ORIGINAL ARTICLE

Applying Quality Function Deployment Model in

Burn Unit Service Improvement
Ali Keshtkaran, PhD, Neda Hashemi, MS, Erfan Kharazmi, PhD, Mehdi Abbasi

Quality function deployment (QFD) is one of the most effective quality design tools.
This study applies QFD technique to improve the quality of the burn unit services
in Ghotbedin Hospital in Shiraz, Iran. First, the patients’ expectations of burn unit
services and their priorities were determined through Delphi method. Thereafter,
burn unit service specifications were determined through Delphi method. Further, the
relationships between the patients’ expectations and service specifications and also the
relationships between service specifications were determined through an expert group’s
opinion. Last, the final importance scores of service specifications were calculated through
simple additive weighting method. The findings show that burn unit patients have 40
expectations in six different areas. These expectations are in 16 priority levels. Burn units
also have 45 service specifications in six different areas. There are four-level relationships
between the patients’ expectations and service specifications and four-level relationships
between service specifications. The most important burn unit service specifications
have been identified in this study. The QFD model developed in the study can be a
general guideline for QFD planners and executives. (J Burn Care Res 2013;XX:00–00)

In today’s healthcare organizations, service quality
has become a substantial tool for meeting the grow-
ing demands of the population and improving the
community’s health. Therefore, many methods have
been designed and applied to enhance health service
quality.1,2 Quality function deployment (QFD) is
one of the most useful one.2,3
Originated in Japan in the 1970s and having
been applied successfully by many Japanese, Ameri-
can, and European organizations for their product
or service development, the QFD is a very effective
and practical quality systems tool, which provides
a means for determining and prioritizing custom-
ers’ expectations and translating them to the quality
characteristics of service design or improvement.4–6
Listening carefully to the “voices of the customers”
to learn and then provide them with what they need,
From the Shiraz University of Medical Sciences, Islamic Republic
of Iran.
The authors declare no conflict of interest.
This research was supported by Shiraz University of Medical
Sciences.
Address correspondence to Ali Keshtkaran, PhD, From the Shiraz
University of Medical Sciences, Shiraz 45794, Islamic Republic
of Iran.
Copyright © 2013 by the American Burn Association
1559-047X/2013
DOI: 10.1097/BCR.0b013e3182920d55
Copyright © American Burn Association. Unauthorized reproduction of this article is prohibited.
QFD helps an organization to become proactive to
quality problems rather than taking a reactive posi-
tion by acting on customer complaints. QFD also
makes the organizational shift from inspecting the
service’s quality to designing quality into the service,
that is, QFD can be referred to as designed-in quality
rather than traditional inspected-in quality.7 Accord-
ing to Yang8, QFD can reduce the service-develop-
ment time and cost, improve service quality, increase
customer satisfaction, and consequently increase the
market share. It can also facilitate continuous service
improvement with emphasis on the impact of orga-
nization’s learning on innovation.
In this regard, there are many QFD studies and
applications in different product and service indus-
tries.4,9–15 Among them few studies have been per-
formed in the health sector.4,14,16–21 Kuo et al19
applied QFD to improve outpatient services for
elderly patients in Taiwan. The QFD model pro-
vided by them not only could reduce costs but also
revealed the crucial outpatient service items that
could improve the quality of medical care for elderly
people. Volpato et al20 used QFD to verify the pos-
sibility of quality planning in the family health units.
The results of their study showed that QFD was an
efficient tool for quality planning in public health
services. Lorenzo et al21 adopted QFD methodology
1

