clinical charts. His superior officer does not expect him to find out a right file and/or document in the possible fastest time because these are kept in a special order, which could be understood only by his superior officer. Because of that, he is not asked by his superior to search the file and documents. The superior works as he likes and picks up the items on his own. This leaves the clerk just sitting in the office frustrated and without obvious tasks to carry out. A community health worker (volunteer), a non-professional, has been working with the professional community health nurse in the past 5 years. The nurse was kind and supportive enough to maintain his job at a community centre, where periodically they have health education for the community on the prevention of infectious diseases. He has few ideas to make the health education sessions better and efficient but cannot tell his idea to the nurse. Why? He feels embarrassed to tell something about the health service to a professional nurse. He is actually afraid that the nurse might resent the idea. The Secretary of Ministry of health has been serving the Ministry for the past 5 years in this position. He started his career from a district public health office after obtaining a masters degree. When he is in the field or even when in his office in the ministry, he sometimes worries that he has no updated knowledge on the health services in the peripheral parts of the country. Although he gets briefings from the directors at the ministry on health indicators from

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the data sent from respective regions of the country, none of the directors discusses matters based on experiences in the remote areas of the country. A 7-year-old school going boy in a compound has to take care of his sister and brother when his mother goes out to attend Growth Monitoring sessions at the nearest health centre with the youngest sister who was just born last year. He knows that the mother will not be home again in the morning period because of the long waiting-time at the health center. He hates to visit the Provincial Hospital when he is sick. He remembers that he once waited in the corridor of the hospital unattended for more than 3 hours. He feels that the hospital is a place to wait with the crowd. A medical doctor is often frustrated to find the X-ray machine is out of function. When he receives a patient suspected of pneumonia and if the machine is out of order, he sometimes gets angry about the disorganization of X-ray department. He does not make complaints, since he knows that this does not happen due to mishandling by radiographers but due to inadequacy of periodical maintenance service. He wants to blame the equipment company, which supplies the equipment, but he is unable to do so. Why? It is because the hospital does not have any service contracts with the company. A registered nurse working at the operation theatre is a bit reluctant to guide her relatives or friends to introduce the hospital she is working for, when someone gets sick. She has noticed that the water supply to the theatre often stops and then the doctors and nurses have to wash their hands using water stocked in a large bucket, from which she has to pour the water to the arms of the surgical team at pre-operative hand washing. Also she is not comfortable to work with the material supplied by the CSSD, which is adjacent to the theatre. Clean instruments are handled on the dirty working table for setting and packing at the CSSD. 05…Our enemies? If there are enemies to prevent our self-development, we have to fight against them first, before starting the learning process. Cynicism and negative ways of thinking that are hiding in the corner of your mind-set are the most serious enemies. You have to be brave enough to fight against them. The enemies here are neither politics of the country, nor incomprehension of the people on health matters. 06…Everybody has to change something for the better. There are many questions on your perception as follows.

-Are you satisfied with the present working condition and performance of your team including yourself? --Do you think that what you do now is the best you can do? --Do you know how capable you are? --Do you know the percentage of your capability that has been effectively used to date? --Do you trust yourselves and your teammates as a team to make further improvement?

If there are external unavoidable conditions that hinder our development, we are the ones that have to change and fight against them. This is what we have to do now, since Health Personnel in our countries have tremendous potential. 07…What are “Management” and “CQI”? 7-1…Management “Management” is the act or process of organizing and controlling the work, project, or organization. Management is “control”. To control your work, you need some instruments. These instruments are the management tools.

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7-1-1…What is the target (object) of the “Management”? Any system or work is under individuals who have to accomplish specified tasks to produce visible outcomes. These are the targets (objects) of management. Management is a method to work with people/objects. Regardless of their category, cadre or job group, they have to do the job as planned and guided (organization and control).

7-1-2…Anything is a Project, large medium or small, whatever.

A Project is a system to create PRODUCTS or certain OUTCOMES as the result of harmonized functional interaction of the SYSTEM (utilizing certain resources as INPUTS). In health sector projects, the outcomes can be observed as the improvement of health indicators, which can lead the target population or area to its GOAL. The goal is the so-called Quality of Life (QOL) of the people under the given circumstances.

Project is a cycle that includes: “(1) Preparation – (2) Design – (3) Implementation – (4) Monitoring – (5) Evaluation”. These elements can be repeated many times if they are well organized. Monitoring is a continuing process to check progress in work implementation and is a managerial tool for providing feedback to control the entire system of the Project.

7-2…CQI Continuous Quality Improvement (CQI) is a process to secure “Productivity” of the Project. This is a non-stop, day-to-day process to improve the standard of your work, followed by all members of the workforce for achieving the best in outcomes (outputs) of service (incl. 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 respective patient wards. The major TOOL for the initiation of CQI process is 5-S, which is elaborated in this manual.

08…Who is a “Manager”? All workforce elements should be managers. All health personnel should have managerial sense and capability. The work each person does is important. Sometimes managerial practices affect the quality of health services as a life-threatening or life-saving factor. All health personnel, irrespective of their cadre and category, should have managerial role and capacity since they have their own work territory and responsibility. In case of community based health services, community health volunteers, community health coordinators, nutritionists, nursing and midwifery professionals, environmental health technologists, clinical officers, sisters-in charge and even medical doctors should have managerial skills and responsibility. 09…Why all health personnel have to manage the work? All health personnel, regardless the cadre and category, have their job territory. He or she is the best knowledgeable person on the job contents, constraints, achievement and the best, or let us say, the only person to develop useful ideas for further improving the work. This is why every health staff serving the people has to be a so-called “manager” of his/her work. Management of Project or Institution is a combination of these managerial practices produced by respective element of the system. It has to be constituted with bottom-up managerial vector and top-down vector of orientation.

