1 Introduction to Management BUS020C414S 2018-2019 R.docx

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Introduction to Management BUS020C414S 2018-2019
Resit due 26TH July 2019
Re-sit Assessment Template for
Students
Academic year and term: Year 1, Term 2
Module title: Introduction to Management (Level 4)
Module code: BUS020C414S
Module Convener:
Dr Guy Bohane
Learning outcomes assessed
within this piece of work as
agreed at the programme
level meeting
Knowledge outcome – On completion of this module you will be
able to
demonstrate an understanding of the processes, procedures and
practices
for effective management in organisations.
Intellectual /transferrable skill outcome – Students who
successfully
complete this module will be developing your competence in

using a range
of basic analytical and managerial techniques and processes
including
objective setting, monitoring and evaluation as well as
interpersonal skills
of successful managers.
Business Readiness
outcomes assessed within
this piece of work as agreed
at the programme level
meeting
Students will be developing an understanding of and using
techniques to
solve business problems with awareness of commercial acumen
as well as
developing your ability to write reports and have confidence in
team
working.
1)Type of assessment:
(one summative assessment
per module)
One summative assessment which is an individual report on a
case study –
The Imperial Hotel. The report will be 2,000 words in total.
• A 2,000 words individual report will address one specific
problem
topic within the case

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Imperial Hotel Case Study
• For students who originally submitted work and need to resit,
the
original report submitted needs to be reworked (the same
problem) and
improved upon and a reflective piece of 500 words added where
the
student would reflect on how their work has been amended
based on the
feedback received and how this might help in future
assignments.
For students who did not originally submit their assessment, the
report
needs to be written and submitted (details of the report topics
are below).
Resit submission date: Friday 26th July 2019, 2pm
For students who are offered a resit: you are required to
improve and
resubmit your original report as well as adding a further
reflective
commentary discussing what you have learned from the process.
You must resubmit your work using the specific resit Turnitin
link on
Moodle.

You should:
1. Review your previously submitted work and read
carefully the
feedback given by the marker.
2. Use this feedback to help you revisit and rewrite your
work,
improving it in the areas identified as weak in the original
marking process
3. Include with your resubmission an additional reflective
piece (up to
500 words) on what you understand was weak, how you set
about
addressing this and what you have learned from this that may
help you
with further assignments. You should address the following
specifically:
i) Identify tutor feedback points on your original work and
identify
where/how the resit work has changed (give page number) in
response to
feedback
ii) Identify the lessons you have learnt from doing the resit
iii) Reflect on how your feedback and this process will help you
improve
future assignments
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For students who did not submit a report at the first opportunity
you
cannot reflect on your feedback. However, you are still required
to

submit a reflective piece in which you identify your reasons for
non-
submission, the implications of non-submission for your future
success
and how you propose to address this in the future.
For deferred students: If you were deferred at the first
assessment
opportunity you do not need to include the reflective piece as
this is a
first submission at a later date, not a resit.
The original marking criteria will still apply (see marking grid
provided
below*) except that the 10% weighting for presentation will be
awarded
instead to your reflective piece.
• A 2,000 words individual report will address one specific
problem
topic within the case (e.g. a human resource management
challenge, an
ethical problem, a performance and productivity issue, etc).
Dates : Submit by 2pm on 26th July 2019
Marks release date: 6pm on 16th August
Submission date and time
Students submit final summative report through Turnitin by
Friday 26th July
2019, 2pm
Marks and feedback date: Feedback and provisional marks
release: – 6pm Friday16th August 2019

Support and feedback on assessment
You will be offered support throughout the planning and writing
of our report. Please contact Guy Bohane the Module Convenor
for a tutorial.
[email protected] He will be on annual leave on Friday 14th
June returning to the University on Monday 24th June. I will
also be unavailable between
13th to 26th July inclusive.
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Summative Assessment: Re-sit Instructions to students
Assessment Case Study – The Imperial Hotel, London
The assessment is based on a business and management case
study which requires a critical approach to identifying and
problem-solving a range of business and
management challenges within the case. Throughout the term
you will undertake research and analysis which will inform your
individual report. Within the individual
report you will include a summary and key justifications for the
resolution of one of the problems in the case supported by
management theories and principles.
The report will be an individual 2,000 words report which will
address one of the five specific ‘problems’ identified in the case
(e.g. a human resource management

challenge, an ethical problem, a performance and productivity
issue, etc). You will receive a full briefing in Week 4.
Students will be expected to apply management theory to
practice throughout the report.
Case Study – The Imperial Hotel, London
The Imperial Hotel is a London 500 bedroom hotel, which is
owned and managed part of a well-known international branded
chain of hotels in the 4 star market –
Star Hotels which operates 25 hotels in the UK. The Imperial
Hotel, located in the heart of London’s West End, caters for
mainly international business and tourists
guests who have high expectation in terms of service standards.
The facilities at the hotel include the following:
• 500 bedrooms, all with en-suite facilities.
• Conference facilities for 1,000 people
• Leisure centre with swimming pool
• 3 Bars and 4 restaurants
• 12 conference rooms
Staff
• 6 Heads of Departments: Food and Beverage; Housekeeping;
Guest Services & Concierge; Front of House & Reception; and
Human Resources & training.
• 450 staff in total (300 full-time and part-time)
• Outside contractors (for specialist cleaning; laundry services;
management of the leisure centre;)

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A new General Manager, Peter Farnsworth, has recently taken
over the management of the whole hotel. He is an experienced
manager having worked in several of
the other Star city centre hotels outside London. The previous
General Manager, who had just retired, had been experiencing a
range of problems in managing the
hotel, namely that:
• There was a very high turnover of staff in all the departments
running around 80% a year mainly due to poor staff morale;
• The hotel was graded the lowest in the whole Star chain in
terms of overall guest satisfaction running at a rate of 60% in
the company’s benchmark grading
system; the overall sales in the hotel are improving,
• Although the hotel occupancy (the ratio of rooms sold against
the total number of rooms available) was running at 90% for the
year, the actual average
room rate (ARR) achieved, currently running at £95 per room
per night was relatively low compared to the local competition.
• The poor performance is having a direct negative effect on the
costs of the hotel and the hotel’s overall profitability.
The Imperial is an old hotel having been in operation for nearly
100 years. The hotel was last fully refurbished some 8 years ago
but is now in need of some restoration
and redecoration. There is a programme of staged refurbishment
in place which means each floor of the hotel is being closed for
building work to be undertaken.
The consequence of this is that, at any one time for the next two
years, 60 rooms will be out of action. This is putting the hotel
under budgetary pressure due to the

ongoing building costs as well as the loss of income from the 60
rooms out of action at any one time.
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Planned Strategy for Resolving the Problems in the Hotel
Peter Farnsworth is under no illusion as to the challenges ahead
and has decided to plan a strategy for resolving the operational,
management and business-related
problems in the hotel. The first part of the plan is to identify the
top five problems for the hotel for the coming year. He
identifies the problems as follows:
• Problem 1: Poor guest satisfaction
• Problem 2: High staff turnover with 80% of the staff leaving
within the year
• Problem 3: A negative work culture amongst the staff with
high levels of sick leave and poor attendance
• Problem 4: Front of house staff (Reception, Conference &
Banqueting, and Restaurant & Bars )– poor team working and
inefficient use of IT systems including the reservation and
property management systems
• Problem 5: Back of house staff (Housekeeping, Kitchen,
Maintenance) – poor operating and control procedures in place
with stock being regularly pilfered and evidence of staff not
meeting basic Standard Operating Procedures (SOPS) resulting
in unusually high operating costs

