case study of quality problem

• Browse All Articles
• Newsletter Sign-Up

• 11 Apr 2023
• Cold Call Podcast

A Rose by Any Other Name: Supply Chains and Carbon Emissions in the Flower Industry

Headquartered in Kitengela, Kenya, Sian Flowers exports roses to Europe. Because cut flowers have a limited shelf life and consumers want them to retain their appearance for as long as possible, Sian and its distributors used international air cargo to transport them to Amsterdam, where they were sold at auction and trucked to markets across Europe. But when the Covid-19 pandemic caused huge increases in shipping costs, Sian launched experiments to ship roses by ocean using refrigerated containers. The company reduced its costs and cut its carbon emissions, but is a flower that travels halfway around the world truly a “low-carbon rose”? Harvard Business School professors Willy Shih and Mike Toffel debate these questions and more in their case, “Sian Flowers: Fresher by Sea?”

• 17 Sep 2019

How a New Leader Broke Through a Culture of Accuse, Blame, and Criticize

Children’s Hospital & Clinics COO Julie Morath sets out to change the culture by instituting a policy of blameless reporting, which encourages employees to report anything that goes wrong or seems substandard, without fear of reprisal. Professor Amy Edmondson discusses getting an organization into the “High Performance Zone.” Open for comment; 0 Comments.

• 27 Feb 2019
• Research & Ideas

The Hidden Cost of a Product Recall

Product failures create managerial challenges for companies but market opportunities for competitors, says Ariel Dora Stern. The stakes have only grown higher. Open for comment; 0 Comments.

• 31 Mar 2018
• Working Paper Summaries

Expected Stock Returns Worldwide: A Log-Linear Present-Value Approach

Over the last 20 years, shortcomings of classical asset-pricing models have motivated research in developing alternative methods for measuring ex ante expected stock returns. This study evaluates the main paradigms for deriving firm-level expected return proxies (ERPs) and proposes a new framework for estimating them.

• 26 Apr 2017

Assessing the Quality of Quality Assessment: The Role of Scheduling

Accurate inspections enable companies to assess the quality, safety, and environmental practices of their business partners, and enable regulators to protect consumers, workers, and the environment. This study finds that inspectors are less stringent later in their workday and after visiting workplaces with fewer problems. Managers and regulators can improve inspection accuracy by mitigating these biases and their consequences.

• 23 Sep 2013

Status: When and Why It Matters

Status plays a key role in everything from the things we buy to the partnerships we make. Professor Daniel Malter explores when status matters most. Closed for comment; 0 Comments.

• 16 May 2011

What Loyalty? High-End Customers are First to Flee

Companies offering top-drawer customer service might have a nasty surprise awaiting them when a new competitor comes to town. Their best customers might be the first to defect. Research by Harvard Business School's Ryan W. Buell, Dennis Campbell, and Frances X. Frei. Key concepts include: Companies that offer high levels of customer service can't expect too much loyalty if a new competitor offers even better service. High-end businesses must avoid complacency and continue to proactively increase relative service levels when they're faced with even the potential threat of increased service competition. Even though high-end customers can be fickle, a company that sustains a superior service position in its local market can attract and retain customers who are more valuable over time. Firms rated lower in service quality are more or less immune from the high-end challenger. Closed for comment; 0 Comments.

• 08 Dec 2008

Thinking Twice About Supply-Chain Layoffs

Cutting the wrong employees can be counterproductive for retailers, according to research from Zeynep Ton. One suggestion: Pay special attention to staff who handle mundane tasks such as stocking and labeling. Your customers do. Closed for comment; 0 Comments.

• 01 Dec 2006
• What Do You Think?

How Important Is Quality of Labor? And How Is It Achieved?

A new book by Gregory Clark identifies "labor quality" as the major enticement for capital flows that lead to economic prosperity. By defining labor quality in terms of discipline and attitudes toward work, this argument minimizes the long-term threat of outsourcing to developed economies. By understanding labor quality, can we better confront anxieties about outsourcing and immigration? Closed for comment; 0 Comments.

• 20 Sep 2004

How Consumers Value Global Brands

What do consumers expect of global brands? Does it hurt to be an American brand? This Harvard Business Review excerpt co-written by HBS professor John A. Quelch identifies the three characteristics consumers look for to make purchase decisions. Closed for comment; 0 Comments.

MBA Knowledge Base

Business • Management • Technology

Home » Management Case Studies » Case Study: Quality Management System at Coca Cola Company

Case Study: Quality Management System at Coca Cola Company

Coca Cola’s history can be traced back to a man called Asa Candler, who bought a specific formula from a pharmacist named Smith Pemberton. Two years later, Asa founded his business and started production of soft drinks based on the formula he had bought. From then, the company grew to become the biggest producers of soft drinks with more than five hundred brands sold and consumed in more than two hundred nations worldwide.

Although the company is said to be the biggest bottler of soft drinks, they do not bottle much. Instead, Coca Cola Company manufactures a syrup concentrate, which is bought by bottlers all over the world. This distribution system ensures the soft drink is bottled by these smaller firms according to the company’s standards and guidelines. Although this franchised method of distribution is the primary method of distribution, the mother company has a key bottler in America, Coca Cola Refreshments.

