Qualitative and quantitative analysis of six sigma in service organizations

The concept of Six Sigma was initiated in the 1980s by Motorola. Since then it has been implemented in several manufacturing and service organizations. Till now Six Sigma implementation is mostly limited to healthcare and financial services in private sector. Its implementation is now gradually picking up in services such as call center, education, construction and related engineering etc. in private as well as public sector. Through a literature review, a questionnaire survey, and multiple case study approach the paper develops a conceptual framework to facilitate widening the scope of Six Sigma implementation in service organizations. Using grounded theory methodology, this study develops theory for Six Sigma implementation in service organizations. The study involves a questionnaire survey and case studies to understand and build a conceptual framework. The survey was conducted in service organizations in Singapore and exploratory in nature. The case studies involved three service organizations which implemented Six Sigma. The objective is to explore and understand the issues highlighted by the survey and the literature. The findings confirm the inclusion of critical success factors, critical-to-quality characteristics, and set of tools and techniques as observed from the literature. In case of key performance indicator, there are different interpretations about it in literature and also by industry practitioners. Some literature explain key performance indicator as performance metrics whereas some feel it as key process input or output variables, which is similar to interpretations by practitioners of Six Sigma. The response of not relevant and unknown to us as reasons for not implementing Six Sigma shows the need for understanding specific requirements of service organizations. Though much theoretical description is available about Six Sigma, but there has been limited rigorous academic research on it. This gap is far more pronounced about Six Sigma implementation in service organizations, where the theory is not mature enough. Identifying this need, the study contributes by going through theory building exercise and developing a conceptual framework to understand the issues involving its implementation in service organizations.

THE meaning of effectiveness

As the Industry Commission prepares to engage in its examination of the Australian nonprofit sector as defined in its draft terms of reference, it confronts what it should regard as a fundamental dilemma; the meaning of the construct `effectiveness'. I should at this point state clearly that the potential difficulties are not unique to the task of the Commission, but have instead plagued human service evaluation for many a long year. At the level of human service or welfare practice, a favoured method of resolving the conundrum has been to dismiss it as irrelevant to the human services as it pursues its task of working for human betterment however understood. Such a response highlights a fundamental characteristic of the human services generally, not only in the nonprofit arena: their relative freedom from evaluation. While there are many reasons for this, some of which we will canvass later in this paper, one stems from a lack of clarity about the meaning of effectiveness coupled with a lack of consensus about its purpose.

Stakeholder service delivery expectations of military facilities management

Purpose – The purpose of this paper is to examine the quality of service of a South East Asian country's military facilities management organisation. Design/methodology/approach – An interview survey and questionnaire survey were used to obtain a description and summary of stakeholders’ expectations and the extent to which they were being satisfied by the services provided. Findings – The method provides a useful means of identifying and prioritising varying expectations between stakeholder groups and of indicating any mismatch in expectations in the management of military facilities. Social implications – The development and use of a method to test and improve the effectiveness and efficiency of the management of military facilities helps in providing better value for money. Originality/value – In addition to re-affirming Parasuraman's overall dimensions of service expectation, the empirical summary of the stakeholders’ expectations obtained in this way is of practical value for the service provider in developing a strategy for expectation management. For the case studied, it is also apparent that although the current processes in service delivery are well understood by all involved stakeholders, there is a need for further improvement with regards to their expectation levels. It is also one of the very few reported studies on the management of military facilities.

Application of Resilience concept for enhanced management of water supply systems

This paper presents an approach to developing indicators for expressing resilience of a generic water supply system. The system is contextualised as a meta-system consisting of three subsystems to represent the water catchment and reservoir, treatment plant and the distribution system supplying the end-users. The level of final service delivery to end-users is considered as a surrogate measure of systemic resilience. A set of modelled relationships are used to explore relationships between system components when placed under simulated stress. Conceptual system behaviour of specific types of simulated pressure is created for illustration of parameters for indicator development. The approach is based on the hypothesis that an in-depth knowledge of resilience would enable development of decision support system capability which in turn will contribute towards enhanced management of a water supply system. In contrast to conventional water supply system management approaches, a resilience approach facilitates improvement in system efficiency by emphasising awareness of points-of-intervention where system managers can adjust operational control measures across the meta-system (and within subsystems) rather than expansion of the system in entirety in the form of new infrastructure development.