2   Keshtkaran et al Month/XXX 2013
to identify clients’ needs in a hospital. According to
the results, QFD methodology was highly useful in
allowing complaints to be related to the results of a
perceived quality questionnaire. It was also beneficial
in identification of the attributes with the greatest
influence on patient satisfaction and identification of
areas for improvement according to clients’ needs.
The basic concept of QFD is to translate the expec-
tations of customers into service specifications, and
subsequently into part specifications, process plans,
and production requirements. In order to estab-
lish these relationships, QFD usually requires four
matrices, each corresponding to a stage of the ser-
vice development or improvement cycle. These are
service planning, part deployment, process planning,
and production planning matrices, respectively. The
service planning matrix translates customers’ expec-
tations into service specifications. It is also called the
house of quality (HOQ), because of its house shape.
Three other matrices translate important service
specifications into part specifications, important part
specifications into manufacturing operations, and
important manufacturing operations into day-to-
day operations and controls, in order.11 Regarding
this, HOQ is the most fundamental and strategically
important matrix of QFD in the QFD system. It is
in this phase that the customer needs for the service
are identified and transformed into service specifica-
tions for the needs. In other words, HOQ links the
voice of the customer to the voice of the develop-
ment team. Although a complete QFD process con-
tains four phases, most organizations that use QFD
stop after developing their customized version of the
HOQ. This is quite understandable, partly because
of the lack of specificity in the literature as how to
develop downstream QFD phases, partly because of
the fact that the structures and analyzing methods
of the other three QFD phases are more or less the
same as those of the HOQ phase.7
Therefore, in this study the QFD model is applied
by focusing on the HOQ phase. The studied ser-
vices are hospital burn unit services because of their
critical conditions. In fact, as different studies show,
burn injury is a devastating event facing burn patients
with spontaneous long-term physical and psychoso-
cial deficits. Thus, burn patients are physically and
psychosocially vulnerable, and any failure in meeting
their expectations in any aspect can harm them and
delay their improvement.22 QFD, as a customer-ori-
ented approach for service development, is a useful
tool that can improve the quality of burn unit ser-
vices based on the burn patients’ expectations. The
hospital under study is Ghotbedin Burn Hospital,
the only burn hospital in Shiraz, Iran.
Copyright © American Burn Association. Unauthorized reproduction of this article is prohibited.
Journal of Burn Care & Research
METHOD
HOQ, as the main matrix of QFD, is a structured and
systematic way to transform the customers’ expecta-
tions for a product into prioritized service specifica-
tions that can be further deployed to develop process
and production plans. A typical HOQ matrix com-
prises six main parts. The QFD process, the constitu-
tion of HOQ matrix, along with the description of
QFD’s key elements are illustrated in Appendix 1.7
In the current study QFD process was performed
through six stages. During these stages the matri-
ces forming HOQ were completed separately and
in order. Figure 1 shows HOQ and its constituent
matrices. The stages of QFD process, as well as,
HOQ constitution are as follows:
First Stage: Identifying Costumers,
Determining and Collecting Costumers’
Expectations of Desired Service,
Constructing A Matrix of House of Quality
In the current study, male and female burn unit
patients were identified as burn unit costumers. In
order to determine their expectations, Delphi tech-
nique was used. The Delphi technique is a widely
used and accepted method of gathering data from
respondents within their domain of expertise. This
technique is useful for situations where individual
judgments must be combined in order to address a
lack of agreement or incomplete state of knowledge,
as was the case for this research.23,24
To form the Delphi team 32 burn unit patients
whose physical status was suitable enough to answer
the research questions written or verbally were iden-
tified, by consulting burn unit nurses. After explant-
ing the research goals and inviting these patients to
participate in the study, 26 patients including 17
women and 9 men stated their agreement to partici-
pate. Therefore, they were selected as Delphi team
members. The Delphi rounds were as follows:
Round 1. The first round instrument was con-
structed from literature reviews and opinions of an
expert group. To allow expression of a wide range
of views, the questionnaire comprised open-ended
questions.25 The number of questions was 33 and
they were structured around five themes; equipment
and materials, human resources, physical space, basic
facilities, and communications and interpersonal
dimensions. The questions are illustrated in Appen-
dix 2. Printed copies of the instrument were distrib-
uted to Delphi team members. If the patients were
 Journal of Burn Care & Research
Volume XX, Number XX Keshtkaran et al   3

D : Service
Specifications’
Relationship
Matrix

B : Service Specifications Matrix

F1 : Competitive Assessment
A: Patients’
Expectations and Matrix
C: Patients’ Expectations and
Their Priorities
Service Specifications’ Relationship
Matrix
Matrix

F2 : Technical Assessment Matrix

E : Service Specifications Priority

Matrix

Figure 1.  House of Quality (HOQ).

able, they wrote the answers to the instrument ques-
tions, otherwise they answered verbally.
Analysis of round 1 responses Each received response
from round 1 was listed as a separate item. Hence, a
total of 721 ideas and suggestions were generated. Then
the data were reviewed, the same ideas were combined
and similar ideas were clustered into emerging themes.
Also, the original patient wording was reformed in
some cases. Three of the authors as the Delphi coor-
dinators did this separately at first and then jointly to
discuss different interpretations. After the analysis of
the responses the number of items and themes were
reduced to 63 and six, respectively. The theme “access”
was emerged besides the five previous themes.
Round 2. In the second round the participants
were presented with the 63 items (eg, “Modern
equipment in the burn unit,” “Burn unit–experi-
enced medical staff,” and “Appropriate accommo-
dations in the inpatient rooms”) belonging to six
themes generated from round 1. The items were
scored by five-point Likert scale (extremely impor-
tant=5, very important=4, moderately important=3,
slightly important=2, low importance=1). Space was
provided for optional comments at the end of each
theme and at the end of instrument.
Analysis of round 2 responses In the study, all data
from Likert-scale questions were analyzed as inter-
val-level data with mean and SD in order to allow for
a cutoff point. Consensus was defined by a cut off
of 3.5 of 5, yielding 70% agreement; if a particular
item received a score lower than 3.5, it was removed
from the list. Forty items in which 70% of partici-
pants agreed were included in this round.
In order to measure the homogeneity for the rank-
ings the Cronbach’s α was calculated. Because the
Cronbach’s value extracted from the data of second
round was .87, consensus was reached in this round
and Delphi rounds were stopped.
Figure 2 summarizes the steps involved in the
two-round Delphi process.
Second Stage: Prioritizing Patients’
Expectations, Constructing A Matrix of
House of Quality
In this stage, patients’ expectations were prioritized
according to their total mean scores in the second

Copyright © American Burn Association. Unauthorized reproduction of this article is prohibited.

 Journal of Burn Care & Research
4   Keshtkaran et al Month/XXX 2013

• Listing items separately

• Combining ideas
• Clustering items to emerging themes
• Constructing 63 item and 6 theme instrument
Analysis of Round 1 Round 2

• Distributing to Delphi team members

• Constructing instrument
• Collecting
• Distributing to Delphi team members
• Collecting
Analysis of Round 2

Round 1
• Including 40 agreed items by a cut off
of 3.5 out of 5
Forming
Delphi team

Measuring
• Consensus Consensus
(alpha> 0.7) Level

Figure 2.  Flow chart of the Delphi process for determining patients’ expectations.