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This two-way practice should be a must for successful management. This is also the important reason why all health personnel have to contribute to managing the work. 10…What will happen if there is no development in management? A Plan will not be used, if there is no attention and intention of doing management in your mind. The planning document will be stored in the shelf of the planner, if there is no improvement in managerial practice. We do not want to see either an inactive administrative practice from the head office to communities or inactive feedback channels from the communities to the head office. In contrast to your visible and invisible capability, your task will not be satisfactorily achieved with effectiveness and efficiency, if your work is done without proper attempt of control. There is no turning point from the present situation, where you have various constraints, if you leave the things as they are. The time will run, as it was in the past, and guide you gradually to indifference and dullness, although you achieved a lot in your exercise in strategic planning in the last few months. These would just be simulated situations, if there is no further development in management practice. 11…What is “Strategy”? Strategy is a well-planned action or a series of actions for achieving an aim using tactics or methods to achieve that specific objective. The planners and/or managers are expected to keep this definition in mind and look to the future from the present status, where he or she stands. Then he or she has to show the overall goal of the Project to the team members and also to various stakeholders. 12…Why “Strategy” is important in Management? Strategic Planning has been successfully practiced in a number of countries with full participation of district health management teams and the health personnel working on front-line health facilities close to the communities. Management is required to be “strategic”, involving running various activities in sequence as small projects that have to be controlled by the cycle of Plan-Do-See. The activities should always be in line with your objectives which contribute to the achievement of the Vision and Mission of the whole Project. In this sense, you should again be “strategic” for implementation and try your best to look to the future and tackle the given challenge to achieve the target as effectively and efficiently as possible. 13…What is “Strategic Management”? Plan-Do-See = Analysis-Choice-Control (incl. Implementation) Strategic management is a process with repeating cycles of Plan-Do-See. In reality the managerial job that you are expected to do, Plan-Do-See is reworded into Analysis-Choice-Control to show the clear linkage of respective managerial actions. Your guidance and instruction should always be given to your management team, based upon the concept of Analysis-Choice-Control. Manager and his or her team firstly analyze, secondly make wise choices based on the analysis and thirdly control the activities smoothly using his or her workforce and knowledge gained from the former two processes. 14…How should the process (steps) of strategic management be organized? Strategic management is an ascending spiral of “Analysis-Choice-Control”. Once you start the activities, you cannot stop them easily. Time factor is vital, particularly in relation to funding, budgeting and expenditure. The more you slow down the process of Analysis-Choice-Control, the more you loose resources. Just like the flow of a river,

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velocity of the management process should be maintained in the most suitable range for the internal and external conditions. 15…What is “Strategic Analysis”? 15-1…STEP-1 Formulating Conceptual framework Vision, Credo and Mission of the Project or Institution, where you are in charge, should be re-confirmed and announced to all your staff. If these statements were written in a difficult and complicated wording and sentences, these should be re-arranged so that all staff can recognize, understand and acknowledge them.

Vision should represent the idea of direction or orientation of the task given to your Project or Institution with messages on history, environment and achievement. Credo should represent the sense of value of your Project or Institution with messages on brief, origin and cultural background.

Mission should represent the concept on duty or role of your Project or Institution with messages on objective, characteristics and range of contribution.

The statements should be short and understandable to all people including potential clients of the Project or Institution. The following is an example of a Mission Statement.

Example of Mission Statement

XXX Health Promotion Project

The mission of this project is to improve health behaviours of XXX region. We intend to achieve the objective by regional health promotion movement. The Project formulates a joint team with the local health authority and directly provides advisory support in promotional activities on safe sex, reducing alcoholism and domestic violence. The principle that we follow in the activities is “Local participation”. Community empowerment is the philosophy that the Project has to always keep in mind for the sustainability of the Project.

It is very important to place the above three conceptual statements all over the Project area or Institution in order to expose all staff and clients to these core messages. By doing this, the manager is motivated towards creation of better working condition. 15-2…STEP-2 Analyzing External environment External environment of the Project or Institution should be studied as the immediate second step. This step is similar to stakeholder analysis, which is well known among planners trained in Project Cycle management or Strategic Planning methodology. The information that you would collect in this step would be useful to know about;

--Beneficiaries (direct or indirect), --Support groups, --Potential collaborators, --Decision making bodies, --Internal and external agencies with training capacities, --Implementation bodies other than own Project or Institution --Potential opponents/competitors, --Regulatory agents and mechanisms, --Funding agencies and its schemes,

and so forth.