In addition to soft drinks, which are Coca Cola’s main products, the company also produces diet soft drinks. These are variations of the original soft drinks with improvements in nutritional value, and reductions in sugar content. Saccharin replaced industrial sugar in 1963 so that the drinks could appeal to health-conscious consumers. A major cause for concern was the inter product competition which saw some sales dwindle in some products in favor of others.

Coca Cola started diversifying its products during the First World War when ‘Fanta’ was introduced. During World War 1, the heads of Coca Cola in Nazi Germany decided to establish a new soft drink into the market. During the ongoing war, America’s promotion in Germany was not acceptable. Therefore, he decided to use a new name and ‘Fanta’ was born. The creation was successful and production continued even after the war. ‘Sprite’ followed soon after.

In the 1990’s, health concerns among consumers of soft drinks forced their manufactures to consider altering the energy content of these products. ‘Minute Maid’ Juices, ‘PowerAde’ sports drinks, and a few flavored teas variants were Coca Cola’s initial reactions to this new interest. Although most of these new products were well received, some did not perform as well. An example of such was Coca Cola classic, dubbed C2.

Coca Cola Company has been a successful company for more than a century. This can be attributed partly to the nature of its products since soft drinks will always appeal to people. In addition to this, Coca Cola has one of the best commercial and public relations programs in the world. The company’s products can be found on adverts in virtually every corner of the globe. This success has led to its support for a wide range of sporting activities. Soccer, baseball, ice hockey, athletics and basketball are some of these sports, where Coca Cola is involved

The Quality Management System at Coca Cola

It is very important that each product that Coca Cola produces is of a high quality standard to ensure that each product is exactly the same. This is important as the company wants to meet with customer requirements and expectations. With the brand having such a global presence, it is vital that these checks are continually consistent. The standardized bottle of Coca Cola has elements that need to be checked whilst on the production line to make sure that a high quality is being met. The most common checks include ingredients, packaging and distribution. Much of the testing being taken place is during the production process, as machines and a small team of employees monitor progress. It is the responsibility of all of Coca Colas staff to check quality from hygiene operators to product and packaging quality. This shows that these constant checks require staff to be on the lookout for problems and take responsibility for this, to ensure maintained quality.

Coca-cola uses inspection throughout its production process, especially in the testing of the Coca-Cola formula to ensure that each product meets specific requirements. Inspection is normally referred to as the sampling of a product after production in order to take corrective action to maintain the quality of products. Coca-Cola has incorporated this method into their organisational structure as it has the ability of eliminating mistakes and maintaining high quality standards, thus reducing the chance of product recall. It is also easy to implement and is cost effective.

Coca-cola uses both Quality Control (QC) and Quality Assurance (QA) throughout its production process. QC mainly focuses on the production line itself, whereas QA focuses on its entire operations process and related functions, addressing potential problems very quickly. In QC and QA, state of the art computers check all aspects of the production process, maintaining consistency and quality by checking the consistency of the formula, the creation of the bottle (blowing), fill levels of each bottle, labeling of each bottle, overall increasing the speed of production and quality checks, which ensures that product demands are met. QC and QA helps reduce the risk of defective products reaching a customer; problems are found and resolved in the production process, for example, bottles that are considered to be defective are placed in a waiting area for inspection. QA also focuses on the quality of supplied goods to Coca-cola, for example sugar, which is supplied by Tate and Lyle. Coca-cola informs that they have never had a problem with their suppliers. QA can also involve the training of staff ensuring that employees understand how to operate machinery. Coca-Cola ensures that all members of staff receive training prior to their employment, so that employees can operate machinery efficiently. Machinery is also under constant maintenance, which requires highly skilled engineers to fix problems, and help Coca-cola maintain high outputs.

Every bottle is also checked that it is at the correct fill level and has the correct label. This is done by a computer which every bottle passes through during the production process. Any faulty products are taken off the main production line. Should the quality control measures find any errors, the production line is frozen up to the last good check that was made. The Coca Cola bottling plant also checks the utilization level of each production line using a scorecard system. This shows the percentage of the line that is being utilized and allows managers to increase the production levels of a line if necessary.

Coca-Cola also uses Total Quality Management (TQM) , which involves the management of quality at every level of the organisation , including; suppliers, production, customers etc. This allows Coca-cola to retain/regain competitiveness to achieve increased customer satisfaction . Coca-cola uses this method to continuously improve the quality of their products. Teamwork is very important and Coca-cola ensures that every member of staff is involved in the production process, meaning that each employee understands their job/roles, thus improving morale and motivation , overall increasing productivity. TQM practices can also increase customer involvement as many organisations, including Coca-Cola relish the opportunity to receive feedback and information from their consumers. Overall, reducing waste and costs, provides Coca-cola with a competitive advantage .

The Production Process

Before production starts on the line cleaning quality tasks are performed to rinse internal pipelines, machines and equipment. This is often performed during a switch over of lines for example, changing Coke to Diet Coke to ensure that the taste is the same. This quality check is performed for both hygiene purposes and product quality. When these checks are performed the production process can begin.

Coca Cola uses a database system called Questar which enables them to perform checks on the line. For example, all materials are coded and each line is issued with a bill of materials before the process starts. This ensures that the correct materials are put on the line. This is a check that is designed to eliminate problems on the production line and is audited regularly. Without this system, product quality wouldn’t be assessed at this high level. Other quality checks on the line include packaging and carbonation which is monitored by an operator who notes down the values to ensure they are meeting standards.

