Total Quality Management

(General Health Nursing)

Prepared by

Zeinab Ibrahim Elsakhawy

Howaida Abdelkreem Alkady

Under Supervision of

Pro. Dr. Mahbouba Sobhy Abd El-Aziz

Professor of Community Health Nursing
Faculty of Nursing
Benha University

Faculty of Nursing
Benha University
 2021

Objectives
General objectives:
By the end of the lecture the post graduate students should be able to
acquire knowledge, attitude and practice related to total quality management.

Specific objectives:

By the end of the lecture the post graduate should be able to:

o Define:
 Quality
 Total Quality
 Total Quality management
o List:
 Principles of total quality management
 Elements of total quality management
 Benefit of total quality management
 Tools of total quality management
o Identify SWOT analysis
Outlines

o Introduction
o Definitions of
 Quality
 Total Quality
 Total quality management (TQM)
o Benefits of TQM in public health sector
o Primary elements of TQM
o Principles of total quality management
o The three popular TQM process
o Tools of Total Quality Management
o Implementation of total quality management in schools
o References
 Introduction

Public health focuses on improving and protecting community health and

well-being, with an emphasis on prevention among large groups of people.
Public health administration is essential for the success of any public health
program whether on the national or local level.

Quality in public health administration can increase the effectiveness and

efficiency of the public health system infrastructure, and is critical for ensuring
the health and well-being of people. TQM is an improvement in all levels of
functioning. Total quality management can guarantee not only greater amount of
production or improved service but also the conformance to specific standards
without fail
:Definition of Quality

Degree of excellence, that doing right thing with the right person in low time
and low cost every time.

:Definition of Total Quality

Total quality refers not only to the product but also to the way the product is
made as well as presented to the customer. Total quality asks for customer
orientation, process orientation & people management.

Definition of Total Quality Management:

TQM is a people driven process. It involves changes in people's attitudes

primarily, in addition, it is approach of the management to achieve long-term
success by focusing on customer satisfaction. The organization works towards a
steady improvement in the quality at all stages of production.
Benefits of Total Qualtiy management in Public Health:

 Improve patient health outcomes (decreased morbidity and mortality)

 Improve efficiency of managerial and clinical processes.

 Avoid costs associated with process failures, errors, and poor outcomes.

 Ensuring that systems of care are reliable and predictable by recognizing

and solving problems before they occur

 Improve communication with the internal and external resources of the

organization.

Primary Elements of TQM (components)

In order to implement total quality management successfully, an organization
must concentrate on the eight elements. These elements drive the force behind
improvement, leadership, design and planning. These elements are:

1. Ethics
2. Integrity
3. Trust
4. Training
5. Teamwork
6. Leadership
7. Communication
8. Recognition

1-Ethics:

Ethics is an element that is concerned with the understanding of the good and
bad in any situation at the workplace. It is a subject related to the organization as
well as the individual. Ethics of an organization set up the business code which
outlines the guidelines that every employee is expected to follow. The individual
ethics include the rights and wrongs.

2-Integrity:

Integrity is an element which refers to the morals, honesty, values, and sincerity
of an individual in the organization. It involves respecting fellow workers and
the policies of the organization. This is one of the important characteristics for
which the customers expect.

3-Trust:

The product of ethical conduct and integrity is trust. The framework of Total
Quality Management cannot be built without trust. It stimulates complete
participation of all members in the organization. It improves the relationship
among employees which helps in better decision making.

4-Training:

To be highly productive, employees must be trained. This responsibility falls

solely on the supervisors who are responsible for implementing Total Quality
Management in their respective departments. Employees must be trained under
decision making, problem-solving, interpersonal skills, technical skills, and
business economics. This is done so that the employees can work effectively and
produce efficient results.

5-Teamwork:
 Teamwork is a crucial element of TQM. It helps the business to receive effective
and efficient solutions to the problems. Teams also provide a permanent
improvement in process and operation. TQM organizations usually adopt three
types of teams. They are:

 Quality improvement team: Also known as excellence teams whose

purpose is to deal with the problems that are repeating often. They are set up for
3 to 12 months.
 Problem-solving team: These teams are set up to solve certain problems
and also to identify the root cause of those problems. They usually last from 1
week to 3 months.
 Natural work team: These teams consist of a group of skilled individuals
who share responsibilities and tasks. They usually work for an hour to two every
week.

6-Leadership:

Leadership is a quality feature of a person who provides an inspiring vision to

the team and sets strategic directions to be understood by all. This is one of the
crucial elements which must be constructive, effective and positive.

7-Communication:

Communication binds the organization together and is the core element of

success. It is necessary to make sure that all the levels of communication among
the suppliers, member and the customers are kept open. The communication
among employees or the members of the organization is done in three ways.
They are:
 Downward communication: Downward communication is the central
form of communication in any organization. It is basically done through
discussions and presentations.
 Upward communication: Upward communication provides a platform to
build trust amongst the employees and the supervisors.
 Sideways communication: This type of communication takes place
among various departments. It allows dealing with customers and suppliers in a
professional way and helps break down the barriers between the departments.

8-Recognition:

This element involves the suggestions and achievements for the teams and the
individuals including positive feedback and encouragement. Every employee
seeks recognition and it is the duty of the supervisor to detect and recognize the
contributors and motivate them. This increases self-esteem and boosts
performance and morale in an individual.

 The 8 universal principles of quality management

The QMS standards apply worldwide, and their application is overseen by the
ISO’s Technical Committee. The principles set out by the ISO 9001 were
invented in the 1990s by a small group of experts.

