CHAPTER I

PROBLEM AND ITS SETTING

Community Health Nursing is a nursing practice outside the hospital which emphases on

the rural and far-off areas. A steadfast legacy observed by the College of Nursing of Ateneo de

Zamboanga University is the commitment in service of others. As a matter of fact, its vision

specifies that of “forming Men and Women for others who will bring about peace and

development by addressing the health needs of people in the city, the region, the nation and the

world.“(Ateneo de Zamboanga College of Nursing Policy Handbook, p. 7). Moreover, its

mission highlights on establishing in the said mentalities or beliefs of nursing students the

prominence of service to God and others through values such as spirituality and citizenship. With

the use of the expertise and capacities in which the students have, they will be able to succeed

excellence through focus, determination and their willpower to accomplish the goal that they are

up to.

During the 2nd week of duty, one of the researchers in Dona Maria Isabel C. Climaco

Health Center, it was observed that there a lot of old people who came by the health center to

have sputum examinations on the TB DOTS Center of the Health facility. It was observed then

that Mothers are bringing children during consultation with chief complaints of colds and

coughs. After that, the researcher noticed that there is a critical pathway on the health center

regarding the National Tuberculosis Program of the DOH. However, the critical pathway of the

NTP is not being utilized by the health center. Also, the system of the health center on how to

entertain clients is not okay even if there are flow charts that are visible on the health center

regarding the system on how to entertain clients.

Thus, in a local health center, Total Quality Management (TQM) must be practiced at all

times. It describes a management approach to long-term success through customer satisfaction.

In a TQM effort, all members of an organization participate in improving processes, products,

services, and the culture in which they work. TQM is considered a customer-focused process and

aims for continual improvement of business operations. It strives to ensure all associated

1
employees work toward the common goals of improving product or service quality, as well as

improving the procedures that are in place for production. Special emphasis is put on fact-based

decision making, using performance metrics to monitor progress. High levels of organizational

communication are encouraged, for the purpose of maintaining employee involvement and

morale.

As a requirement in Total Quality Management, a clearly specified list of problems is the

most suitable basis for identifying potential solutions. Problems can be identified, both now and

in the future, as evidence that objectives are not being achieved. However, objectives are often

rather abstract, and it may be easier for members of the public to understand a strategy based on

clearly identified problems. This problem-oriented approach to strategy formulation is an

alternative to starting with objectives, but does still need to be checked against the full list of

objectives.

1.1 Purpose/Rationale

As explicated, the conduct of problem identification and analysis is part of the approach

of the Ateneo de Zamboanga University College of Nursing in committing to the service of God

and Country. This is also done to determine the usage of the different quality improvement tools

that can be utilized to identify and analyze problems in the health center.

The Seven Basic Tools of Quality is a designation given to a fixed set of graphical

techniques identified as being most helpful in troubleshooting issues related to quality. They are

called basic because they are suitable for people with little formal training in statistics and

because they can be used to solve the vast majority of quality-related issues.

Most organizations use quality tools for various purposes related to controlling and

assuring quality. Although a good number of quality tools specific are available for certain

domains, fields and practices, some of the quality tools can be used across such domains. These

quality tools are quite generic and can be applied to any condition.

2
1.2 Review of the Related Literature

“Community” here refers to a group of people with a shared interest, including spatial,

political, social and economic interests. Orr (2007) defines community organizing as “the

process that engages people, organizations, and communities toward the goals of increased

individual and community control, political efficacy, improved quality of life, and social justice .

. . The central feature of community organizing is that it is a process and strategy designed to

build political power” (p. 2).

Duquesne University emphasizes that Health Management Systems is an integration of

healthcare, business management, and information systems. As the healthcare delivery system is

held to greater accountability, healthcare providers and entities must demonstrate quality

outcomes, fiscal responsibility, and efficient and effective practices.

Sullivan (2013) says that Healthcare organizations are continually battling conflicting

priorities. Our customers tell us they need to focus on delivering high quality patient care,

preventing infections, maintaining hospital security, and ensuring patient safety – all with

extremely stretched resources. Noncompliance with regulatory standards can lead to a disruption

in operations, poor quality of care, safety issues, and substantial fines. At the same time, as

energy demand rises, many countries are requiring healthcare facilities to reduce carbon output

and meet mandates for energy reductions.

