Service Quality in Hospital

My father passed away in this Morning. My experience is so bad, which is because not only missing my father but also the arrangement of Hospital in the last week. It makes me to think about the service quality in Hospital and try to determine the gaps through ServQual Gap model proposed by Parasuraman developed in 1985.

I have modified the GAP model as below.

The story of my father (in his last stage) is summarized as follows:

My father was confirmed to have cancer originated at pancreas on 28 Nov 2008. He received bypass surgery on 5 Dec 2008 and discharged on 23 Dec 2008. Then he was sent back to hospital (emergency ward) on 9 Jan 2009 due to infection by “Enterobacter cloacae”. He was arranged to stay in Internal Medicine until 20 Jan 2009, and transferred to Rehabilitation Block. It does not make sense to me and my family that Rehabilitation Block is the suitable place for him. It is because, from our observations in that period, my father needed oxygen supply, his blood pressure was low, and very often we found he was breathless. Moreover, he did not allow eating or drinking. I strongly requested my father to be arranged to “Palliative Cane & Hospice Ward” through a complaint letter on 24 Jan 2009. After transferred to Rehabilitation Block and showering, he cannot speak but write to communicate.

Gap 1: Difference between “Doctors’ Instructions of Patient Needs & Service” and “Patient & Family Expected Service”. In my father’s case, the responsible doctor instructed to transfer my father to “Rehabilitation Block” because there was no response from “Palliative Cane & Hospice Ward”. The service given in Rehabilitation Block is not suitable for patient in his last stage of life.

Gap 2: Difference between “Doctors’ Instructions of Patient Needs & Service” and “Translation of Those Instructions into Treatment & Arrangement”. Nurses and other doctors were followed team lead’s instruction. There is no problem.

Gap 3: Difference between “Translation of Those Instructions into Treatment & Arrangement” and “Service Delivered”, which was the major problem. Front line staffs who took care of my father were found not sympathetic enough such as for showering. It caused my father suffered very much in his end of life. Even though we understand the reason of the responsible doctor to make the decision but the outcome was not satisfactory. When we knew my father was suffering, we employed a registered nurse to look after him (Hospital permitted us informally because of some reasons.) Fortunately, my father felt satisfactory about the special arrangement. (He wrote a Chinese word “順” that means he was satisfactory.)

Gap 4: Difference between “Service Delivery” and “Communications to Patient & Their Family”. Doctors in public hospital were too busy so as it was very difficult to make an appointment with them. We had left message to contact the responsible doctor but no response was received. The problem observed was that front line staffs in Rehabilitation Block did not recognize how the severity of my father was. The situation seemed to be improved after I sent the complaint letter to Hospital Authority and left a copy to the doctor on duty.

Gap 5: Difference between “Patient & Family Expected Service” and “Patient Perceived Service”. This gap depends on the size and direction of the four gaps associated with the delivery of service quality on the hospital's side. In this case, the most important gaps are Gap 1 & 3.

Overall, we appreciate Doctor’s & Nurse’s effort put for my father. I believe their professions. One improvement point of front line staff in hospital is to take care patient’s basic need such as moving, showering, eating, etc. The customer perception comes from the fundamental care and their heart of service.

Parasuraman, A., Zeithaml, V.A. and Berry, L.L. (1985), “A conceptual model of service quality and its implications for future research”, Journal of Marketing, Vol.49, No.3, pp. 41-50.


Cancer Prevention and Intestinal Bacteria (II)

Carcinogen-producing bacteria (Digestive system)

Most of the bacteria in the intestine can be divided into two categories: lactic acid bacteria (feed on sugars/carbohydrates) and putrefactive bacteria (feed on proteins).

One theory holds that these intestinal bacteria transform fat into a carcinogen. Another possibility is that – since a person eating meat or egg takes in protein as well as fat – the proteins are being transformed into carcinogens.

Putrefactive bacteria (e.g. Bacteroides, E. coli, Veillonella, and Clostridium) break down proteins into ammonia, hydrogen sulfide, amines, phenol, and indole. Phenol and indole are known promoters of intestinal and other cancers. (They are also components of coal tar.)

