Total quality management (TQM) is still a new issue for the organisations in Yemen. These organisations need to establish a new strategy towards quality management. Focuses on the difficulties and barriers to the introduction and implementation of TQM in such a culture. The researcher draws on two case study organisations and on the activities proposed by the European excellence model to exemplify TQM. Time was spent explaining these activities to the people involved and was followed by a discussion of the difficulties. By the end of this process the researcher came out with several points to be considered under each activity for the aim of improving the organisations in Yemen and when embarking on implementation of TQM. Other issues include the need for proactive government support, for better technical understanding of TQM, and for a change in organisational culture.

Top management commitment is considered a significant factor in improvement programmes, and many papers have been written about the role of top management commitment in implementing a quality management system. However, not considering other management levels' commitment, such as middle management, may lead to issues in achieving organisational development. Public organisations that work through vertical structures may face a lack of middle management commitment, which might have a negative impact on lower and non-management staff commitment to improvement programmes. In this regard, this study seeks to examine the impact of middle management's commitment towards improvement initiatives in public organisations. Methodology: Empirical research with a mixed-method design used semi-structured interviews and a questionnaire to explore the current practices of continuous improvement (CI) and examine employees' views from different management levels of the implications of current improvements in a Saudi public service organisation. Findings: The analysis indicated that the lower managers and non-management staff agree that, after the implementation of the quality management system, the organisation's middle management showed a lack of commitment to that system. Moreover, this lack of commitment is recognised in the analysis of participants' views of CI practices recorded in the questionnaire and interviews. This lack of commitment has caused poor employee commitment and thus a lack of problem solving in organisational departments. It is also responsible for a lack of employee involvement, the centralisation of decisions, deficiencies in terms of determining and applying training, inequality between employees and a lack of trust between employees and their managers. These issues could be managed and resolved through middle management and their commitment. Practical implications: Increasing middle managers' awareness of the importance of their commitment to improvement initiatives can have an impact on employees' commitment towards improvement initiatives, especially in those public organisations that have vertical/hierarchical structures. The level of commitment towards the implementation of improvement programmes needs further in-depth analyses to identify which factors influence public organisation leaders' commitment to improvement programmes. Value: The results of this study could motivate middle managers in public organisations to review their policies and to facilitate CI initiatives.

Purpose The purpose of this paper is to develop an auditing framework which would assist the organizations that experience difficulties with the current ISO 9001 quality audits to achieve their planned objectives with regard to their auditing of conformance, performance, risk management (RM) and improvement collectively. Design/methodology/approach A literature review was conducted to develop a conceptual audit framework (CAF). Subsequently, a preliminary audit framework (PAF) was developed. It includes the questions that are based on the CAF and connected with the complaints of the concerned organization. This PAF was thoroughly tested and validated by performing 11 internal audits, 2 management reviews (MR) and 3 workshops. Findings Applying this PAF indicated that in order to help organizations to audit their performance, RM and improvement collectively, they need to: change their audit approach from ISO elements to ISO principles, integrate the tools that are related to ISO 9001 Principles within the audit’s phases, perform pre-audits in the form of self-auditing, induce auditors to learn all tools to determine the ideal tools for particular situation, audit each department in combination with its internal customer, involve their auditors in problem solving, perform MR prior to closing the audit and analyze the results of audits with their causes by using one of the appropriate qualitative methods, such as analysis by themes. Finally, an auditing framework was developed to meet these needs. It includes the PAF’s questions that led to the discovery of chronic and systematic audit findings. It enhances any ISO 9001 Quality Auditing Questionnaires Checklist. Originality/value This study enhances the role of auditors to include risk identification, problem solving and data analysis by development of an auditing framework that is based on ISO 9001 Principles rather than clauses.

This paper focuses on how service-based organisations establish and sustain incremental performance improvement. A review of existing continuous improvement (CI) evolution theory provides a model for comparison with the observations from the case study organisation. The research employs a longitudinal, embedded case study, involving two units of analysis and multiple research cycles. The use of narrative enquiry provides a means of understanding the evolution of CI over almost a decade of activity. It allows the testing of Bessant et al's (2001) Maturity Model against real world situations, specifically in the service sector, via comparison of the impact of differing approaches, actions, obstacles and achievements within the two units of analysis, all the while operating under the umbrella of a common organisation that was evolving in reaction to market challenges.

3173 The Cleveland Clinic Taussig Cancer Institute completed a pilot project on distress screening as part of the plan to address the American College of Surgeons Commission on Cancer requirement (Standard 3.2: Psychosocial Distress Screening) to screen malignant and benign hematology patients for distress and psychosocial health needs. Over a two week period every hematology patient seeing a physician or mid-level provider completed the distress screening instrument Emotions Thermometer (ET), a five dimensional tool that includes four predictor domains: distress, anxiety, depression, anger and one outcome domain of need for help. Each domain is rated on a 0 to 10 Likert type scale, in a thermometer format. With respect to validity and reliability, the sensitivity and specificity of the ET tool has been found comparable to known validity and reliability of other accepted measures of distress, depression, and anxiety (Mitchell, et al, 2009). Per National Comprehensive Cancer Network (NCCN) guidelines, a score of 4 or higher on distress screening warrants a referral to a psychosocial professional. Distress scores 4 and over were compared among the diagnoses using the Chi-Square test. When the overall P-value was significant (P <0.05), at least two groups differed, and pairwise comparisons were conducted to determine which diagnostic groups differed. Of the five thermometer domains, patients scored highest on anxiety. There were no differences among diagnoses on anger (P=0.51), but there were differences in the other four domains (P<0.001 distress, depression, and need for help; P=0.026 anxiety). For all four, pairwise comparisons indicated that multiple myeloma patients had higher (worse) scores on anxiety, distress, depression, and need for help than all other diagnoses; there were no differences among benign hematology, leukemia/MDS/CML, or lymphoma/CLL. While this pilot project does not answer why multiple myeloma patients report levels of psychosocial distress significantly higher than other hematology patients, increased attention needs to be given to address these patients' experience of anxiety, depression, and distress. This project provides valuable information about the levels of distress experienced among all hematology patients and is useful for determining staffing levels of psychosocial professionals needed to address distress. Percentage of Emotion Thermometer Scores Over 4 Diagnosis Distress Anxiety Depression Anger Help Benign Hem 18% 27% 18% 12% 7% Leuk/MDS/CML 19% 28% 17% 9% 14% Lymph/CLL 18% 31% 16% 14% 13% Myeloma 38% 44% 35% 15% 27% P-value <0.001 0.026 <0.001 0.51 <0.001 Disclosures: No relevant conflicts of interest to declare.