Tuberculosis (TB) is a potentially serious infectious disease that mainly affects your

lungs. The bacteria that cause tuberculosis are spread from one person to another through tiny

droplets released into the air via coughs and sneezes. Tuberculosis (TB) is an infectious disease

usually caused by the bacterium Mycobacterium tuberculosis (MTB). Tuberculosis generally

affects the lungs, but can also affect other parts of the body. Most infections do not have

symptoms, in which case it is known as latent tuberculosis.

Acute respiratory infection is an infection that may interfere with normal breathing. It can

affect just your upper respiratory system, which starts at your sinuses and ends at your vocal

chords. It can also affect just your lower respiratory system, which starts at your vocal chords

3
and ends at your lungs.This infection is particularly dangerous for children, older adults, and

people with immune system disorders.

U.S. National Library of Medicine stresses that high blood pressure, also called

“hypertension,” is a serious medical condition. It happens when the force of the blood pumping

through your arteries is too strong. When your heart beats, it pushes blood through your arteries

to the rest of your body. When the blood pushes harder against the walls of your arteries, your

blood pressure goes up. Your blood pressure may be different at different times of the day. It is

usually higher when you first wake up, after you exercise, or when you are under stress. Having

higher blood pressure for short amounts of time is normal. However, when your blood pressure

stays high for most of the time, it can cause serious health problems (2017).

According to the American Heart Association (AHA), over time, a reading of 140/90

may require treatment. The top number signifies the pressure in the arteries, and the lower

number signifies the pressure between the heartbeats. High blood pressure doesn’t always

produce obvious symptoms. However, it causes progressive damage to arteries and veins, which

can interfere with blood flow throughout the body. This may lead to stroke, heart disease, and

heart failure. Other parts of the body, including the kidneys, limbs, and eyes, also may suffer

damage. (2014).

1.3 Statement of the Problem

This paper specifically aims to answer the following questions:

1. What are the problems of the said health center that need attention?

2. Which problems should be ranked, prioritized and addressed accordingly?

3. What are the actions and arrangements to implement to resolve the corresponding

problems?

4
1.4 Methodology

Before venturing into health centers, the researchers went to plan out on the different

things to do for the identification of the problems and analysis. The researchers first

brainstormed on the possible problems that the health center currently faces.

After the thorough research on the different quality tools, Affinity diagram was used to

identify common ideas of the researchers regarding the possible problems and solutions they

have thought during brainstorming.

Afterwards, Collection of data was initialized by going to the health center and asking for

the vital statistics for the year 2017. Also, the data that were collected were transcribed into line

graphs, bar graphs, and pie charts.

Next step taken was the ocular survey of Farmers Drive through home visit done by one

of the researchers of 20 families. The main research instrument used to achieve this is an

Assessment Database (ADB) which covers demographic, socio-economic and health related data

regarding the families. Selection of families was done randomly which definitely refers to

selecting respondents without any exact order or manner (random sampling). The data gathered

from the Assessment Database Base were gathered and organized to statistically characterize the

whole community of Farmers Drive in terms of the aspects involved in ADB.

After the gathering of the data, three concerns were identified by the community these are

as follows: (1) poor management system (2) acute respiratory infection, (3) hypertension and (4)

Pulmonary Tuberculosis. A Problem Tree diagram was used to identify the root cause and its

effects for the different problems that were discussed.

The researchers have thought of to develop a critical pathway through flowcharts for the

cases of tuberculosis which causes high morbidity rates in the health center. These critical

pathways are adapted from the different hospitals and health centers in the country. The use of

the control pathways will make an impact for the faster processing and for the initial system of

the health center.

5
 Other quality improvement tools are used to determine the problems and analyze more

the solutions to be used such as the histogram, radar chart, scatter plot diagram and etc.