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The Problems in Detail
Problem 1: Poor guest satisfaction
The hotel was graded the lowest in the whole Star chain in
terms of overall customer satisfaction running at a rate of 60%
in the company’s benchmark grading
system. The company average is 78%. In every hotel in the
chain the company undertakes a monthly Guest Satisfaction
Survey (GSS) with regular guests and this
includes a summary of guest cards completed by guests in their
hotel rooms, as well as more formal online monthly survey with
major business clients. The survey
asks clients to grade all the facilities in the hotel (see Appendix
1 for the most recent monthly survey results for the Imperial
Hotel).
The most regular complaints received are in relation to issues
about checking in and checking out of the hotel, the quality of
the rooms themselves and the poor
quality of staff. There have been a number of complaints about
the reception staff being indifferent and sometimes rude to
guests. Other guests have been critical
of having to wait in queues at reception both for checking into
the hotel as well as checking out. A considerable number of
guests have complained of repeatedly
being charged incorrectly in their final bill. Most worrying is
the fact that some guests are also complaining that there has

been little or no timely response to their
complaints.
In terms of the accommodation in the hotel a growing number of
guest are being critical of the quality of the hotel rooms and in
particular the cleanliness of the
bathrooms, with numerous requests for room changes due to
showers not working properly, noisy air conditioning, and
technology not working in the rooms.
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Problem 2: High staff turnover with 80% of the staff leaving
within the year
Staff turnover in the hotel sector is generally high due to the
temporary nature of employment of, for example: students;
foreign nationals from the European Union
wanting to work for short periods in London; and generally low
pay (on average just at the living wage rate). The turnover of
staff is particularly high in the Imperial
hotel for front-line staff.
The exit interviews with leaving staff have identified a number
of issues around: poor perception of the work culture within the
hotel with sometimes aggressive
supervisory and management styles in evidence: the unsociable
working hours; a lack of proper and regular training; poor pay
levels compared to working for
example food retailing; little opportunity for promotion or
bonuses; the high cost of travelling to work in central London

and difficulties in getting transport home
at night; A number of young and talented supervisory staff have
also left the hotel to work at competitor hotel companies who
offer better pay, working conditions
and benefits.
The high level of staff turnover puts direct pressure on the
staffing budget with staff costs currently running at around 35%
of sales for the hotel which is a particularly
high for this type of hotel. The need to continuously employ
new staff has considerably increased induction training costs as
well as had a negative impact of the
overall quality of the service to guests, particularly the regular
guests who are now reducing in number and appear to be using
other hotels.
There appears to be a cycle emerging which may be linked to
the high level of staff turnover which subsequently affecting the
whole organisation. In terms of
individual members of staff there appears to be decreased job
satisfaction and a lack of commitment to the hotel with an intent
to leave. This shows itself in
attendance problems, decreased work performance, and
sometimes stress. As a consequence there is an increased
pressure on colleagues to pick up the slack which
contributes to routine system problems and a ‘culture of
turnover’. This operational staff as well as management as well
as this often results in a decreased pool of
promotable staff and managers. The result of this for the hotel
is that there are managerial succession problems. Other
consequences include operational
bureaucracy.
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Problem 3: A negative work culture amongst the staff with high
levels of sick leave and poor attendance
The organisational culture of working within Star Hotels is
performance driven. The General Manager, and the Heads of
Departments are under continuous pressure
to increase sales month-by-month by increasing the occupancy
of the hotel as well as pushing up the average room rate. The
hotel is assessed on a monthly basis
and managers’ bonus schemes are directly linked to the
financial performance of increasing sales and reducing and
controlling costs. The espoused values of Star
Hotels is about excellence in customer service and hence
performance is also linked to the results of the Guest
Satisfaction Surveys (GSS). The London hotels
consistently perform worse than the other hotels in the Star
Group and this is linked to guests’ perceptions that London
hotels are overly expensive and offer poor
value for money. The managers and Heads of Department often
complain that that the guest surveys put them at a disadvantage
because comparing experiences
and views of guests staying in a London hotel is completely
different to say a leisure-based hotel in Scotland whereby guests
are more relaxed.
The work culture in the hotel under the previous General
Manager was somewhat toxic. The hotel, being a busy London
24 hour and 365 day a year operation, means
that there are often long working hours, particularly for those
staff covering for staff who may have gone off sick at short
notice. Many of the part-time staff are
female and have family commitments, and in many cases have
other part-time jobs to fit round those family commitments.

This has often resulted in these staff
turning up late for their work shifts, and there have been many
occasions whereby staff ask their colleagues to cover for them
for short periods without informing
their supervisors. The levels of supervision of staff has been
minimal because of the high turnover of supervisory staff.
In the recent past the style of management could be described as
authoritarian and often dictatorial with very little consultation
with lower levels of staff in terms
of ways of improving performance and minimal feedback in
terms of how to improve on working practices or meet the
guests’ needs.
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Problem 4: Front of house staff (Reception, Conference &
Banqueting, and Restaurant & Bars)
– poor team working and inefficient use of IT systems including
the reservation and property management systems
The front of house staff, particularly in the Reception have a
pivotal customer-facing role in offering service and support to
guests. The Reception needs to be open
24 hours a day and is the first point-of-call for guests as well
key staff in all Departments to have up-to-date information and
data on guest arrivals and departures,
specific guest needs and guest billing data. The Reception staff

at the Imperial Hotel work three, 8 hour shifts working in
teams. Each team has a supervisor and they
have a particularly challenging function of managing Reception
teams as well as in passing on important guest information and
data on to the next shift. The hotel
uses a Micros Fidelio reservation and Property Management
System (PMS) which provides up-to-date information on real-
time and prospective guests and their
reservations. The other departments including the kitchen,
restaurants and conferencing are dependent on Reception for
guest numbers and data.
Some of the key Reception staff have been in conflict with the
other Departments after numerous complaints about wrong and
inaccurate information being provided.
Housekeeping have been given wrong or out-of-date data on
room availability, and whether a guest is staying on in the hotel.
Reception have also failed to inform
Housekeeping about early and late arrivals and subsequently
rooms have not been cleaned in time with guests having to wait
for long periods to get their room
keys. The conference and banqueting staff have complained that
they have not been provided with proper data on numbers of
guests coming in for meetings and
conferences. This, combined with complaints from guests that
Reception staff are often abrupt or even rude in dealing with
even the most basic request has caused
a lot of animosity within the Reception staff and other staff
throughout the hotel. The Reception Department has become
somewhat dysfunctional and there are
examples of Reception shift teams arguing with in the incoming
teams about not providing proper handover information.
A new Head of Department of Front Office and Reception,
working closing with the General Manager, is aware of the
conflict issues within the department as well

as with the other departments within the hotel and intends to
undertake a stand to manage the conflict quickly and efficiently.
The Reception teams’ dynamics are
not good, and there is a blame culture with staff not working
constructively and there is a clash of some strong personalities
within the Department. He is going to
review: the way the teams are structured; the individual
performance of staff in terms of performance and productivity;
the rewards and benefit being offered for
good performance; and training and development needs. He also
intends to develop and co-ordinate a team-based approach to
managing the staff. The poor data
issues can be dealt with through improved use of the IT systems
(PMS) although the animosity within and between working
teams will be more difficult to resolve
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Problem 5: Back of house staff (Housekeeping, Kitchen,
Maintenance)
– poor operating and control procedures in place with stock
being regularly pilfered and evidence of staff not meeting basic
Standard Operating Procedures
(SOPS) resulting in unusually high operating costs
Staffing the Housekeeping Department at the Imperial hotel is
always a challenge. There are up to 400-500 rooms to service a
day, and this overseen by the Executive
Housekeeper and 12 supervisory and administration staff. In the
past year, it has proved very difficult to recruit room attendants,
and those who are employed only
tend to stay for no longer than 6 months. The staff turnover in

the department is currently 60% a year. The hotel therefore
resorted, two years ago to using a
recruitment agency, ABC (International) to fill 30 of the 50
room attendants jobs in the departments. The 20 in-house staff
are a hardcore of long-term employees
who have worked for the company for many years.
ABC (International) is a recruitment company run by Charles
Santos who has considerable experience in the hotel industry in
England and Spain. Each candidate is
interviewed and assessed on their English before they are
included on the database. All candidates produce three
references which are checked by ABC prior to their
departure from Spain. They must have considerable practical
experience of working in a hotel housekeeping department
before taking up a post. If the hotel cannot
provide staff accommodation then ABC will organise it for
them.
The quality of the Spanish staffs’ work is good overall, and the
cost of employing the staff through the agency is only
marginally more expensive that employing
home staff. The Spanish staff tend to stay with the hotel for up
to a year. The Spanish staff prefer to work together in their
shifts with other Spanish staff, and are
supervised and provided on-the-job training as to the brand
standards for the hotel by the in-house Assistant Head
Housekeeper, herself a fluent Spanish speaker.
There has been considerable discontent from the in-house room
attendant claiming that the Spanish staff are un-cooperative
when asked to work with non-Spanish
staff. The Spanish staff are used to working in teams in their
shifts, working together in pairs who are allocated 20 room a
day to service. The standard of the in-
house staffs’ working has been dropping. The hotel uses the

Texlon system, which is a hand-held tracker system whereby a
supervisor will undertake a sample check
of the room standards and rank and score the standards of a
serviced room. The results are subsequently plugged into the
hotel computer and each member of staff
is given a ranking out of 100. The Spanish staff (75%+ scores)
consistently score higher than the in-house staff (60%-65%),
which again has caused considerable
resentment. The attendance of the in-house staff, all employed
on full-time contracts, is getting progressively worse which has
put pressure on the housekeeping
budget.
There have recently been a number of complaints from hotel
guests, who have not been happy with the general level of
cleanliness in the hotel bedroom and in
particular the bathroom. There have also been a number of
complaints about housekeeping room attendants being abrupt
and sometimes rude. When these cases
have been investigated, it is becoming clear that full-time staff
have poor motivation levels.
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General information relevant to all the problems listed
Staff Incentive Schemes