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15-3…STEP-3 Analyzing Internal environment Internal environment: Existing capacity in terms of resources under your control should be carefully analyzed including the adequacy and potential of facilities, finances and human resource teams in place. This step will be useful to check up the feasibility of planned future activities. It is meaningful to know the past achievement and shortcomings of the Project in this step and also to formulate some ideas for strengthening internal capacities. Analysis of the internal and external environments should highlight the strengths, weaknesses (internal), opportunities and threats (external) –SWOT- of the organization. 16…What is “Strategic Choice”? 16-1…STEP-1 Networking Networking with your catchments (external environment of the Project) is the first step of Strategic Choice. In Strategic Analysis STEP-1, You have already collected full information on the important counterparts in the catchments and even on the potential opponents/competitors outside of the Project. Using your knowledge, you will be expected to communicate with important collaborating and supporting agencies / groups as well as superior decision-makers. The communication will be the key to open up various channels, which are useful for the implementation of your activities. Planning on sharing of tasks and benefits can be initiated by this step, among your partner groups / agencies in line with your strategic action plan. At the same time, you will be able to minimize the risk in relation to potential opponents or competitors, through your careful information exchange with them conducted in advance of the commencement of your major activities. Networking is a process of continuous bilateral communication and information exchange between Project or Institution and the catchments. 16-2…STEP-2 Organizing service contents Your Service contents in the activities are the “Products” of your Project or Institution. Undoubtedly, health service, promotional, preventive, curative or rehabilitative, is a part of social service. The service is a “help” that people expect with a certain standard whether or not they pay for it. People should be happy and satisfied with the services being offered. Health service provider or the providing organization should concentrate in making the service relevant, effective, and efficient. Professional skills and knowledge are required for this designing process. To have the best achievable and feasible service content, you should guide your teammates in elaborating the best design, making maximal use of your analytical outcomes (Analysis STEP-2) and networking (Choice STEP-1). Service contents, such as immunization, Growth Monitoring and Programme plus (GMP+), nutritional consultation, neonatal clinic service, safe delivery at health centre and so on, are all “Products” that the system under your control produces. The Products should be the best obtainable for the clients and also for the providers. 16-3…STEP-3 Cluster formation Cluster is an implementation unit which is strategically organized to deliver your service or to sell your products. In the public health service, you need not discuss much about selling the service (products). The mind for selling product is sometimes still necessary even for free health service to fight against negative way of thinking of the

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people in neglecting or avoiding your service. The service should be attractive to them. The information on the usefulness of the service should reach the people in a right way and in a timely manner. Implementation unit arrangement is, in this sense, highly important to deliver your service efficiently to your clients. For District health Office, the clients are the Health Centres. For Health Centres, the clients are walk-in patients and community health workers. And for community health workers, the clients are definitely the residents of their working territories. Clusters as implementation units should be organized in line with the convenience of service delivery. For District Level Health Authority, team approach of the officers and other collaborators will be critical to mobilize limited human resource. Cluster formation and team organization is the area to show his or her skill and experience in the management process. 16-4…STEP-4 Overall diagnosis Overall Diagnosis is then required for the finalization of the “Choice”. Based on your interactive work on networking, service contents and clusters as implementation units, the Project or Institution has to make the final decision. The important question in this stage is what sort of service package you want to provide in the catchments, using which network, and by which implementation unit (cluster). SWOT (Strengths, Weaknesses, Opportunities, and Threats) Analysis and Portfolio Analysis and other analytical processes can be applied for this phase. However, in reality, the most practical approach is to have concentrated dialogues among key planning team members. An atmosphere which allows every team member to raise question to others, even to superior persons, listening to others to know what you do not know, might be a fundamental requirement for effective decision-making by top management. Risk is there all the time when you have to make decisions, particularly on the issue of financial input. The responsibility of the top management is to take the risk and guide the people under your management to tackle the objective with their best capabilities. It is, therefore, important to make that decision as logical and relevant as possible to your organization. 17…What is “Strategic Control”? 17-1…STEP-1 Target setting for implementation units Specific targets for each activity under the Project or Institution under your control have to be set. Under your Vision, Credo and Mission, that you have already formulated, specific Objectives, Strategies and activities under each strategy should be clearly stated. Targets* to be achieved should be set for each activity and/or strategy, and should be assigned to specific clusters (implementation units) within your organization for implementation. In case of typical front-line hospital or health centre, there are various sections, such as

--Security guard office --Kitchen, --Maintenance technician’s office, --Pharmacy --Laboratory --OPD --Patient Wards --Delivery room --Operation Theatre --CSSD --Room for clinical officers or doctors

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--Administrative office --Matron’s office --Hospital Doctor’s Office.

These are the implementation units (clusters). Every unit should have a responsible manager/cordinator. Each unit should be given a relevant “managerial objective” to be achieved in a given time frame. Overall Goal and Objective of the entire Institution or Project will never be achieved before fulfilling respective “Targets”*, which are indicated in the plan. In case of community activities, such as GMP+, the activities should be linked to clusters as in hospitals or health centres. These are as follows.

--Venue for GMP+, --Instrument kits, --Consumables for immunization, --Documents and document files, --Health education materials, --Vehicle for transporting staff and items --Community health volunteers, --Community health coordinator,

Again, these are the implementation units (clusters). Every unit should have a responsible manager/cordinator with each unit being given a relevant “managerial objective” to be achieved in a given time frame. Overall Goal and Objective of the activity will never be achieved before fulfilling the respective “Targets”*. 17-2…STEP-2 Quality Control Quality of service should be your concern when you wish to make your Project or Institution best in performance. Health sector is specifically sensitive on this due to the nature of the health service. Quality of service (product of service sector) is the highest interest of the clients. Even if the activity plan is superb in quality, “”Quality of Service” is not guaranteed and may not be acceptable for the clients. Then what is “Quality of Service” for us serving the people in the public health service? Quality of service can be explained from the context of a regular customer in a restaurant. The reason the customer remains regular is not only because of the taste of food that is offered. They have their own expectations for the occasion when you dine out. There are many elements to meet the expectations: waiting time should not be long; the waiter should be kind and polite; food served should be warm; the texture of “Ugali” should be nice to the tongue; the table should be clean; and so forth. As a regular customer of a restaurant, you expect the above elements of dining to be fully met when you dine out. “Preparedness” of the complete set of elements, which constitute the service, is “Quality of Service”. In your routine health service to your customer (client, patient), the same applies. For example, if you want to treat a skin injury by suturing at OPD, there will be following steps.

