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Learning outcomes are as follows: students will discover the importance of process orientation in management; students will determine the root cause of the problem by applying root cause analysis technique; students will identify the failure modes, analyze their effect, score them on a scale and prioritize the corrective action to prevent the failures; students will analyze the processes and propose error-proof system/s; and students will analyze organizational culture and ethical issues.

Purpose: This case study is intended as a class-exercise, for students to discover the importance of process-orientation in management, analyze the ethical dilemma in health care and to apply quality management techniques, such as five-why, root cause analysis, failure mode and effect analysis (FMEA) and error-proofing, in the management of the health-care and service industry. Design/methodology/approach: A voluntary reporting of a case of “radiation overdose” in a hospital’s radio therapy treatment unit, which led to an ethical dilemma. Consequently, a study was conducted to establish the causes of the incident and to develop a fail-proof system, to avoid recurrence. Findings: After careful analysis of the process-flow and the root causes, 25 potential failure modes were detected and the team had assigned a risk priority number (RPN) for each potential incident, selected the top ten RPNs and developed an error-proofing system to prevent recurrence. Subsequently, the improvement process was carried out for all the 25 potential incidents and a new control mechanism was implemented. The question of ethical dilemma remained unresolved. Research limitations/implications: Ishikawa diagram, FMEA and Poka-Yoke techniques require a multi-disciplinary team with process knowledge in identifying the possible root causes for errors, potential risks and also the possible error-proofing method/s. Besides, these techniques need frank discussions and agreement among team members on the efforts for the development of action plan, implementation and control of the new processes. Practical implications: Students can take the case data to identify root cause analysis and the RPN (RPN = possibility of detection × probability of occurrence × severity), to redesign the protocols, through systematic identification of the deficiencies of the existing protocols. Further, they can recommend quality improvement projects. Faculty can navigate the case session orientation, emphasizing quality management or ethical practices, depending on the course for which the case is selected.

MBA or PG Diploma in Management – health-care management, hospital administration, operations management, services operations, total quality management (TQM) and ethics.

Teaching Notes are available for educators only.

CSS 9: Operations and Logistics.

This case is the second of a three-part series that follows the managerial, strategic, and communications decisions of the Swachh Bharat Mission (SBM) or Clean India Mission, the flagship programme of the Government of India to eliminate the practice of open defecation (i.e., not using a toilet) from 2014 to 2019. As of 2014, 550 million people in India practiced open defecation. This problem posed a massive public health hazard and economic drag for the country as well as a threat to global health. Written from an insider's perspective, the cases centre on the decisions made by a new Secretary of India's Ministry of Drinking Water and Sanitation, who was hired to manage SBM, and the team he assembled. Case B discusses the start-up challenges for SBM, including implementation in India's complex federal system, workplace culture, and the deep-rooted behaviour of open defecation in rural India and the managerial and communication strategies formulated to address them. The case concludes by framing the difficulties with slow-moving states and monitoring rigour that the leadership SBM, with a new team, strategic focus, and early momentum, faced as the mission entered its final two years.

An instructor could link the case to lean production principles and Kurt Lewin’s change management model, key reading materials on these theories are, namely,  Lewin, K (1947) Frontiers in group dynamics: concept, method and reality in social science; equilibrium and social change. Human Relations 1(1): 5–41  Stewart, J. (2012). The Toyota Kaizen continuum: a practical guide to implementing lean. Boca Raton, FL: CRC Press. Wickramasinghe, V. and Wickramasinghe, G. L. D. (2020). Effects of human resource management practices, lean production practices and lean duration on performance. The International Journal of Human Resource Management, 31(11), 1467–1512.

This case was developed from both primary and secondary sources. The primary source included three face to face meetings with Mr CK in University Putra Malaysia (two meetings) and WSAE factory (Rawang, Malaysia – one meeting), respectively. Interviewed three workers at Rawang factory. The secondary source was taken from the company website and company reports.

Dr Wan, the Chief Executive Officer of WSA Engineering Sdn Bhd (WSAE) accepted the invitation from Small Medium Industries Development Corporation to participate in a Malaysian-Japanese Industry Cooperation program that focused on Lean Production System (LPS). Dr Wan was worried about Malaysia’s culture incompatible with Japanese-originated LPS. The case shares how the organization and behavioral change took place, for LPS buy-in. Successes and challenges WSAE faced in the 10-year journey of implementing LPS were elaborated.

This case was written for use in an operations management course, on the topic of lean production. It can also be used as a training material targeting the operation managers of a manufacturing company aiming to implement lean production or any change management process.