There are currently a number of incentive schemes to
encourage staff to meet excellent standards of work, and to
improve productivity. These include: Employee of
the Month (for the whole hotel - £200) and employee of the
month for each department (£50); staff (including agency staff)
consistently meeting individual and
performance targets in three consecutive months within the
department (£200 vouchers towards staying in any one of Star
Hotels); department, end-of-year parties
(funded by the hotel); college fees being paid (NVQ levels 2-4).
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Tasks
As an independent consultant, you have been asked by Peter
Farnsworth to take responsibility for analysing one of the five
problems, putting forward and prioritise
the problem.
Tasks for the report:
• Discuss the problem’s likely causes from a management and
operational perspective including any relationships with the
other 4 problems
• Put forward a 3 point plan for resolving the problem
particularly in terms of improving the quality of service, staff
morale, operational efficiency

and productivity to make the hotel financially sustainable.
• Support your answer with management and operations theories
and principles
The expectation is that within 12 months there should be
dramatic improvement and change in performance in all five
areas. You have asked to write a 2,000 word
report addressing your single problem topic to attempt to
resolve that problem in the hotel.
End of case
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Marking criteria:
Individual report element: 2,000 words (100% weighting for the
module)
o A review of management theory to one specific problem in the
case
with appropriate use of essential texts and academic reading
30%

o An analysis of one specific problem within the case
demonstrating
an understanding of the processes and procedures for effective
management 40%
o A summary and justification of key proposals for the
resolution of the problem in the
organisation 20%
o Reflection on your Report (Re-sit students only) 10%
Suggested report format:
§ Title Page
§ Introduction – Explain the background to your individual
problem in the context of the case (250 words approx).
§ Analysis of the individual problem – Summarise and interpret
the data from your secondary research into published literature
and management theory.
Describe and present your results for effective management of
the problem. A summary and justification of key proposals for
the resolution of the problem in
the organisation (1500 words approx.)
§ Conclusion – This should be a brief summary of findings of
the analysis of the individual problem. (250 words)
§ Bibliography
Support and feedback on assessment
You will be offered support throughout the planning and writing
of our report. Please contact Guy Bohane the Module Convenor
for a tutorial.
[email protected] He will be on annual leave on Friday 14th
June returning to the University on Monday 24th June. I will

also be unavailable between
13th to 26th July inclusive.
• Referencing - You MUST use the Harvard System. The
Harvard system is very easy to use once you become familiar
with it.
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Assignment submission:
A 2,000 words individual report will address one specific
problem topic within the case (e.g. a human resource
management challenge, an ethical problem, a
performance and productivity issue, etc).
Those undertaking a resubmission please complete the reflective
piece as shown above.
Dates : Submit by 2pm on 26th July 2019
Marks release date: 6pm on 16th August
StudentZone
http://studentzone.roehampton.ac.uk/howtostudy/index.html.
Mitigating circumstances – The University Mitigating
Circumstances Policy can be found on the University website -

Mitigating Circumstances Policy
• Marking and feedback process (for Year 1 modules) - Between
you handing in your final report and then receiving your
feedback and marks within 20 days, there
are a number of quality assurance processes that we go through
to ensure that you receive marks which reflects their work. A
brief summary is provided below:
• Step One – The module and marking team meet to agree
standards, expectations and how feedback will be provided.
• Step Two – A subject expert will mark your work using the
criteria provided in the assessment brief above.
• Step Three – A moderation meeting takes place where all
members of the teaching and marking team will review the
marking of others to
confirm whether they agree with the mark and the feedback that
has been provided.
• Step Four – Your mark and feedback is processed by the
Office and made available to you.
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Re-sit Assessment Rubric – Introduction to Management
BUS020C414S
Report 2,000
words

100 Exemplary 85
Excellent
75
Very good
65
Good
55
Competent
45
Weak
35
Marginal Fail
20
Fail
A review of
management
theory to one
specific problem
in the case
with
appropriate use
of essential
texts and
academic
reading
30% weighting
Exceptional
ability to

examine
complex issues
in a way that
potentially
challenges
existing
theories. The
quality of the
examination
demonstrates a
potential to add
value and
novelty to the
concepts
studied.
Excellent
application of
management
theories,
supported by
excellent
interpretation
skills of the
topic and
effective and
review and
analysis of the
existing
theories.
Clear ability of
identifying the
most relevant
theories, and
reasonable

application of
basic concepts
to the problem,
with
predominance
of analysis over
description.
Only minor
gaps.
Displays and
understanding
of the problem
but requires
more
systematic,
critical analysis
of the topic
supported by a
theoretical
discussion.
Some application
of basic
management
concepts and
theories to the
question involving
an analytical
approach, limited
by description.
Very limited use of
basic concepts
and management
theories in

relation to the
problem and work
is largely
descriptive..
Irrelevant and
superficial
application of any
management
theory and
concepts to the
examination of
the problem.
Little or no
analysis of
management
theory, even at a
superficial level.
An analysis of
one specific
problem within
the case
demonstrating
an
understanding
of the processes
and procedures
for effective
management
40% weighting
Student has
gone beyond
what is

expected to
analyse the
problem.
Exceptional
understanding
of the subject
area, with
unique and
additional
contribution to
Excellent
understanding
of the subject
area with very
good analysis of
the problem.
Form grasp of
knowledge.
Demonstrates
evidence of
assessing
sources beyond
minimum.
Reflects
understanding
of the problem
in question
through the
analysis.
Relevant
knowledge is
presented
accurately with
only minor

gaps.
Clear
demonstration
of knowledge
but some gaps
or lack of focus
in the analysis.
Analysis
demonstrated at
a fairly basic level.
Some attempt to
demonstrate an
understanding of
processes and
procedures for
effective
management.
Analysis
demonstrated at a
very basic level.
Information
briefly
summarised and
incomplete in
parts. Limited
understanding of
effective
management.
Very little attempt
or effort to
coherently analyse
the problem in

relation to
effective
management.
Clear confusion of
knowledge with
obvious errors.
Lack of
understanding.
No real work
done. The
majority of
information
included is
irrelevant to the
problem in
question
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existing
knowledge.
A summary and
justification of
key proposals for
the resolution of
the problem in
the
organisation 20%
weighting
An excellent

summary with
an outstanding,
coherent
justification for
the proposals.
A very well
considered and
convincing
justification for
the proposals to
the resolution
of the
problems.
The summary
offers a
reasonably
convincing
justification for
the proposals.
A competent
justification for
the key
proposals for
the resolution
of the problem.
The summary
offers an
adequate
justification for
the proposals but
lack rigour

The summary and
justification of the
key proposals are
at a very basic
level and offer
only limited
coherence in the
context.
The summary of
proposals makes
little sense in the
context of the
problem and
would clearly fail
to resolve the
problem.
Summary offers
little or no
coherent
justification for
the proposals.
Clarity, structure,
grammar, correct
referencing
10% weighting
An outstanding
report which
would be
considered
excellent in a
business
context. The

structure and
use of language
and report
writing skills are
exceptional.
Faultless use of
the Harvard
system.
An extremely
good, coherent
report
demonstrating
a very
convincing set
of writing skills
in terms of use
of language and
in the
structuring of
the report.
Excellent use of
the Harvard
system.
A good report,
clearly written
and well
communicated
in terms of
language and
use of grammar.
Sources and
citations are
well presented
using the

Harvard system.
A competent
report
demonstrating
adequate report
writing skills.
Reasonably
coherent use of
language and
grammar.
Appropriate use
of Harvard
referencing.
Adequate report
writing skills in
evidence. Some
minor errors in
spelling, the use
of appropriate
language as well
as in the
application of the
Harvard
referencing
system.
Weak report
writing skills and
poor structuring
of the report.
Some spelling
errors and poor
use of language.
Some errors

evident in the use
of the Harvard
referencing.
Very poor
structure for the
report which only
partially meets the
guidance on
report structure.
Numerous spelling
and grammatical
errors. Numerous
errors in the use
of Harvard
referencing
system.
No attempt to
structure a
coherent report in
line with the
guidance. No or
limited
referencing of
sources with
inappropriate use
of the Harvard
system. Extremely
poor writing skills
in evidence
making the report
largely incoherent.