To test product quality further lab technicians carry out over 2000 spot checks a day to ensure quality and consistency. This process can be prior to production or during production which can involve taking a sample of bottles off the production line. Quality tests include, the CO2 and sugar values, micro testing, packaging quality and cap tightness. These tests are designed so that total quality management ideas can be put forward. For example, one way in which Coca Cola has improved their production process is during the wrapping stage at the end of the line. The machine performed revolutions around the products wrapping it in plastic until the contents were secure. One initiative they adopted meant that one less revolution was needed. This idea however, did not impact on the quality of the packaging or the actual product therefore saving large amounts of money on packaging costs. This change has been beneficial to the organisation. Continuous improvement can also be used to adhere to environmental and social principles which the company has the responsibility to abide by. Continuous Improvement methods are sometimes easy to identify but could lead to a big changes within the organisation. The idea of continuous improvement is to reveal opportunities which could change the way something is performed. Any sources of waste, scrap or rework are potential projects which can be improved.

The successfulness of this system can be measured by assessing the consistency of the product quality. Coca Cola say that ‘Our Company’s Global Product Quality Index rating has consistently reached averages near 94 since 2007, with a 94.3 in 2010, while our Company Global Package Quality Index has steadily increased since 2007 to a 92.6 rating in 2010, our highest value to date’. This is an obvious indication this quality system is working well throughout the organisation. This increase of the index shows that the consistency of the products is being recognized by consumers.

Related Posts:

• Case Study of Toyota: Birth of Lexus
• Case Study: An Assessment of Wal-Mart's Global Expansion Strategy
• Case Study of KFC: Establishment of a Successful Global Business Model
• Case Study of Papa John's: Quality as a Core Business Strategy
• Case Study: Starbucks Social Media Marketing Strategy
• Case Study: Dell Social Business Strategy
• Case Study: The Collaboration Between Sony and Ericsson
• Case Study: Nestle's Growth Strategy
• Case Study: Success of Starbucks Mobile Payment Application
• Case Study of FedEx: Leveraging Information Technology to Grow Business

Leave a Reply Cancel reply

Your email address will not be published. Required fields are marked *

5 quality failures that shook the world

Find out why the 2008 global financial crisis and the 1986 challenger space shuttle explosion were caused by a lack of compliance in quality assurance, control and management.

Quality assurance, control and management are key pillars of business stability and success. Failure to adhere to these principles can lead to catastrophe and indeed tragic consequences, as these five events reveal.

The global financial crisis – ‘the biggest quality failure of all time’

How do you even begin to dissect the myriad of events leading up to the global financial crisis? 

The 2010 film ‘Inside Job’ provides a starting point. It paints a backdrop of unscrupulous Wall Street bankers, laissez-faire regulators, and credit rating agencies and investors failing to price the risk of mortgage-related financial products.

But it’s Paul Moore, former head of group regulatory risk at HBOS (part of the Lloyds Banking Group since 2009), who provides an explanation straight from the horse’s mouth. Moore was dismissed from his role in 2004, after he warned senior executives of the perils of excessive risk-taking. Five years later, HBOS was one of the UK’s most high-profile victims of the credit crunch, requiring a takeover and billions of pounds in government bailout money to stay afloat. Moore was the only senior risk and compliance executive in the UK banking sector to speak out publicly, and dubs the crisis ‘the biggest quality failure of all time.’

Don't miss any news, updates or insider tips from PEX Network by getting them delivered to your inbox. Sign up to our newsletter and join our community of experts. 

'A culture of greed, unethical behavior and an indisposition to challenge.’

It was during his time at American Express as head of compliance that Moore was charged with implementing total quality management – a project that saw him compete for the prestigious Baldridge award. He theorized that if the financial sector thought in terms of quality rather than risk, compliance or governance, and positioned culture and people above processes and structure, the events leading up to the crisis could have been avoided. Stringent governance processes mean nothing, Moore argues, if they are ‘carried out in a culture of greed, unethical behavior and an indisposition to challenge.’

Moore points to the mis-selling of pensions, endowment, home income plans, precipice bonds and interest rate swaps as examples of unethical behavior. He draws parallels with the manufacturing industry, likening the devastating effects intangible financial promises had on consumer health and sentiment to the quality failures associated with a faulty brake or tyre.

The Challenger Space Shuttle explosion

On January 28, 1986, the NASA Shuttle Challenger exploded minutes after take-off, resulting in the tragic death of all seven astronauts on board. The hardware failure of a solid rocket booster (SRB) ‘O’ ring was cited as the immediate, mechanical cause, but human culpability lay with the decision-making process behind the launch.

In an extensive report , Jeff Forest from the Metropolitan State College pointed to a flawed Group Decision Support System (GDSS), which misrepresented risk and failed to communicate concerns surrounding quality assurance.

Thiokol, the subcontractor behind the supply of the ‘O’ rings, warned NASA of the potentially adverse effects of cold temperature on their performance a day before launch. Engineers conceded that the database behind the ‘O’ rings quality testing program could be corrupted, and recommended waiting till outside air temperatures reached 53®F before proceeding with launch.