round of Delphi method. Then, A matrix of HOQ
was completed.
Third Stage: Determining Service
Specifications, Constructing B Matrix of
House of Quality
In order to determine the service specifications, Del-
phi technique was used. To form the Delphi team, 28
burn unit doctors and nurses as well as hospital direc-
tors were identified. Twenty-eight mails including
explanations about research rounds and goals along
with an invitation to participate in the study were
sent to each individual. Twenty-four of invitees stated
their agreement to participate in the study. There-
fore, they were selected as Delphi team members.
Round 1. The items of the first round instrument
were extracted from literature reviews and expert
group’s opinions. The instrument comprised 38
open-ended questions. The questions were struc-
tured around six themes; equipment and materi-
als, human resources, physical space, basic facilities,
communications and interpersonal dimensions, and
access. The questions are illustrated in Appendix 3.
Printed copies of the instrument were distributed to
Delphi team members, and these copies were col-
lated after a specific period of time.
Analysis of round 1 response The considerations in
analyzing the first round were the same as those of
determining patients’ expectations. At the end of the
analysis 264 items and six themes were produced.
Round 2. In the second round, the participants
were presented with 264 items around six themes
emerging from previous round (eg, “Installing of new
equipment,” “Increasing the number of experienced
medical staff,” and “Increasing burn unit physical
space”). The items were scored by five-point Likert
scale (extremely important=5, very important=4, mod-
erately important=3, slightly important=2, low impor-
tance=1). Space was provided for comments (if any) at
the end of each theme and at the end of the instrument.
Analysis of round 2 responses The considerations in
analyzing the second round responses were the same
as those of determining patients’ expectations. In
this round, also, the additional comments of respon-
dents were listed as separate items and put into previ-
ous themes according to their coordination. Because
the Cronbach’s value extracted from the data of sec-
ond round was .59, consensus was not reached in
this round, and Delphi method was continued in the
third round.
Round 3. In the third round the research instru-
ment included the following parts:
•• One hundred forty-one agreed items remain-
ing from previous rounds accompanied by
total mean score, and SD of each item as well
as score of each item were given by individuals
themselves from the second round (two mean
scores were presented for comparing).
•• Five new items based on the obtained com-
ments from Delphi team members from previ-
ous round.
The participants were requested to repeat the points’
allocation process after taking the round 2 results into
account. If necessary the provided information was
explained to them. They were reminded that they were
free to change their “vote” based on the results, or to
vote the same way as they did in round 2. Space was
again made available at the end of each theme as well
as at the end of the instrument for optional comments.
Analysis of round 3 responses To analyze the gath-
ered data in this round, the total mean score for each

Copyright © American Burn Association. Unauthorized reproduction of this article is prohibited.

 Journal of Burn Care & Research
Volume XX, Number XX Keshtkaran et al   5

• Listing items separately

• Combining ideas
• Clustering items to emerging themes Round 2
Analysis of Round 1
• Constructing 264 item and 6 theme instrument

• Distributing to Delphi team members

• Constructing instrument
• Collecting
• Distributing to Delphi team members
• Collecting
Analysis of Round 2

Round 1
• Including 141 agreed items by a cut off
of 3.5 out of 5
Forming
• Constructing 146 item and 6 theme instrument
Delphi team
Round 3

• Distributing to Delphi team members

• Collecting

Analysis of Round 3
• Consensus • Including 45 agreed items by
(alpha> 0.7) a cut off of 3.5 out of 5
Measuring Consensus
Level

Figure 3.  Flow chart of the Delphi process for determining service specifications.

item was calculated again. The considerations in
scoring were as same as those in the second round
analysis. 45 items in which 70% of participants agreed
were included in this round.
At the end of the round, Cronbach’s α was cal-
culated; because this value was .83, the Delphi team
members reached consensus and Delphi rounds were
stopped. The steps of three rounds of the Delphi
process are depicted in Figure 3.
Finally B matrix of HOQ was constructed.
Fourth Stage: Determining the Relationship
Between the Patients’ Expectations and
Service Specifications, Constructing C
Matrix of House of Quality
In this stage, the relationships between the patients’
expectations and service specifications were deter-
mined through the opinions of a seven-member
expert group including nurses, doctors, and hospital
directors of Delphi team, as well as, two of the authors.
The expert group members did this individually at
first and then discussed different responses to find the
best one. The relationships were determined in four
levels including no relationship (0), weak relationship
(1), medium relationship (3), and strong relationship
(9). At last, C matrix of HOQ was completed.
Fifth Stage: Determining the Relationship
Between Service Specifications,
Constructing D Matrix of House of Quality
In this stage, the relationships between service speci-
fications were determined through opinions of a
seven-member expert group. The team members
were the same as those in the fourth stage, and by
using the same method the relationships between
service specifications were determined. The relation-
ships were specified in five levels including strong
negative relationship, weak negative relationship, no
relationship, weak positive relationship, and strong
positive relationship. Finally, D matrix of HOQ was
constructed.
Sixth Stage: Prioritizing Service
Specifications, Constructing E Matrix of
House of Quality
In this stage, the priorities of the service specifica-
tions were determined by their importance rating.
The importance rating of the service the following
simple additive weighting formula:
Importance rating of
a service specification = Σ(importance rating of
patients’ expectation ×
relationship value between
patients’ expectation and
the service specification)
At the end of this stage, E matrix of HOQ was
constructed.
Because Ghotbedin Burn Hospital is the only burn
center in Shiraz, it does not have any competitor in
the current study. Therefore, the two final stages of
QFD including competitive assessment and techni-
cal assessment, implemented by comparing against
competitors, were excluded from the study. These

Copyright © American Burn Association. Unauthorized reproduction of this article is prohibited.