Immigrants and the utilization of hospital emergency departments

BACKGROUND: Immigrants with language barriers are at high risk of having poor access to health care services. However, several studies have indicated that immigrants tend to use emergency departments (EDs) as their primary source of care at the expense of primary care. This may place an additional burden on already overcrowded EDs and lead to a low level of patient satisfaction with ED care. The study was to review if immigrants utilize ED care differently from host populations and to assess immigrants’ satisfaction with ED care. DATA SOURCES: Studies about immigrants' utilization of EDs in Australia and worldwide were reviewed. RESULTS: There are confl icting results in the literature about the pattern of ED care use among immigrants. Some studies have shown higher utilization by immigrants compared to host populations and others have shown lower utilization. Overall, immigrants use ED care heavily, make inappropriate visits to EDs, have a longer length of stay in EDs, and are less satisfi ed with ED care as compared to host populations. CONCLUSIONS: Immigrants might use ED care differently from host populations due to language and cultural barriers. There is sparse Australian literature regarding immigrants' access to health care including ED care. To ensure equity, further research is needed to inform policy when planning health care provision to immigrants. KEY WORDS: Emergency department; Health service; Immigrants; Language; Utilization

Delineating the practice profile of advanced practice nursing : a cross-sectional survey using the modified strong model of advanced practice

AIMS: To test a model that delineates advanced practice nursing from the practice profile of other nursing roles and titles. BACKGROUND: There is extensive literature on advanced practice reporting the importance of this level of nursing to contemporary health service and patient outcomes. Literature also reports confusion and ambiguity associated with advanced practice nursing. Several countries have regulation and delineation for the nurse practitioner, but there is less clarity in definition and service focus of other advanced practice nursing roles. DESIGN: A statewide survey. METHODS: Using the modified Strong Model of Advanced Practice Role Delineation tool, a survey was conducted in 2009 with a random sample of registered nurses/midwives from government facilities in Queensland, Australia. Analysis of variance compared total and subscale scores across groups according to grade. Linear, stepwise multiple regression analysis examined factors influencing advanced practice nursing activities across all domains. RESULTS: There were important differences according to grade in mean scores for total activities in all domains of advanced practice nursing. Nurses working in advanced practice roles (excluding nurse practitioners) performed more activities across most advanced practice domains. Regression analysis indicated that working in clinical advanced practice nursing roles with higher levels of education were strong predictors of advanced practice activities overall. CONCLUSION: Essential and appropriate use of advanced practice nurses requires clarity in defining roles and practice levels. This research delineated nursing work according to grade and level of practice, further validating the tool for the Queensland context and providing operational information for assigning innovative nursing service.

Using the Donabedian framework to examine the quality and safety of nursing service innovation

Aims and objectives To evaluate the safety and quality of nurse practitioner service using the audit framework of Structure,Process and Outcome. Background Health service and workforce reform are on the agenda of governments and other service providers seeking to contain healthcare costs whilst providing safe and effective health care to communities. The nurse practitioner service is one health workforce innovation that has been adopted globally to improve timely access to clinical care, but there is scant literature reporting evaluation of the quality of this service innovation. Design. A mixed-methods design within the Donabedian evaluation framework was used. Methods The Donabedian framework was used to evaluate the Structure, Process and Outcome of nurse practitioner service. A range of data collection approaches was used, including stakeholder survey (n=36), in-depth interviews (11 patients and 13 nurse practitioners) and health records data on service processes. Results The study identified that adequate and detailed preparation of Structure and Process is essential for the successful implementation of a service innovation. The multidisciplinary team was accepting of the addition of nurse practitioner service, and nurse practitioner clinical care was shown to be effective, satisfactory and safe from the perspective of the clinician stakeholders and patients. Conclusions This study demonstrated that the Donabedian framework of Structure, Process and Outcome evaluation is a valuable and validated approach to examine the safety and quality of a service innovation. Furthermore, in this study, specific Structure elements were shown to influence the quality of service processes further validating the framework and the interdependence of the Structure, Process and Outcome components. Relevance to clinical practice Understanding the structure and process requirements for establishing nursing service innovation lays the foundation for safe, effective and patient-centred clinical care.