1--History taking 2--Diagnosis 3--Pre-treatment instruction and explanation 4--Preparation of the local anaesthesia and suturing 5--Debridement of the wound 6--Disinfection of the wound 7--Draping 8--Local anaesthesia 9--Preparation of the skin fragment or flap by scalpel or scissors 10--Undermining suture 11--Skin suture 12--Disinfection before dressing

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13--Dressing 14--Taping 15--Observation of the general condition 16--Prescription 17--Post-treatment instruction and explanation

Just for making suture of minor injury of the skin at OPD, there are at least 17 steps in your service elements. These elements should all be well prepared. Preparedness is, however, not the sole condition for “Quality of Service”. There are three more important conditions for assuring quality service as follows. “Standardization” should be there in addition to “Preparedness”. Each service element, as shown above, has a specific target. There is an outcome from the action that produces something valuable for the entire service. For example, what is the outcome of “Draping”? It is quite simple to say that draping is done, by clean drape material, for protecting the sutured wound. For this purpose, the drape should not be too loose. Also it should not be too tight, not to disturb the blood supply to the wound. It should be fixed nicely to prevent looseness. To achieve these conditions, the procedure of draping and material used have to be properly organised. This is standardization. However, Preparedness and Standardization are not the only two conditions for “Quality of Service”. There are a few more. “Timeliness” should be added to the above two conditions. For the wound treatment, the above 17 elements of the service should be done with appropriate timing and also with efficient sequence of actions. The care providers, therefore, should be professionally trained to deliver the service as precisely and efficiently as possible. As mentioned above, each element has a specific role to play in assuring quality. It is, therefore, important to find out the most suitable timing and maneuver for the respective actions. This will be a task for the team working for the section (cluster) to study and brush up with regard to their technical standards. This effort will lead the team to be able to provide timely service. “Communication” between service provider and customer (care provider and patient) is the last condition for assuring quality. If the above 17 service elements for wound treatment, using suturing, are done without human conversation, the values of “Preparedness”, “Standardization” and “Timeliness” are undermined because customer satisfaction is not guaranteed. Technically, the procedures are quite OK but not fulfilling the requirement of “Quality of Service” due to the lack of interaction between provider and recipient of the service. The patient cannot appreciate the value of your technical and professional consideration if there is no human communication. Preparedness, standardization, timeliness and communication are the 4 important conditions that constitute the concept of “Quality of Service”. Regardless of the workplace and category of work, you have to scrutinize your quality of work and quality of service from the viewpoint of provider and also of customer/client with the use of following steps. You will find a lot could be improved.

Step 1…..Categorizing your service contents Step 2…..Breaking-down your service into technical elements Step 3…..Identifying each aim, outcome or end of action in each element Step 4…..Preparing all elements in order and in workable sequence Step 5…..Standardizing each action of the element Step 6…..Studying the most suitable timeliness and manipulation Step 7…..Considering necessary human communication

Quality of Service will be further highlighted with a practical management tool (5S-Principles) in the latter pat of this manual. Guidance for actions and system establishment within your Project or Institution is one of the most important learning objectives in this manual. At the end of the study of this manual, participants should have a strong armament to fight against negative ways of thinking about “Quality” development! 17-3…STEP-3 Resource Control

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Additional major funding is not necessary to complete the above STEP-1 and STEP-2. In any case, it is not easy to mobilize or introduce big amount of money from higher organization levels or aid agencies just to improve your routine work. You cannot rely on outside people so much for your strategic control of your Project or Institution. Maximal utilization of existing resources should be well considered and planned before seeking additional funding from higher levels or external aid agencies. If you are in charge of a health institution you definitely have (1) excellent human resources, (2) facilities, equipment and consumables and (3) an annual budget for capital and recurrent costs. In case of a Project, whether small or large, you must be responsible for the control of some human, financial and material resources whose utilization should be well planned. Allocation of existing resources (human, material, financial) will be made through decision-making of the top management after sufficient discussions with middle-level management teams. For this purpose, all implementation units (clusters) and the service contents have to be reviewed by top and middle management teams. During budget preparation for the following fiscal year opportunity should be taken to define priorities and rationalize allocation of resources. Priority setting in resource allocation is mandatory for your resource allocation since your resources are not unlimited. Priority setting is not an easy job for everybody, even for the prime minister or head of state of a country. Full utilization of your knowledge and experience in strategic management (Analysis-Choice and Control STEP-1 and STEP-2) is required to make this important decision. For public health service, it is impossible to put priority only on a few units and leave the others unattended or unfunded because all activities are part of a social service. Resource allocation firstly has to be based on the requirements of the respective units (clusters) due to the nature of public health service. You cannot remove some units from your system only because of inadequate resources. All are necessary elements of your system. So, what should we do? “Quality of Service” comes up as a key issue in resource allocation. “Focusing” is important in planning and management. Where there are multiple constraints, we have to focus on selected priorities and tackle them instead of spreading thinly our efforts and resources. Time factor should be taken into consideration as we monitor implementation. How can we select the items or units or services to be focused on? “Quality of Service”, prepared by each implementation unit will be a useful guide for prioritization together with the demand-side factors in the target area of your Project and Institution. Put your priority on the unit or service contents which have high demand and are also prepared for enhanced productivity with “Quality of Service”. If all units are essential, extra resource allocation has to be given to the unit which is expected to achieve more in “Quality of Service”. The management responsibility will be on the shoulder of top management, although your teammates and staff will be able to support you. Top manager has to confront this situation and take risk by him- or her-self in priority setting. Being a top manager is a tough job but at the same time a dynamic job. 17-4…STEP-4 Monitoring & Evaluation “Built-in Monitoring and Evaluation System” guides you to the next phase of the Project. This is the final part of the first cycle of strategic management, which leads you to the second cycle starting with the decision making on whether or not to amend or modify your Vision-Credo-Mission. Monitoring is the process of assessing progress in implementation of activities under your control. Knowing the rate of progress will enable you to control the activities and accelerate implementation as may be required. To facilitate monitoring implementation, the Project or Institution should have a set of indicators. Evaluation is the process of reviewing activity implementation midway, or after the completion of all processes, in order to know how efficient, effective, and relevant it was. At the same time, evaluation should also be conducted to know what positive and, sometimes, negative impacts were created as a result of Project implementation.