6   Keshtkaran et al Month/XXX 2013
two stages construct F1 and F2 matrices of HOQ in
Figure 1.
RESULTS
The findings show that Ghotbedin Hospital burn unit
patients have 40 expectations on six themes includ-
ing equipment and materials, human resources,
physical space, basic facilities, access, and communi-
cations and interpersonal dimensions. Table 1 dis-
plays these expectations. Furthermore, 16 priorities
were identified for burn unit patients’ expectations.
These priorities were scored from five for the first
priority to 3.45 for the 16th priority. The patients’
expectations matrix in Figure 4 shows the patients’
expectations depicted with A1 to A40 codes (illus-
trated in Table 1) and their priorities.
According to the findings, the burn unit had 45
service specifications on six themes including equip-
ment and materials, human resources, physical
space, basic facilities, access, and communications
and interpersonal dimensions. Table 1 shows these
service specifications. The service specifications are
depicted with B1 to B45 codes in Figure 4.
Figure 4 also shows the relationships between
burn unit patients’ expectations (eg, high-quality
medical care) and service specifications (eg, increas-
ing the number of experienced medical staff). These
relationships are shown in the body matrix of HOQ.
According to the results, almost 56% of the service
specifications have a strong relationship with at least
one patient’s expectation, and 60% of the service
specifications have a medium relationship with at least
one patient’s expectation. Almost 16% of the service
specifications have only weak relationships with the
patients’ expectations. Moreover, 50%, 62/5%, and
10% of the patients’ expectations, respectively, had
strong, medium, and weak relationships with at least
one service specification.
On the basis of the Figure 4 findings, there are
four relationship levels between some of the burn
unit service specifications (eg, between repair-
ing burn unit equipment and improving burn unit
ventilation system). The relationship levels include
strong negative relationship, no relationship, weak
positive relationship, and strong positive relation-
ship. Accordingly, 3% of the service specifications’
relationships were strong negative, 92% were weak
positive, and 4% were strong positive. None of the
relationships is weak negative. Service specifications’
relationships are shown by various symbols in the
roof matrix of HOQ in Figure 4.
As the results show, burn unit service specifica-
tions’ priorities were scored from 136.8 for the
Copyright © American Burn Association. Unauthorized reproduction of this article is prohibited.
Journal of Burn Care & Research
highest priority to 13.25 for lowest priority. The
relative importance matrix in Figure 4 indicates the
service specifications’ priorities.
DISCUSSION
QFD is a customer-driven planning process for
product or service development as well as for qual-
ity management in general. It is also “a flexible tool
that can be fashioned to be effective in a wide range
of applications and for many types of organizations”
with many commonly known benefits. This article
applied QFD in improving burn unit services of
Ghotbedin Hospital.8
Accordingly, Ghotbedin Hospital burn unit
patients have 40 main expectations on six different
dimensions. The most important expectations are
skillful doctors, knowledgeable doctors, adequate
number of nurses, skillful nurses, and high-quality
nursery care. As the results show, the most important
patients’ expectations are related to clinical staff and
received clinical services. Aerlyn in a review of the lit-
erature distinguished 10 most commonly addressed
categories of expectations in patients’ expectations
studies. These expectations were related to medical
information, medication/prescription, counseling/
psychosocial support, diagnostic testing, refer-
ral, physical examination, health advice, outcome
of surgery or treatment, therapeutic listening, and
waiting time.26 Bostan et al27 conducted a survey
measuring the patients’ expectations hierarchy lev-
els on various factors. The survey showed that the
level of the expectations of the patients was at an
acceptable level on the factor of medical services.
The comparison between the results of the current
study and Aerlyn and Bostan’s studies indicate that
in all the three studies almost all of the most impor-
tant patients’ expectations are based around clinical
dimensions of care.
According to the results, Ghotbedin Hospital
burn unit has 45 service specifications on six differ-
ent areas. A study by Moores determined seven ser-
vice specifications for radiation safety management,
two of which, including equipment and training,
are similar to burn unit service specifications.28 The
difference of other specifications is the result of the
existent diversity between radiology and burn unit
services. In another study, Jeong and Oh29 noted 10
service specifications for a hotel, seven of which are
similar to burn unit service specifications in physi-
cal space, basic facilities, communications, and access
dimensions. Three other service specifications in
Jeong’s study are performed well in the burn unit,
so there is no more need to develop them.
 Journal of Burn Care & Research
Volume XX, Number XX Keshtkaran et al   7