Calling for help : a responsive evaluation of Child Health Line

The project examined the responsiveness of the telenursing service provided by the Child Health Line (hereinafter referred to as CHL). It aimed to provide an account of population usage of the service, the call request types and the response of the service to the calls. In so doing, the project extends the current body of knowledge pertaining to the provision of parenting support through telenursing. Approximately 900 calls to the CHL were audio-recorded over the December 2005-2006 Christmas-New Year period. A protocol was developed to code characteristics of the call, the interactional features between the caller and nurse call-taker, and the extent to which there was (a) agreement on problem definition and the plan of action and (b) interactional alignment between nurse and caller. A quantitative analysis examined the frequencies of the main topics covered in calls to the CHL and any statistical associations between types of calls, length of calls and nurse-caller alignment. In addition, a detailed qualitative analysis was conducted on a subset of calls dealing with the nurse management of calls seeking medical advice and information. Key findings include: • Overall, 74% of the calls discussed parenting and child development issues, 48% discussed health/medical issues, and 16% were information-seeking calls. • More specifically: o 21% discussed health/medical and parenting and child development issues. o 3% discussed parenting and information-seeking issues. o 5% discussed health/medical, parenting/development and information issues. o 18% exclusively focussed on health and medical issues and therefore were outside the remit of the intended scope of the CHL. These calls caused interactional dilemmas for the nurse call-takers as they simultaneously dealt with parental expectations for help and the CHL guidelines indicating that offering medical advice was outside the remit of the service. • Most frequent reasons for calling were to discuss sleep, feeding, normative infant physical functions and parenting advice. • The average length of calls to the CHL was 7 minutes. • Longer calls were more likely to involve nurse call-takers giving advice on more than one topic, the caller displaying strong emotions, the caller not specifically providing the reason for the call, and the caller discussing parenting and developmental issues. • Shorter calls were characterised by the nurse suggesting that the child receive immediate medical attention, the nurse emphasising the importance or urgency of the plan of action, the caller referring to or requesting confirmation of a diagnosis, and caller and nurse call-taker discussion of health and medical issues. • The majority of calls, 92%, achieved parent-nurse alignment by the conclusion of the call. However, 8% did not. • The 8% of calls that were not aligned require further quantitative and qualitative investigation of the interactional features. The findings are pertinent in the current context where Child Health Line now resides within 13HEALTH. These findings indicate: 1. A high demand for parenting advice. 2. Nurse call-takers have a high level of competency in dealing with calls about parenting and normal child development, which is the remit of the CHL. 3. Nurse call-takers and callers achieve a high degree of alignment when both parties agree on a course of action. 4. There is scope for developing professional practice in calls that present difficulties in terms of call content, interactional behaviour and call closure. Recommendations of the project: 1. There are numerous opportunities for further research on interactional aspects of calls to the CHL, such as further investigations of the interactional features and the association of the features to alignment and nonalignment. The rich and detailed insights into the patterns of nurse-parent interactions were afforded by the audio-recording and analysis of calls to the CHL. 2. The regular recording of calls would serve as a way of increasing understanding of the type and nature of calls received, and provide a valuable training resource. Recording and analysing calls to CHL provides insight into the operation of the service, including evidence about the effectiveness of triaging calls. 3. Training in both recognising and dealing with problem calls may be beneficial. For example, calls where the caller showed strong emotion, appeared stressed, frustrated or troubled were less likely to be rated as aligned calls. In calls where the callers described being ‘at their wits end’, or responded to each proposed suggestion with ‘I’ve tried that’, the callers were fairly resistant to advice-giving. 4. Training could focus on strategies for managing calls relating to parenting support and advice, and parental well-being. The project found that these calls were more likely to be rated as being nonaligned. 5. With the implementation of 13HEALTH, future research could compare nurse-parent interaction following the implementation of triaging. Of the calls, 21% had both medical and parenting topics discussed and 5.3% discussed medical, parenting and information topics. Added to this, in 12% of calls, there was ambiguity between the caller and nurse call-taker as to whether the problem was medical or behavioural.