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Indicators are formulated during the planning phase for use in monitoring and evaluation of project implementation. It is necessary to have a set of indicators which may be quantitative and/or qualitative for measuring progress in achieving set targets. A workable good indicator would address the following.

--What is to be measured, --Where the measurement point is, --What is the extent of change being measured, --What the time frame for the quantitative change is, --The quality of change being measured, --Target duration (time-frame) for the measurement --Whether or not the measurement cost is low,

Good indicators are in sentence form and are informative enough to know the above conditions with low cost of measurement. Just for your information, here you have an example of unworkable and workable indicators. As you can see below a good indicator should be in a sentence form.

Examples

Unworkable indicators --Number of clients visiting delivery point of GMP+ --Health behaviours of adult compound residents improved. Workable indicator --Number of clients (per day in average) of GMP+ delivery point at YYY School increased from 200 (Jun 2004) to over 350 (May 2005). --Hand washing practice of the adult (18-60 year-old) resident of ABC compound was improved in the response to questionnaire conducted at randomly selected 500 respondents from 25% (Jun 2004) to 50% (Dec 2004) as the actual hand washing practice after toilet usage

As a routine activity, Monitoring and Evaluation (M&E) System should be built into the management system of a Project or Institution. There are cost implications for having a M & E system and this should be taken into account during elaboration of “Quality of Service”. M&E is also a service for all implementation units and the key to success is implementation units and top management creating a simple, effective and affordable M&E system. PART 2…CQI using 5S Principles 18…The first challenge in CQI towards “Quality of Service” Improving the work environment is the first challenge in Continuous Quality Improvement (CQI). Without a well-organized environment for the work, we cannot provide well- prepared, standardized, and timely services with proper communication with our clients. It means that you cannot achieve the standards of quality of service, but this is what you can now do as the entry point for CQI. Work environment is not just the physical, such as building, equipment, and instruments. It includes functional aspects of your working areas, such as personnel teams, meetings, recording/reporting systems, time arrangement for work and communication systems among staff and external counterparts. Environment often defines the behaviour 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

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contrary, under unfavourable and inconvenient work environment where they have to use extra energy to overcome the inconvenience, people’s willingness to work naturally deteriorates. How can you arrange the user-friendly and convenient work environment? Do you think that your work environments are good enough to promote motivation to work? Are you satisfied with the present condition? Are you sensitive enough to detect inconvenience to your staff? There are so many questions, which have to be answered by you. The responsibility of a manager includes the arrangement of the best obtainable work environment for the teammates and staff. Now we have to discuss a feasible approach for us to improve the work environment. One approach that we can employ in our various settings will be KAIZEN in the Japanese language or Continuous Quality Improvement (CQI). The instrument for the initiation of this approach is 5S-Principles. 19…KAIZEN 19-1…What is KAIZEN? 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 contents to the best obtainable condition and maintain it as user-friendly and convenient as possible. 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, 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 the manufacturing sector in Japan to improve productivity. You can imagine a factory manufacturing vehicles. There over 2500 parts prepared, standardized and supplied timely for the assembly process of one vehicle. Also there should be a workable communication system among different sections and offices to control the production process. The production line should be perfectly in order since they have to assemble the 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 at the best achievable level. The issue is to reduce the number of end products which are rejected at final evaluation. If there are many rejected items/products, the company looses money. It also negatively affects the quality of vehicles produced and finally the credibility of the company in the market is compromised. You can also imagine maize instead of vehicles. Maize is the staple food in many African countries. The logic is the same as the above-mentioned industry. The quality of maize-meal (milled maize) is crucially important in the market where several production companies are competing to attract consumers. Each process of maize-meal production should, therefore, be the best achievable to sell in the competitive market. I trust you to understand what the quality is, since we have already been exposed to the term “quality” in the chapter of Strategic Control SEP-2. 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 production process. 19-2…Health service and KAIZEN (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 “Service” as you have already learnt in the previous chapters. Health service too is handled by various groups of people. Therefore, you, managers of the health service, are the persons who have to strengthen internal mechanisms 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 centre or hospital set up. We need a situation where every division always looks

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into the potential 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. Community health activities, such as GMP+ are not an exception for KAIZEN (CQI) target. On average, over 200 clients have to be handled within 3 hours by a limited number of health staff. This situation is not an easy one to standardize and guarantee the expected outcomes whilst maintaining quality of service. As you can see below there are various activities and tasks to be accomplished by the team, which consists of non-professional community health volunteers and professional community health staff. KAIZEN (CQI), by which the team aims to improve the preparedness, standardization, timeliness and communication, enable the personnel to seek quality of service.

