The Zen of Healthcare

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 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).

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 satisfy our customers.  To succeed today, we need to expand our approach to one of ‘Total Quality’ or ‘Big Q’.

In Boston in 1987, leaders from 21 health care organizations together with industrial quality experts launched the National Demonstration Project (NDP) on quality improvement in health care.  The participant organizations, assisted by their assigned quality experts, formed teams to tackle the subject through pilot projects.

The key lessons they learnt are particularly relevant to India, which has an unmatched reservoir of medical resources, and will be useful to professionals in other industries too.

Committed leadership is the sine quanon 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 the time and energy of CEOs and other senior executives, organizations simply cannot achieve the cultural, strategic and technical changes required to manage quality.

Several bottlenecks hamper Total Quality Management
Insufficient facilitation is a frequent problem.  Either there are too few facilitators or there is too little progress in facilitative management.

• 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 constancy of purpose.  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 adopted TQM as a strategy in the early 1980s
• Executive turnover is a potentially lethal factor.  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.

Physician involvement is an extremely important factor
Any health care organization that begins a major TQM initiative without the involvement of physicians and physician-leaders does so as its peril.                         

Physicians (especially those not salaried) have not been trained to understand some of the issues of interdependency, customer focus, and process-mindedness that characterize TQM.  Like others (including executives), they must unlearn old assumptions.  Many hospitals have achieved a restless peace with their medical staffs by erecting artificial barriers between clinical and administrative issues.

It takes time and energy for TQM leaders to commit to involving doctors.  But these investments pay off later as doctors emerge as champions of a process that they understand and enjoy.

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

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 - only one element of which is quality improvement projects.

In conclusion, one can say that organizational change requires a 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.  It must not be forgotten that quality improvement projects are an essential part of TQM, but they are not TQM itself.