Ch.6 – The OM Blog by Heizer, Render, & Munson

OM in the News: Quality Problems in Hospital Internship Training

Giving residents less time on duty and more time to sleep was supposed to lead to fewer medical errors. But the latest research, says Time (March 26, 2013), shows that’s not the case. Since 2011, new regulations restricting the number of continuous hours 1st-year residents spend on call cut the time that trainees spend at the hospital from 24 to 16 hours. Excessively long shifts were leading to fatigue and stress that hampered not just the learning process, but the care these doctors provided.

But in a large new study that compared interns serving before the 2011 work-hour limit was implemented with interns working after the new rule, the number of medical errors the post-2011 doctors reported was higher than those among previous trainees. In the year before the new duty-hour rules took effect, 19.9% of the interns reported committing an error that harmed a patient, but this percentage went up to 23.3% after the new rules went into effect.

How could fewer hours lead to more errors? For one, interns were still expected to accomplish the same amount that previous classes had, so they had less time to complete their duties. This “work compression” increases the risk of errors or mistakes if residents don’t have as much time to make and recheck patient-care decisions. And the reduction in work hours has not been accompanied, for the most part, by increase in funding to off-load the work, so current interns have about 20 fewer hours/week to complete the same work. Another source of errors came as one intern going off duty handed his cases to another. With fewer work hours, the number of handoffs has increased from an average of 3 during a shift to as many as 9. Anytime a doctor passes on care of a patient to another physician, there is a chance for error in communicating complications, allergies, or other aspects of the patient’s health.

Discussion questions:

1. Relate this issue to the 10 determinants of service quality in Table 6.5 in the text.

2. What can be done from an OM perspective to improve the intern situation?

OM in the News: J&J’s Hip Implants Run 40% Defective

For a great case study in OM ethics and quality, the New York Times (Jan. 26, 2013) reports that an internal analysis conducted by Johnson & Johnson not long after its 2010 recall of a troubled hip implant (called the A.S.R.) estimated that the all-metal device would fail within 5 years in nearly 40% of patients who received it. J&J never released those projections for the device. And at the same time that the medical products giant was performing that analysis, it was publicly playing down similar findings from a British implant registry about the device’s early failure rate.

The company’s analysis also suggests that the implant is likely to fail prematurely over the next few years in thousands more patients in addition to those who have already had painful and costly procedures to replace it. The J&J analysis is among hundreds of internal company documents expected to become public as the first of over 10,000 lawsuits by patients who got an implant goes to trial this month. The episode represents one of the biggest medical device failures in recent decades. Last year, the company took a $3 billion special charge related to medical/legal costs associated with the device.

The A.S.R. belongs to a once-popular class of hip implants in which a device’s cup and ball component were both made of metal. Surgeons have largely abandoned using such devices in standard hip replacement because their components can grind together, releasing metallic debris that damages a patient’s tissue and bone. Hip implants, which are generally made from metal and plastic, often last for 15 years before they wear out and need to be replaced. The early replacement rate is typically 1% after a year, or 5% at five years.

J&J decided in 2009 to sell off its A.S.R. inventories just weeks after the F.D.A. demanded safety data about the implant. But the F.D.A. said J&J could not dump the device in the U.S. because of concerns about “high concentration of metal ions” in the blood of patients who received it.

Discussion questions:

1. Ask students to follow and report on the current status of the lawsuit.

2. What are the ethical implications of J&J continuing to sell the implant after British and F.D.A. studies warned of its dangers?

Guest Post: A Pareto Exercise Using M&M’s

Today’s Guest Post comes from Coleman R. Rich, who is Chair of Elon University’s Marketing and Entrepreneurship Department. Coleman is also Senior Lecturer in Operations and Supply Chain Management.

I used many quality tools in the textile industry before coming to academia and I wanted to create an exercise where students could understand the use of two common tools, the check sheet and the Pareto chart.

Here are the items needed: Blank check sheet, Graph paper, paper plates, and a 1.69 oz bag of M&M’s for each student.

Instructions: I tell the students they are finished goods inspectors and each color of M&M is a defect. They are to count the number of defects using tick marks and record that information on their check sheet. Then they are to rank each color from high number of occurrences to the lowest number of occurrences and calculate the cumulative percent. From this information, draw a Pareto Chart of the colors on the graph paper and correctly label the chart.