Elements of GMP+ at community 01--Advance message delivery to the catchment areas about the time/date, location of GMP+ (CHV) 02--Venue and equipment set up by community health volunteers (CHV) 03--Client administration (CHV) 04--Group health education (CHV) 05--Health talk and drama performance (CHV) 06--Body weight measurement of children (CHV) 09--Screening the children for immunization and nutrition counseling (CHV) 10--Immunization (Community Health Nurse, CHN) 11--Vitamin A supplement administration (CHV) 12--Nutrition counseling (CHV) and individual health education 13--Referral form preparation upon necessity 14--Family planning consultation (CHN)

20…Entry point of KAIZEN (CQI) is 5S Principles 5S Principles are your reliable instruments to make a break-through in improving your work environment and staff attending various types of jobs in your Project or Institution. This is not only a concept but also a set of actions which have to be conducted systematically with the full participation of staff serving in the Project or Institution. 5S activities are practiced in a real participatory movement to improve the quality of both the work environment and service contents delivered to your clients. 5S is literally 5 abbreviations of Japanese words with 5 initials of S. These are 1 - Seiri, 2 - Seiton, 3 - Seiso, 4 - Seiketsu and 5 - Shitsuke. Convenient translation to English similarly provides 5 words with initials of S. ……………………………………………………………………………………………………………………………. 1 - Sort: Remove unused stuff from your venue of work; and reduce clutter (Removal / organization) 2 - Set: Organize everything needed in proper order for easy operation (orderliness) 3 - Shine: Maintain high standard of cleanness (Cleanness) 4 - Standardize: Set up the above three Ss as norms in every section of your place (Standardize) 5 - Sustain: Train and maintain discipline of the personnel engaged. (Discipline) ……………………………………………………………………………………………………………………………. Five steps of Sort-Set-Shine-Standardize-Sustain are a sequence of activities to improve your work environment to as convenient and comfortable a level as possible and thereby to improve your service contents with regard to preparedness, standardization, timeliness and communication. Health personnel are technology oriented, since its delivery is based on application of specific techniques. 5S activities are the tools to prepare the best obtainable stage for them to make maximal use of their skill and knowledge. Two different grades are identified in the standard of 5S activities in the service sector particularly in the health service. 5S has been used not only to make <Grade 1> physical work environment better, but also for the <Grade 2> software matters such as:

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--Job sequence and contents, --Time management, --Communication system such as meetings and briefings.

If your guidance is strategic, you will be able to reach the standard on the above Grade 2 and tackle the functional aspects of your work for the better. 21…What are the targets (objects) of 5S activities in health services? 21-1…5S for community health activities There are various activities to accomplish the task for the team, which consists of non-professional community health volunteers and professional community health staff. It is clear that these complicated processes could be improved if 5S (Sort, Set, Shine, Standardize and Sustain) is applied with the participation of staff who are already familiar with the work.

Elements of GMP+ at community 01--Advance message delivery to the catchments about the time/date, location of GMP+ (CHV) 02--Venue and equipment set up by community health volunteers (CHV) 03--Client administration (CHV) 04--Group health education (CHV) 05--Health talk and drama performance (CHV) 06--Body weight measurement of children (CHV) 09--Screening the children for immunization and nutrition counseling (CHV) 10--Immunization (Community Health Nurse, CHN) 11--Vitamin A supplement administration (CHV) 12--Nutrition counseling (CHV) and individual health education 13--Referral form preparation upon necessity 14--Family planning consultation (CHN)

The listed elements of GMP+ need to be looked into from the point of view of 5S application, although the GMP+ team is a group of health personnel who are well trained and familiar with the task. There are some important questions that are often asked in the process of KAIZEN (CQI) and 5S implementation. Q1--Are there any unnecessary elements? (Sort) Q2--Are the elements properly given a workable arrangement both in placing and time management? (Set)

Q3--Are the venue, equipment and pharmaceuticals arranged in the cleanest obtainable condition? (Shine) Q4--Are the elements well standardized as much as possible, at various different service delivery points? (Standardize) Q5--Are the health personnel managing and working on the elements well disciplined to serve the clients with a high quality service, particularly on communication? (Sustain)

21-2…5S for health institutions Health centres and hospitals are the typical targets of 5S, since these systems are rather complicated and difficult to maintain for delivery of various services in the best obtainable condition. There are divisions, as implementation units (Clusters), which need to have respective objectives as essential functional components of the institution.

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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.

Pharmacy Drugs are well managed and delivered to the clients precisely Laboratory Standardized and quick laboratory tests are available OPD Outpatients are nicely treated with minimum waiting time Patient Wards Inpatients receive treatment under comfortable environment Delivery room Normal deliveries are conducted in a safe, clean and efficient system Operation Theatre Surgical care is given under a safe, clean and efficient system CSSD Supply and sterilization system supports the safety and cleanliness Room for clinical officers or doctors The utility provides staff relaxation and readiness to work Administrative office Office is functioning as the management centre Matron’s office Office works as the management center for nursing/ auxiliary staff Hospital Doctor’s Office Office works as the centre for decision-making and management The above is an example of target setting for clusters (implementation units) at a health centre. To have a tangible outcome, each division is required to fulfill the task in the best obtainable working condition, avoiding excessive workload to the staff responsible. The workload should be moderate and under stimulating working conditions to allow the staff to be innovative in developing various ideas or proposals for making the the jobs and outcomes better. It is, however, not easy in practice to realize the above situation. Too many clients, too much paper work and too much complexity in the reporting systems are often seen in workplaces. These are all targets of 5S activities. By the continuous actions of Sort-Set-Shine-Standardize-Sustain, you can reduce your workload and make maximal use of given working hours in your service to your clients and in addition be able to have time for an extra cup of tea, because your system becomes lean and maximally efficient through the application of 5S. 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 working area shining by daily cleaning and also standardize the process of Sort-Set-Shine successfully. In the process of standardization, you acquired good attitudes to be the driving force of this KAIZEN (CQI) and 5S movement to sustain and improve the “Quality of Service” of the health centre or hospital. 22…How can we organize 5-S activities in our respective workplaces? An approach to mainstream 5S activities is necessary in the process of KAIZEN (CQI). The following sequence will be the most common and useful for introducing this movement in your office, health centre, hospital and community service. The Health Centre or Hospital will specifically be able to apply this sequence for establishment of the implementation structure of 5S. Central organizations, such as ministries and Project headquarters, are not exceptions. Regardless of the size of the project or institution, you can make use of the following strategy and sequence of work. 22-1…Decision-making of top management Learn about 5S by yourself using this manualnow. The starting point is the determination to improve your organization. Improving your work environment by yourself is the first action that you have to do if you want to be a more powerful leader with high potential for further development. Just decide to practice 5S and move forward. 22-2…Exposure and training for the staff Exposure and empowerment seminars for your executive staff (limited attendance of under 10 in number) is the second step after you achieve a little by your own efforts in improvement of your territory (such as your own desktop or office). You are the only able person to guide your core staff members toward 5S. You may arrange a small 2-3 hour seminar on 5S, inviting a moderator form outside.

