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!

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. INTEGRATION OF IMPROVEMENT INITIATIVES

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. TMH has 57 active Quality Circles in diverse work areas like the Hospital laundry and kitchen, Steward section, Nursing section etc.

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 Chow.W.Chee, The balanced scorecard: A potent tool for energizing and focusing healthcare organisation managementJournal of HealthcareManagement 43:3 May/June 1998 Hutchins David In pursuit of Quality Wheeler Publishing, 1992 Jaganathan.G. Getting more at less costThe value engineering way. Tata McGraw Hill, New Delhi,1992 Total Quality Handbook, Tata Steel

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3. Unlike the QIP and VE teams, a Quality Circle is permanent. 4. 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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