Mary Cruickshank, Godfrey Isouard, Lyn Irwin, Jeanne Madison, Michele Chandler

After studying this chapter, the reader should be able to:

Identify reasons for making a paradigm shift from the traditional quality assurance approach in health care organisations to more modern comprehensive management approaches to improving quality.

Demonstrate understanding of concepts underpinning total quality management and continuous quality improvement.

Identify the key principles of total quality management.

Discuss the fundamental components of continuous quality improvement.

Demonstrate understanding of emerging issues of quality in the aged care sector.

INTRODUCTION

Today, the debate on how to improve the quality of care delivered in health care organisations continues due to the complex and diverse range of perceptions surrounding the concept of quality. For example, quality can have a very different meaning for a family member standing at a patient’s bedside, an employee mopping the floors outside a patient’s room, or a staff member hurrying down the corridor with pathology results in hand. According to Ennis and Harrington (2001, p 149), the different concepts of quality are a major concern in how best to define quality within health care because of the wide group of stakeholders who each hold different perceptions of quality. Stakeholders are suggested to include government departments, doctors, nurses, paramedics, patients, families and carers.

This chapter is designed to bring coherence to the wide variety of perspectives that must be considered when exploring issues associated with quality health care. It is unlikely that any other discipline or workplace manager has a more complicated task than that confronted by the health professional in providing documentation of and commitment to the quality of the work undertaken. The control of quality is an important part of the role of the health services manager. There are serious consequences for clients and the organisation when there is little evidence of managerial and organisational commitment to quality. Clients entrust their lives and health to the staff and organisation of health facilities and services. It is a responsibility of the health services manager to ensure that the staff of the organisation comply with the highest possible standards, are supported by the most qualified available clinicians and that there are processes for ongoing, preventive surveillance of the services provided to patients, clients and communities.

Over the past two decades, the emphasis of the health system has moved slowly from a biomedical illness model to a preventive, health promotion model. At the same time managerial thinking has evolved from an emphasis on managing facilities to managing vertically integrated health care systems (see Chapter 13). The majority of research studies worldwide indicate that the most efficient and effective use of health care dollars is in the prevention of illness and the promotion of health rather than the treatment of illness. Simultaneously, the assurance of quality in health care has changed from a unilateral inspection model to a participative, preventive and quality promotion model. These two changes have occurred concurrently as responsibility for the quality of health care has been dispersed more appropriately to include all health professionals, not just medical practitioners, and because of increased government funding and control of the provision of health services.

In organisations with highly evolved quality philosophies and procedures, formal orientation programs expose all new health care employees to a well-considered, intensive summary of the employer’s expectations regarding quality in the workplace. As it is often presented by the chief executive officer (CEO) or even the chairman of the governing body, the new employee can hardly miss the importance placed on this elusive notion; that is, the assurance of high-quality health care. The new employee may be an entry-level engineer, a department head, an assistant in nursing, or a medical specialist. This chapter aims to establish that all employees play an important role in the quality of care provided by any health care organisation.

Years ago, the first formal regulatory requirements to document the quality of care provided in a health care organisation resulted in ‘audits’ that basically involved counting or inspecting hospital documents or medical records. These investigations were usually closely associated with medical and nursing practice. Following the example of large industries in the manufacturing and business sectors over the past 20 years, health care has developed far more sophisticated strategies for assuring the quality of services. This chapter provides a comprehensive overview of contemporary approaches to quality improvement in health care. The change of focus from the ‘illness’ or problem-oriented approach to the promotion of quality through proactive preventive strategies is apparent.

Accordingly, this chapter has two main themes. The issues associated with total quality management (TQM) in the Australian health care arena are described and discussed first. The notion of continuous quality improvement (CQI) as it relates to health care in Australia today is covered next. Although the terms TQM and CQI are often used synonymously, there is a distinction. Total quality management is a management philosophy that encapsulates the whole organisation, whereas continuous quality improvement is specific to one element of the organisation. This distinction is discussed further later in the chapter. These two paradigms are the foundation of quality programs throughout the health care industry here in Australia and elsewhere around the world. They are the basis on which health professionals aim to assure the consumers of health care that the services that are provided in their organisation(s) are quality products.

QUALITY ASSURANCE

An overview of quality assurance

In 1974, the Australian Medical Association (AMA) and the Australian Hospital Association (AHA) established the Australian Council on Hospital Standards. The primary goal of the Australian Council on Hospital Standards was to improve the quality of client care in Australian hospitals by setting standards and evaluating performance. However, when the Committee of Inquiry into Hospital Services in South Australia was asked to report on quality of care in 1983, the inquiry stated that it was unable to fully report ‘because the relevant data were simply not available’ (Renwick & Harvey 1989, p 1). This became known as the Sax report, and it was significant for two reasons:

for the first time there was official recognition that high quality care could not be taken for granted in Australian hospitals, and it was formally acknowledged that there was no body of routine information on which to draw to describe quality of care.