18
19
Appendix 2
A sample benchmark statement for the quality performance at
the Imperial Hotel
Making the Case for Quality
Reducing Wait for MRI Exams Gives
Akron Children’s Hospital
Competitive Edge
• AkronChildren’sHospital
usedLeanSixSigma
toincreaseMRIexam
volumesandreduce
patientwaittimes.
• Atwo-daykaizenevent
allowedamultidisciplinary
teamtoidentifyasystemof

rootcauses,developaset
ofcountermeasures,and
rapidlyimplementchanges.
•Waittimesforexams
weresignificantlyreduced
afterthekaizen.Daysand
weekswereeliminated
betweenschedulingandthe
examday.Shorterpatient
waittimesandincreased
weeklyexamvolume
continuetobesustained.
• $1.2millioninincremental
revenuewasearnedthe
yearfollowingtheproject.
AtaGlance... Introduction
The problem in the Radiology
Department at Akron Children’s
Hospital in 2009 was two-fold.
First, the addition of a second
MRI machine in 2007 did not
lead to a proportional increase
in the average number of daily
exams (Figure 1). Second, and
more important to patients and
their families, wait times for MRI scans were excessive. In fact,
the wait time for a multiple-exam
study with contrast was 25 days. If the patient required
sedation, the wait time was six to eight weeks.
This represented a common dilemma seen throughout
healthcare: the inability to meet customer
demand despite the presence of excess capacity.

Designing countermeasures to this problem was important to the
leadership at Akron Children’s. Access
to patient care is a key measure of quality, one of the four key
pillars of the hospital’s strategic plan. Rapid
access to radiologic exams is a significant advantage for a
children’s hospital in a highly competitive market.
Addressing this issue presented an opportunity to enhance
revenue and increase the return on the
investment from a second MRI scanner. Furthermore, improving
access to patient care became impera-
tive because the hospital’s service area had grown and the
department was confronted by a 23-percent
increase in patients.
About Akron Children’s Hospital
Akron Children’s is the largest pediatric healthcare provider in
northeast Ohio, with two pediatric
hospitals and services at more than 80 locations across the
region. It offers care in all pediatric subspe-
cialty areas that draw more than half a million patients each
year, including children, teens, and adults
from all 50 states and around the world. The hospital also
provides more than 100 advocacy, education,
outreach, and research programs to children and their families
throughout the region.
The hospital has earned the Gold Seal of Approval from The
Joint Commission and Magnet
Recognition Status from the American Nurses Credentialing
Center. It is a founding member of the
Austen BioInnovation Institute in Akron, a collaboration of
research, education, and health institutions
designed to pioneer the next generation of life-enhancing and

life-saving innovations.
by David Chand and Anne Musitano
April2011
ASQ www.asq.org Page1of5
• A3: An eight-week formal training program that teaches
frontline staff the basics of Lean, culminating in the
completion of a project in the participant’s home department.
• Green Belt: A formal training program and project that lasts
six to 12 months, following the DMAIC (define, measure,
analyze, improve, and control) format.
• Kaizen: Events lasting two to five days, resulting in rapid
implementation of countermeasures.
• Blue Belt: Training for managers and departmental leaders
focusing on daily management in a Lean enterprise through
tools, processes, and systems.
• Black Belt: Twelve-month projects involving large value
streams, using more advanced Lean Six Sigma tools.
To increase MRI exam volumes and reduce patient wait times,
the hospital formed a multidisciplinary team comprised of:
• Radiology technologists
• Radiologists
• Nurses
• Exam schedulers
• Representatives from the Authorization & Registration

Center (ARC)
• Executive leaders
• Members of the hospital’s COE
A two-day kaizen (Japanese for “change for the better”) helped
reveal the system of root causes and a series of countermeasures
to address the issues identified. The MRI kaizen was successful
for many reasons. The team was selected to include representa-
tives from all the affected stakeholder groups. As change can
often be difficult, making sure that stakeholders are engaged
in the process was essential for a successful outcome. The
Department of Radiology has participated in four of the five
aforementioned programs, allowing the culture of continuous
Quality Journey
This MRI project truly embodied the culture necessary to com-
plete a successful Lean Six Sigma project. Quality improvement
projects are led by the Center for Operations Excellence (COE)
at
the hospital. The COE came to fruition in 2008, championed by
Mark Watson, now president of the Akron Children’s Regional
Network, who saw Lean Six Sigma as the edge that would allow
the hospital to thrive in a highly competitive market. Now com-
prised of a senior director, five project leaders, one data
analyst,
and an office coordinator, the COE has facilitated projects in
nearly every department across the organization.
The COE’s philosophy can be summarized succinctly by the
phrase “Process Improvement Through People
DevelopmentTM.”
In other words, the key to successful continuous improvement is
to develop the people who do the work to change the work for
the better. The operating system at Akron Children’s revolves

around five major programs:
Numberofbeds: 253atmaincampus
50atMahoningValleycampus
6atRobinsonMemorialHospital
Medicalstaff: 738
Numberofemployees: 4,127
Servicearea: 25-countyregion,including
allofnortheastOhioand
westernPennsylvania
Annualradiologyprocedures: 100,000
Admissions(2010): 8,756
Totaloutpatientvisits(2010): 604,357
AkronChildren’sHospital—BriefStatistics
Figure 1— Average number of daily exams before the project
Ja
n.
O
7
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b.
O
7

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ar
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7
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r.
O
7
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ay
O
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ly
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g.
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ct.
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ov
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7
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ar
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b.
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9
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ar
. O
9
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r.
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9

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ay
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8
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ne
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8
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ly
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8
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g.
O
8
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p.
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8
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ct.
O
8

N
ov
. O
8
De
c.
O
8
0
2
4
6
8
10
12
MRI 1 MRI 2 MRI 1 and 2
Figure 2— Process capability prior to the kaizen of MRI 1 and 2
(February 2009 – July 2009)
Process Data

LSL 112
Target *
USL *
Sample Mean 86.5455
Sample N 22
StDev (Within) 6.71892
StDev (Overall) 7.30771
Potential (Within) Capability
Cp *
CPL -1.26
CPU *
Cpk -1.26
Overall Capability
Pp *
PPL -1.16
PPU *
Ppk -1.16
Cpm *
Observed Performance
PPM < LSL 1000000.00
PPM > USL *
PPM Total 1000000.00
Exp. With Performance
PPM < LSL 999924.22
PPM > USL *
PPM Total 999924.22
Exp. Overall Performance
PPM < LSL 999752.31
PPM > USL *
PPM Total 999752.31

72
LSL
80 88 96 104 112
Within
Overall
improvement to permeate the department. The kaizen followed
A3 and Green Belt projects. After the kaizen, the department
became the first to participate in the Blue Belt program.
The A3 and Green Belt projects led to several key improve-
ments: standardization of the ordering, scheduling, and
communication processes; standardization of the exam protocols
by the radiologist; and identification of the 75-minute timeslot
as the ideal duration to maintain patient flow. Despite these
changes, more work was required to improve patient wait times.
Figure 1 illustrates that the addition of a second MRI scanner
did not
lead to the expected increase in the number of exams completed.
The
stated goal of the kaizen was to increase the number of weekly
exams
(Monday through Friday) performed on MRI #1 and MRI #2
from 86
to 112 by August 24, 2009, representing a 30-percent
improvement.
A capability analysis revealed that the current process was not
capable of reaching the stated goal (Figure 2). The team used
a fishbone diagram and ease/impact chart to identify contribut-
ing factors and prioritize potential countermeasures. The master
schedule and the insurance authorization process were identified

as the two major factors to address.
After reviewing utilization data, the master schedule was
modified to better meet the needs of the customers, includ-
ing outpatients, inpatients, families, and ordering physicians
(Figure 3). The new schedule provided better flexibility and
more accurately matched the customer demand.
The insurance authorization process was modified to allow
authori-
zation during scheduling, enabling the radiology schedulers to
pull
patients into the MRI schedule prior to the original
appointment.
MRI1
Monday Tuesday Wednesday Thursday Friday
7:15 OP OP IP OP OP
8:30 OP-S OP-S OP-S OP-S OP-S
11:00 OP-S OP-S IP OP-S OP-S
12:15 OP-S OP-S W OP-S OP-S
4:00 OP OP OP OP OP
NewOPspots
FlippedIP/OPspots
MRI2
Monday Tuesday Wednesday Thursday Friday
7:15 OP7:45 OP7:45 OP7:45 OP OP
8:30 OP

OP
OP OP OP
9:45 IP ♥
10:00–12:00
OP OP
11:00 IP IP IP IP
12:15 W W ♥
12:00–2:00
W W
1:30 OP
OP
1:30–3:30
OP-S OP
2:45 OP
♥
2:00–4:00
OP-S OP
4:00 OP OP IP OP/IP-S OP
5:15 OP OP OP OP OP
6:30
W
L–6:30–7:15
W
L–6:30–7:15