Table 1. Burn unit patients expectations and service specifications

Patients Expectations Service Specifications

A1 Modern equipments B1 Increasing the number of some equipments (such as ICU beds, IV stands, …)
A2 Enough equipments B2 Installing of new equipments (such as ceiling IV stands, patients buzzer by
the beds,…)
A3 High quality equipments B3 Repairing some of the equipments (such as some beds, …)
A4 All kinds of required materials provided B4 Buying foreign types of some medications (such as antibiotics)
A5 Sufficient materials B4 Buying foreign types of some medications (such as antibiotics)
A6 High quality materials B6 Using high quality equipments by cleaning companies in contract with the
hospital
A7 Adequate medical staff B7 Using high quality materials by cleaning companies in contract with the
hospital
A8 Experienced medical staff B8 Increasing the quality of some materials (such as syringe, microcet, bandage,
detergent, …)
A9 Skillful medical staff B9 Increasing the number of medical staff
A10 Knowledgeable medical staff B10 Increasing the number of medical specialist staff
A11 High quality medical care B11 Increasing the number of experienced medical staff
A12 Adequate nursing staff B12 Increasing the number of nursing staff
A13 Knowledgeable nursing staff B13 Developing training courses for nursing staff, before their entrance to
the unit
A14 Skillful nursing staff B14 Developing training courses for nursing staff
A15 High quality nursery care B15 Developing training courses for medical staff
A16 K
 nowledgeable clinical staff about the latest B16 Increasing appropriate financial incentives for nursing staff
scientific advances
A17 O
 bserving infection control instructions by B17 Increasing appropriate nonfinancial incentives for nursing staff
clinical staff
A18 Clean unit B18 Increasing appropriate financial incentives for medical staff
A19 Good physical appearance of the burn unit B19 Increasing appropriate nonfinancial incentives for medical staff
A20 Burn unit adequate physical space B20 Training clinical staff about dealing with fire
A21 Allocating all required physical spaces B21 Performing a greater hygiene observance and infection control by the staff of
burn unit
A22 Clean inpatient rooms B22 Improving cleaning service workers’ skills by cleaning companies in contract
with the hospital
A23 A
 dequate physical space of the burn unit B23 Improving cleaning service workers’ awareness by cleaning companies in
noninpatient spaces contract with the hospital
A24 Adequate physical space of inpatient rooms B24 Providing permanent cleaning service workers in evening and night shifts
A25 Clean toilets B25 Increasing burn unit physical space (such as inpatient rooms space, corridors
space)
A26 Clean bathrooms B26 Improving burn unit physical access to other units
A27 A
 ppropriate accommodations in inpatient B27 Increasing the number of some physical spaces (such as dressing room,
rooms isolation room, …)
A28 Good ventilation system of the burn unit B28 Constructing new physical spaces (such as dirty room, medication room, …)
A29 G
 ood heating and cooling system of the B29 Repairing some of the physical defects (such as nonwashable walls, ruinous
burn unit windows, …)
A30 Consideration of patient safety B30 Reforming some of the physical spaces (such as dressing room, nursing
station, …)`
A31 Polite clinical staff B31 Improving ventilation system of the burn unit
A32 Kind clinical staff B32 Improving heating and cooling system of the burn unit
A33 Patient clinical staff B33 Installing hands-free electronic-eye faucets
A34 Patient's privacy protection B34 Improving electrical system of the burn unit
A35 Patient involvement in medical decision making B35 Improving sanitation system of the burn unit
A36 Personal hygiene training B36 Observing safety requirements when giving radiation to inpatient rooms
A37 Quick and timely access to the nursing services B37 Improving fire control system of the burn unit (eg, by central fire control
system, fire sensors, …)
A38 Easy contact with related doctors B38 Providing accommodations (such as televisions, refrigerators, etc) for patients
(Continued)

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 Journal of Burn Care & Research
8   Keshtkaran et al Month/XXX 2013

Table 1. (Continued)
Patients Expectations Service Specifications

A39 Suitable hospital cost B39 Creating a better relationship with patients
A40 Sufficient meeting time for patients' companions B40 Protecting patient's privacy (eg, while changing their clothes, talking about
their problems, …)
B41 Describing side effects of medications for patients
B42 Describing treatment procedures for patients
B43 Training patients about personal hygiene principles
B44 Quick and timely patient's access to nursing services
B45 Taking appropriate measures to help poor patients for hospital cost payments

ICU, intensive care unit; IV, intravenous.

The HOQ analysis clearly shows that for develop- working experience, and the number of specialists is
ing burn unit services a number of issues need to low. Therefore, there is an urgent need for employ-
be addressed. The first and most important issue is ing more specialists, as well as, more experienced
increasing burn unit physical space. In fact, Ghot- doctors. On the basis of these results, the next most
bedin Hospital is the only burn center for patients important issue is constructing some new physical
in Fars and its neighboring provinces, and has to spaces such as dirty room and medication room in
admit a large number of patients. Moreover, this the burn unit because there is a lack of these spaces
hospital is an old structure and its current space is in the current structure of the unit. Increased obser-
not sufficient for the patient population. Regarding vance of hygiene and infection control by burn unit
this, lack of enough physical space is one of the most staff is the next issue to be improved in the burn unit.
obvious problems not only in the burn unit but also Burn unit patients are vulnerable to infection, and
in all units of the Ghotbedin Hospital. The second the importance of control and prevention is undeni-
and third most important issues are increasing the able. Some measures include strict aseptic technique,
number of specialists and experienced doctors. Cur- use of sterile gloves and dressing materials, wearing
rently most of the medical services in the burn unit masks for dressing changes, and special separation of
are provided by general physicians with few years of patients by private rooms or cubicles.30

Strong Positive Relationship

Weak Positive Relationship

Strong Negetive Relationship

Weak Negetive Relationship

SERVICE Communications and

Equipments and Materials Human Resources Physical Space Basic Facilities Interpersonal Dimensions Access
SPECIFICATION

PATIENTS’
EXPECTATIONS B1 B2 B3 B4 B5 B6 B7 B8 B9 B10 B11 B12 B13 B14 B15 B16 B17 B18 B19 B20 B21 B22 B23 B24 B25 B26 B27 B28 B29 B30 B31 B32 B33 B34 B35 B36 B37 B38 B39 B40 B41 B42 B43 B44 B45

A1 4.75 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 3 1 1 1 1 1 0 0 0 0 0 0 0
Equipments and

A2 4.65 9 3 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 3 0 0 0 0 0 0 0
Materials

A3 4.75 1 1 3 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 1 1 1 1 1 0 0 0 0 0 0 0
A4 4.9 0 0 0 3 9 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
A5 4.75 0 0 0 1 3 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
A6 4.6 0 0 0 9 3 0 0 9 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
A7 4.55 0 0 0 0 0 0 0 0 9 9 9 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
A8 4.9 0 0 0 0 0 0 0 0 1 3 9 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
A9 5 0 0 0 0 0 0 0 0 1 3 3 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Human Resources