Agricultural biodiversity, farm level technical efficiency and conservation benefits : an empirical investigation

The issues involved in agricultural biodiversity are important and interesting areas for the application of economic theory. However, very little theoretical and empirical work has been undertaken to understand the benefits of conserving agricultural biodiversity. Accordingly, the main objectives of this PhD thesis are to: (1) Investigate farmers’ valuation of agricultural biodiversity; (2) Identify factors influencing farmers’ demand for agricultural biodiversity; (3) Examine farmers’ demand for biodiversity rich farming systems; (4) Investigate the relationship between agricultural biodiversity and farm level technical efficiency. This PhD thesis investigates these issues by using primary data in small-scale farms, along with secondary data from Sri Lanka. The overall findings of the thesis can be summarized as follows. Firstly, owing to educational and poverty issues of those being interviewed, some policy makers in developed countries question whether non-market valuation techniques such as Choice Experiment (CE) can be applied to developing countries such as Sri Lanka. The CE study in this thesis indicates that carefully designed and pre-tested nonmarket valuation techniques can be applied in developing countries with a high level of reliability. The CE findings support the priori assumption that small-scale farms and their multiple attributes contribute positively and significantly to the utility of farm families in Sri Lanka. Farmers have strong positive attitudes towards increasing agricultural biodiversity in rural areas. This suggests that these attitudes can be the basis on which appropriate policies can be introduced to improve agricultural biodiversity. Secondly, the thesis identifies the factors which influence farmers’ demand for agricultural biodiversity and farmers’ demands on biodiversity rich farming systems. As such they provide important tools for the implementation of policies designed to avoid the loss agricultural biodiversity which is shown to be a major impediment to agricultural growth and sustainable development in a number of developing countries. The results illustrate that certain key household, market and other characteristics (such as agricultural subsidies, percentage of investment of owned money and farm size) are the major determinants of demand for agricultural biodiversity on small-scale farms. The significant household characteristics that determine crop and livestock diversity include household member participation on the farm, off-farm income, shared labour, market price fluctuations and household wealth. Furthermore, it is shown that all the included market characteristics as well as agricultural subsidies are also important determinants of agricultural biodiversity. Thirdly, it is found that when the efficiency of agricultural production is measured in practice, the role of agricultural biodiversity has rarely been investigated in the literature. The results in the final section of the thesis show that crop diversity, livestock diversity and mix farming system are positively related to farm level technical efficiency. In addition to these variables education level, number of separate plots, agricultural extension service, credit access, membership of farm organization and land ownerships are significant and direct policy relevant variables in the inefficiency model. The results of the study therefore have important policy implications for conserving agricultural biodiversity in Sri Lanka.

Situational non-flammable control valves for oxygen service

Past work has clearly demonstrated that numerous commonly used metallic materials will support burning in oxygen, especially at higher pressures. An approach to rectify this significant safety problem has been successfully developed and implemented by applying the concept of Situational Non-Flammability. This approach essentially removes or breaks one leg of the conceptual fire triangle, a tool commonly used to define the three things that are required to support burning; a fuel, an ignition source and an oxidizer. Since an oxidiser is always present in an oxygen system as are ignition sources, the concept of Situational Non-Flammability essentially removes the fuel leg of the fire triangle by only utilising materials that will not burn at the maximum pressure, for example, that the control valve is to be used in. The utilisation of this approach has lead to the development of a range of oxygen components that are practically unable to burn while in service at their design pressure thus providing an unparalleled level of first safety while not compromising on the performance or endurance required in the function of these components. This paper describes the concept of Situational Non-Flammability, how it was used to theoretically evaluate designs of components for oxygen service and the outcomes of the actual development, fabrication and finally utilisation of these components in real oxygen systems in a range of flow control devices.