W
L–6:30–7:15
W
L–6:30–7:15
W
L–6:30–7:15
7:45 OP OP OP OP OP
9:00 OP OP OP OP OP
10:15 OP OP OP OP
OPOP,Outpatient;IP,Inpatient;W,WildCard;-
S,Sedationneeded;♥,CardiacMRI
Figure 3— Master schedule modifications
Moving authorization upstream in the process created an
effectively
larger pool of patients who were eligible to fill the available
slots.
One of the most powerful effects of the kaizen was that it
allowed
people from various steps along the value stream to work
together,
face-to-face, to solve the issues they identified.
Figure 4 shows the immediate impact of the project, as wait
times
for exams rapidly decreased, the improvement in access times
continued to be sustained. The results in Figure 5 demonstrated
that the process was now capable of achieving the project goal,

as
evidenced by the C
pk
of -0.17, compared with C
pk
of -1.26 before
the project. The histogram of exams per week is shifted to the
right, compared to Figure 2, with some totals exceeding the
proj-
ect goal. The sustainability is best demonstrated with the
control
chart in Figure 6. The mean number of exams per week steadily
increased after each Lean Six Sigma project.
In October 2010, 13 months after the kaizen, 126 exams were
completed in one week, exceeding the project goal by 14 exams.
The average wait time for a single study was reduced to same-
day, a multi-exam study with contrast was five to 11 days, and
about 14 days if sedation is needed.
In February 2011, 17 months after the kaizen, results continue
to be
sustained with 114 exams completed in one week. February’s
wait
time for a single study was same-day, eight days for a multi-
exam
study with contrast, and about two to 14 days if sedation was
needed.
While improving patient access to care was the driver of Akron
Children’s project, the hospital earned $1,271,603 in first-year
incremental revenue.

Continuing Commitment to Quality
The Department of Radiology exemplifies continuous improve-
ment. Every Monday, the director of radiology and his
supervisors review exam volume and access time data from the
previous week. If targets are not reached, for example, if less
than 95 MRI exams were completed in a week, a root cause
analysis is performed to understand the contributing factors and
countermeasures are generated. This process is driven by daily
huddles, identification of improvement opportunities, and the
use of displayed metric boards.
The multidisciplinary team was recently recognized by the
International Quality & Productivity Center (IQPC) with
an Honorable Mention award in the “Best Project Under 90
Days” category at the 12th Annual Lean Six Sigma & Process
Improvement Summit of 2011.
Reporting
period/date
Simple exam
(no contrast/sedation)
Single exam
(with contrast)
Exam with
sedation
January–June,2009 ~4–5days 25days 6–8weeks
July13,2009 4–5days 25days 27days
September17,2009 3days 3days 6days
October2,2009 1day 3days 10days
November6,2009 1day 3days 8days

November27,2009 1day 2days 9days
Now, whether contrast is scheduled or not, access times are the
same
February28,2010 Sameday 7to11days
May29,2010 Sameday 1to16days
July17,2010 Sameday 2to14days
October23,2010 Sameday 2to10days
December11,2010 2days 3to12days
January1,2010 Sameday 3to16days
February5,2011 2days 2to14days
Figure 4— Improvements in patient access times
Figure 5— Process capability after the kaizen of MRI 1 and 2
making goal of 112 exams per week
(August 2009 – February 2011)
Process Data
LSL 112
Target *
USL *
Sample Mean 106.935
Sample N 62
StDev (Within) 9.83702
StDev (Overall) 10.3018
Potential (Within) Capability
Cp *
CPL -0.17
CPU *
Cpk -0.17
Overall Capability
Pp *

PPL -0.16
PPU *
Ppk -0.16
Cpm *
Observed Performance
PPM < LSL 677419.35
PPM > USL *
PPM Total 677419.35
Exp. With Performance
PPM < LSL 696668.54
PPM > USL *
PPM Total 696668.54
Exp. Overall Performance
PPM < LSL 688504.25
PPM > USL *
PPM Total 688504.25
90
LSL
100 110 120 130
Within
Overall
Key Learning Points:
• The true success of the project is that the department

understands the importance of continuous improvement, which
has allowed them to sustain the gains they had achieved.
• The kaizen has exemplified how focusing on improving the
customer experience, in this case by reducing patient wait
times,
leads to financial benefits and support of the corporate strategy.
• A key success factor was the selection of team members,
ensuring
that all stakeholders along the value stream were represented.
• The systematic, data-driven approach to quality improvement
embodied by the Lean Six Sigma methodology provides a
competitive advantage in a highly competitive market.
For More Information
• Please contact David V. Chand ([email protected]) or Anne
Musitano ([email protected]) for more information about
the Center for Operations Excellence at Akron Children’s.
• The website for the Center for Operations Excellence is
https://www.akronchildrens.org/cms/site/e0e103f1c27ca6fa/
index.html.
• Learn more about Lean Six Sigma in healthcare at
http://asq.org/healthcaresixsigma/.
• Read more case studies showing examples
of process improvements in healthcare at
www.asq.org/healthcare-use/why-quality/case-studies.html.
About the Authors
David Chand, MD, is a pediatric hospitalist and Lean Six

Sigma project leader at Akron Children’s. Prior to joining the
hospital in 2008, Chand was a business management consultant
for McKinsey & Company, where he focused on growth strategy
and operations for healthcare providers in North America. He
earned his bachelor’s and master’s degrees from Johns Hopkins
University and his doctor of medicine degree at Harvard
Medical
School and The Massachusetts Institute of Technology. He com-
pleted his residency and chief residency in pediatrics at
Rainbow
Babies & Children’s Hospital in Cleveland, OH. In 2009, he
earned his Green Belt in Lean Six Sigma from the Center for
Innovation in Quality Patient Care at Johns Hopkins University.
Chand is working on a master’s degree in business operational
excellence at The Ohio State University.
Anne Musitano, PharmD, is a Lean Six Sigma project leader
at Akron Children’s. She joined the hospital in 2001 as a staff
pharmacist in the outpatient pharmacy after graduating from
The
Ohio State University with a bachelor’s degree in pharmacy. In
2004, she became the supervisor of the pharmacy and returned
to Ohio State to earn her PharmD degree. In October 2008,
Musitano helped build the program that has now become the
Center for Operations Excellence (COE) at Akron Children’s.
She completed her master’s degree in business operational
excel-
lence at Ohio State in 2010.
140
UCL = 136.45
X = 106.94
LCL = 77.42

To
ta
l N
um
be
r
of
W
ee
kl
y
Ex
am
s 130
120
110
100
90
80
70
60
Week Beginning

Pre
Green
Belt A3 Kaizen
2/
16
/0
9
5/
4/
09
7/
20
/0
9
10
/9
/0
9
1/
2/
10
3/
21
/1

0
6/
6/
10
8/
22
/1
0
11
/7
/1
0
2/
12
/1
1
Figure 6— Sustained results in weekly exams MRI 1
and 2
mailto:[email protected]
https://www.akronchildrens.org/cms/site/e0e103f1c27ca6fa/inde
x.html
https://www.akronchildrens.org/cms/site/e0e103f1c27ca6fa/inde
x.html
http://asq.org/healthcaresixsigma/
http://www.asq.org/healthcare-use/why-quality/case-
studies.html

This excerpt from the
new book describes the
8D problem-solving approach
and application.
Introduction to 8D
Problem Solving
Ali Zarghami and Don Benbow
Problem solvers are a very impor-tant resource in any
organization.
These are the people who are able to
identify creatively and remove barri-
ers that keep the organization from
accomplishing its mission. All person-
nel should understand that part of their
job is to solve problems, that is, identify
and overcome barriers to improvement.
Some organizations find it useful to
require periodic written reports detailing
problems identified and progress toward
their resolution.
Many problems can be solved by an
individual working alone. Other prob-
lems require a group effort involving
people with various skills and knowl-
edge bases. The purpose of this book is
to provide a structure for the problem-

solving process.
What does “fad” mean? Merriam-
Webster online dictionary defines fad as
“a practice or interest followed for a time
with exaggerated zeal,”1 Is the 8D process
another fad that will fade away in a few
years? Before we answer this question,
let us review a practice called the quality
circle (QC), which was popular begin-
ning in the 1970s.
The QC worked as follows:
• A team of volunteers was assembled.
• The team members worked in the
same area.
• The team members selected their own
project/problem on which to work.
• Almost all of the projects were related
to the area where they worked.
• Typical projects addressed safety,
human resources, and other area-
related issues.
• On most projects, the team used very
basic analysis tools to solve problems.
• Once the problem was solved, the team
reported its findings to management.
• The team selected another project and

