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Total Quality Management in Healthcare

Gunjan Patel
B.E.-Biomedical Engg, PGD-Quality Management, MS-Medical Software (1st sem)-MCIS, Manipal University
E-mail: gunjannpatel@gmail.com

Abstract
This paper presents the description on Healthcare strategy. Thus, TQM, which places on improved customer
organizations are required to focus on Total quality improve:- satisfaction, offers the prospect of great market share and
Rendering acceptable, quality health services to patients at profitability.
affordable price within reasonable price, within in a TQM can be an important part of hospitals competitive
reasonable time; Applying zero errors to all patients services; strategy in quality of healthcare system. Hospitals in
maintaining a continuous error prevention program; Training competitive markets are more likely to attempt to differentiate
employees in medical care on such aspects as error prevention, themselves from their competitors on the basic of greater
reducing delay time and providing prompt reasonable to service quality. Thus, TQM which places a heavy emphasis on
patients needs; management system have always improvement improvement in Customer satisfaction index that offers the
in such systems to realize the true nature of the quality of prospect of grater combines internal quality measures with
healthcare and to be motivated towards improving this quality. value analysis and conformance to specifications. Acceptable
In spite of billions of dollars of money spent worldwide, most quality services not only include direct medical services such
of the healthcare is seen to be ineffective, inefficient and as diagnoses, medicines, surgery and treatment but indirect
inadequate. Therefore there is a crying need to bring about a operations such as administration and purchasing whose costs
paradigm shift in the quality of health care delivery and to are reflected in what the buyer pays. It may also include Total
monitor and sustain it. It is obvious that those institutions, Quality of performance that is directly related to healthcare
which are quality conscious and are committed to continuous safety, security, attitude of nursing and word boy, role of
quality improvement, will gain the highest consumer doctors in terms of ‘time’ includes appointment, delay time,
acceptance and will flourish at the expense of others. The service time, timing with regards to medical treatment and
'Quality Revolution', as it is sometimes referred to, is nothing surgery.
but putting the patient at the heart of health care and wrapping
the care around it, rather than the other way around. The Concept of Total Quality Management:
Quality Measuring and assessing service is important,
particularly when multiple sources of variation are present.
Analyzing all medical processes to remove rework and waste
could build healthcare quality and lead to significant
reductions in patient cost. The use of quality-assurance
programs and statistical tools can be directly applied to health-
care organizations with improved quality of patient's
objectives and the results of care from the patient's viewpoint.

I. Introduction Fig. 1, TQM structure

Now a day, Healthcare systems are of fundamental People define quality in many ways. Some think of quality as
interests to all level of Hospitals in our societies. Eventually, superiority of excellence, others vies it as a lack of patient care
increasing importance and reliance are placed on total quality and service defects. According to Crosby, quality is
management in healthcare systems. Due to this rising 'conformance to requirements'. (Zero defects). Today most
importance that is also reflected in the increasing percentage mangers agree that the main reason to purse quality is to
of national and international resources for both private and satisfy the customers. The American National Standards
public sector to allocated in hospital management systems. Institute (ANSI) and American Society Quality (ASQ) define
Hospitals and other healthcare organization across the globe quality as “The totality of features and characterizes of a care
have been progressively implementing TQM to reduce costs, or service that bears on its ability to satisfy given needs”. The
improve efficiency and provide high quality patient care. view of quality as the satisfaction of customer needs is often
Contrary to popular belief, the TQM movements were not the called fitness for use.
start of concerns about quality in healthcare. The roots of
quality assurance initiatives in healthcare extends at least as II. The importance of TQM in Healthcare systems:
far back as the time of Florance Nightangles’s work during the
Crimean War(1854-1856),when the introduction of nutrition, Health services include a wide variety of quality aspects, all of
sanitation and infection control initiatives in war hospitals which are important. In the case of medical services, the seller
contributed to reduction in the death rate from 43% to 10%. is doctors, hospitals, nursing homes, clinics, etc. because they
TQM can be an important part of hospitals’ competitive offer health services for sale as stipulated prices. They buyer
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is the client or patient who buys these health services at the