Discussion: After the exercise, I call on students to tell me the number of blue, green, orange, etc. defects in their bag and the total number of M&M’s in their bag. I record this information on the board for the class to see the randomness of the different colors in each bag. I focus on the total number of M&M’s in each bag which you’ll see will vary between 63 and 57 M&M’s per bag. This leads to a discussion of variation and SPC. I also discuss what is Critical to Quality to the manufacturer and the Consumer. Finally I have the students visually inspect the M&M’s for chips, cracks, shapes, etc., and ask why the Mars company doesn’t try to create a perfect M&M. I think you know the answer to that.

Dr. Matt Valle, Professor of Management, here at Elon University has taken this exercise a step further using other quality tools in our paper, “Quality Tools for Project Management: A Classroom Exercise” to be published in Business Education Innovation Journal, Vol. 4, No. 2, December 2012.

OM in the News: Toyota and “The Cost of Quality”

In our Chapter 6 discussion of the cost of quality (COQ), we note the external costs that occur after delivery of defective products (such as rework, liabilities, lost goodwill, etc.). Philip Crosby, author of Quality is Free, wrote that the cost of poor quality is understated and “there is absolutely no reason for having errors or defects in any product or service.” The New York Times (Oct. 10, 2012) article that Toyota just announced the recall of 7.4 million vehicles worldwide, including 2.5 million in the U.S., to repair power-window switches that can break down and start a fire , certainly brings Crosby’s ideas to the forefront for your class.

It was only 2-3 years ago that the company recalled more than 11 million cars to replace floor mats and sticky accelerator pedals. It has been seeking to reassure consumers about the quality of its vehicles since then. The recall could surely set back its efforts.

The vehicles affected in the U.S. include more than a million Camrys. Eight months ago, the National Highway Traffic Safety Administration opened an investigation into reports of smoke and fire coming from doors. During its investigation, the safety agency collected reports of 161 fires and of 9 injuries. In its news release, Toyota said there were “no crashes related to the recall,” but did not mention fires or injuries. Toyota said it originally wanted to conduct a “customer satisfaction campaign” but decided to pursue the recall after discussions with the agency. Toyota described the recall as voluntary, but under federal regulations once a manufacturer learns of a safety problem it must, within 5 business days, tell the safety agency of its plan for a recall or face a civil fine.

Discussion questions:

1. Will such recalls impact your students’ images of Toyota’s quality?

2. How does this compare to GE’s dishwasher recall several years ago in which the cost of repairs exceeded the value of all the machines?

OM in the News: Quality Control in Intensive Care Units

If you want an example of how the tools of OM can result in major improvements in the field of health care, read The Wall Street Journal (Sept. 11, 2012) article on the use of checklists in hospital intensive care units. A national patient-safety program, sparked by the death a decade ago of an 18-month-old child, reduced the rate of a deadly bloodstream infection by 40% in hospital ICUs.

The initiative, led by Johns Hopkins’ VP-Quality, Dr. Peter Pronovost, was implemented in more than 1,100 ICUs in 44 states. It took aim at bloodstream infections associated with catheters used to deliver drugs directly into patients’ major veins. The result of the effort was a reduction in the rate of infections to 1.137 per 1,000 days of catheter use, from 1.903, over the first 18 months that hospitals implemented the program. This cut represented at least 2,000 infections avoided, more than 500 lives saved and $34 million in health-care cost savings.

One professor who helped with the rollout of the program in Rhode Island, said the results are “dramatic.” Though the ideas in the program weren’t new, its developers “figured out how to bundle those best practices and insert them into the daily practice of nurses, physicians and other health-care professionals.”

Mortality for central-line infections in the U.S. is 12% to 25%. The CDC estimated there were around 18,000 of the infections in ICUs in 2009, down from 43,000 in 2001. The entire program is built on checklists like pilots use. Key practices on the checklist include hand washing, properly covering up care givers and patients when a catheter is inserted, and using the right disinfectant at the site of insertion. But equally important, according to Dr. Pronovost, were cultural changes, such as authorizing nurses to ensure that doctors adhere to the lists.

Discussion questions:

1. How else can operations management tools be used in ICUs?

2. Ask students to report on Dr. Pronovost’s book, Safe Patients, Smart Hospitals, which we described in this blog last year.