started working on it.
• Eventually the team ran out of mean-
ingful projects.
• The team failed to receive managerial
support and the QC died.
We are not here to judge whether man-
agement made a good or bad decision.
The bottom line is that management
often perceived team projects with a
short-term, return-on-investment (ROI)
perspective. If the project did not pay
back for the time the team was spending
on it, the QC was abandoned.
www.asq.org/pub/jqp 23
http://www.asq.org/pub/jqp
The Journal for QualiTy & ParTiciPaTion October 201724
There was nothing wrong with the QC team
concepts and basic statistical tools that the team
used to solve problems. It appears as though the
type of project the team selected was not judged to
have sufficient return for the time invested, thereby
killing the QC. That is exactly why the 8D process
will not die. In the current environment, it is not
the worker or management selecting projects; it is
the customer.
Management and workers have a similar interest
in solving the problem. Both parties want to save

the job, making it a win-win for everyone.
The customer who pays the bill demands a
solution to the problem. The customer wants to
know why the quality system in place to protect
the customer has failed and perhaps caused pro-
duction issues on the customer’s production floor.
It is also an issue that could have surfaced after
the consumer received the product, which is the
worst case. The bottom line is that a solution to the
problem is in everyone’s interest. The 8D format
itself is not unique. There are dozens of multistep,
problem-solving tools around that are very simi-
lar. For example, the seven-step method we put
together in the 1980s denoted step three “Quick
fix: Procedure used to keep alligators at bay during
swamp draining.” The 8D process is almost a de
facto standard in the manufacturing sector and is
unique in its origination with the customer.
In its simplest form, this is how the 8D process
works.
• Customer has a very specific problem and
requests a solution.
• Producer of problem assembles a team of experts
to address the problem.
• Team resolves the issue and reports finding.
• Team disbands.
Of course, the problem could come from any-
where, not exclusively from the customer, as long
as the project is deemed important enough to

assemble a team to work on it.
Overview of the 8D Problem-Solving Methodology
8D stands for eight discipline problem-solving
methodology. The 8Ds are listed below:
D1—Select an appropriate team.
D2—Formulate the problem definition.
D3—Activate interim containment.
D4—Find root cause(s).
D5—Select and verify correction(s).
D6— Implement and validate corrective action(s).
D7—Take preventive steps.
D8—Congratulate the team.
There is some parallelism between the 8D steps
and the DMAIC steps used by Six Sigma practitio-
ners in that D2 is essentially the DMAIC Define
step, D4 is similar to the DMAIC Analyze step, D5
and D6 are like the DMAIC Improve step, and D7
parallels the DMAIC Control step. The 8D objective
is to define the problem, implement containment,
Introduction to 8D Problem Solving:
Including Practical Applications and Examples
Authors: Ali Zarghami
and Don Benbow

Abstract: The eight
discipline (8D) problem-
solving methodology
includes these steps—
select an appropriate team, formulate the
problem definition, activate interim contain-
ment, find root cause(s), select and verify
correction(s), implement and validate cor-
rective action(s), take preventive steps, and
congratulate the team. This unique book pro-
vides an overview of the 8D process, gives
guidance on tools for finding root causes,
shows the 8D process in action using eight case
studies, and gives five unsolved problems on
which readers can apply 8D practices. Anyone
who wants to improve quality, regardless of
industry will benefit from the 8D approach;
it has been successfully applied in healthcare,
retail, finance, government, and manufacturing.
Publisher: ASQ Quality Press
ISBN: 978-0-87389-955-0
Format/Length: Softcover/60 pages
Price: $21 (ASQ members); $35 (Nonmembers)
correct and eliminate the concern, improve quality
control systems, and document and report findings.

It is important to note that the problem could be
product or process related, and the 8D process is well
equipped to address both. The 8D is a highly struc-
tured and scientific approach to problem solving.
More Detail on the Steps
The next few paragraphs cover the 8D steps in
more detail. As each step is completed, it should be
added to the 8D document (see Figure 1). This docu-
ment could be developed internally or specified by
a customer.
D0—Initiation
We call this step D0 because it precedes the formal
steps D1 to D8. In this phase, a customer or internal
management indicates it has a specific problem
that needs to be addressed. At this time, a quality
alert is generated and vigorous containment effort is
started to isolate the problem from the customer(s).
Management will decide whether this problem is
simple and can be handled by an individual or
whether it is significant enough to launch an 8D
problem-solving team.
The 8D effort requires significant time and
resources, management support allocating time,
and team authorization— all of which are essential
for the success of the team.
D1—A Team Approach
Management is responsible for assembling a
team that has relevant knowledge and experience

to address the issue. Management needs to allow
Figure 1: Sample Form for Documenting 8D Projects
Team 8D Working Document
Concern Number:
Date Initiated:
D1—Team Members:
D2—Problem Statement/Description:
D3—Interim Containment Action(s):
D4—Root Cause(s):
D5—Choose and verify permanent correction(s):
D6—Implement and validate corrective actions:
D7—Take preventive actions:
D8—Congratulate your team: Date/Notes
time for the team to go through the four phases of
team development—forming, norming, storming,
and performing—to be effective. In some organiza-
tions, a senior manager is assigned as champion for
the team to provide additional support and remove
barriers for the team.

It is very important that management assigns
a team leader for the project. The team leader
should be experienced (subject-matter expert)
and should have completed a few 8D projects. The
team leader must have the authority as needed to
allocate time and acquire other resources needed
for the team.
In manufacturing cases, the team members
could be from production, industrial engineering,
design engineering, purchasing, programming,
human resources, quality, and so forth. In retail
cases, the team members could be retail associ-
ates, shift supervisors, marketing representatives,
maintenance workers, delivery persons, and so
forth. For healthcare, the team members could be
nurses, nurse supervisors, programmers, doctors,
etc. In the food industry, the team members could
include hostesses, servers, bus people, cooks, bar-
tenders, shift supervisors, dietitians, accountants,
and so forth.
Depending on the team’s level of experience, the
team leader might facilitate some root cause analy-
sis training with the team members. It is the team
leader’s responsibility to keep the team on track and
provide an open line of communication among all
stakeholders. It is also the team leader’s responsi-
bility to ensure that all team meeting minutes are
kept, including team progress, action plans, and
individual assignments and dates.
Documentation of learning is a very important
part of the 8D process. A form called the “8D
Documentation Form”2 is provided on the Iowa

Quality Systems website. It is suggested that as each
step is completed, every attempt be made to com-
plete and update this form.
D2—Define and Explain the Problem
The team will detail the problem precisely. It is
extremely important that the problem is described
in measurable terms. It is important to remember
that it is difficult to improve something that can’t
be measured. A nice tool available to define the
problem is called the “Five Ws and Two Hs.” It is
defined as follows:
• Who is complaining?
• What are they complaining about?
• When did it start?
• Where is the problem occurring?
• Why is this problem occurring (an educated guess)?
• How did this problem occur (an educated guess)?
• How many problems (measurable and magnitude)?
Document your learning on the 8D documenta-
tion form.
D3—Interim Containment Action
All nonconforming material must be isolated
from the customer. This step is typically already in
progress as discussed in step D0. An open and hon-

est line of communication between producer and
recipient of the problem is required in this step.
Every effort is taken to isolate the problem
from the customer. It may involve 100 percent
inspection of the product in-house and in the
customer’s warehouse and additional steps in the
process to ensure that the integrity of the product
produced is maintained. It is the team’s responsi-
bility to review whether the containment action
taken already is appropriate and to modify the
action plan if needed.
Containment action is not a substitute for a
permanent solution. Most containment actions
are inspection in nature, are temporary Band-
Aids™, add cost, and are no substitute for a
permanent solution. The containment action
plan must be documented on the 8D form and
reviewed periodically.
D4—Root Cause Analysis
Finding the root cause is the most difficult part
of the 8D process. If this problem was simple and
easily solved, it would be resolved already. Two
types of variability exist that should be consid-
ered—special cause and random cause. Naturally,
we are interested in finding the special cause that
is deeply hidden in the process. The main reason
teams with subject-matter experts are formed is to
find the special cause.
Problem-solving tools are sometimes catego-
rized as soft or hard. The term “hard” here refers
to those using statistical analysis. In this book, we

concentrate on the following soft tools:
• Team brainstorming events
• Five whys process
• Flowcharts
• Checklists and check sheets
• Fishbone diagrams
Fortunately, these simple tools are easy to
learn and very effective in solving the majority
of problems. If the team is working on a com-
plex and more sophisticated problem, statistical
tools such as hypothesis testing, analysis of vari-
ance, and design of experiments are needed. In
these cases, a statistical expert should be engaged
with the team. In many situations, sophisticated
statistical tools will not be needed to solve the
problem. The key is to have all team members
engaged and contributing.
The root cause must be documented on the 8D
form and reviewed periodically.
D5—Develop Permanent Corrective Action
Once the root cause of the problem has been
identified, a number of corrections may be dis-
cussed. Scientific methods should be utilized to

screen for the best solution.
It is essential that the correction(s) are real-
istic, practical, cost-effective, and robust against
process variability. Error proofing the process is a
preferred method.
The team must ensure that the correction does
not create unintended consequences. At this stage,
the correction should be implemented on a small
scale to verify its effectiveness.
Permanent corrective action should be docu-
mented on the 8D form.
D6—Implement Permanent Corrective Actions
At this stage a permanent correction has been
verified. The next step is to validate the correction
on a large production scale. Again, the team needs
to ensure the correction does not create other
issues. All changes need to be documented and all
procedures updated. As the team implements the
permanent solution, other people will be affected
and need to be made aware of it and trained.
An environment needs to be created so that the
user(s) of the new method will have an opportu-
nity to participate and receive encouragement to do
so. All suggestions from other groups need to be
reviewed and, if valid, incorporated into the total
change process.
Implementation of permanent corrective action
should be documented on the 8D form.