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22-3…Trial and making showcase for advertisement of 5S You may choose a limited number of offices or work areas for making a showcase for the rest of staff to make them interested on the process and outcome of 5S. The executives or core staff who attended the 5S seminar have to work together with you for this step. Maybe your office will be a good place for demonstration purposes. In addition to your office, you may choose the most neglected areas, both in terms of attention to people and funding. In most cases, the suitable target will be the Support Staff (SS) and their areas of work. Cleaning will be one of the most useful target jobs for 5S. You can make small financial input and improve the 5S practices, for example, by replacing old and broken cleaning tools with new items (Sort) and the installation of toolboxes or rockers (Set). This definitely is an opportunity to improve the working environment for support staff. If the top management directly shows their interest on the job of support staff by encouragement or instruction, the quality of their work will definitely improve with the implementation of 5S activities. This is the second of the points / areas to expand your movement to other parts of the organization. 22-4…Appointment of 5S Manager Appoint one person out of your core staff members as the responsible for the entire process of 5S activities. Do not be the Manager yourself. You have to create the organization, where 5S manager is fully authorized by you to control 5S implementation. You need to set a situation where the 5S manager can assess your territory, such as office or filing system and in later stages to check whether or not the continuing efforts on 5S are being properly implemented. This is a strategy to construct the sham-flat-organization under the given cadre system or ladder of human resource. Flat-organization is the utopia where you can work on 5S and KAIZEN (CQI) most efficiently. It is, however, very difficult to eliminate the borders between ranks and sections. Sham-flat-organization is the compensation for this but is very useful. 22-5…Exposure of middle-level management personnel to the showcase A gathering of middle-level technical and administrative staff is necessary to endorse the information and support the guidance on 5S directly from 5S Manager and the top management. Request them to do something on Sort and Set just after this meeting. Half or one hour meeting is quite enough just to explain the objective and methods of 5S activities and expecting outcomes in a statement, such as “you can enjoy one more cup of tea in the afternoon after organizing your work area. Your headache of the workload too will be gradually well controlled by 5S.” It is important to have such meetings several times during working hours. Do not organize big meetings after or before working hours. This sort of extra duty makes them lose interest in the 5S process. 22-6…Declaration of 5S activities to all staff in the first 5S Day or Festival 5S activities should not be a stress to your staff. You can make it enjoyable. People have to enjoy the process aimed to achieve the best work environment. You could identify one convenient date and arrange an enjoyable festivity in lunchtime for example. The purpose is to make official announcement from top management that this organization will adapt 5S activities as the official movement for Quality Improvement of Work. If you have a fund, you can treat your staff with refreshment or lunch and accommodate entertainment such as singing or dancing, in which you may incorporate the message on 5S. 5S Manager will be officially introduced by you but in an enjoyable manner. You can prepare a special costume or cap to symbolize his or her role. This festivity will be definitely remain memorable among your personnel as a milestone in the long process of improvement. After several years, if you are in the same position, you will find the visible outcomes of 5S and recall this date of orientation and initiation. 22-7… Daily 10 minutes 5S activities and in-service training for middle-level management personnel The top management and the 5S manager announce that a specific time in the working hours, in most cases, the first 10 minutes of morning, working hours is called as “Daily 10 min. 5S time”. This special time frame has to be used only for 5S activities. If you have an in-house broadcasting system, you may release announcements every