A portion of the phenol is reabsorbed by the digestive tract and is detoxified in the liver, either by combining with glucuronic acid or sulfuric acid to form a harmless compound which is then eliminated in the urine; or by being released into the intestines and mixed with bile. The glucuronic acid compound with the bile is reconverted to phenol by the action of an enzyme known as beta-glucuronidase (It is most active in putrefactive bacteria such as E. coli and Clostridium welchii.), which is produced by some intestinal bacteria.

beta-glucuronidase formula
This circulation between the intestines and the liver (It is known as enterohepatic circulation.) indicates that some carcinogens are not eliminated, but remain in the body.

enterohepatic circulation diagram

Bile acids are the main ingredient of bile which aids in the digestion and absorption of fat. However, the remaining bile acids are not absorbed and returned to the liver, but flow into the large intestine. They are converted into secondary bile acids such as deoxycholic acid (deoxycholate) and lithocholic acid (lithocolate) by the action of Veillonella, Bacteroides, and other putrefactive bacteria. When the intestinal wall’s mucous membrane is stimulated by secondary bile acids, it changes appearance. This action is believed to raise the risk of colon cancer.

Lactic acid bacteria feed on sugars to produce lactic acid. Intestine dominated by lactic acid bacteria leans toward acidity that suppresses growth in putrefactive bacteria (which favor an alkaline environment). By weakening the influence of the putrefactive bacteria that produce carcinogens and induce enterohepatic circulation, Lactobacilli can play a significant role in improving the intestinal environment.

(The stool’s color is mainly from bilirubin, a reddish-yellow bile pigment produced in the liver from the hemoglobin contained in old red blood cells. Bilirubin’s color varies with acidity.
Acidic environment: Yellow
Neutral environment: Orange to brown
Alkaline environment: Greenish- or Blackish-brown.
Yoshio Aso (1997) “Lactic Acid Bacteria and Cancer Prevention” Shufunotomo


Cancer Prevention and Intestinal Bacteria (I)

I would like to share what I read from “How the lactic acid bacteria in your daily diet may inhibit cancer?” I will continue to study this topic because my father was found to have pancreatic cancer. It is sad that pancreatic cancer (last stage) cannot be cure but I believe the diet can help to prevent it.

How cancer grows?
Cancer is a mass of tumor cells and each cancer cell is a normal cell that has undergone a transformation.

Growth factors and growth inhibitory factors are proteins that message to multiply, and the latter to stop multiplying, so as to main the certain number of cell.

The so-called accelerator is known as the proto-oncogene that controls the functions of receiving messages at the cell membrane. The gene responsible for applying the brakes to the cellular proliferation process is the tumor suppressor gene.

How genetic malfunction produces cancer cells?
Gene in a normal cell (proto-oncogene):
1. “Antenna” intercepts extracellular message.
2. Messages are correctly transmitted to the cell’s interior.
3. After being scrutinized and processed, messages are transmitted to nucleus.
4. Another gene within the nucleus is activated and initiates and cellular proliferation process.

Malfunctioning gene (oncogene):
1. Malfunctioning “antenna” does not receive messages, but continues to signal cells to multiply.
2. “Antenna” transmits messages not received from outside.
3. Erroneous messages described in (1) and (2) are passed on to the nucleus.
4. The cellular proliferation switch remains perpetually in the “on” position.

The transformation of a normal cell to a cancer cell begins with the process by which a proto-oncogene becomes an oncogene. The process named initiation and anything that sets this process is known as an initiator. (e.g. viruses (hepatitis B & C); radiation; ultraviolet rays; cigarette smoke and automotive exhaust; and the chemical substances present in charred meat or fish.)

The next stage, extending from when a cancer cell develops until it begins proliferating, is considered a separate process. The process called promotion, and anything that instigates the process is known as promoter. (e.g. sex hormones, secondary bile acids, and chemicals such as saccharin, and artificial sweetener.)

Experiments have shown that vitamins C and E, as well as beta-carotent (a precursor of vitamin A) weaken the action of initiators, and that beta-carotent and vitamin A combat promoters within a cell.

One cancer cell does not constitute cancer
The smallest tumor detectable by various modern medical equipments consists of about a billion cells, weighs about 1g, and measures about 1 cm in diameter. (A cell weighs one one-billionth of a gram, even a growth of a million cancer cells weighs only about 1mg and is about 1mm in diameter.)

A stressful lifestyle or other factors can reduce the effectiveness of the cellular surveillance, rendering the body more likely to allow cancer to progress.

Yoshio Aso (1997) “Lactic Acid Bacteria and Cancer Prevention” Shufunotomo


Quality in Outsourcing

Outsourcing is one of popular quality topics in this year. Mr. Govind Ramu was invited by HKSQ to present a seminar “Quality in Outsourcing” on 10 Jan 09 and the summary is shown as follows.