D7—Prevent Future Reoccurrence
For a reasonable time, the team should monitor
whether the improved process is meeting all team
goals set at the onset and should ensure that the
ongoing performance metrics are not negatively
affected and are meeting all requirements. The
lessons learned from this effort should now be
leveraged on similar processes. All quality control
systems should now be in place and validated.
Permanent future reoccurrence effort should be
documented on the 8D form.
D8—Recognizing the Team
Once the team task is completed and results
meet all customer requirements, the team needs
to be formally recognized and thanked by the
management. The team members should thank
all others who helped it to succeed, and the team
members should complete all relevant paperwork
and publish their work for future use. Team focus
should focus on lessons learned and application to
similar processes.
At this time, the team is dissolved and members
wait for another opportunity to serve.
More Online

To examine a case study example, go to
www.asq.org/pub/jqp/. The online supplement also
demonstrates the application of the 8D documentation form.
References
1. Merriam Webster Online Dictionary,
(https://www.merriam-webster.com/dictionary/fad).
2. Iowa Quality Systems, “8D Documentation Form,”
http://www.iowaqualitysystems.com/.
Donald W. Benbow
Ali Zarghami
Donald W. Benbow is a principal at Iowa Quality
Systems. For nearly 30 years, he has conducted industrial
statistics courses for the employees of approximately 100
companies. He previously taught mathematics, statistics,
and quality assurance courses at Marshalltown Community
College. Benbow is an ASQ Certified Quality Auditor (CQA),
Quality Technician (CQT), Quality Engineer (CQE), and
Reliability Engineer (CRE). He is co-author of three other
books—The Certified Quality Technician Handbook,
The Certified Six Sigma Black Belt Handbook, and The
Certified Reliability Engineer Handbook. He can be
reached at [email protected]
Ali Zarghami is the CEO of Road Show Logistics LLC. For
more than 35 years, he worked in leadership positions in
product design and evaluation for a number of industries.
He specializes in application of statistics for quality,
warranty, regulatory, and agency requirements. Zarghami
has taught mathematics and business statistics at William
Penn University and has consulted in the application of
quality and reliability engineering internationally. He

is an ASQ Certified Quality Engineer (CQE), Reliability
Engineer (CRE), and Six Sigma Black Belt. For more
information on 8D problem solving, he can be contacted
at [email protected]
http://www.asq.org/pub/jqp/
https://www.merriam-webster.com/dictionary/fad
http://www.iowaqualitysystems.com/
Making the Case for Quality
Clean Approach Saves Global Pharmaceutical
Drug Manufacturer Time, Money
• A team-based Lean Six
Sigma project aimed
to reduce equipment
cleaning time.
• Using a variety of quality
tools, including process
mapping, brainstorming,
and root cause analysis,
the team created a new
cleaning procedure.
• Meeting all objectives,
the project resulted
in significant annual
cost savings.
• The team was named

a finalist in ASQ’s
International Team
Excellence Award Process.
At a Glance . . .
The cleaning procedure at Mallinckrodt Pharmaceuticals’ salts
facility in St. Louis, MO, was hindered
by significant bottlenecks. The fill, boil, and drain method, used
to clean the five 2,000-gallon produc-
tion tanks, was highly inefficient, resulting in rework and
reducing capacity. In fact, production in
this building had been on back order for more than a year; with
an average changeover time between
products of nearly three days, and a clean-out failure rate over
50 percent. Company leaders set out to
identify ways to improve the efficiency of the process.
About Mallinckrodt Pharmaceuticals
Mallinckrodt is a global specialty pharmaceutical business that
develops, manufactures, markets, and
distributes specialty pharmaceutical products and medical
imaging agents. The company’s Specialty
Pharmaceuticals segment includes branded and specialty generic
drugs and active pharmaceutical
ingredients, and the Global Medical Imaging segment includes
contrast media and nuclear imag-
ing agents. Mallinckrodt has approximately 5,500 employees
worldwide and commercial presence in
roughly 70 countries. The company’s fiscal 2013 revenue
totaled $2.2 billion.
Selecting the Project
To find impactful improvement projects,

Mallinckrodt uses a rigorous selection process
to evaluate which potential initiatives are most
directly linked to the company’s strategic
goals. Table 1 shows the various tools used in
the selection process.
The proposed project focused on procedures
for cleaning equipment after one product was
made and before employees could start manu-
facturing a different product. The process was
so time consuming and ineffective that it was
viewed as low-hanging fruit. “Any improve-
ment in the process would shorten the timeline
and allow additional time for manufacture of
actual product,” said lead validation engineer
Cindy Duhigg, “which is profit rather than
time wasted.”
by Janet Jacobsen
April 2014
ASQ www.asq.org Page 1 of 5
Table 1 – Data and quality tools play key roles
in project selection at Mallinckrodt.
Tools/data Why this is used
Project hopper To ensure that projects are aligned with
the company’s goals and objectives.
Gemba + To take management to the front lines
looking for waste and opportunities.
Brainstorming + To provide a wide range of ideas.

SWOT analysis + To evaluate each project’s
strength, weaknesses/limitations,
opportunities, and threats.
Affinity diagrams + To organize large sets of ideas produced
during the brainstorming sessions.
Takt To determine the time required per unit output.
Feasibility study To provide a historical background of
the project, description of the product,
accounting statements, details of the operation,
financial data, and legal requirements to
estimate the project’s chances of success.
Project rating To ensure the project has a
suitable cost-benefit ratio.
• Mohamed Razouk, operational excellence leader
• Josh Steele, manufacturing engineer technician IV
• Robyn Patrick, chemical technician III
• Bill Gast, process engineer
• Shirley Gause, lead operator
• Amy Slovacek, industrial engineer
• Josh Blough, production supervisor
• Athena Tanner, manufacturing engineer technician IV
• Bob Mohr, manufacturing maintenance
Using Quality Tools to Improve the Process
The first step in developing an effective improvement strategy
involved
pinpointing issues in the current process. Some of the quality

tools used
to accomplish this task are highlighted in Table 2. Of these
tools, root
cause analysis identified key drivers for the first-time right
issues and
revealed a 62 percent cleanout failure rate the team needed to
address.
Next, team members narrowed the list of potential
improvements by
analyzing data related to the current state. At this stage, process
maps
revealed several cycle-time issues within the batch records, and
these
issues were prioritized in a cause-and-effect matrix. Of the
possible
The primary factors that supported this project’s selec-
tion included the following:
• It was aligned with company strategy.
• The project would improve the health of the
business with cost savings through energy and
water conservation.
• It would afford the opportunity to increase
production capacity and reduce back orders.
• The implementation of modern technology would
yield a higher-quality cleaning process.
• It showed potential to eliminate rework and
promote a zero-defect culture.