Good OM Reading: Big Medicine vs. The Cheesecake Factory

It was back in January, 2011 that we blogged about Dr. Atul Gawande’s excellent book on health care quality called The Checklist Manifesto . Gawande’s newest piece, “Big Med,”‘ which appears in the New Yorker (August 13, 2012) is an amazing read as you prepare to teach quality management in Chapter 6. He argues that healthcare can must learn from all high-reliable industries, from aviation, to pit crews, to construction, to the Cheesecake Factory.

Gawande writes: “In medicine, we are trying to deliver a range of services to millions of people at a reasonable cost and with a consistent level of quality. Unlike the Cheesecake Factory, we haven’t figured out how. Our costs are soaring, the service is typically mediocre, and the quality is unreliable. Every clinician has his or her own way of doing things, and the rates of failure and complication (not to mention the costs) for a given service routinely vary by a factor of 2 or 3, even within the same hospital. Big chains thrive because they provide goods and services of greater variety, better quality, and lower cost than would otherwise be available. Size is the key. It gives them buying power, lets them centralize common functions, and allows them to adopt and diffuse innovations faster than they could if they were a bunch of small, independent operations. Such advantages have made Wal-Mart the most successful retailer on earth.”

Physicians, though, have been mostly self-employed, working alone or in small private-practice groups. But that’s changing. Hospitals and clinics have been forming into large conglomerates. And physicians—facing escalating demands to lower costs, adopt expensive information technology, and account for performance—have been flocking to join them. Only 1/4 of U.S. doctors are now self-employed—an extraordinary turnabout from a decade ago, when over 50% were independent.

Enjoy Gawande’s description of his tour of The Cheesecake Factory’s kitchen and the disheartening comparison to a hospital’s medical operations. It’s a good 15 minute investment of your time.

Teaching Tip: Teaching Quality Inspection Using Chickens

In Chapter 6, our favorite line when discussing inspection is: “Quality cannot be inspected into a product.” What better way to discuss this important topic with your students than the controversial move by the USDA last week to streamline chicken inspection by cutting by 75% the number of government inspectors who eye chicken carcasses for defects. The Los Angeles Times (June 6, 2012) reports that the USDA move to let chicken slaughterhouses run production lines 25% faster is angering food safety advocates and poultry plant workers.

The USDA says it can eliminate 800 inspector positions and save the federal government $30 million a year. Consumer advocates said the rising rates of salmonella infection in recent years should give pause to any plans to cut the number of inspectors. But in testing its relaxed rules at 25 poultry slaughterhouses, the USDA found little difference with conventional plants in the instances of salmonella and other diseases. “The test plants performed exceptionally well”, the department said. (In other words, more inspection did not equal more quality.)
Under existing rules, the production line can move as fast as 140 birds a minute. Four federal inspectors positioned along the line inspect carcasses and remove those that have visual defects. No single inspector inspects more than 35 birds a minute. The relaxed rules allow lines to speed to 175 birds per minute while relying on plant employees to spot defective carcasses and pull them from the line. They then move past a single line inspector.

The CDC estimates that there are 1.2 million incidents of salmonella illness each year–and growing. When Consumer Reports tested 382 broiler chickens bought from grocery stores, 14% were found to contain salmonella. The union that represents poultry workers said the new rules would mean “more danger on the job.” The industry’s worker injury rate already is about a third higher than the average for all manufacturing industries. They often are prone to back problems, and 59% of line workers already have carpal tunnel syndrome — at line speeds of 70 to 91 birds a minute.

This story can make for a good Ethical Dilemma exercise as well.

OM in the News: Hospital Quality Rising–But 1 in 20 Patients Gets a Dangerous Infection

“Nationwide,” writes The Wall Street Journal (June 5,2012), ” about one in 20 patients entering a hospital will get a potentially deadly infection, accounting for some $33 billion in preventable costs.” Dangers lurk not only in vulnerable places like operating rooms, but from sink faucets and TV remote controls, which can harbor the most deadly bacteria. (By the way, it is not just hospitals that transmit deadly germs. TV remotes are now being sanitized and plastic-wrapped in 2,200 Best Western Hotels).

