Total Quality Management

If God has given you administrative ability and put you in charge of the work of others, take the responsibility seriously." ROMANS 12:8

What is Quality?
The National Academies Institute of Medicine (IOM) provides the most widely definition of Health Care quality as the degree to which Health services for individuals or populations increase the likelihood of desired health outcomes and are consistent with the current professional knowledge

4 Components of quality in Health care

Avedis Donabedian, a physician who was a leading advocate for improving health care quality

during the last half of the 20th century, defined

quality as having at least four components.

4 Components of quality in Health care

Donabedians four Components(1986) of Quality in Health Care Savage and Williams (2007) explanation in stakeholder perspectives to understand health care Focuses on the clinical performance of health care providers. Speak to patients interest in pursuing individual well-being. Underscores the co-production of care by both the provider and patients.

1. The technical management of health and illness. 2. The amenities of care. 3. The management of the interpersonal relationship between the providers of care and their clients. 4. The ethical principles that govern the conduct of affairs in general and the healthcare enterprise in particular.

Ethical principles speak to providers interests in furthering societal and organizational well-being (or effectiveness).

What is Total Quality Management(TQM)

also referred to as Continuous Quality Improvement (CQI)

a philosophy developed by Dr. W. Edward Deming.

According to Burrill & Ledolter (1999) "TQM is a management methodology, a way to run the business, not a fad or some gimmick to spur productivity momentarily or to improve some special factor."

TQM can also be defined as an institution-wide process to create and

produce customer satisfaction; a strategy to improve product and service

quality; and an approach to improve competitiveness (Lenka & Suar, 2008).

Evolution of TQM

Philosophy or Feature of TQM

1. Customer Focus
Quality is defined as meeting or exceeding customer expectations. The goal is to first identify and then meet customer needs. In TQM, there are both internal and external customers: External customers are patients, employers and the community Internal customers are those departments that contribute to patient care such as pharmacy, radiology and medical laboratory.

Philosophy or Feature of TQM

2. Employee Empowerment
Before, employees were afraid to identify problems for fear that they would be reprimanded. The new concept of quality, TQM, provides incentives for employees to identify quality problems. TQM empower all employees by providing positive feedback and reinforcing attitudes and behaviors that support quality and productivity.

TQM trusts the employees to be knowledgeable, accountable, and

responsible and provides education and training for employees at all levels

Philosophy or Feature of TQM

3. Continuous Improvement
Because TQM is a never-ending process, everything and everyone in the organization are subject to continuous improvement efforts. Continuous improvement, called kaizen by the Japanese, requires that the company continually strive to be better through learning and problem solving. Because we can never achieve perfection, we must always evaluate our performance and take measures to improve it. 2 approaches in Continuous improvement Benchmarking PDSA cycle

Philosophy or Feature of TQM

Benchmarking

Another way companies implement continuous improvement is by studying business practices of companies considered best in class. This is called benchmarking. The ability to learn and study how others do things is an important part of continuous improvement.

Philosophy or Feature of TQM

PDSA cycle

Plan The first step in the PDSA cycle is to plan. Managers must evaluate the current process and make plans based on any problems they find. They need to document all current procedures, collect data, and identify problems. This information should then be studied and used to develop a plan for improvement as well as specific measures to evaluate performance. Do The next step in the cycle is implementing the plan (do). During the implementation process managers should document all changes made and collect data for evaluation. Study The third step is to study the data collected in the previous phase. The data are evaluated to see whether the plan is achieving the goals established in the plan phase. Act The last phase of the cycle is to act on the basis of the results of the first three phases. The best way to accomplish this is to communicate the results to other members in the company and then implement the new procedure if it has been successful.

Philosophy or Feature of TQM

4. Leadership TQM requires total commitment by top

management, it is a long-range, focusing on the achievement of top quality in every relationship with every customer. . Long term leadership is needed to

achieve continuous improvement of productivity and

services for the consumer.

Philosophy or Feature of TQM

Leader
Envisions high-quality care Encourages others to be involved in quality improvement Encourages setting high standards Is proactive versus reactive Facilitates interdisciplinary quality improvement Builds a culture of Quality

Manager
Organizes quality-driven sevices Selects standards and measures of those standards with others Facilitates collecting and analyzing data Determines discrepancies between care provided and standards Facilitates ongoing quality improvement

Philosophy or Feature of TQM

5. Culture and Climate
The total quality culture exists in a warm, friendly climate in which employees
feel good about themselves, others and their work. Fear has been driven out through leadership that has promoted teamwork, respect, and trust. TQM requires a favorable environment for total quality behavior in which values are shared as worthwhile or desirable and beliefs as truth. All employees, including top management, believe in an employee focus, teamwork, safety and candor. There is total involvement because individual

employees are empowered to identify and solve problems.

