TOOLS OF TOTAL QUALITY MANAGEMENT

Sujata Mitra

Implementing TQM in the hospital

posed certain challenges. It meant convincing
people that Quality was not extra work, it was
an integral part of work and the way to work.
People had to be motivated to achieve gobeyond-service Quality. The approach was to
encourage people to be creative and find
solutions to their own problems.
Which brings us to the next stumbling
block. Would all the individual efforts combine
to give a significant thrust to the Quality
movement or would they remain isolated
islands of improvement? There was need to
align and prioritise the individual goals with
the organisational goals, conversely, the
organisational goals had to cascade down to
individual goals. Specialised training in IVF
technique could be an individual need, but if
the organisational goal was to reduce average
hospital stay, laparoscopic training would be
given priority.
Prioritisation and alignment was done
through the Balanced Scorecard concept.
1. BALACED SCORECARD
This is a set of measurements and
targets that are used to prioritise and quantify
goals (Ref.Chow,et.al,1998). A hospital may
have identified cost competitiveness as its goal.
How is this communicated to all the working
units? In the scorecard, an overall target for
cost saving is set which is then broken into
specific targets for different areas like power
consumption, rightsizing, revenue generation
etc. Each department sets its own target in
these specific areas and plans to achieve it
through improvement projects, value
engineering etc. Ultimately, two and two may
not just be four, but even five due to this
synergistic working.
The scorecard is like a progress report.
It is a ready reckoner for planning as well as
assessing progress vis.a.vis the targets (Ref.
Fig. 2, An introduction to TBEM model).

II.

QUALITY IMPROVEMENT
PROJECT

A quality improvement project is taken

up preferably by a cross-functional team to
tackle chronic, recurrent problems which
impact upon customer satisfaction (Ref. Total
Quality Handbook, Tata Steel). Most of these
problems are either not obvious or have been
swept under the carpet. The job of the team
lies in correctly identifying the problem,
analysing it and coming up with a solution that is
acceptable to all. If it is a problem that cuts
across different work areas, a cross functional
team ensures that benefits are shared by all.
A number of patient complaints related
to long waiting time in the out-patient
department. One of the hospital goals
therefore, was to reduce average waiting time in
OPD to less than 30 minutes. The Cardiology
department took up the challenge and included
this as their departmental goal. A QIP team
was formed. After data collection and
brainstorming for all possible causes, the main
reason identified for the increased waiting time
was too many patients arriving at the same
time. The analogy of congestive cardiac failure
was drawn- increase in preload (number of
patients) leading to pump failure (doctors
unable to cope with the sudden rush). The
solution was again drawn from the analogyreduce the preload! An appointment system
was put in place, with segregated time slots
for different patient categories. The solution
appealed to both, doctors and patients, and the
pump efficiency increased to 90% patients seen
within 30 minutes! (Ref.Bharat et.al, 1999). This
solution has been emulated by other clinical
departments too so that today the average
waiting time in OPDs is less than 15 minutes
and more than 95% patients are dealt with in
less than half hour of their arrival.
III.

VALUE ENGINEERING PROJECT

Cost effectiveness is the need of the hour

for any organisation. A value engineering
project helps to achieve this
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strategic goal. It aims at Value added service.

It implies reducing wastage, not spending.
Teams use creativity and innovation to come
up with alternatives that may be cheaper,
eliminate wastage or add value to existing
services (Ref. Jaganathan, 1998).
A classic example is the value
engineering done in the Nursery to reduce
wastage of nappies. Irrespective of baby size
or need, bulky, full size nappies were provided to
all babies, which, besides wastage, were quite
uncomfortable for the little customers. Nurses
and doctors brainstormed to find out what the
ideal nappy size should be. The existing nappies
were reduced to a quarter, wastage was
eliminated and the babies smiled!

IV.

QUALITY CIRCLE

A Quality Circle is a small group of

employees from the same work area who
voluntarily meet regularly to identify, analyse
and resolve work related problems (Ref.
Hutchins, In pursuit of Quality 1990) This not
only improves the performance of any
organisation, it also motivates and enriches the
work life of employees. The philosophy behind
Quality Circles is building people.
A Quality Circle tackles small, work
related problems through teamwork.
Statistical tools are used to analyse problems,
members arrive at a solution by consensus and
implement it themselves. This leads to
empowerment at the grass root level.

but innovative solution was rearranging the

food on the trolleys. The chappatis were now
wrapped in a cloth and placed directly on top
of the steaming dalcontainer.
Patient satisfaction on hospital services
is greatly influenced by mundane matters like
food. If professional expertise is not backed
with concern in areas like hospitality, patient
dissatisfaction is bound to linger. With
successful quality circles taking care of such
pinpricks, the hospital administration can rest
easy.
V.

How do these improvement initiatives

contribute to improving the overall
performance of the hospital? As described, all
targets cascade from the scorecard. The
integration of improvement projects with the
scorecard is shown in Fig.l

REFERENCES
1.

Bharat.V., Mohanty.B., Das.N.K,

Waiting time reduction in out patient
services -an analogy to heart failure
therapy. Indian Journal of Occupational
and Environmental Medicine; 1999; 3,
181-184

2.

Chow.W.Chee, The balanced scorecard: A

potent tool for energizing and focusing
healthcare organisation managementJournal of HealthcareManagement 43:3
May/June 1998

3.

Hutchins David In pursuit of Quality

Wheeler Publishing, 1992

4.

Jaganathan.G. Getting more at less costThe value engineering way. Tata McGraw
Hill, New Delhi,1992

5.

Total Quality Handbook, Tata Steel

TMH has 57 active Quality Circles in

diverse work areas like the Hospital laundry
and kitchen, Steward section, Nursing section
etc.
Unlike the QIP and VE teams, a Quality
Circle is permanent.
The quality circle of the hospital kitchen
was worried about the complaints regarding
the quality of food. The chappatis in particular,
were singled out for criticism. The fluffy, soft
chappatis leaving the kitchen became cold and
hard by the time they reached the patients. The
defect lay in the distribution system. A simple,
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INTEGRATION OF
IMPROVEMENT INITIATIVES