This was met with outrage among NASA officials, who were wary of the political and financial repercussions of another delay. It was at this point that Thiokol ended a video live-link so officials could confer among themselves. The Thiokol chief engineer was told to put his ‘management, not engineering cap on,’ and five minutes later, the supplier re-joined the GDSS and ratified the launch.

Forest blames the sacrifice of ‘social and ethical decision making,’ which would have observed quality and safety concerns expressed by Thiokol engineers, for the ‘sake of cost, schedule and outside environmental demands.’

Thalidomide withdrawn after causing birth defects

The case of anti-nausea and sedative drug thalidomide, which helped negate the symptoms of women suffering from morning sickness, represented a watershed moment in the establishment of quality frameworks for pharmaceutical drug development.

Thalidomide, launched by German company Grunenthal, was sold from 1957 until 1962. It was withdrawn after being identified as a teratogen by Australian obstetrician William McBride and German pediatrician Widukind Lenz – an agent that can cause numerous birth defects.

In total, 10,000 children across 46 countries were born with deformities that included the malformation of limbs and internal organs. More recent estimates put the number of victims worldwide closer to 20,000. The withdrawal of thalidomide prompted concerted efforts to prevent teratogenicity and an appraisal of the clinical trials process.

The BP Deepwater Horizon explosion and oil spill

The overarching cause was a quality management failure. Contractors did not test the weak cement around the oil well, which failed to contain hydrocarbons within the reservoir and allowed flammable gas and liquids to flow up the production casing. Technicians misinterpreted fluid pressure tests, and gas passed through the ventilation system into the engine room, paving the way for ignition. After the explosion, the oil rig’s blow-out preventer located on the sea-bed failed to activate and seal the well.

Three corporations were implicated: BP for the flawed well design, Transocean as the owners of the rig, and Halliburton as the contractor who provided the bungled cement. 

The Ford Pinto is discontinued due to safety risks

In response to competition from Japanese imports, Ford released the Pinto in 1971 – a populist automotive icon that looked to capture consumer hearts with its $2,000 price-tag.

The Pinto’s aesthetic quality was always in question. In 1977, however, lawsuits emerged on the back of allegations of a structural design fault. The fuel tank was understood to be in close proximity to the rear bumper and rear axle, meaning that rear-end collisions would elevate the risk of fires.

'A cost-benefit analysis compared the price of $11 per-vehicle repairs with the cost of settlements for deaths, injuries and burnouts.'

Ford’s decision to recall 1.4 million units in 1978 saved no face, as investigative journalist Mark Dowie revealed that Ford had been aware of the design flaw during production. He published a cost-benefit analysis document that saw Ford compare the price of $11 per-vehicle repairs with the cost of settlements for deaths, injuries and burnouts.

The subcompact car was decommissioned in 1980, but the vehicle has been the source of historical discourse. Revisionists point to the success of selling 3 million units, and claim that fresh examinations of incident data rank the Pinto as safe, or safer than, cars in the same class. Regardless, Ford’s callous cost-benefit analysis left a legacy of crooked corporate culture.

• Total quality management as a business philosophy
• Take a mobile game approach to process compliance
• The global state of process excellence 2024

Strategic Transformation & Operational Excellence Europe 2024

Meet and learn from the leaders and experts in the field of operational excellence, business process and digital transformation. Discover the latest tools and best practices for achieving customer-centricity, agility, and innovation. Register now and join the most influential community of business transformation and process professionals in Europe.

To view this content, please fill out the form to register and become a member. Or, if you're already a member, sign in below to view.

Sign In Register Email Address Password Remember Me Login No account? Sign Up

Please note: That all fields marked with an asterisk (*) are required.

By entering in your information and submitting the form, you give the sponsor permission to contact you regarding their product and you agree to our User Agreement , Privacy Policy , and Cookie Policy .

We respect your privacy, by clicking 'Subscribe' you will receive our e-newsletter, including information on Podcasts, Webinars, event discounts, online learning opportunities and agree to our User Agreement. You have the right to object. For further information on how we process and monitor your personal data click here . You can unsubscribe at any time.

FIND CONTENT BY TYPE

• White Papers
• Press Releases

Process Excellence Network COMMUNITY

• Advertise With Us
• What is Process Excellence
• User Agreement
• Cookie Policy
• PEX Network App
• All Access from PEX Network
• Become a Member Today
• Media Partners

ADVERTISE WITH US

Reach Process Excellence professionals through cost-effective marketing opportunities to deliver your message, position yourself as a thought leader, and introduce new products, techniques and strategies to the market.

JOIN THE Process Excellence Network COMMUNITY

Join Process Excellence Network today and interact with a vibrant network of professionals, keeping up to date with the industry by accessing our wealth of articles, videos, live conferences and more.

Process Excellence Network, a division of IQPC

Careers With IQPC | Contact Us | About Us | Cookie Policy

Become a Member today!

PLEASE ENTER YOUR EMAIL TO JOIN FOR FREE

Already an IQPC Community Member? Sign in Here or Forgot Password Sign up now and get FREE access to our extensive library of reports, infographics, whitepapers, webinars and online events from the world’s foremost thought leaders.

Power Quality problems in hospital: a case study

Ieee account.