(Renwick & Harvey 1989, p 1)

In 1987, standards for QA became mandatory for accreditation by the Australian Council of Hospital Standards. Because it was decided to include other health care facilities, in 1988 the council changed its name to the Australian Council on Health Care Standards (ACHS). Thus, the role of the ACHS was to award or deny accreditation not only to hospitals but also to other types of health care facilities, such as community health services, nursing homes and day-procedure facilities.

When discussing QA and the Australian health care system, Eastman (1992, p 219) noted that:

… traditional clinical QA methods and programs have been highly developed and implemented at all levels of the Australian health care system and through government legislation, accrediting bodies (such as the Australian Council of Hospital Standards) and professional organisations (such as the Royal Colleges and specialist societies), and at hospital level through clinical departments and units.

Over the past 20 years, management systems and approaches for improving quality in organisations have evolved rapidly in the United States and the United Kingdom and more recently in Australia, with criticisms being made of the traditional QA approach adopted in health care facilities. A major limitation of QA programs is that they instruct staff to direct, inspect and repair rather than prevent, innovate and develop personnel (Schroeder 1988). According to Schmele (1996, p 142), efforts in QA have ‘reflected professional values, and focused on inspection and identifying deficiencies rather than on continuous improvement and preventing problems’ (p 142). While the development of measurable standards has been viewed as a critical component of QA programs, Ellis and Whittington (1993, p 61) pointed out:

Increasingly, the development of measurable standards and clearly documented procedures is seen to be a necessary but by no means sufficient part of assuring quality. Of greater importance in maintaining and indeed exceeding predetermined standards of excellence are the attitudes and perceptions of everyone associated with the organisation.

Criticisms of the traditional QA approach coupled with changes in economic, political and societal forces led health care leaders in the 1990s to reassess the ways they viewed the concept of quality as it related to quality care in the hospital setting. This brought a paradigm shift ‘from reacting to deficiencies to proacting to prevent problems, with consumer input the driving force in the new paradigm’ (Schmele 1996, p 142). Thus, changing from detection to prevention required a change in management style and way of thinking.

However, despite a major shift from assurance to improvement, it should not be thought that assurance no longer has a place, or assumed, as described by Batalden (1993, p 70), citing Roberts and Schyve, ‘that quality improvement (QI) is somehow what QA is really all about; they are different’. Batalden, drawing on Berwick, distinguishes the differences between QA and QI, as described in Table 16.1.

Table 16.1 Distinctions between quality assurance and quality improvement

QUALITY ASSURANCE	QUALITY IMPROVEMENT
A specialised staff job	The primary job of every manager
Examines the professionals who provide care	Studies the processes of production
Asks who does what here	Asks how the hospital work is accomplished
Looks for deviations from the norm to correct unacceptable variation	Looks at deviations, but is more interested in improving the average
Asks why this is different	Asks how can we make this continuously better
Documents its clinical indicators against the national or benchmark rate and perhaps reports no significant problems were detected	Sets an objective to reduce and improve a rate in a predetermined period
Uses performance standards and expects action plans to respond where standards are not met	Tries to continuously improve the capability of action plans to respond where standards are not met
Activities involve the professions	Is based on the premise that all must be involved in analysing problems and formulating solutions
Uses more judgmental language such as ‘excellence needs improvement’	Is less judgmental, more analytical, uses process flow diagrams and control charts
Reports are prepared by staff members	Reports are written by team members from across departments
Reports ask for specific actions	Reports provide information to improve quality

Source: Adapted from Batalden P 1993 Organisation-wide quality improvement in health care. In: Al-Assaf AF, Schmele JA (eds), Textbook of total quality in health care. St Lucie Press, Delray Beach, Florida, pp 70–1

TOTAL QUALITY MANAGEMENT

An overview of total quality management

Total quality management (TQM) and continuous quality improvement (CQI) are management terms that are receiving increasing attention worldwide. A definition of each concept is presented and will be discussed throughout the chapter.

Total quality management is defined as the:

method of management and system operation used to achieve CQI. TQM promotes an organizational culture that supports customer needs, empowers employees to work as teams, emphasizes self-development, and requires a new leadership style in which employees are viewed as resources.

(DeLaune & Ladner 1998, p 194)

Continuous quality improvement is the:

approach to quality management in which scientific, data-driven approaches are used to study work processes that lead to long-term system improvements. This concept has evolved into systems such as process improvement or performance improvement.

(DeLaune & Ladner 1998, p 194)

The first main theme to be addressed in this chapter is the TQM philosophy of constantly seeking better ways of delivering a quality service to all customers.

