Quality Improvement in Healthcare

Thinking About Quality
Few services affect the lives of people so directly and personally as those offered by health care professionals.  For this reason, particularly in the developed world, quality has always been a primary concern in the health care field.  Quality determines how successfully we prevent and treat physical and mental illness - key concerns affecting the lives and well being of our patients and their families.

In today’s competitive environment, quality has a direct impact on organizational success.  In its study of hundreds of thriving organizations, Juran Institute has identified the practices most characteristic of a quality environment.  Juran Institute found that the same organizational practices that attract and retain customers, contribute to more empowered employees, higher revenue and lower costs.  These practices are ongoing processes, generally referred to as Total Quality Management (TQM) or Continuous Quality Improvement (CQI).

Not long ago, the concept of quality simply meant the absence of defects from a manufactured physical good.  In health care, quality tended to be limited to established standards for structure and process in clinical care.  We now understand that this “limited quality” or “little q” view restricts our ability to delight our customers.  To succeed today, we need to expand our approach to one of “Total Quality” or “Big Q”.  Total Quality means:

• Customers are all those affected by what we do
• Products include both goods and services
• Processes include all functions:
  • Clinical care
  • Service to all customers
  • Support services
  • Business operations.

Quality Management
The three processes associated with Total Quality Management are:

• Quality planning
• Quality control
• Quality improvement.

Each of these processes serves a very clear and distinct purpose in an organization, and each is needed for success.

When an organization commits to making significant improvements in quality, its senior management creates a Quality Council to:

• Establish the necessary internal organization
• Provide the resources to achieve its goals.

The Quality Council selects, guides and support teams responsible for specific quality improvement projects.

Quality Results
Quality features drive an organization’s revenues, and reduced deficiencies lower costs.  Both improve overall financial performance.  Organizations that have initiated quality improvement efforts report significant results.  Dr J M Juran, Founder and Chairman Emeritus of Juran Institute, summarizes them as follows:

• “The most visible feature of these achievements in their stunning magnitude....numerous cases in which during a few years:
• The time to provide customer service has been reduced by an order of magnitude
• Defect levels have been reduced by an order of magnitude
• Productivity has been doubled
• Costs have been cut by 50 per cent.”

Quality Improvement in Health Care
In the fall of 1987, leaders from 21 health care organizations met with industrial quality experts in Boston to launch the National Demonstration Project (NDP) on Quality Improvement in Health Care.  The participant health care organizations, assisted by their assigned quality experts, formed teams to tackle the subject in their own real-world operations through pilot projects.

The key lessons the health care organizations learned will be no surprise to quality professionals or quality leaders.  These lessons are not unique to health care.  In fact, quality professionals in widely diverse industries, both service and manufacturing, will find them useful, too.

1. Committed leadership is the sine qua non of effective TQM.  Effective quality management begins at the top or, at the very least, is owned by the top soon after it begins. Without deep investment of the time and energy of CEO’s and other senior executives, organizations simply cannot achieve the cultural, strategic and technical changes required to manage quality. Health care organizations are now rediscovering this principle.
2. Several bottlenecks hamper TQM.  Committed health care leaders report a common set of             bottlenecks that decelerate their progression to mature quality management:
   • Insufficient facilitation - either too few facilitators or too little progress in facilitative management - to support, quality improvement methods at the rate the organization wants to learn and use those methods is a frequent problem
   • Insufficient senior management involvement and education is frequently reported. Executives and physician leaders appear to hope that the senior management need not get too deeply involved in operations and, therefore, limit the senior management involvement in TQM to updates and short reports
   • Rapid turnover in medical staff leadership confounds the constancy of purpose that TQM demands.  Many medical staff presidents serve for only one year.  This makes long term quality planning difficult
   • Excessive word crafting of mission statements or guiding principles has characterized a few of the organizations that engaged TQM early
   • Executive turnover is a potentially lethal factor to organizational TQM.  When a change in CEO, for example, is imminent within a year or two, few managers have the confidence to carry the TQM ball until the name and agenda of a new executive are known.

3. Physician involvement is extremely important. Any health care organization that begins a major TQM initiative without the involvement of physicians and physician leaders does so at its peril. Leaving physicians out of the quality process initially, no matter how comfortable that seems, increases the total cost of the change.

   Physicians (especially those not salaried) have not been trained to understand some of theissues of interdependency, customer focus, and process-mindedness that characterize TQM. Like others (including executives), they must unlearn old assumptions.  Unsalaried physicians have great deal of trouble devoting the time to learning and team participation that TQM demands.  Their beepers go off, and, due to the structure of their work, they leave the room. Many hospitals have achieved a restless peace with their medical staffs by erecting artificial barriers between clinical and administrative issues, even though, through the TQM lens, very few processes turn out to be purely clinical (ie, involving only doctors and patients) or purely administrative (ie, not involving doctors at all).

   It takes time and energy for TQM leaders to commit to involving doctors at the start.  It takes even more for those leaders to define physician involvement in specific, useful, credible, and operational terms.  But these investments pay off later as doctors emerge as champions of a process that they understand and enjoy.

4. Structure is critical if TQM is to work. There is no magic formula for TQM organizations. What works well in one health care organization might not work in another. Each health care organization has to recreate a quality management structure in its own image and likeness.

   But structure does seem to be especially important in health care organizations. In many, strategic planning has not been a strength. They do not have a clear, shared vision or well defined key objective translated and developed throughout the entire organization. It is no surprise, then, that many of the quality projects are the useful many rather than the vital few.

5. Quality management is much more than quality improvement projects. Although there were good reasons for the NDP’s starting with quality improvement projects, those projects should not be confused with TQM.  The latter involves a fundamental change in business strategy and management culture - one, and only one, element of which is quality improvement projects.

   Organizational change requires systematic review and alteration of management systems - such as human resources, information, leadership behaviour, design methods, customer knowledge systems, benchmarking methods - as well as some form of strategic quality   planning that sets the organization’s priorities and helps align the work of teams and departments with those priorities.

   Unless quality improvement projects are informed and guided by a general theory, they will have a tendency to become self-serving - focusing on meeting the needs of internal rather than external customers. Quality improvement projects are an essential part of TQM, but they are not TQM itself.