A10 5 0 0 0 0 0 0 0 0 1 9 3 0 0 0 3 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
A11 4.8 1 1 1 1 1 0 0 1 1 3 3 0 0 0 1 0 0 1 1 0 1 0 0 0 1 0 1 1 0 0 0 0 0 0 0 0 0 0 0 1 1 1 1 0 0
A12 5 0 0 0 0 0 0 0 0 0 0 0 9 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
A13 4.9 0 0 0 0 0 0 0 0 0 0 0 1 3 3 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
A14 5 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
A15 5 1 1 1 1 1 0 0 1 0 0 0 1 1 1 0 1 1 0 0 0 3 0 0 0 1 0 1 1 0 0 0 0 0 0 0 0 0 0 1 1 1 1 1 1 0
A16 4.5 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
A17 4.8 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 0 0 0 9 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 1 0 0
A18 4.9 0 0 0 0 0 3 3 0 0 0 0 0 0 0 0 0 0 0 0 0 1 3 1 3 0 0 0 0 3 3 1 0 0 0 1 0 0 0 0 0 0 0 1 0 0
A19 4.15 3 3 0 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 3 0 3 3 1 3 0 0 0 0 0 3 0 0 0 0 0 0 0 0 0
A20 4.45 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 9 0 9 3 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Physical Space

A21 4.6 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 3 0 0 9 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
A22 4.85 0 0 0 0 0 3 3 0 0 0 0 0 0 0 0 0 0 0 0 0 1 3 1 3 0 0 0 0 3 3 1 0 0 0 1 0 0 0 0 0 0 0 1 0 0
A23 4.7 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 9 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
A24 4.65 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 3 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
A25 4.65 0 0 0 0 0 3 3 0 0 0 0 0 0 0 0 0 0 0 0 0 1 3 1 3 0 0 0 0 0 0 0 0 0 0 3 0 0 0 0 0 0 0 1 0 0
A26 4.65 0 0 0 0 0 3 3 0 0 0 0 0 0 0 0 0 0 0 0 0 1 3 1 3 0 0 0 0 0 0 0 0 0 0 3 0 0 0 0 0 0 0 1 0 0
A27 3.95 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 9 0 0 0 0 9 0 0 0 0 0 0 0
A28 4.85 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 9 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Facilities
Basic

A29 4.8 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 9 0 0 0 0 0 0 0 0 0 0 0 0 0
A30 4.75 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 0 0 3 0 0 0 0 0 1 0 0 0 0 0 0 0 9 0 9 9 0 0 0 0 0 0 3 0
A31 4.6 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 1 1 0 0 0 0 0 3 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 9 1 0 0 0 0 0
Communications and

A32 4.5 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 1 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 3 0 0 0 0 0 0
Interpersonal
Dimensions

A33 4.6 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 1 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 3 0 0 0 0 0 0
A34 4.45 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 0 0 0 0 0 3 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 1 9 0 0 0 0 0
A35 3.45 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0
A36 4.5 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 9 0 0
A37 4.8 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 1 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 9 0
A38 4.3 0 0 0 0 0 0 0 0 1 1 1 0 0 0 0 0 0 1 1 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Access

A39 4.65 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 9
A40 4.25 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Relative Importance 77.55 49.65 28.7 70.65 81.95 61.3 61.3 51.2 64.95 134.4 133.8 64.7 64.85 64.85 65.25 23.5 23.5 18.2 18.2 24.15 86.55 57.15 46.2 57.15 136.8 23.4 66.75 86.65 33.4 41.7 62.9 52.7 59.35 52.25 47.15 64.7 52.25 59 78.15 54.45 13.25 13.25 74.15 62.45 41.85

Figure 4.  House of quality matrix of Ghotbedin Hospital Burn Unit.

Copyright © American Burn Association. Unauthorized reproduction of this article is prohibited.