Philosophy or Feature of TQM

6. Prevention not Detection
Prevention not detection is the key to producing
high quality. Thus, identifying and doing the right things, the right way, the first time and problemprevention planning-not inspection and reactive problem solving-lead to quality outcomes.

Philosophy or Feature of TQM

The old concept is reactive, designed to correct quality problems after they occur.

The new concept is proactive, designed to build quality into the product and process design.

Quality Gurus and their contributions

Quality Gurus in Health Care management

W. Edwards Deming (1900-1993)
referred to as the father of quality control.

He translated his famous 14 points or the Total quality management principles for quality management in Health Care. Several Health Care systems have instituted Demings process for quality and productivity management. Avedis Donabedian (1919-2000) referred to as the dean of quality assessment, assumed 20 years ago the classic approach of quality assessment and improvement. Dr. Donabedian further defines health care systems in terms of efficiency, or achieving a desired goal at minimum expense. Appropriateness is another component because this matches service with respect to patients specific health care needs. Effectiveness, links the system to outcome or outputs with the goal of improved or maintained health.

Principles of TQM (Demings 14 points)

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. Create constancy of purpose The new philosophy Cease dependence on mass inspection End lowest tender contracts Improve every process Institute training on the job Institute leadership Drive out fear Break down barriers Eliminate exhortations Eliminate arbitrary numerical targets Permit pride of workmanship Encourage education Top management commitment and action

Elements of TQM
Elements of TQM by Swansburg (2002)
Decentralization and participatory management Management by objectives (MBO) Statistical analyses Team building

Quality Circles
Theory z

Elements of TQM
Decentralization and participatory management. It is the process of making decisions at lower levels in the organizational hierarchy. This process involves every employee in making management contributions; it allows them to fix things instead of being treated like robots. Management by Objectives (MBO). It was first popularized by Peter Drucker. It is a process of defining objectives within an organization so that management and employees agree to the objectives and understand what they need to do in the organization. The basic principle behind Management by Objectives (MBO) is for employees to have a clear understanding of the roles and responsibilities expected of them. MBO also places importance on fulfilling the personal goals of each employee. Some of the important features and advantages of MBO are: Motivation Better communication and Coordination Clarity of goals Subordinates tend to have a higher commitment to objectives Managers can ensure that objectives of the subordinates are linked to the organization's objectives.

Elements of TQM
Statistical analyses. Statistical process control (SPC) is the application of statistical methods to the monitoring and control of a process to ensure that it operates at its full potential to produce conforming product. Team Building. A wide range of activities, designed for improving team performance.Team building is pursued via a variety of practices, and can range from simple bonding exercises to complex simulations and multi-day team building retreats designed to develop a teamwork. Quality Circles. Workers are taught the statistical concepts and use them through trained, organized, structured groups of four to fifteen employees, called quality circles. It was initiated in Japan after World War II through the teaching of W.E. Deming. Theory Z. This theory was synthesized by William Ouchi where the leadership style is a democratic one that includes decentralization, participatory management, employee involvement, and an emphasis on quality of life.

Use of quality tools

TQM places a great deal of responsibility on all workers. They need to understand how to assess quality by using a variety of quality control tools, how

to interpret findings, and how to correct problems.

They are extremely useful in identifying and analyzing quality problems. Sometimes workers use only one tool at a time, but often a combination of tools is most helpful.

7 tools of quality control

Cause-and-effect diagrams are problem-solving tools commonly used by quality control teams. Specific causes of problems can be explored through brainstorming.The development of a cause-and-effect diagram requires the team to think through all the possible causes of poor quality. Example:

7 tools of quality control

Flowchart is a schematic diagram of the sequence of steps involved in an operation or process. By seeing the steps involved in an operation or process, everyone develops a clear picture of how the operation works and where problems could arise. Example:

7 tools of quality control

Checklist is a list of common defects and the number of observed occurrences of these defects. It is a simple yet effective fact-finding tool that allows the worker to collect specific information regarding the defects observed. Example:

7 tools of quality control

Control charts are a very important quality control tool. These charts are used to evaluate whether a process is operating within expectations relative to some measured value such as weight, width, or volume. Example:

7 tools of quality control

Scatter diagrams are graphs that show how two variables are related to one another. They are particularly useful in detecting the amount of correlation, or the degree of linear relationship, between two variables. Example:

7 tools of quality control

Pareto analysis is a technique used to identify quality problems based on their degree of importance. The logic behind Pareto analysis is that only a few quality problems are important, whereas many others are not critical. The technique was named after Vilfredo Pareto, a nineteenth-century Italian economist who determined that only a small percentage of people controlled most of the wealth. Example:

7 tools of quality control

Histogram is a chart that shows the frequency distribution of observed values of a variable. We can see from the plot what type of distribution a particular variable displays, such as whether it has a normal distribution and whether the distribution is symmetrical. Example:

Major Characteristics of TQM

The essential characteristics of an effective TQM system are:

Every company member, from the CEO to the lowest level employee is focused on product or service quality. If management is not behind TQM, then it will fail. Everyone must have the required training and be familiar with the necessary TQM techniques. Anyone can suggest areas for improvement - as general operatives will be more familiar with their work station than anyone else is, valuable ideas for improvement at a production line level can, in many cases, come from line workers. All departments are expected to focus on quality and productivity improvement and implement changes for their area. In addition, all departments interact with each other to fix common problems in the product or process. Collaboration on external issues is expected from all departments. Decisions made are based on the best solutions, not on hidden agendas or favoritism. Quality becomes a governing part of operations, with decisions that impact on quality, rejected immediately; despite perceived cost-savings involved.

Why TQM efforts fail?

Lack of a genuine quality culture The most important factor in the success or failure of TQM efforts is the genuineness of the organizations commitment. Lack of top management support and commitment Another mistake is the view that the responsibility for quality and elimination of waste lies with employees other than top management. It is a let the workers do it mentality. Over- and under-reliance on statistical process control (SPC) methods A third common mistake is over- or under-reliance on statistical process control (SPC) methods. SPC is not a substitute for continuous improvement, teamwork, and a change in the organizations belief system. However, SPC is a necessary tool for identifying quality problems.

Application of TQM in Nursing

TQM can be implemented in nursing with or without implementation in the total organization. First, the lead team should all read Out of the Crisis, in which Deming describes his theory of TQM and the seven deadly diseases of management and recommends a management philosophy

Second, the team can write its management plan for implementing TQM. The first goal of a nursing management plan is to write the stated purpose of nursing service so that it is constant and provides a clear goal for everyone for every day, month after month. This is the First of Demings 14 points (Figure 1.7). All 14 points should be discussed by the lead team. The management plan should also list activities to achieve each of these points. Teams can be assigned to develop plans for assessing the culture and climate and making plans to change them.

Application of TQM in Nursing

Third, quality management should be decentralized Nurses would develop quality methods to check the application of nursing process to patients, check process and outcomes, and fix any deficits (variance) in the process. When necessary, these nurses subject the nursing process to Pareto and Fishbone analysis. They may repeat the process at more specific levels to identify the solution to a problem. Nurses will commit to do right principles: maintain control of every process, post quality evidences on the walls, brook no compromises, find a way to check every unit, fix their own mistakes, and assess continual involvement in quality improvement projects.

Application of TQM in Nursing

Lastly, well-established destructive habits of management can be changed. The following are some principles for making changes: The individual manager or leader must perceive a need to change, must genuinely admit and accept that he or she must change, and must commit to the change. The change must be voluntary, not coercive The change process requires a philosophical base, a statement of beliefs about how people will be managed. The change process requires the support of others participating in the same process. The process should be broken into steps that can be accomplished in sequence.

Example of TQM in U.S. Hospital Brazosport Memorial Hospital ______________________________________________________________________ Brazosport Memorial Hospital established a quality improvement process of quality orientation, continuous process involvement, and total employee involvement. A quality improvement council of top administrators developed a policy with employee input: it is our commitment at BMH to promote genuine pride in excellence among our employees and other professionals in order to continuously improve the quality and value of the services provided to achieve customer satisfaction. A definition of quality states: Providing health care services which are continuously improved to meet the needs and expectations of our patients, physicians, employees, payers and the community we serve. Employees are encouraged to speak freely about Hospital operations and generate ideas for improvement. They are encouraged to collect and analyze data in process improvement. Questionnaires are sent every 6 months to 300 former patients to assess quality. Process includes quality improvement teams, training, changes including management style, commitment, stress on ideas, and networking among others. Source: E. Penzer, A Philadelphia Story, incentive, July 1991, 33-34, 36.

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