1.5 Limitation of the Study

The paper is limited to Dona Maria Isabel Climaco Health Center and to the 20 families

of Farmers Drive, Sta. Maria. It precisely focuses on the problems identified by the researchers

which are the poor management system, tuberculosis, acute respiratory infection and

hypertension. This paper is limited only to identify and analyze the problems by utilizing the

different quality improvement tools in Total Quality Management.

1.6 Problem Identification

There are four tools that can be used to identify problems in the clinical setting; Affinity

Diagram, Brain Storming, Flowchart and Nominal Group Technique.

During the brainstorming activity of the researchers, we have found out that we should

focus on the problems such as the incidence of cases such as Tuberculosis, Acute Respiratory

Infection, Hypertension, and the Poor Management System of the community. With the

brainstorming conducted, we have utilized the Affinity Diagram. In which, an Affinity Diagram

is a tool that gathers large amounts of language data (ideas, opinions, issues) and organizes them

into groupings based on their natural relationships. The Affinity process is often used to group

ideas generated by Brainstorming.

Increasing cases of
Increasing Cases of Poor Management
Increasing cases of PTB Acute Respiratory
Hypertension System
Infection
•Poor usage of critical •Poor Home •High number of Old •"Palakasan" System
pathways Management (IMCI) Age people in the •Not following the
•Poor implementation •Common in Barangay Flowcharts that are
of DOH programs Squattered Areas due •Sedentary Lifestyle displayed in the health
•Poor early diagnosis to congestion •No "Bantay Presyon center
and prompt treatment •Common in children Program" in the •Lack of staff members
of PTB Barangay
•Low salience of the •Poor prompt
problem treatment for
Hypertension

Figure 1.1

Figure 1.1 shows the affinity diagram of the topics that were discussed during the

Brainstorming Activity. It is said that brainstorming is a group creativity technique by which

6
efforts are made to find a conclusion for a specific problem by gathering a list of ideas

spontaneously contributed by its members. Hence, the four major concerns were discussed and

the causes were identified. The Affinity diagram shows the cause-effect relationship.

With the four major problems that were identified, we have utilized another tool to see

the flow of the problem identification, tools to be used, priority ranking and solutions to be

made. Flowchart is Is a type of diagram that represents an algorithm, workflow or process. The

flowchart shows the steps as boxes of various kinds, and their order by connecting the boxes

with arrows. This diagrammatic representation illustrates a solution model to a given problem.

Flowcharts are used in analyzing, designing, documenting or managing a process or program in

various fields. Flowcharts are used in designing and documenting simple processes or programs.

Like other types of diagrams, they help visualize what is going on and thereby help understand a

process, and perhaps also find less-obvious features within the process, like flaws and

bottlenecks.

Problems of the Health Center

Gather data regarding the

Problems of the Health Center

Analyze the data and Prioritze

the problems accordingly

Make solutions based on the

given problems of the community

Figure 1.2

Figure 1.2 shows the flowchart series of the paper. The researchers thought of the process

that they should follow in order to identify the problems and make solutions on the identified

problems with a followed step-by-step process.

7
 With the given flowchart of the paper, the researchers thought of using the nominal group

technique. Nominal Group Technique is a group process involving problem identification,

solution generation, and decision making. It can be used in groups of many sizes, who want to

make their decision quickly, as by a vote, but want everyone's opinions taken into account (as

opposed to traditional voting, where only the largest group is considered).The method of tallying

is the difference. First, every member of the group gives their view of the solution, with a short

explanation. Then, duplicate solutions are eliminated from the list of all solutions, and the

members proceed to rank the solutions, 1st, 2nd, 3rd, 4th, and so on.

Problem Tally

ARI 1

Tuberculosis 3

Poor Management System 1

Hypertension 0

Figure 1.3

Based on the NGT, the group found out that based on their votes. They focused the

increasing cases of tuberculosis as the main problem of the research paper since that there is a

need to address the problem with Tuberculosis. However, they also thought of solving the poor

management system of the health center to further solve the other problems concerning all the

levels of clientele in the community.

Hence, the problems that were noticed are the focus of the paper and the data that were

gathered throughout the period of time.