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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.

From 2002 to 2011, coffee-machine manufacturer Keurig Incorporated had grown from a privately held company with just over $20 million in revenues and a plan to enter the single serve coffee arena for home consumers, to a wholly owned subsidiary of Green Mountain Coffee Roasters, Inc., a publicly traded company with net revenues of $1.36 billion and a market capitalization of between $8 and $9 billion. In 2003 Keurig had introduced its first At Home brewer. Now, approximately 25 percent of all coffee makers sold in the United States were Keurig-branded machines, and Keurig was recognized as among the leaders in the marketplace. The company had just concluded agreements with both Dunkin' Donuts and Starbucks that would make these retailers' coffee available for use with Keurig's specialized brewing system. The company faced far different challenges than when it was a small, unknown marketplace entrant. John Whoriskey, vice president and general manager of Keurig's At Home division, had to consider the impact that impending expiration of key technology patents and the perceived environmental impact of the K-Cup® portion packs would have on the company's growth. Whoriskey also wondered what Keurig's growth potential was, and how the new arrangements with Starbucks and Dunkin' Donuts could be leveraged to achieve it.