• Change Username/Password
• Update Address

Purchase Details

• Payment Options
• Order History
• View Purchased Documents

Profile Information

• Communications Preferences
• Profession and Education
• Technical Interests
• US & Canada: +1 800 678 4333
• Worldwide: +1 732 981 0060
• Contact & Support
• About IEEE Xplore
• Accessibility
• Terms of Use
• Nondiscrimination Policy
• Privacy & Opting Out of Cookies

A not-for-profit organization, IEEE is the world's largest technical professional organization dedicated to advancing technology for the benefit of humanity. © Copyright 2024 IEEE - All rights reserved. Use of this web site signifies your agreement to the terms and conditions.

Log in using your username and password

• Search More Search for this keyword Advanced search
• Latest content
• Current issue
• BMJ Journals More You are viewing from: Google Indexer

You are here

• Online First
• Assessing quality of direct-to-consumer telemedicine in China: a cross-sectional study using unannounced standardised patients
• Article Text
• Article info
• Citation Tools
• Rapid Responses
• Article metrics

• Zhen Zeng 1 ,
• Dong (Roman) Xu 2 ,
• Yiyuan Cai 3 ,
• http://orcid.org/0000-0002-7943-4041 Wenjie Gong 1 , 4 , 5
• 1 HER Team and Department of Maternal and Child Health, Xiangya School of Public Health , Central South University , Changsha , China
• 2 SMU Institute for Global Health (SIGHT), School of Health Management and Dermatology Hospital , Southern Medical University (SMU) , Guangzhou , China
• 3 Department of Epidemiology and Health Statistics, School of Public Health , Guizhou Medical University , Guiyang , China
• 4 Institute of Applied Health Research , University of Birmingham , Birmingham B15 2TT , UK
• 5 Department of Psychiatry , University of Rochester , Rochester , New York , USA
• Correspondence to Professor Wenjie Gong, HER Team and Department of Maternal and Child Health, Xiangya School of Public Health, Central South University, Changsha, Hunan, 410078, China; gongwenjie{at}csu.edu.cn

Direct-to-onsumer telemedicine (DTCT) has become popular as an alternative to traditional care. However, uncertainties about the potential risks associated with the lack of comprehensive quality evaluation could influence its long-term development. This study aimed to assess the quality of care provided by DTCT platforms in China using unannounced standardised patients (USP) between July 2021 and January 2022. The study assessed consultation services on both hospital and enterprise-sponsored platforms using the Institute of Medicine quality framework. It employed 10 USP cases, covering conditions such as diabetes, asthma, common cold, gastritis, angina, low back pain, child diarrhoea, child dermatitis, stress urinary incontinence and postpartum depression. Descriptive and regression analyses were employed to examine platform characteristics and compare quality across platform types. The results showed that of 170 USP visits across 107 different telemedicine platforms, enterprise-sponsored platforms achieved a 100% success in access, while hospital-sponsored platforms had a success rate of only 47.5% (56/118). Analysis highlighted a low overall correct diagnosis rate of 45% and inadequate adherence to clinical guidelines across all platforms. Notably, enterprise-sponsored platforms outperformed in accessibility, response time and case management compared with hospital-sponsored platforms. This study highlights the suboptimal quality of DTCT platforms in China, particularly for hospital-sponsored platforms. To further enhance DTCT services, future studies should compare DTCT and in-person care, aiming to identify gaps and potential risks associated with using DTCT as alternatives or supplements to traditional care. The potential of future development in enhancing DTCT services may involve exploring the integration of hospital resources with the technology and market capabilities of enterprise-sponsored platforms.

• Health services research
• Quality measurement
• Performance measures
• Patient-centred care

https://doi.org/10.1136/bmjqs-2024-017072

Statistics from Altmetric.com

Request permissions.

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.

Introduction

Direct-to-consumer telemedicine (DTCT) signifies a revolutionary global healthcare delivery model. It involves patients independently initiating medical services remotely, engaging directly with healthcare providers through text messaging or video/phone calls. By bypassing traditional intermediaries like referral clinicians or facilitators, DTCT empowers patients to access medical care swiftly and efficiently. 1 In China, DTCT is burgeoning, boasting over 1700 registered platforms, 2 each serving as an individual website or application for DTCT services. These platforms are categorised into two main types: hospital sponsored and enterprise sponsored. Hospital-sponsored platforms, associated with single physical hospitals, primarily use in-house medical staff and offer streamlined functions due to resource limitations. In contrast, enterprise-sponsored platforms, supported by larger corporations, provide access to a wider network of licensed physicians and offer a diverse range of functions with sophisticated user interfaces. 3 Despite enhanced accessibility and convenience compared with in-person care, DTCT faces quality challenges, such as communication difficulties and antibiotic misuse. 4 5 However, research on DTCT quality remains limited, especially in the context of China. To address this gap, our study employs unannounced standardised patients (USPs)—individuals trained and validated to portray specific medical conditions in a consistent and standardised manner 6 7 —to assess DTCT quality in China across different platform types based on the Institute of Medicine (IOM) quality framework.