For decades, US hospitals have based room cleaning quality on visual checks. These “are no longer sufficient,” says the infection prevention director at New Jersey’s Hunterdon Medical Center. That hospital conducts random audits of 300 surfaces a month with a new swabbing device (shown in photo). Over 95% of checks get a passing grade, up from only 75% 3 years ago. Hunterdon also cut its rate of C. diff (Clostridium difficile) infections by 79% and reduced MRSA infections by 66% in the past 5 years. A bug called VRE that was on the rise for several years dropped 23% at Hunterdon last year. (C.diff is linked to 14,000 US deaths a year.)

Helping to spur action, the US government has set a goal of reducing hospital infections and other preventable problems by 40% by next year from 2010 levels. Medicare has stopped paying to treat some infections acquired in the hospital. And facilities with the highest rates of hospital-acquired conditions will face reduced federal payments starting in 2015.

What are hospitals doing? We now know that C. diff can survive for weeks on a doorknob, alcohol-based sanitizers don’t kill it, and hand washing is not sufficient. Cleaning crews need to use bleach and hydrogen peroxide, rooms have to be scrubbed carefully (even in corners), and “high-touch” surfaces carefully disinfected.

Discussion questions:

1. Why haven’t hospitals mastered quality control of cleaning?

2. How can the tools in Chapter 6 be used in this process?

3. Is 95% cleaning quality sufficient?

OM in the News: Pink Slime and Lean Hospitals

The public is continually subjected to health-related scares, from food packaging to water bottles that contain BPA, a chemical that has been linked to cancer. The media also highlights food additives that are not really harmful, but just sound unappetizing, such as “pink slime” in ground beef and the use of dried insects to color beverages at Starbucks. Yet, according to The Reporter (May 10, 2012), our nation’s hospitals are the one place where people actually have the most reasons to be scared and to demand change.

Studies estimate that 100,000 Americans die each year from preventable medical errors and another 100,000 die as the result of hospital-acquired infections. This health-care safety problem can be tackled with the OM tools of lean and TQM. We see this in one of our text’s most popular video case studies, “The Culture of Quality at Arnold Palmer Hospital”– worth showing when teaching Chapter 6.

The good news is that a growing number of hospitals are dramatically reducing different types of preventable errors, including patient falls, bedsores, wrong-site surgeries and medication mistakes, using the principles of lean (Chapter 16). Dr. Richard Shannon helped his Pittsburgh hospital achieve, in just 90 days, a 95 percent reduction in deaths caused by central-line-associated blood-stream infections–through improved teamwork and making sure the correct supplies are always readily available. Because these improvements do not rely on expensive technology or years of specialized training, they can be replicated in any hospital.

A 2010 survey, however, shows the bad news–that most hospitals are not devoting time or resources to prevent central-line infections, which claim 30,000 lives annually. And these hospital-acquired infections cost the U.S. about $30 billion a year in unnecessary medical expenses.

Discussion questions:

1. What OM tools in Chapter 6 can be applied to help prevent infections in hospitals?

2. After watching the video, what does Arnold Palmer Hospital do to maintain quality?

OM in the News: Building a Reputation for Quality No Easy Task for Chrysler

As we discuss in Chapter 6, quality can take on a wide range of attributes. For auto makers, and their customers, these attributes range from safety, to the choice of interior materials, to the way parts fit together—all of which affect perceptions of a brand. The Wall Street Journal (May 10, 2012) reports the bad news for Chrysler–that through bailouts and bankruptcy, there is one liability that the automaker hasn’t yet managed to shed: its reputation for lousy quality. “You can lose your reputation in a year, but it takes five to 10 years to rebuild it,” says the director of the Consumer Reports.

Despite surging sales, the auto maker remains dogged by a long trail of recalls, customer complaints and poor ratings on quality surveys. In 2008, the London Times proclaimed Chrysler’s now-discontinued Sebring “almost certainly the worst car in the entire world.” The Journal quotes Chrysler’s quality chief, Doug Betts, as saying: “We were building cars that were functional, and other than that, they were boxes you got into that hopefully kept the rain off your head.”

But today, dealers, customers and independent reviewers say Chrysler’s efforts are starting to pay off, with better finishes and higher quality scores on new models such as the Jeep Grand Cherokee SUV and 300 sedan. Last year, the brands earned their highest ratings in years in Consumer Reports’ annual reliability survey, rising from the bottom of the pack to the middle. That year, Betts used his new authority to delay a restyled Chrysler 300 after inspection of a prototype found a right rear tail light that wasn’t flush with the body. The one-millimeter projection was hardly visible, Betts said, but it was enough to “catch a rag if someone was hand-washing” the car.