 Journal of Burn Care & Research
Volume XX, Number XX Keshtkaran et al   9
Among the most important service specifica-
tions discussed above, increasing burn unit physical
space has a weak positive relationship with preserv-
ing patient’s privacy and strong negative relationship
with quick and timely access of the patient to nurs-
ing services. Constructing new physical spaces has a
weak positive relationship with increased observance
of hygiene and infection control by burn unit staff, and
the latter has a weak positive relationship with increas-
ing the number of some physical spaces, installing
hands-free electronic-eye faucets, and training patients
on personal hygiene principles. All these relationships
displayed in the roof of HOQ must be regarded in
developing burn unit services. In other words, these
relationships indicate the effect of one service specifi-
cation on another. If this effect is positive, the impor-
tance of effective service specification increases, but if
the effect is negative the importance decreases.
On the contrary, the results show that one of the
least important issues to be improved in the burn
unit is explaining to the patients the side effects of
medications and treatment procedures they must
undergo. In fact, both side effects and treatment
procedures are considered to be of professional sig-
nificance only, such that informing patients about
these issues and patients’ knowledge about them
do not have high priority. Two further least impor-
tant service specifications are increasing appropri-
ate financial and nonfinancial incentives for medical
staff. Because these service specifications do not have
direct influence on patient satisfaction, they have low
priority in HOQ.
In sum, QFD is a service development and
improvement support method, which provides a
structured way for service providers to assure qual-
ity and customer satisfaction.31 In the current study,
QFD is used to improve Ghotbedin Hospital burn
unit services according to patients’ expectations. On
this basis 45 service specifications, as well as their
priorities, are determined based on 40 patients’
expectations. This information accompanied by the
relationships represented in the roof matrix of HOQ
can be a general guideline for burn unit decision
makers and administrators in order to improve burn
unit services.
In this regard, after this study a committee of
directors and supervisors, as well as, some related
experts of the Ghotbedin Hospital was organized.
The purpose of the committee was to enhance the
quality of burn unit services according to the find-
ings of the study. Recently, some achievements were
attained by this committee regarding increasing
the number of experienced doctors and increased
hygiene observance and infection control in the
Copyright © American Burn Association. Unauthorized reproduction of this article is prohibited.
burn unit. Moreover, the results of the study were
conveyed to the president of Shiraz University of
Medical Sciences, and the application of QFD for
improving the quality of services in other healthcare
centers was recommended.
CONCLUSIONS
QFD is a dominating approach that assures that cus-
tomers’ expectations actually do guide the service
improvement, and supports structuring and the rep-
resenting of information on customers’ expectations,
specially with regard to how customers’ expectations
can be linked to service specifications. The HOQ anal-
ysis has demonstrated that the most important burn
unit patients’ expectations include skillful and knowl-
edgeable medical staff, adequate and skillful nursing
staff, and high-quality nursery care. On the basis of
these expectations, the most important service speci-
fications to be improved in the burn unit are increas-
ing burn unit physical space, increasing the number
of specialists, increasing the number of experienced
doctors, constructing some new physical spaces, and
greater observance of hygiene, and increased infection
control by burn unit staff, in that order.
The QFD model proposed in this article can guide
burn unit planners and administrators as a general
map and provides a scientific and structured frame-
work in their attempts toward improving burn unit
services. In fact, each matrix of HOQ can be regarded
as valuable source of information, which provides
beneficial points for the quality-enhancement proj-
ect. Therefore, by considering this information burn
unit administrators will be able to improve burn unit
services in an effective way.
ACKNOWLEDGMENTS
We express sincere gratitude and appreciation to vice-
chancellor of research of Shiraz University of Medical Sci-
ences for financial support. Moreover, we acknowledge
the executive manager of Ghotbedin Burn Hospital for his
support and Delphi team members and other experts for
their valuable cooperation.
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Appendix 1: Quality Function Deployment (QFD) Process
The stages of QFD process are as follows:
Stage 1:
QFD starts with the customers. The first stage is:
•• To identify the customers of the product/service
•• To collect their expectations or needs for the product/service
•• To reveal the expectations in terms of their priority, as ­perceived
by the customers
Stage 2:
The second stage is determining product/service specifications,
which give technical descriptions of how to realize the custom-
ers’ expectations in the product/service. These product require-
ments represent a translation from the customer’s language to the
organization’s technical language, by which managers can improve
product/service quality, based on customers’ expectations
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Journal of Burn Care & Research
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31. Andronikidis A, Georgiou AC, Gotzamani K, Kamvysi K.
The application of quality function deployment in service
quality management. The TQM J 2009;21(4):319–33.
Constructing the first
matrix of HOQ
Constructing the second
matrix of HOQ
 Journal of Burn Care & Research
Volume XX, Number XX Keshtkaran et al   11

Stage 3:
The third stage is determining the relationship between customers’
expectations and product/service specifications. In this stage the
Constructing the third
degree of relationship or linkage between each customer’s expecta- matrix of HOQ
tion and each product/service specification is identified. Perform-
ing this stage is a vital step in the QFD process because the final
analysis stage relies heavily on the relationships between customers’
expectations and product/service specifications

Stage 4:
The fourth stage is determining the relationship between product/
service specifications. In this stage the development team assesses
which product/service specifications are interrelated and how
strong these relationships are. This assessment can be obtained
through engineering analysis and experience. Usually, after the prod-
uct/service specifications have been determined, the development Constructing the fourth
team will be able to see that as one product/service specification is matrix of HOQ

changed, the others will be influenced. The degrees and directions

of these influences have serious effects on the development effort.
Especially, negative effects of one product/service specification on
the others represent bottlenecks in the design, which call for special
planning or breakthrough attempts. In other words, by performing
this stage we will understand which technical areas need close com-
munication and collaboration and which areas do not

Stage 5:
In the fifth stage the relative importance of service specifications
is determined. The relative importance scores are comprehensive
measures indicating the degree to which the product/service spec- Constructing the fifth
matrix of HOQ
ification is related to all the customers’ expectations. These ratings
reflect the basic importance of the product/service specifications
developed in relation to the customers’ expectations. Most of the
quality-improvement measures are taken based on these ratings

Stage 6-1:
The step 1 of the sixth stage is competitive customer evaluations of Constructing the sixth
the company’s product/service compared with its main competi- matrix of HOQ
tors’ similar products in terms of the products/services’ perfor-
mance, based on customer expectations

Stage 6-2:
Constructing the seventh
The step 2 of the sixth stage is to conduct competitive technical matrix of HOQ
assessments to compare company’s product/service’s technical
performance and the performance of company’s competitors’ simi-
lar products on each product/service specification

Copyright © American Burn Association. Unauthorized reproduction of this article is prohibited.