This cross-sectional study examined both types of DTCT platforms that offered Chinese language services. The study was conducted between July 2021 and January 2022. Prior informed consent was waived due to minimal risk, and all analyses were performed on fully deidentified aggregated data. 8

To assess consultation service quality, we employed 10 different USP cases, each representing a specific medical condition (details in online supplemental eMethods and online supplemental example of a USP case ). Following thorough training and assessment, we selected 15 qualified USPs from the initial pool of 25 candidates. Each case was assigned at least one USP. As USPs’ initial requests for physician consultations could be denied for various reasons, mirroring real-world scenarios, each case made consultation requests until they completed at least five consultations on each platform type. The USPs captured screenshots and recorded the consultation process, including any failed attempts and reasons for failure. We evaluated the access success rate and assessed consultation quality using the IOM quality framework 9 ( table 1 ).

Supplemental material

• View inline

Quality outcome indicators

We conducted descriptive and regression analyses to evaluate platform characteristics and quality outcomes. Regression analyses compared quality differences using ordinary least squares and logistic regressions, with hospital-sponsored platforms as the benchmark and controlling for patient case fixed effects. Adjusted differences and 95% CIs were reported, adjusted for platform-level clustering. Statistical significance was set at α=0.05. Stata SE (V.16.0) was used for all analyses.

Our study involved 170 visits, with 52 visits on 10 enterprise-sponsored platforms and 118 visits on 97 hospital-sponsored platforms (summarised in online supplemental eTable 1 ). The overall access rate was 63.5% (108/170). Enterprise-sponsored platforms achieved a 100% access rate (52/52), significantly higher than hospital-sponsored ones (56/118, 47.5%) (p<0.001). Common reasons for unsuccessful consultations included incomplete functions, like platforms claiming to offer DTCT services but lacking an accessible feature for initiating online consultations with physicians (25/62, 40.3%), and no response (13/62, 21.0%).

Of 108 successful consultations, 49 consultations (45%) received a correct diagnosis, while adherence to published guidelines was low for consultation (15%) and management decisions (31%). On average, physicians took 3 hours and 47 min to respond, with the total interaction time spanning 12 hours and 19 min. After controlling for disease case fixed effects and adjusting SEs for clustering at platform level, enterprise-sponsored platforms had higher rates of completed management decisions, shorter response times and higher costs ( table 2 ).

Comparison on main quality outcomes between platform types for successful consultations

In this study, we rigorously evaluated the quality of care across two types of DTCT platforms in China using USPs. With 108 successful visits out of 170 attempts, we found a diagnostic accuracy of approximately 45%, along with a decline in completion rates for recommended management decisions to 31%. This may be linked to the limited inquiries during USP encounters, with clinicians asking only about 15% of recommended consultation questions per visit. Besides traditional quality metrics, the timeliness of DTCT services is concerning, with a response time of 3 hours and 47 min and an overall interaction time of 12 hours and 19 min. In China, DTCT predominantly operates asynchronously, leading to these extended durations. Despite offering a more flexible alternative to in-person counselling by eliminating the need for travel, prolonged waiting times may still impact user satisfaction and the perceived effectiveness of DTCT platforms. Future research should prioritise enhancing the timeliness of DTCT services to ensure prompt access and timely interactions. The patient-centredness score averaging 2.4, indicating a medium to low level of patient-centred care, 10 is potentially influenced by less satisfactory outcomes discussed earlier in terms of effectiveness, safety and timeliness. These findings raise concerns about how effective DTCT services are. Further evaluation, including a direct comparison with in-person care, is needed for a clearer understanding of their quality. This can guide improvement measures, especially when DTCT services act as alternatives or supplements to traditional in-person care.

Notably, enterprise-sponsored platforms achieved 100% access success, surpassing hospital-sponsored ones at 47.5%. They exhibited superior performance in response times and completion rates for management decisions. Despite recent growth and policy support, 3 hospital-sponsored platforms seem to be in early developmental stages, potentially limiting medical resource accessibility. These findings challenge a marketing survey suggesting a preference for hospital-sponsored platforms, 11 emphasising higher access denial risks and less timely responses for consumers on these platforms.

This study was limited by the use of a uniform USP for each case. Using standardised scenarios with different USPs potentially allows for a comprehensive assessment of equity. However, due to constraints imposed by scripted scenarios in our study, this aspect was not explored.

Our study highlights the suboptimal quality of DTCT in China, specifically disparities between hospital-sponsored and enterprise-sponsored platforms. These findings likely echo broader challenges and principles inherent in DTCT globally. As DTCT gains momentum after COVID-19, future research becomes critical to effectively address these issues.

Ethics statements

Patient consent for publication.

Not applicable.

Ethics approval

This study involves human participants and was approved by Xiangya School of Public Health (IRB No XYGW-2021-37). Prior informed consent was waived due to minimal risk and no individually identifiable information on physicians.

Acknowledgments

We sincerely thank Xiaohui Wang, Yaolong Chen, Yun Lu, Xiaojing Fan, Zhongliang Zhou, Jay Pan, and Chengxiang Tang for their unwavering leadership in development and management the SP cases. We also apperciate Lu Liu, Chunping Li, and Huanyu Hu for their their diligent efforts as project assistants, as well as all the standardized patients and study coordinators for their hard work.

• Elliott T ,
• iiMedia Report
• Resneck JS ,
• Steuer M , et al
• Gidengil CA , et al
• Peabody JW ,
• Glassman P , et al
• Colliver JA ,
• Rhodes KV ,
• Institute of Medicine (US) Committee on Quality of Health Care in America
• Tu J , et al

Supplementary materials

Supplementary data.