The Chairman of HKSQ, Dr. Albert Tsang, gave an opening speech and introduced Mr. Govind Ramu. Mr. Ramu is an ASQ Fellow and holds six ASQ certifications including certification for quality manager, quality engineer, Six Sigma Black Belt, quality auditor, software quality engineer and reliability engineer. He has serviced in the quality related functions in different countries since 1985.

Govind introduced “What is Outsouring?” and terminology used for outsourcing. Few of them are given as follows:
i) Outsourcing is the transfer of products, services, and business processes to an external service provider.
ii) Outsourcing involves contracting with an outsourcing partner, which may or may not involve offshoring.
iii) Other terms used in the outsourcing world are “multisourcing”, “nearshoring”, etc.

His second question was “Why Outsourcing?” Four factors were considered:
i) Significantly reduce overall costs.
ii) Reduce “Time to Volume” (TTV) for new products.
iii) Access to an abundance of human resources, localized skills and knowledge, etc.
iv) Supply chain efficiencies when products are shipped directly to customers (Drop Ship) – which related to Lean.

Then he asked “What Does Quality have to do with outsourcing?” He mentioned Quality is applicable to the overall process of creating products and/or services, which all aspects of outsourcing are considered. Without due diligence and appropriate controls, outsourcing could end up being costlier than in-house manufacturing or service, and customer dissatisfaction. Moreover, he stated ISO 9001:2008 version concerned the control over outsourced processes.

After that, he introduced six categories of “Quality in outsourcing BoK” as follows:

i) Quality in Project Management
· Scope Creep, Risk Management & Lessons Learned
· Challenges: IP Protection
ii) Quality in Team Management
· Managing multicultural team and their roles & responsibilities
· RACI or RASCI (Who responsible? Who accountable? Who to be consulted? Who to be informed? Who to be supporter?)
· Challenges: Team Attribute and Virtual Teams
iii) Quality in Communications Management
· Avoid the lost out of listening (using active listening)
· Challenges: Technical Interpretation & Virtual Teams
iv) Quality in Knowledge Management
· Structured Approach: DIKW Chain-the-metaphorical (Link, pace & node of transfer)
· Challenges: Tacit Knowledge (Encourage documenting tacit knowledge by driving out fear)
v) Quality in Supply Chain Management
· Supplier Selection, Performance, Improvement & Service Level Agreement (SLA)
· Challenges: IP Protection
vi) Quality in Engineering Management
· Business Model; Traceability-record Retention and Third Party Surveillance
· Challenges: Failure Cost

During Q&A question, participants were actively involved. “What is the different between outsourcing partner and supplier?” was raised. Two-way communication with outsourcing partner is a crucial factor for success when supplier may be only order taken and product delivered.

Further, a participant (Aaron, HKSQ ex-chairman) shared his opinion to get outsourcing activities success:
i) Avoid to develop competitors via outsourcing partner
ii) Require contingency plan for outsourcing project
iii) Be the major client of the outsourcing partner so as to get the best services
iv) Implement information security system for protection IP
v) Get single source but not sole source
vi) Always keep core competency in your company

Finally, Dr. Albert Tsang presented a souvenir to the speaker for his great presentation.

After the seminar, HKSQ ex-co members had a lunch with Mr. G. Ramu together.

Reference: (Speaker’s paper)
Govindarajan Ramu (2008) “IN THE Know – A BoK dedicated to quality in outsourcing is essential in today’s global marketplace” Quality Progress, Vol.41, Issue 8, pp.36 – 43.


ISO 9001:2008 & Economic Downturn Challenges

The seminar “Upgrade your ISO 9001:2000 to ISO 9001:2008 & Get Equipped to meet the Challenges of the Economic Downturn” was held on 5 Jan 2009, which was organized by The Hong Kong Institution of Engineers – MIE Division and Hong Kong Society for Quality.

The Chairman of HKIE – MIE division, Ir. Dr. Winco Yung, gave an opening speech.

Then Dr. Albert Tsang, Chairman of HKSQ, gave an introduction speech of the seminar. He reminded that it was the forth revision of ISO 9001 standard.

The first speaker was Mr. Cliff Poon, Lead Auditor in SGS and his topic was “Identify the Differences between ISO 9001:2000 and ISO 9001:2008”.

He shared the history of ISO 9001 and described the main differences between ISO 9001:2000 and ISO 9001: 2008. He mentioned the important summary of the changes were recorded in Annex B – Table B.1 in ISO 9001:2008.

The second speaker was Mr. Lotto Lai, Vice-chairman of HKSQ and Quality Manager in HKSTP, and presented “Practical Tips to PASS ISO 9001:2008 Audit”.