Advanced practice nursing role development : factor analysis of a modified role delineation tool

Aim his study reports the use of exploratory factor analysis to determine construct validity of a modified advanced practice role delineation tool. Background Little research exists on specific activities and domains of practice within advanced practice nursing roles, making it difficult to define service parameters of this level of nursing practice. A valid and reliable tool would assist those responsible for employing or deploying advanced practice nurses by identifying and defining their service profile. This is the third paper from a multi-phase Australian study aimed at assigning advanced practice roles. Methods A postal survey was conducted of a random sample of state government employed Registered nurses and midwives, across various levels and grades of practice in the state of Queensland, Australia, using the modified Advanced Practice Role Delineation tool. Exploratory factor analysis, using principal axis factoring was undertaken to examine factors in the modified tool. Cronbach’s alpha coefficient determined reliability of the overall scale and identified factors. Results There were 658 responses (42% response rate). The five factors found with loadings of ≥.400 for 40 of the 41 APN activities were similar to the five domains in the Strong model. Cronbach’s alpha coefficient was .94 overall and for the factors ranged from 0.83 to 0.95. Conclusion Exploratory factor analysis of the modified tool supports validity of the five domains of the original tool. Further investigation will identify use of the tool in a broader healthcare environment.

Are Malaysian Teachers Ready to Assume the Duties of Reporting Child Abuse and Neglect?

Mandatory child abuse and neglect reporting laws apply to teachers in many countries of the world. However, such laws have not yet been introduced for teachers in Malaysia, and there is debate about whether the laws should be extended to teachers at all. This paper aimed to investigate the level of support among teachers to assume mandatory reporting duties and to identify factors determining this support in Malaysia. A total of 668 teachers from 14 randomly selected public primary schools completed an anonymous self-administered questionnaire. Results showed that 44.4 per cent of the respondents supported legislation requiring teachers to report child abuse. Teachers of Indian ethnicity, those with a shorter duration of service in teaching (< 5 years), the availability of knowledgeable and supportive school staff and a higher level of commitment to reporting were significant factors affecting teachers' support for mandatory reporting. This study provides important insights into factors influencing teachers' support for the introduction of mandatory reporting legislation for teachers in Malaysia. Teachers do not unanimously support these laws and there is a lack of clarity about what such laws will mean for teachers. The data highlight the need for specific training programmes to raise teachers' awareness, build their confidence and enhance their willingness to report child abuse.

Factors influencing funding decisions by elected politicians at the state/provincial level : a case study of public libraries in Canada

The purpose of this study was to determine factors (internal and external) that influenced Canadian provincial (state) politicians when making funding decisions about public libraries. Using the case study methodology, Canadian provincial/state level funding for public libraries in the 2009-10 fiscal year was examined. After reviewing funding levels across the country, three jurisdictions were chosen for the case: British Columbia's budget revealed dramatically decreased funding, Alberta's budget showed dramatically increased funding, and Ontario's budget was unchanged from the previous year. The primary source of data for the case was a series of semi-structured interviews with elected officials and senior bureaucrats from the three jurisdictions. An examination of primary and secondary documents was also undertaken to help set the political and economic context as well as to provide triangulation for the case interviews. The data were analysed to determine whether Cialdini's theory of influence (2001) and specifically any of the six tactics of influence (i.e, commitment and consistency, authority, liking, social proof, scarcity and reciprocity) were instrumental in these budget processes. Findings show the principles of "authority", "consistency and commitment" and "liking" were relevant, and that "liking" were especially important to these decisions. When these decision makers were considering funding for public libraries, they most often used three distinct lenses: the consistency lens (what are my values? what would my party do?), the authority lens (is someone with hierarchical power telling me to do this? are the requests legitimate?), and most importantly, the liking lens (how much do I like and know about the requester?). These findings are consistent with Cialdini's theory, which suggests the quality of some relationships is one of six factors that can most influence a decision maker. The small number of prior research studies exploring the reasons for increases or decreases in public library funding allocation decisions have given little insight into the factors that motivate those politicians involved in the process and the variables that contribute to these decisions. No prior studies have examined the construct of influence in decision making about funding for Canadian public libraries at any level of government. Additionally, no prior studies have examined the construct of influence in decision making within the context of Canadian provincial politics. While many public libraries are facing difficult decisions in the face of uncertain funding futures, the ability of the sector to obtain favourable responses to requests for increases may require a less simplistic approach than previously thought. The ability to create meaningful connections with individuals in many communities and across all levels of government should be emphasised as a key factor in influencing funding decisions.