This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.

• Data supplement 1

Contributors WG conceived the study. ZZ coordinated the daily implementation of this study under the supervision of DRX, YC and WG. ZZ carried out data analysis and composed the initial manuscript draft, receiving guidance from WG and DRX. All authors contributed to critical review of the manuscript and approved the final draft.

Funding This study was funded by China Medical Board (20-368), Swiss Agency for Development and Cooperation (81067392) and the National Natural Science Foundation of China (82273643).

Competing interests None declared.

Provenance and peer review Not commissioned; internally peer reviewed.

Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

Read the full text or download the PDF:

New study uncovers compelling potential of trees planted near highways: 'They can help reduce the severity of the problem'

Researchers are making the case for bringing the forest to cities, but the reason might surprise you. 

While trees and bushes add much-needed greenery to concrete jungles, planting them near highways can also dramatically lower air pollution from cars, according to a new Georgia State University study published in PLoS One.

According to a news release on the findings, researchers took air-quality samples at five locations near metro Atlanta highways during two three-month periods. They found that sites with natural or ornamental plants had 37% less soot and 7% fewer ultrafine particles than their treeless counterparts. 

"Trees and bushes near roadways don't solve the problem of air pollution caused by motor vehicles, but they can help reduce the severity of the problem," said lead author Roby Greenwald, associate professor at the GSU School of Public Health.

The Environmental Protection Agency says that particle and roadway air pollution can cause a host of health issues, including asthma, difficulty breathing, cardiovascular disease, preterm births, and childhood cancer. 

Because of the serious health problems associated with vehicle pollution, Greenwald and his colleagues stressed the urgency of implementing solutions, such as planting trees. Roadside vegetation helps remove air pollution because the trees act like Velcro, catching tiny pollution particles that cling to them. 

Watch now: The most sustainable thing about the new Rivian? Its price tag

However, while trees and bushes can reduce air pollution, they unfortunately don't help with carbon or ozone pollution, according to Greenwald. 

He said that to further reduce health issues and poor air quality associated with interstates, cities should make it safer and easier for people to travel without cars. Improving public transportation or bicycle and pedestrian infrastructure would give people more options to go carless. 

Luckily, cities worldwide are helping to make biking and walking trendy again, from Paris banning cars in certain neighborhoods to city planners turning an old steel mill in Utah into a walkable city . Montreal also showed what's possible by transforming a busy downtown street into a car-free zone.  

"We should plant more trees along roadways because they provide benefits that go beyond aesthetics," Greenwald said . "But I don't want to give anyone the impression that we can solve all of the problems associated with motor vehicle emissions simply by planting trees."

With ingenuity and progressive thinking, we can start regreening our cities, making them healthier, safer places for everyone. While planting more trees isn't a comprehensive solution, other ways cities can make a difference include ramping up electric vehicle charging and electrifying city buses . 

Join our free newsletter for cool news and cool tips that make it easy to help yourself while helping the planet.

New study uncovers compelling potential of trees planted near highways: 'They can help reduce the severity of the problem' first appeared on The Cool Down .

The fishy death of Red Lobster

Endless Shrimp didn't sink the seafood chain. Wall Street did.

With the chain on the verge of bankruptcy, it has become abundantly clear that Red Lobster letting customers eat all the shrimp their hearts desire was not a great business idea . It's also not the reason the restaurant is in a deep financial mess .

In mid-April, Bloomberg reported the debt-laden seafood chain and home of beloved cheddar biscuits was considering filing for Chapter 11 bankruptcy protection. Red Lobster is being bogged down by increased labor costs and expensive leases on its restaurants. Some observers were quick to blame the financial woes on its decision last year to make its "Endless Shrimp" promotion, which used to be an occasional, limited-time offering, permanent. The move was not a smart one. While Red Lobster increased traffic somewhat, people coming in to chow down on all-you-can-eat shrimp was a money bleeder. The company blamed Endless Shrimp for its $11 million losses in the third quarter of 2023, and in the fourth quarter, the picture got even worse, with the restaurant chain seeing $12.5 million in operating losses.

But the story about what's gone wrong with Red Lobster is much more complicated than a bunch of stoners pigging out on shrimp (and, later, lobster ) en masse. The brand has been plagued by various problems — waning customer interest, constant leadership turnover, and, as has become a common tale, private equity's meddling in the business.

"If anything, the Endless Shrimp deals are probably as much a symbol of just either desperation or poor management or both," Jonathan Maze, the editor in chief of Restaurant Business Magazine, said.

Red Lobster first opened in Lakeland, Florida, in 1968 and was acquired by the food conglomerate General Mills in 1970. General Mills then spun the chain off in 1995 along with the rest of its restaurant division, which also included Olive Garden, as Darden Restaurants. In 2014, amid flagging sales and pressure from investors, Darden sold Red Lobster for $2.1 billion to Golden Gate Capital, a San Francisco private-equity firm.

If anything, the Endless Shrimp deals are probably as much a symbol of just either desperation or poor management or both.