He shared the experience during ISO 9001:2008 audit. He identified the following points and solutions:
i) Outsourced Process (Solution: ISO 17025 clause 4.5 was employed)
ii) Document & Record Control (Solution: HOKLAS Policy 4.13.H was followed and Electronic Documents System was used.)
iii) Necessary Competence (Solution: ISO 17025 clause 5.2 – Demonstrated Skill)
iv) Infrastructure in IT and Personal Data (Solution: ISO 27001 A.10.6 Network security management and A.15.1.4 data protection and personal information were compiled.)
v) Monitoring Customer Perception (Solution: Design new questionnaire for data analysis and development Fan Club.)
Finally, he concluded most changes in ISO 9001:2008 create value for CUSTOMER.

The last speaker was Ir. Dr. Aaron Tong, ISO/TC-176 Observer, and he presented “Get Equipped to meet the Challenges of the Economic Downturn”.

He compared USA turndown in 1930 and economic crisis in 2008. In 1930, it was worse than now but the worst had not happened yet.
Aaron proposed that the company should be back to fundamental principles such as efficient and effectiveness, faster response to market and quality enhancement, etc. He raised two examples:
i) Michelangelo was asked how to make the sculpture of lion so real? He replied that it was simple to remove all things not like lion in the sculpture.
ii) Taiichi Ohno was asked how to manage Toyota so well? He replied that it was simple to remove MUDA (waste) at all.
Therefore, Lean Business is the trend of the solution to overcome the economic downturn. Another new term suggested was “Force Implement” (挾施). Lastly, he reminded that winter is coming. Are you ready?

The last session was panel discussion. We invited the representation of TUV (Mr. Berry Yeung), SGS (Mr. Cliff Poon), ISO/TC observer (Dr. Aaron Tong), HKIE-MIE (Dr. Victor Lo) and HKSQ (Mr. Lotto Lai) to share their opinions.

Finally, we present the souvenir to all panel members.


ISO/TC 176 observer


The presentation files (pdf) have been posted in HKSQ website at http://www.hksq.org/slide.htm .


New Year 2009

Happy New Year for all visitors.

New Year, New Quality Plan!

I hope my blog can share as much quality related knowledge as possible.

Activities Summary 2008

I would like to summarize all quality related activities I attended in 2008 as follows:(YYYYMMDD)

i) Quality Seminar x12; Quality Training x5 and Quality Visit x2;

20080429: Jadeite Jade classification
20080730: How to improve the training effectiveness in cost-effective way
20080801: ISO 9001:2000 UPGRADE to 2008 Version Secure your information with ISO 27001
20080911: ISO 9001:2008 Implementation Seminar
20081018: Solutions for Profits Seminar (I)
20081028: The 6th ANQ Congress 2008
20081106: DuPont Risk Based Process Safety Management (PSM)
20081122: Solutions for Profits Seminar (II)
20081129: Innovation.Technology.2008
20081202: Face-reading & Management
20081212: HKQAA Symposium 2008
20081219: Managing the Design of 2008 Beijing Olympics Projects

20080516: Certified Lean Master course I
20080521: IRCA OHSAS 18001 Auditor Conversion Training Course
20080620: Certified Lean Master course II
20080720: Certified Lean Master course III
20081016: BCM implementation training

20080530: Kwong Sun Hong
20081107: Yakult (HK)

ii) Biotech Seminar x5; Biotech Training x 2 and Biotech Visit x3;

20080311: Biological Waste Management – Anaerobic Digestion, Composting and Vermicomposting
20080313: Medical Devices and Limulus Amebocyte Lysate (LAL) Testing
20080704: Considerations for Medical Device Manufacturing – Optimization of materials, applications and sterilization and 2008 Healthcare Innovative Solutions by Advanced Medical Plastics
20080729: Exchange @ Science Park
20081114: Advanced Design & Technology in Healthcare & Laboratory Facilities Training

20071203: Biosafety Management and Biosafety Level 3 Practices
20081211: Laboratory Biosafety

20080407: HKBU’s Biotechnology laboratory and Dangerous Good Storage
20080425: Molecular Biology and Biotechnology Instrument Laboratory in CUHK
20080509: Visit to Mainland Factories of Vincent Raya Co., Ltd. and Providence Enterprise Limited

iii) Solar Energy Seminar x4

20080929: Nanotechnology Forum – Solar Energy
20081204: APP International Photovoltaic Reliability Workshop (IPRW)
20081210: InnoAsia 2008 Conference: Enabling Sustainability
20081218: Synopsys TCAD Seminar – Solar Cell Simulation

I hope all of you will have a new achievement in 2009.


Related Posts with Thumbnails