Total quality management is a management term which has been adapted from industrial quality control theory and was first suggested in the United States. It was further refined and developed in Japan where it became a key management strategy to underpin industrial development over the past four decades. It is widely acknowledged that Dr W Edwards Deming, an expert in process and quality control, profoundly influenced the development of Japanese industry in the early post-war years through the application of his quality management principles, and the quality philosophy enunciated by Deming is clearly stated in his now famous Fourteen Point Management Method (Omachonu & Ross 1994, Wilkinson et al 1998). More recently, western firms have adopted TQM as a tool to enhance international competitiveness.

A review of the literature revealed numerous TQM resources, including textbooks, applied and theoretical journals and publications, all dealing with the development, implementation and monitoring phases of TQM. A review of the literature also revealed several definitions of TQM, all having similar themes and principles. It is evident from the literature that the meaning of TQM is fluid and it would appear that the concept of TQM is often defined to ‘fit’ with the strategies and practices of an organisation. As mentioned in the introduction to this chapter, quality can have a very different meaning for different individuals. So it is not surprising that there have always been definitional problems associated with the term ‘quality’. These definitional problems also extend to the term ‘total quality management’. However, some managers view the many different interpretations of quality as advantageous because it provides opportunity for the TQM method adopted by an organisation to be ‘moulded’ to suit the specific vision and objectives of the organisation.

In addition, the terms total quality management and continuous quality improvement are often used interchangeably, and this is discussed further in the chapter. For clarity purposes, we are using the definition of TQM by DeLaune and Ladner (1998) (see above).

There are several key principles of TQM, with some receiving more emphasis than others. For example, Deming (1982) believes that the fundamental management principle of TQM is to seek continuous improvement in the quality of improvement of all the processes, products and services of an organisation. Other proponents of TQM identify the important principles as a strong customer focus, assessment of an organisation’s culture, and an increased emphasis on leadership, employee involvement, employee empowerment and teamwork. These principles represent a paradigm shift from the traditional model of QA.

The philosophy of TQM places great emphasis on ‘meeting customer requirements’. Identifying the ‘customer’ (both internal and external) is the first step towards continuous improvement. The concept of customer has been defined by several authors, and the definitions all have a similar theme and include recognition of both internal and external customers. For example, Schmele (1996, p 319) defined customer as anyone who is the recipient of another’s work, and stated that ‘customers — patients, providers, payers — are at the core of quality management’. Internal customers can be providers of care while external customers may be viewed as patients and payers; however, these categories of internal and external customers are not rigidly fixed. In many health care organisations, it is often decided by the individual health care facility at the time of planning for TQM.

While many health professionals and health services are reluctant to use the term ‘customer’, it is an important concept for health care, not only because health care is essentially a service industry but also because it affects the perception and focus of an organisation’s quality management process. Sower et al (2001, p 47) suggest that ‘even though patients have also been considered as one of the key stakeholders, management has typically focused on meeting patients’ clinical needs while paying much less attention to their needs as a consumer of the total health care experience’. They also suggest that ‘administrators (have) begun to expand their focus to meet the needs, wants, and desires of their patient customers, not only for a positive clinical outcome, but also for a positive health care experience’. They further state that ‘the term “patients” implies a passive person who “patiently” waits for service from the medical experts’ and ‘previous efforts to improve quality care have focused on the provider’s orientation needs rather than those of the patient’.

Overall, however, TQM is a comprehensive approach to quality, which engages all employees in a process of quality improvement to meet both internal and external customer requirements.

In addition to the numerous interpretations and principles of TQM, there are two aspects of TQM — the ‘hard’ and the ‘soft’ aspects. The ‘hard’ aspects reflect the production-oriented aspects of TQM, which include systems, data collection and measurement, while the ‘soft’ aspects reflect the human resource factors in an organisation. The soft aspects include supervision and leadership styles, employee involvement and teamworking, and organisational culture.

In more recent times, other techniques for improving quality in health care, such as rapid-cycle improvement, lean manufacturing systems, Six Sigma, and the Baldrige Criteria, have emerged in the United States which according to Potthoff (2004, p 37) are all ‘important tools that work in tandem to achieve quality results’. However, despite these recent initiatives in the United States, McGlynn et al (2003b, p 2639) suggest that a major overhaul of the current health information systems is required ‘with a focus on automating the entry and retrieval of key data for clinical decision-making and for the measurement and reporting of quality’. In the United Kingdom quality initiatives that have been introduced into the health care system include the European Foundation for Quality Management (EFQM) Excellence Model, Investors in People, ISO 9000, Clinical Governance, Controls Assurance, Resource Management, Clinical Audit, Evidence-Based Medicine, Patient-Focused Care, and the NHS Plan and Working Lives (Stahr 2001).