Discussion questions:

1. Why is a quality reputation easy to lose, but hard to gain?

2. What caused Chrysler’s reputation to drop?

OM in the News: Infection Rates and the Outsourcing of Hospital Cleaning

The Vancouver Sun (May 7,2012) has just reported another outbreak of infection rates at Canadian hospitals. The article states that health authorities have been warned for 10 years or more that the outsourcing of hospital cleaners – key personnel in any infection prevention and control program – was a misguided attempt to save money and would put patients at risk. In 2004, incidents at Surrey Memorial Hospital concluded that infection prevention had completely broken down. An auditor-general’s 2007 review found that the ministry of health had failed to implement systems for the prevention and control of infection.

Things heated up in 2009 when Vancouver released reports from its Centre for Disease Control (CDC) on a persistent and lethal infection out-break at Nanaimo Regional General Hospital, the third in four years. The CDC found that: “There were insufficient numbers of cleaning staff to meet the basic daily needs of the facility and they were not adequately trained in appropriate cleaning procedures for a health care facility. They were not able to meet the increased demand for environmental cleaning that is required to control an outbreak.”

Best practices in infection prevention programs highlight the vital role of hospital cleaning: adequate staffing and training, proper equipment and supplies, and real communication and cooperation among hospital personnel at all levels. None of these factors are included in the government-ordered cleaning audits (which were confined to visual inspections only) that report hospitals passing with flying colors even while infection outbreaks were raging.

Scotland banned the outsourcing of hospital housekeeping in 2008 and brought cleaning back in house. The result? Infection cases have dropped dramatically. Reviews of Ontario’s devastating 2003 SARS outbreak named hospital cleanliness as a critical component in preventing and containing infections, and hospital cleaners’ involvement essential.

Discussion questions:

1. Why are janitorial services successfully outsourced in most organizations, but not here?

2. What OM tools are available to address this quality issue?

OM in the News: Quality and the Dreamliner

When we discuss quality in Chapter 6, we note that there are 3 views of the term. The 1st is user-based — quality “lies the eyes of the beholder.” The 2nd is manufacturing-based–conforming to standards. And the 3rd is product-based–quality is a “precise and measurable variable”. The Wall Street Journal’s article ( Feb.16,2012), “How Dreamy is the Dreamliner”, covers all three in analyzing Boeing’s new 787, which is now in its 4th month of service and flying daily from Tokyo to Frankfurt for All Nippon Airways.

To passengers (users), the plane approaches a revolution in air travel with better cabin climate, less airsickness, reduced jet lag, and fewer headaches. The humidity level is a more breathable 10-15%, vs. 4-7% for existing planes. The cabin pressurizes at 6,000 feet vs. 8,000 feet on others. Overhead bins are 2 inches larger. Big windows help reduce motion sickness, and a new stability system makes for a smoother ride in turbulence. Cabin attendants even claim the atmosphere is much better for their skin.

From a manufacturing perspective, the body of the plane, constructed from super-strong plastics — carbon fibre composite materials — instead of aluminum, makes the plane lighter and more fuel-efficient. And the number of holes drilled in the fuselage (under 10,000 vs. 1 million in a 747) means better aerodynamics.

The products-based view of quality can claim a plane that flies at Mach .85, compared to Mach .785 for a Boeing 737. Fuel efficiency and emissions are 20% better than on a similar-sized 767.

Discussion questions:

1. Did Boeing’s continuing supply chain problems on the 787 impact the plane’s quality?

2. Which aspect of quality is most important to Boeing? To the airline buying the 787? To the passenger?

OM in the News: The Fall and Rise of Quality in American Cars

An interesting perspective on the quality (or lack thereof) of American-made autos comes from the Fort Worth Star-Telegram (Feb.10,2012). For decades we have bemoaned quality problems in the industry, but until recently the situation was simply considered normal. It goes back to around 1915, when GM’s chief production guy told a reporter that his new model “would boast massive improvements.” When queried for details, he replied that Chevys would now have a mesh screen under the motor that “would catch all the screws and parts that came loose while driving.” Even as late as 1949, it was common knowledge that a Ford could not be taken through a car wash without its occupants being drenched.