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morning. At the same time, 5S Manager should be given a freehand for scheduling his or her routine work and go around all the units managed by middle-level managers. 5S manager has to nicely push the middle-level managers and staff to mobilize the Sort-Set-Shine-Standardize system. In addition to that, the 5S manager should identify good candidates for 5S committees representing respective cadres or job categories. 22-8…5S Committee establishment 5S Committee should be formulated. This committee consists of representatives from each cadre or job group and is chaired by the 5S manager. The committee should have authority to assess progress in implementation of 5S activities by each implementation unit. This committee should hold meetings every month to discuss and make decisions immediately on any unresolved issues related to 5S. For example, suppose there is rubbish accumulating in the common space of the health centre. This rubbish has not been removed due to the inefficiency of the responsible division. The Committee comes to see the site and should immediately make decisions to clear the rubbish and deal with the responsible division later. This 5S Committee is not a body just to discuss matters and leave them at abeyance but has full authority to make decisions on the implementation actions of 5S. 22-9…Continuing education programmes on 5S for all the personnel as the activity to Sustain You may have a scheme to educate all categories of staff on 5S, every month or every 2 months.. This scheme can be organized by the 5S Committee with the leadership of the 5S Manager in consultation with the Top management. One hour in-depth learning on the actual methods of 5S from other divisions should be organized by the 5S Committee. The Committee appoints one or two divisions which have shown good achievement. The representatives of these divisionsshould be commended and their efforts and achievements should be presented to all staff. The meetings should not be long. Punctuality to such meetings by all staff should be given emphasis. 22-10...Monitoring and reporting of the achievement and constraints Simple reporting system can be developed in line with the existing management information system (MIS). It is not necessary to build up a new and separate reporting system for the documentation of 5S. It is useless and just increases the paper work of your staff. Conduct 5S on the existing MIS, which is sometimes observed as the burden to your routine work but which can be reformed to a lean and efficient system. The effects of 5S can be demonstrated in the work outputs of each division. This practice leads you to the GRADE-2 of 5S activities, so-called 5S for software matters, which will be elaborated in a separate version of this manual. 22-11…Bi-annual award ceremony for the best performing division of in 5S (Sustain) People have to be praised if their performance is excellent. 5S Committee will make objective assessments on the progress of 5S and identify the best division or implementation unit (job group) for the 6 months duration. It is important to encourage/motivate people to actively join the competition on 5S practice in your process of KAIZEN (CQI). Small awards can be granted with a reasonable amount of cash to the winning groups. The cash can be managed by the 5S Committee and that can allow them to purchase items for further improving their work environment. It is also possible to make use of such funds for their amenity such as a table for tea or utensils. It is a monetary incentive for a non-monetary purpose, granted to a team and not to an individual. The usage of money is genuine and is for common interests. In 5S activities, incentives should be used only for the improvement of 5S activities. 22-12…Annual report at 5S festival in the next year showing up the achievement Evaluation from outside of the organization could be the best incentive for the staff. The second 5S-day (Festival) should be arranged as a day for publicity on 5S, for the people outside the institution. If the photo materials are collected during the past 12 months, you may demonstrate the “change” by visual material to the guests. It is useful to demonstrate the situations both before and after the application of 5S. Like for the first festivity for initiation of 5S, you may organize the event to make it enjoyable for all people. Then your management cycle will return to the beginning. As you know, top management is always like this. You are on the upward spiral of the development line.

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Even if you are a bit tired, you have to continue this movement. This guarantees a lot in terms of your development of managerial skill at the same time. Let’s make the quality of health services of in our countries No. 1 in Africa…! 23…Managers’ love song part 2

You never know

You never know just how much I trust you You never know just how much I care And if I try, I still couldn’t hide my trust for you You have to know that surely I told you so A million a more times

I go away and my heart stays with you I speak your name in my every prayer If there’s some other ways to prove that I trust you I swear I don’t know how You never know if you don’t know now

If there’s some other ways to prove that I trust you I swear I don’t know how You never know if you don’t know now

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25…For further reading Counte, M. A. and S. Meurer, 2001 “Issues in the assessment of continuous quality improvement implementation in health care organizations”. International Journal for Quality in Health Care, Vol. no. 13, pp. 197-207. De Geyndt, W., 1995, Managing the Quality of Health Care in Developing Countries, The International Bank for Reconstruction and Development/ The World Bank, Washington D.C. Grant, R.M., R. Shani and R. Krishnan, 1994, ‘TQM’s challenge to management theory and practice’, Sloan Management Review, vol. no. 43, pp. 25-35 Hirano, H. and B. Talbot, 1995, 5 pillars of the visual work place, Productivity Press, Portland Hasegawa, T. 2003, Strategic Hospital management, Igakushoin (ISBN 4260240730), Tokyo, Japan Institute of Medicine, 1990, Medicare- A Strategy for Quality Assurance, vol. I and II, National Academy of Press, Washington D.C. Koeck, C., 1998, ‘Time for organizational development in healthcare organisations’, British Medical Journal, vol. no. 317, pp. 1267-1268 Laraia, A.C., P.E E. Moody and R.W. Hall, 1999, The Kaizen Blitz: accelerating breakthroughs in productivity and performance, John Wiley & Sons, Inc., New York Masaaki, I., 1997, Gemba Kaizen: a commonsense low-cost approach to management, MCgRAW-Hill, New York McLaughlin, C.P. and A.D. Kaluzny, 1999, Continuous Quality Improvement in Health Care, Aspen publishers, Maryland Moss,F., P Garside and S Dawson, 1998, ‘Organizational change: the key to quality improvement’, Quality in Health Care, vol. no. 7(suppl), pp. S37-44 Niven, P.R., 2002, Balanced Scorecard step by step: maximizing performance and maintaining results, John Wiley & Sons, Inc., New York Patrick, C., 2000, How Kaizen developed…and developed…and develops, In Colenso, M., editor. Kazen strategies for improving team performance, Pearson Education, London. 23-40 Preker, A.S. and A.L. Harding (eds), 2003, Innovations in health service delivery: the corporatization of public hospitals, World Bank, Washington, D.C. Shortell, S.M., D.Z.Levin, J.L. O’Brien et al, 1995, ‘Assessing the evidence of CQI: is the glass half empty or half full’, Hospital and Health Services Administration, vol. no. 40, pp.4-24 Smith,T., 2002, ‘Relationship between quality, safety and organizational behaviour’, Quality and Safety in Health Care, vol. no. 11, pp. 98-100 Wellington, P., 2000, Instant Kaizen-what it is and how it works. In Colenso, M., editor. Kazen strategies for improving team performance, Pearson Education, London. 3-22 Witanachchi, N., W.Karandagoda, and Y. Handa, 2004, A performance improvement at a public hospital in Sri Lanka: an introduction, Journal of Health Organization and Management, Vol.18., No.5, 361-369, 2004

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26…Annex (Illustrations for conceptualization and usage in training) The attached illustrations are arranged by the authors for the benefit of users of this manual for training on KAIZEN (CQI) and 5-S.

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