To raise enough cash to make the deal happen, Golden Gate sold off Red Lobster's real estate to another entity — in this case, a company called American Realty Capital Properties — and then immediately leased the restaurants back. The next year, Red Lobster bought back some sites, but many of its restaurants were suddenly strapped with added rent expenses. Even if Darden had kept Red Lobster, it's not clear it would have taken a different route: A press release from the time says it had contacted buyers to explore such a transaction. But in Maze's view, the sale of the real estate was sort of an original sin for Red Lobster's current troubles. He compared it to throwing out a spare parachute — chances are, you'll be OK, but if the first parachute fails, you're in deep trouble.

"The thing that private equity does is just unload assets and monetize assets. And so they effectively paid for the purchase of Red Lobster by selling the real estate," he said. "It'll probably be fine, generally, but there's going to come a time in which your sales fall, your profitability is challenged, and your debt looks too bad, and then suddenly those leases are going to look awfully ugly."

That time, according to recent reporting, is now. With struggling sales and operational losses, the leases are an added headache that is helping push the company to the brink, though bankruptcy may help Red Lobster get some wiggle room on them.

Eileen Appelbaum, a codirector of the Center for Economic and Policy Research, a progressive think tank, and a longtime private-equity critic, said in 2014 that private equity wouldn't be the solution to Red Lobster's ills. She isn't surprised about how this is all turning out.

"Once they sell the real estate, then the private-equity company is golden, and they've made their money back and probably more than what they paid," she said, noting that this was a common theme in other restaurants and retailers and adding: "The retail apocalypse is all about having your real estate sold out from under you so that you have to pay the rent in good times and in bad."

After the real estate move, Golden Gate sold 25% of the company in 2016 to Thai Union, a Thailand seafood company, for $575 million and unloaded the rest of the company to an investor group called the Seafood Alliance, of which Thai Union was a part, in 2020. Golden Gate likely came out ahead, but the same can't be said for Thai Union, which also controls the Chicken of the Sea brand. It is now looking to get out of its stake in Red Lobster and took a one-time charge of $530 million on its investment in the fourth quarter of last year. In 2021, Red Lobster refinanced its debt, with one of its new lenders being Fortress Investment Group, an investment-management group and private-equity firm. According to Bloomberg, it's one of the "key lenders" involved in debt negotiations now.

Beyond the pandemic-related troubles that hit restaurants across the country , analysts and experts say that Red Lobster's particular problems are attributable to a mix of poor brand positioning and unstable leadership. The seafood-restaurant business is a tough one in the US, and people who are hankering for lobster or fish are increasingly going to steak houses that offer those options, said Darren Tristano, the CEO and founder of Foodservice Results, a food-industry consultancy.

"What's truly happened with Red Lobster is that the consumer base has changed and Red Lobster hasn't," he said. "Red Lobster isn't losing to a competitor in their space — they're losing to competitors outside their space."

John Gordon, a restaurant analyst in San Diego, said Red Lobster had been on the decline for 20 years but that it didn't "fall on the knife" until Thai Union got it. "They were totally unprepared to hold a casual-dining restaurant," he said. Kim Lopdrup, Red Lobster's longtime CEO, retired in 2021, and since then, the restaurant hasn't had much in the way of stable leadership. His successor resigned after only a matter of months, and the role remained vacant for more than a year before someone else was appointed. He's left, too, and now Jonathan Tibus, an expert in restructuring, is at the helm.

"One of the problems is that Thai Union just had no credibility in terms of recruiting a new CEO," Gordon said.

Essentially, Red Lobster finds itself in a landscape where there just aren't a lot of bright spots. Add on the weight of the debt and lease obligations the company's private-equity owners saddled the brand with, and a turnaround becomes a gargantuan task.

"It's hard to blame leadership when you have a problem that is unsolvable — I mean, getting the consumer back in the door, increasing traffic. All-you-can-eat shrimp can only do so much," Tristano said.

Red Lobster did not respond to a request for comment for this story. Golden Gate declined to comment. Thai Union pointed to a press release about its intention to exit its investment and said it didn't wish to comment further.

One bad promotion should not doom a restaurant chain like that.

As to what drove Red Lobster to the edge, it's clear that despite not being a very good idea, the blame doesn't fall on Endless Shrimp. Years of changing tastes, tough industry conditions, and poor brand management all contributed to the chain's difficult position. But plenty of other restaurants have faced similar issues and aren't on the verge of bankruptcy. What separates Red Lobster is a decade of private-equity and investor tampering. Pinging from owner to owner makes it hard to settle on a turnaround vision. The company faces challenges that necessitate a long-term view that requires patience — the kind that the short-term-focused Wall Street often struggles to tackle. Whether Red Lobster can turn it around from here remains to be seen: Even if it files for bankruptcy protection, the chain may not disappear. Plenty of companies go bankrupt and keep on keeping on.

"You've got to at least be able to pay your bills, and what's happened over the last five years is the cost of operating a restaurant has taken off," Maze said. "One bad promotion should not doom a restaurant chain like that."

Emily Stewart is a senior correspondent at Business Insider, writing about business and the economy.

About Discourse Stories

Through our Discourse journalism, Business Insider seeks to explore and illuminate the day’s most fascinating issues and ideas. Our writers provide thought-provoking perspectives, informed by analysis, reporting, and expertise. Read more Discourse stories here .

Related stories

More from Retail

Most popular

• Main content