Area of residence is associated with Australian women’s uptake of long-acting contraception

Objective: Several new types of contraception became available in Australia over the last twelve years (the implant in 2001, progestogen intra-uterine device (IUD) in 2003, and vaginal contraceptive ring in 2007). Most methods of contraception require access to health services. Permanent sterilisation and the insertion of an implant or IUD involve a surgical procedure. Access to health professionals providing these specialised services may be more difficult in rural areas. This paper examines uptake of permanent or long-acting reversible contraception (LARCs) among Australian women in rural areas compared to women in urban areas. Method: Participants in the Australian Longitudinal Study on Women's Health born in 1973-78 reported on their contraceptive use at three surveys: 2003, 2006 and 2009. Contraceptive methods included permanent sterilisation (tubal ligation, vasectomy), non-daily or LARC methods (implant, IUD, injection, vaginal ring), and other methods including daily, barrier or "natural" methods (oral contraceptive pills, condoms, withdrawal, safe period). Sociodemographic, reproductive history and health service use factors associated with using permanent, LARC or other methods were examined using a multivariable logistic regression analysis. Results: Of 9,081 women aged 25-30 in 2003, 3% used permanent methods and 4% used LARCs. Six years later in 2009, of 8,200 women (aged 31-36), 11% used permanent methods and 9% used LARCs. The fully adjusted parsimonious regression model showed that the likelihood of a woman using LARCs and permanent methods increased with number of children. Women whose youngest child was school-age were more likely to use LARCs (OR=1.83, 95%CI 1.43-2.33) or permanent methods (OR=4.39, 95%CI 3.54-5.46) compared to women with pre-school children. Compared to women living in major cities, women in inner regional areas were more likely to use LARCs (OR=1.26, 95%CI 1.03-1.55) or permanent methods (OR=1.43, 95%CI 1.17-1.76). Women living in outer regional and remote areas were more likely than women living in cities to use LARCs (OR=1.65, 95%CI 1.31-2.08) or permanent methods (OR=1.69, 95%CI 1.43-2.14). Women with poorer access to GPs were more likely to use permanent methods (OR=1.27, 95%CI 1.07-1.52). Conclusions: Location of residence and access to health services are important factors in women's choices about long-acting contraception in addition to the number and age of their children. There is a low level of uptake of non-daily, long-acting methods of contraception among Australian women in their mid-thirties.

Assessing resilience of water resources systems under the impacts of climate change

This paper presents an approach to assess the resilience of a water supply system under the impacts of climate change. Changes to climate characteristics such as rainfall, evapotranspiration and temperature can result in changes to the global hydrological cycle and thereby adversely impact on the ability of water supply systems to meet service standards in the future. Changes to the frequency and characteristics of floods and droughts as well as the quality of water provided by groundwater and surface water resources are the other consequences of climate change that will affect water supply system functionality. The extent and significance of these changes underline the necessity for assessing the future functionality of water supply systems under the impacts of climate change. Resilience can be a tool for assessing the ability of a water supply system to meet service standards under the future climate conditions. The study approach is based on defining resilience as the ability of a system to absorb pressure without going into failure state as well as its ability to achieve an acceptable level of function quickly after failure. In order to present this definition in the form of a mathematical function, a surrogate measure of resilience has been proposed in this paper. In addition, a step-by-step approach to estimate resilience of water storage reservoirs is presented. This approach will enable a comprehensive understanding of the functioning of a water storage reservoir under future climate scenarios and can also be a robust tool to predict future challenges faced by water supply systems under the consequence of climate change.