12   Keshtkaran et al Month/XXX 2013
Appendix 2: Patient’s Expectations
Questionnaire
Equipment and Materials
1. In your opinion, what are the required specifica-
tions of clinical equipments (eg, pressure meter,
thermometer, stethoscope, flashlight, scale,
ophthalmoscope, and so on) in the burn unit?
2. In your opinion, what are the required specifi-
cations of welfare equipment (eg, bed, curtain,
chair, wheelchair, brancard, paravan, trolley,
and so on) in the burn unit?
3. Express your expectations regarding any spe-
cific equipment in the burn unit?
4. In your opinion, what are the required speci-
fications of clinical materials (eg, medication,
syringe, bandage, cotton, adhesive plaster,
catheter, and so on) in the burn unit?
5. In your opinion, what are the required specifi-
cations of welfare materials (eg, patient cloth-
ing, detergent, and so on) in the burn unit?
6. Express your expectations regarding any spe-
cific material in the burn unit?
Human Resources
7. How do you think the burn unit medical staff
should be?
8. How do you think the burn unit nursing staff
should be?
9. How do you think the burn unit cleaning work-
ers should be?
10. What are your suggestions on how provide
appropriate medical services in the burn unit?
11. What are your suggestions on how to provide
appropriate nursery services in the burn unit?
12. What are your suggestions on how to provide
favorable nonclinical services (ie, welfare ser-
vices) in the burn unit?
Physical Space
13. In your opinion, what are the requirements for
suitable inpatient room in the burn unit?
14. In your opinion, what are the requirements
for suitable noninpatient spaces (eg, burn unit
nursing station, burn unit corridor, dressing
room, and so on) in the burn unit?
15. In your opinion, what are the requirements for
suitable bathrooms and toilets in the burn unit?
Basic Facilities
The basic facilities of the burn unit are as follows.
Express your expectations regarding each one:
(16–22)
Copyright © American Burn Association. Unauthorized reproduction of this article is prohibited.
Journal of Burn Care & Research
16. Water-supply system
17. Electrical system
18. Ventilation system
19. Telephone and communication services
20. Heating and cooling system
21. Fire-control system
22. Sanitation system
23. Gas system
24. What welfare facilities do you expect to be pro-
vided in the burn unit?
25. For your companions, what welfare facilities do
you expect to be provided?
Communication and Interpersonal Dimension
26. How do you expect burn unit doctors to behave
with you?
27. How do you expect burn unit nurses to behave
with you?
28. How do you expect burn unit cleaning workers
to behave with you?
29. As a burn unit patient, in what cases would you
like to have freedom of choice?
30. As a burn unit patient, in what cases would you
like to be consulted by the medical team?
31. As a burn unit patient, in what cases is protect-
ing your privacy important?
32. What kind of information and advice do you
want to get from burn unit clinical staff (doc-
tors and nurses)?
33. As a burn unit patient, what other expectations
do you have?
Appendix 3: Service Specifications
Questionnaire
Equipment and Materials
1. Is there enough clinical equipment (eg, pres-
sure meter, thermometer, stethoscope, flashlight,
scale, ophthalmoscope, and so on) in the burn
unit? If the answer is negative, in your opinion
what measures can be taken to solve this shortage?
2. Is there enough welfare equipment (eg, bed,
curtain, chair, wheelchair, brancard, paravan,
trolley, and so on) in the burn unit? If the
answer is negative, in your opinion what mea-
sures can be taken to solve this shortage?
3. Are there enough clinical materials (eg, medica-
tion, syringe, bandage, cotton, adhesive plas-
ter, catheter, and so on) in the burn unit? If the
answer is negative, in your opinion what measures
can be taken to solve this shortage?
4. Are there enough welfare materials (eg, patient
clothing, detergent, and so on) in the burn
 Journal of Burn Care & Research
Volume XX, Number XX Keshtkaran et al   13
unit? If the answer is negative, in your opin-
ion what measures can be taken to solve this
shortage?
5. Is there high-quality clinical equipment in the
burn unit? If answer is negative, in your opin-
ion what measures can be taken to improve the
quality?
6. Is there high-quality welfare equipment in the
burn unit? If answer is negative, in your opin-
ion what measures can be taken to improve the
quality?
7. Are there high-quality clinical materials in the
burn unit? If answer is negative, in your opin-
ion what measures can be taken to improve the
quality?
8. Are there high-quality welfare materials in the
burn unit? If answer is negative, in your opin-
ion what measures can be taken to improve the
quality?
Human Resources
9. In your opinion, are there enough doctors in
the burn unit?
10. What ways do you recommend to improve the
abilities of the burn unit medical staff abilities?
11. In your opinion, are there enough nurses in the
burn unit?
12. What ways do you recommend to improve the
abilities of the burn unit nursing staff?
13. In your opinion, are there enough cleaning
workers in the burn unit?
14. What ways do you recommend to improve the
abilities of the burn unit cleaning workers?
Physical Space
15. In your opinion, are there any problems in the
burn unit physical space? If answer is positive,
what are they?
16. In your opinion, are there any problems with
the burn unit cleaning and hygiene? If answer
is positive, what are they?
17. In your opinion, are there any problems with
the burn unit design? If answer is positive, what
are they?
Basic Facilities
18. In your opinion, what measures can be taken
to improve burn unit patients’ welfare facilities?
Copyright © American Burn Association. Unauthorized reproduction of this article is prohibited.
19. In your opinion, what measures can be taken to
improve the welfare facilities dedicated to burn
unit patients’ companions?
20. In your opinion, what measures can be taken to
improve the burn unit patients’ safety?
The basic facilities of the burn unit are as follows.
If there is any problem in each one, describe the
problem as well as your solutions.
21. Water-supply system
22. Electrical system
23. Ventilation system
24. Communication system
25. Heating and cooling system
26. Fire-control system
27. Sanitation system
28. Gas system
Communication and Interpersonal Dimension
29. In your opinion, what actions can be taken to
improve burn unit doctors’ relationships with
patients?
30. In your opinion, what actions can be taken to
improve burn unit nurses’ relationships with
patients?
31. In your opinion, what measures can be taken
to increase burn unit patients’ participation in
making decisions regarding their treatment?
32. What are your suggestions to improve the burn
unit patients’ privacy?
33. In your opinion, what kind of information and
advice is necessary for burn unit patients?
Access
34. In your opinion, do the burn unit patients have
quick access to their doctors?
35. In your opinion, do the burn unit patients have
quick access to their nurses?
36. In your opinion, do the burn unit patients have
enough visits from their companions? If answer
is negative, what are your recommendations?
37. From what financial resources (eg, out-of-
pocket payments, healthcare insurances, chari-
ties, and so on) do burn unit patients pay
hospital costs?
38. What other problems are there in the burn
unit? What are your suggestions to solve
them?