stipulated prices. It may also included quality of performance
that is directly connected and closely related to healthcare TQM is a people-focused management system that aims at
such as food, housing, safety, security, attitude of employees, continue increases in customer satisfaction at continually
and other factors that arise in connection with hospitals and lower real cost. TQM system approach and an integral part of
nursing homes. So, the time takes in to the fix an appointment, high level strategy, it works horizontally across functions and
delay time, services time, timing with regard to medical departments, involves all employees, top to bottom and
treatment and surgery. extends backward and forward to include the sully chain and
• Quality of administration and management the customer chain. TQ stresses learning and adaption to
• Quality of doctors continual change as keys to organization success.
• Quality of hospital care
Deming principles to healthcare Systems:
III. Principle of Total Quality management:
• Insists on zero defects eliminate inspection through
The basic principle of TQM should be carried out using the 8 proper quality control on suppliers.
QM principles otherwise the resultant system will not satisfy • Constant improve the system
the intent of the quality standards in the healthcare • Educational and Training program
management system. • Maintain the records
• Eliminate numerical goals, work standards and slogans
Table 1. TQM Principles: • Remove the barriers that hinder the worker through the
day
• Top management support for implementing TQM
Organizations depend on their customers
Customer and therefore should understand current IV. The basic elements of TQM :
1 focused and future customer needs, should meet
organization customer requirements and strive to A. Customer Focus:
exceed customer expectations
The customer is the judge of quality. From the TQ
Leaders establish unity of purpose and perspective, all strategic decisions a healthcare institute makes
direction. They should create and are “customer driven”. Customer driven firms measure the
2 Leadership maintain the internal environment in factors that drive customer satisfaction. The perception of
which people can become fully involved value and satisfaction are infused by many factors through the
in achieving the organization's objectives customers overall purchase, ownership and services. Also
People at all levels are the essence of an reducing defects and error and eliminating causes of
Involvement organization and their full involvement dissatisfaction contribute significantly to company’s views of
3 quality. Also, customer opinion surveys and focuses
of people enables their abilities to be used for the
organization's benefit. techniques can help to understand the customer requirements
and values. Customer focus extends beyond the customer and
A desired result is achieved more
Process internal relationships; however society represents an important
4 efficiently when activities and related
approach customer of business. Business ethics, patient’s health and
resources are managed as a process.
safety, environment and sharing of quality standards in the
Identifying, understanding and managing healthcare systems and communities are necessary activities.
System a system of interrelated processes as a
5 approach to system contributes to the organization’s B. Strategic planning and Leadership:
management effectiveness and efficiency in achieving
its objectives. Strategic planning needs to anticipate many changes such as
Continual improvement of the customer’s expectations, new opportunities, advance
Continual organization's overall performance should diagnostic technologies development; evolving patients care
6
improvement be a permanent objective of the system and social expectations. Achieving quality and
organization. healthcare service leadership requires a strong future
Factual orientation and a willingness to make, long-term relations ion
approach to Effective decisions are based on the to key customers, employees, doctors, nurses, suppliers, the
7
decision analysis of data and information. public and private community. Through their personal roles in
making planning, reviewing healthcare quality performance, and staffs
Mutually An organization and its suppliers are for quality achieving, the senior’s leaders serve as role model
beneficial interdependent and a mutually beneficial
8
supplier relationship enhances the ability of both
relationships to create value.
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reinforcing the values and encouraging leadership through the G. Quality Assurance and Control:
organization.
Quality assurance is the planned or systematic actions
C. Continues improvement and learning: necessary to provide adequate confidence that a patient
services or safety will satisfy given requirement for quality.
Continues improvement is part of the management of all The activity of this department includes quality planning,
system and process. Achieving the highest of performance control, improvement, internal audit and reliability. Moreover
requires a well-defined and well-executed approach to it also includes quality advice and expertise, training of
continues improvement and learning. Learning refers to personnel in quality, analysis of customer diagnosis, treatment
adaption to changes, leading to new goals or approaches. records, medical claims details, and patients liability cases.
Improvements and learning need to be embedded in the way Management is responsible for defining, documenting and
an organization operates. The process of continues supporting the quality policy, quality manual, performance,
improvement must contain regular cycles of planning, safety and dependability.
execution and evolution. In quality manual system that defined as an assembly of
components such as the organization structure, responsibility,
D. Empowerment and Teamwork: procedures and resources for implementing quality
management must be documented in the form of a quality
A healthcare institute’s success depends increasingly on the manual.
knowledge, skills, and motivation of its work force. In
healthcare management, individuals and departments work for V. Six-Sigma Quality concepts:
themselves. In TQ individuals cooperate in team structures
such as quality circles, steering committees and self-directed The concepts surrounding the drive to Six Sigma quality are
work teams. Department works together towards system essentially those of statistics and probability. In simple
optimization through cross-function team-work language, these concepts boil down to, “How confident can I
be that what I planned to happen actually will happen?”
.
Basically, the concept of Six Sigma deals with measuring and
E. Process management: improving how close we come to delivering on what we
planned to do.
Deming and Juran observed that while majority of the quality For any process with a standard distribution (something that
problems are associated with processes, few are caused by looks like a bell-shaped curve), the probability is 68.26% that
workers themselves. It is involves planning and administrator the next value will be within one standard deviation from the
the activities necessary to achieve a high level of performance mean. The probability is 95.44% that the same next value will
fall within two standard deviations. The probability is 99.73%
in a process and identifying opportunities for improving
that it will be within three sigma; and 99.994% that it will be
quality and customer satisfaction. within four sigma. Standard distribution curve with mean,
sigma values and four sigma tolerances. For a product to be
F. Tools for process management: virtually defect free, it must be designed with both normal
process variation and process drift in mind. With these things
The tools and techniques, along with management practices considered, a Six Sigma design specification width would
and the organizational infrastructure and fundamentals produce a yield of 99.99966%–3.4 defects per million
components of TQM. opportunities or virtually zero defects.
The various tools for improving process management are:
• Team-building and group-integration tools
• Specific process/technical tools
• Process flow chart
• Check sheet and Histograms
• Pareto analysis
• Fishbone Charts
• Process control chart
• Quality function Deployment (QFD)
• Poka-Yoka or Fail sating
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Fig.2 Standard distribution curve with mean, sigma values and organization’s philosophy into a clear vision of what a quality
DPMO = defects per million opportunities transformation would require.
The following initiated TQM in IHMC:
If the range of acceptability, or tolerance limit, for your • The healthcare services, which were good old time, barely
product is at or outside the four sigma point on the distribution meet the requirement of today and will adequate
curve for your process, you are virtually assured of producing tomorrow. Customers need to continue increase demands
acceptable material every time–provided, of course, that your in services.
process is centered and stays centered on your target value. To • In the age of technological revolution in medical,
achieve Six Sigma Quality, a process must produce no more customers expected speedy response to their queries and
than 3.4 defects per million opportunities. An "opportunity" is services.
defined as a chance for nonconformance, or not meeting the • Employee involvement in quality improvement was not to
required specifications. the desired levels. There was resistance to change among
them to suit the changing business environment. This
VI. Reliability and Maintainer: resistance needed to be reduced in order to ensure better
employee indolent.
Reliability is the ability of the patient service to performance • The management was satisfied with the prevailing levels
as expected over time is one of the principal domination or of quality. This satisfaction arose out of comparing the
present performance with the previous year’s
key elements of quality that is multi-dimension in the nature.
performance, instead of the performance expected
Reliability is the probability that a patient care, piece of customers.
medical equipment or system performs its indented function • The present hospital quality program is based on the
for a stated period of time under specified operating condition. evolution of departmental practices against establish the
Maintenance covers all the operations such as monitoring, standards. The focus is therefore on subsystem with the
inspection, adjusting, repairing, and/or doing whatever is hospital quality control programmed essential the sum of
necessary to keep a machine, piece of medical equipment or all departments program.
system may consist of break-down maintenance, simple • The standards, which have been set, are by medical
officers, not the patients, and thus they create a mismatch
preventive maintenance and total productive maintenance. between the user needs and the services provided.
Furthermore, the set standards tend to remain static, so
VII. Benchmarking: that improvement occurs within a limited range.
• After several months of planning a quality transformation
Benchmarking is defined as “measuring our performance model was developed to help participants visualize the
against that of best in class companies determining how the score of the quality management effort.
best in time achieve those performance levels and using the
Reference:
information as a basic for hospital’s strategies, planning, and
implementation. [1] K.Shridhara Bhat, “Total quality management (text and
cases)”, 4nd edition. Himalaya publishing, India 2007, ch-1, 3,
VIII. Case study: 6, 8,9,17.
[2] R.P. Mohanty & R.R. Lakhe, “ TQM in service sectors”,
The IHMC is composed do medicine and health sciences, a 2nd edition. Jaico publishing, India-2006, pp-340-396
150 bed tertiary care hospital and full time clinical faculty. [3] James R. Evans and James W. Dean, “ TQM organization,
The major selling point of continues quality improvement was and strategy”, 2nd edition. South-western,Thomson learning
its philosophical underpinnings. IHMC administrators quickly publishing, Singapore-2002, pp:5-30
realized that the transformation would require a major [4] http://www.ge.com/en/company/companyinfo/quality/
commitment form top management. They also realized that whatis.htm
the management team would face a challenge translating the