And surprisingly, when MIT did its famous 5-year study of the auto industry, which was published as The Machine That Changed the World, it was pointed out that Mercedes put more man-hours into fixing vehicles after production than Lexus needed to build one of its flagship sedans–which had zero problems leaving the assembly line. Of course, it was the auto workers who would take most of the blame for the lack of quality in their cars. But for the most part, it was mediocre engineering –not just in vehicle design, but in factory layout as well. How else can you explain how Buicks occasionally ended up with Chevy dashboards installed–and that GM would refuse to replace them when the errors were discovered at the dealer showroom.

Perhaps the greatest untold automotive story this decade is that no company builds a bad car anymore. Thanks to the integration of Japanese design and production techniques, we will never see a car produced whose A/C compressor falls off or whose fenders come in different colors. Just as Mercedes had to compare itself to Lexus, GM and Ford had to measure up to Honda and Toyota–and to accept the principles of Japanese engineering.

Discussion questions:

1. Why is poor quality accepted in any product?

2. Has US auto manufacturing reached quality levels equal to Japan and Germany?

OM in the News: How Alaska and Delta Airlines Reengineered Quality Control

If you fly a lot, you will want to read this article in The Wall Street Journal (Jan.5, 2012) and use it in class when you cover the topic of Managing Quality (Ch.6). It begins by dealing with American Airlines, which ranked dead last (again) in customer service in the Journal’s annual analysis of major air carriers. The score card ranks airlines on on-time arrivals, delays, cancelled flights, missing bags, bumped passengers , and complaints filed with the DOT.

Alaska Airlines, which overhauled its operations in 2007 after several dismal years of reliability came in 1st in 4 of the 7 key operational areas. What did it do to change? For one thing, Alaska has set 50 internal quality checkpoint standards on a timeline for each departure. Flight attendants have to be on board 45 min. before departure; agents must board the 1st passenger 40 min. before departure; 90% of passengers need to be boarded 10 min. before departure; the cargo door must be opened 3 min. after arrival; the 1st bag has to be on the conveyor belt within 15 min. of arrival; and so on with 45 other measures for which data are collected on every flight.

Similarly, Delta engineered a major operational turnaround last year after coming in 2nd worst in punctuality and baggage handling and worst in cancelled flights and customer complaints. It has opened maintenance operations in 9 new cities to keep more its fleet ready to fly. It has also invested in a new baggage system and new technology in its operations control center. “There are a lot of side benefits of running a good, clean operation”, says Delta’s VP-Operations.

Discussion questions:

1. Why do some airlines, like Jet Blue, have a terrible problems with delayed flights, while others, like Alaska, do not?

2. What quality measures would students select to monitor besides the ones mentioned here?

OM in the News: Harada–How America Can Fight Against Low-Cost Labor in China

Norman Bodek has visited Japan 78 times to study the Japanese continuous-improvement philosophy. On his most recent trip Bodek met with Takashi Harada, who has developed the ultimate recipe for competing against low-cost labor in China and India. The Harada Method, reported in IndustryWeek (Oct.25,2011), is one part monozukuri (or product excellence) and one part hitozukuri (or people excellence), and is steeped in respect for people. The Harada Method is designed to help shop-floor workers develop their skills and capabilities–on their own.

The key, says Bodek, is “self-reliance”, where “you, the worker can make a decision for yourself and your company and for your customer that is right. This is missing in so many American corporations. You call a company and the first thing you get is ‘ This call is being recorded’ . Why are they recording it? They don’t trust their people, and they don’t empower them to be trusted”.

The Harada Method, already taught to 55,000 managers at 380 companies in Japan, is enormously popular there because Japan (like the US) is struggling to compete with low-cost labor in China and other emerging economies.

Through the method, workers are encouraged to pick a skill that they’d like to master, and to set goals to help them accomplish it. Employees write down their goals, create a step-by-step plan to attain them, measure themselves against their goals and receive feedback and guidance. To achieve hitozukuri, managers provide lifelong training and mentoring of employees. “What I’m trying to do is get American mangers to focus on their people — recognizing that developing people doesn’t even cost you anything. It doesn’t”, says Bodek.

Discussion questions:

1. Compare the Harada Method to some of the quality improvement philosophies used in the US.

2. How can ordinary people become heroes in their own lives, and how does this apply to the factory floor?