Completing such an improvement project would
achieve the following organizational goals, key perfor-
mance indicators, and deployment strategies:
• Significant cost savings
• 20 percent waste reduction/five years
• No negative audit findings
• 10 percent cost-of-poor-quality reduction
• 20 percent increase in schedule attainment
• 75 percent decrease in backorders
• Promote zero-defect culture
After careful evaluation, the project was formally
selected in late 2011, and work began in January 2012.
Forming the Team
The company’s operational excellence training pro-
gram helps develop high-potential Green and Black
Belt candidates while also providing general aware-
ness and skills training for other staff members. This
program prepares employees to join various project
improvement teams. A diverse group representing
multiple disciplines was named to the improvement
team, including:
Improvement team
Table 2 – Quality tools helped identify potential improvement
opportunities in the cleaning process.
Tools used to
identify possible
improvements

What data was analyzed How analysis was performed
Process map Flowchart of entire process
including cycle times
Visual observation to detect
excessive complexity
Waste walk Facility and process were
observed during operation
Team documented areas of waste,
prompted by a standardized form
Brainstorming Group knowledge and experience Team and
technical subject
matter experts met to identify
potential improvements
Benchmarking Industry standards and practices Subject matter
experts provided
insight into most current solutions
Root cause
analysis
Process history and flowchart Causal relationships between
inputs and outputs were identified
improvements cited in the waste walk, five were significant
enough to war-
rant implementation. The team also utilized root cause analysis

to determine
which improvements might be most beneficial in solving the
bottlenecks in
the cleaning process.
Developing Strategies
To bring greater focus to possible improvement actions, three
evaluation methods
were used: value stream mapping (VSM) (see Figure 1),
screening experiments,
and benchmarking.
The maps clarified the steps needed to achieve the project’s
objectives.
They also verified the location of the bottlenecks in the process
and
where nonvalue-added waste was occurring, such as the time
needed to
clean out the tanks.
The value stream mapping for the current process allowed the
team to determine that an
entirely new procedure was necessary to satisfy the project’s
objectives. Team members
developed a five-part strategy, which consisted of the following
changes:
• Converting from a batch process where each tank was filled
and dumped
sequentially to a continuous process where tanks could be jet-
sprayed with a tank-
cleaning machine (from Gamajet).
• Externalizing process tasks such as using a heat exchanger to
provide hot water,

instead of filling the tanks, then heating the entire volume; and
draining the tanks
continuously while cleaning, instead of having to wait until
agitation was complete
before draining.
• Separating sample collections.
• Utilizing other water sources.
• Standardizing the process, labeling the lines, and providing
more detailed
batch records.
Sprayball
Screening experiments for differ-
ent tank-cleaning machines plotted
the cleaning efficacy against time
to determine whether a specific
sprayball could achieve the
required objectives. The data
collected from these experi-
ments prompted the purchase of
multiple sprayballs and manways
(used to access the tanks). Finally,
benchmarking activities allowed team
members to learn about past successes
to create a foundation for determining
the best solutions to decrease the clean-
out cycle time.
Gaps were analyzed between the

current and future state based on obser-
vations made during a changeover time
analysis. Eleven tasks were identified,
reducing the cleanout cycle time from
21 hours to 3.5 hours by implementing
the sprayball technique to blast away
contaminants and residues via high-
impact cleaning jets.
The team believed if they could imple-
ment a high-impact tank-cleaning
machine with a continuous water
stream, their solution would match
the project’s objectives and perhaps
provide even greater benefits. A new
rapid, continuous cleaning procedure
using a sprayball would address the fol-
lowing items:
• The long, 64-hour changeover time
• The low, 84 percent system
availability
• A task ratio of 60 internalized to
zero externalized tasks
• An operational equipment
effectiveness measure of 75 percent
Selecting Final
Solution

s
To gauge the effectiveness of the
proposed improvements, team
members collaborated with stake-
holders to compare possible results
of these actions against organiza-
tional goals. They determined the
Figure 1 — Current state VSM
improvements—particularly cycle-time reduction and improved
first-time right percentage—would have a positive effect.
Quality tools played a major role in the selection of the final
improvement actions, including:
• Failure mode effects analysis (FMEA) to analyze what issues
could arise with the improvements and what corrective
actions were necessary to mitigate any possible concerns.

• A cause-and-effect matrix narrowed the improvement list to
a manageable number of options.
• Engineering studies verified what sprayball option provided
the best, sustainable cleaning results.
The data analyzed included the specification needs of the tank-
cleaning machine and what benefits it could produce under the
projected conditions of use. The tank manway improvements
would need to withstand a specific temperature and provide a
perfect fit for the sprayball to clean the 2,000-gallon tanks effi-
ciently. In addition, the batch record cycle-time data was
studied
for ways to reduce steps, or shift steps, so specific steps could
be
completed simultaneously. Finally, piping changes were needed
in the manufacturing setting so specific dimensions were
analyzed
to ensure that the proposed changes would indeed work.
Reducing Cleaning Time, Saving Money
The five improvement actions—sprayball utilization, new man-
ways, new batch records, standardized work, and externalized
process tasks—were implemented as a week-long kaizen activ-

ity. Duhigg, an ASQ Certified Six Sigma Black Belt (CSSBB)
and Quality Auditor (CQA), says planning and the use of
detailed to-do lists were the keys to success during the week
of intense activity. During the kaizen week, the tank-cleaning
machine was qualified and the procedure was optimized. All
steps were standardized and the work was then captured in a
formal batch record to ensure the operation would be performed
in the same manner every time. This standardization would
drive the improvement actions to be sustained over time.
The new procedure, combined with the standardized work,
offers a means to ensure that the equipment is cleaned effec-
tively each time. Since the implementation of the improvements,
the average cleanout time (including two off-line tanks, which
could not be upgraded) is 27 hours compared to the previous
average of 64 hours, as shown in Figure 3.
Results
The reduced changeover time helped the Mallinckrodt focus
factory to introduce an additional product, not originally pro-
duced on this line. This added $700,000 in increased absorption,
or new product manufactured, as shown in Table 3.
Table 3 – Results attributed to the improvement project

were substantial.
Metric Baseline Results Change
Steam usage $938.70/year $469.35/year $469.35
Water/sewer usage $2,577.60/year $2,062.08/year $515.52
Additional production hours N/A +360 hours +$308,000/
360 hours
Additional absorption N/A +$700,000 +$700,000
Total yearly savings N/A N/A $1 million+
260,000
255,000
250,000
245,000
240,000

235,000
230,000
Current rate/month with
2.7 day cleanout
Future rate with cleanout time
reduction of 1.1 days
240,240
254,848
Line balance chart – Rate per month
Figure 2 — Cleanout time reduction
Summary: The takt time was being met by 240 lbs. at the
current state
production rate and current cleanout rate. By reducing the
cleanout time
with the implementation of the spray balls and standard work
the building
would be able to create 1.6 days of extra processing per month,

which
yield approximately 430 extra lbs./day or 13,000 lbs./month.
Figure 3 — Cleanout times (2010 to 2013)
160
140
120
100
80
60
40
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3
Cleanout times (2010 to 2013)
FTR% since new cleanout: 100%
Cleanout time

New
cleanout
introduced
The results had a direct impact on organizational goals as the
improvements reduced the number of cleaning failures nearly to
zero, eliminating as many as two to three cleaning reworks per
month. The project goal of promoting a zero-defect culture with
a first-time right measure of 100 percent was reached, showing
a 62 percent improvement. Also, nearly $2 million in
backorders
were completely eliminated at this focus factory, which led to
the inclusion of a new product into the schedule. In addition to
the tangible financial benefits, the newly installed manways not
only improve the facility’s current good manufacturing
practices,
but also eliminate the potentially dangerous situation in the pre-
vious process, when 2,000-gallon tanks full of water would be
heated to boiling and agitated, then abruptly dumped.

Duhigg said the company is now planning on implementing
improved cleaning processes throughout the site. “This project
was essentially a pilot for our 20 different focus factories,” she
said. “We are now going through and doing the same thing,
across the entire 44-acre St. Louis facility.”
Earning Recognition
This project’s inclusion in the ASQ International Team
Excellence Awards (ITEA) competition actually began on
somewhat of a whim. As a new ASQ member, Duhigg received
an email about the annual competition hosted at the World
Conference on Quality and Improvement (WCQI), and was
immediately intrigued. With support from Mallinckrodt’s Site
Leadership Team, and especially Operational Excellence and
Quality management, the team assembled their application. The
ASQ judges approved, and the project was named a finalist in
the 2012 competition. In May 2013, Duhigg and her colleague
Josh Blough presented the project at WCQI, along with repre-
sentatives of 31 other teams from around the world. She said
this project was a great match for the ITEA Process because of
the value it delivered to the organization, “The benefits were so
over-the-top, extravagantly obvious—$1 million a year,”

Duhigg
said, “the only question was, ‘Why didn’t we do it sooner?’”
For More Information
• To learn more about Mallinckrodt,
visit www.mallinckrodt.com
• For more about the Gamajet spray machine,
visit www.gamajet.com.
• For details on the International Team Excellence Award
Process, visit wcqi.asq.org/team-award/.
• To read more examples of quality success, visit the
ASQ Knowledge Center Case Studies landing page at
asq.org/knowledge-center/case-studies.
About the Author
Janet Jacobsen is a freelance writer specializing in quality and
compliance topics. A graduate of Drake University, she resides
in Cedar Rapids, IA.
http://www.mallinckrodt.com

http://www.gamajet.com
http://wcqi.asq.org/team-award/
http://asq.org/knowledge-center/case-studies

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