1. Is customer-focused. Everything a company does—from training

employees to buying new tools—is done with the customer in mind.
2. Involves all employees. Employees must be empowered to work toward
common goals and allowed to operate in a workplace free from fear.
3. Is process-centric. By endorsing processes that take inputs and turn them
into outputs, you can consistently create high-quality products regardless
of the people involved.
 4. Is integrated.  All developed processes must be integrated into one larger
process, and everyone must be on the same page, buying into the
company’s vision, mission, and guiding principles.
5. Has a strategic and systematic focus. Companies must formulate
strategic plans that include quality integration as a fundamental
component.
6. Is constantly improved upon. Empowered managers and employees
must continually look for new ways to increase product competitiveness
and efficacy.
7. Involves fact-based decision-making. You must gather data on
performance in order to know how well you’re doing. You also need to
analyze this data to constantly improve and refine how you do things.
8. Facilitates communication. Managers, employees, and owners need to
communicate routinely and effectively to help maintain morale and boost
motivation.

 The three popular TQM process:-

Now that you know what total quality management is, it’s time to dive deeper
into three new processes that build on its original principles: ISO 9000, Lean
manufacturing, and Six Sigma.

1. ISO 9000: Focuses on people.

ISO 9000—first published in 1987 by the International Organization for

Standardization—encompasses an entire family of quality management systems
standards. ISO 9000 is based on seven quality management principles:

1. Customer focus. Companies should focus first and foremost on meeting

customer expectations.
 2. Leadership. Good leaders are necessary to maintain the right internal
environment and drive companies toward their objectives.
3. Engagement of people. Employees must be empowered to take full
advantage of their abilities.
4. Process-centric. All activities and resources should be managed as a
system-wide process.
5. Improvement. Companies must continuously and actively seek
improvement.
6. Evidence-based decision-making. Decisions should be based on
analyzed data.
7. Relationship management. Companies should maintain healthy and
mutually beneficial relationships with suppliers, contractors, and service
providers.

2. Lean manufacturing: Focuses on waste.

Lean manufacturing is a systematic method of eliminating waste and

inefficiency within manufacturing while continuing to produce products at the
same (or even higher) level.

Lean manufacturing focuses on seven types of waste:

1. Transport: Moving around things that aren’t necessary for production.

2. Inventory: Anything that isn’t involved in production.
3. Motion: People or equipment moving more than is required for
production.
4. Waiting: Inactivity before the next production step.
5. Over production: Producing more than is required.
6. Over processing: Using more activity than is necessary to produce the
end product.
 7. Defects: Expending too much effort fixing problems with the finished
product.

3. Six Sigma: Focuses on process.

Six Sigma, developed in the 1980s at Motorola, is a set of techniques for

improving on processes in an organization. This method aims to improve
product quality by identifying and eliminating variability that can cause defects.
Six Sigma is a quality-control methodology developed in 1986 by Motorola,
Inc. The method uses a data-driven review to limit mistakes or defects in a
corporate or business process.  Six Sigma points to the fact that, mathematically,
it would take a six-standard-deviation event from the mean for an error to
happen.

Six Sigma projects follow two methodologies, each with five phases: DMAIC
and DMADV.

DMAIC:

1. Define the system. Figure out what the customer wants.

2. Measure key aspects of the current process. Collect the data.
3. Analyze the data. Determine the cause of a defect.
4. Improve the current process. Create a new future state process.
5. Control the future state process. Put control systems in place and
constantly monitor the process.

DMADV:

1. Define design goals. Figure out what the customer wants.

2. Measure and identify characteristics that are critical to
quality. Collect the data.
3. Analyze the data. Figure out how to develop and design alternatives.
 4. Design an improved alternative. Fix the problem.
5. Verify the design. Implement the production process and then monitor it.

 Tools for Total Quality Management

The following are the basic 7 tools for achieving total quality management.

1-Cause-and-Effect Diagram (Fish bone diagram).

Cause-and-effect diagram assists in identifying the possible causes for an effect

and sorts ideas into suitable categories. This diagram allows you to visualize all
possible causes of a problem or effect and then categorize them.

2-Check Sheet
Check sheet is an organized and arranged form for accumulating data. This tool
can be utilized for a number of purposes. Check Sheet is a pre-made form for
gathering one type of data over time, so it’s only useful for frequently recurring
data.

3-Control Charts

The changes in the process over time are portrayed in control charts. This chart
is a graphical description of how processes and results change over time.

4-Histogram
Histogram portrays frequency distributions and determines how often a specific
value occurs in a set of data. This shows the frequency of a problem’s cause, as
well as how and where results cluster.

5-Pareto Chart

 It is a bar graph displaying more significant factors over the rest. The

chart posits that 80 percent of problems are linked to 20 percent of causes.
It helps you identify which problems fall into which categories.

6-Scatter Diagram
Scatter diagram shows pairs of numerical data with variable on a different axis
to determine relationships. This diagram plots data on the x and y axes to
determine how results change as the variables change.

7-Stratification

The technique of bifurcating data accumulated from a variety of sources so that

patterns can be spotted by Stratification. This represents how different factors
join in a process. 

 Implementation of total quality management using SWOT

analysis in schools

1-SWOT Analysis
The SWOT tool can automatically lead to useful changes in the structure or
functioning of an organization. SWOT is an acronym for Strengths,
Weaknesses, Opportunities and Threats. By definition, Strengths (S) and
Weaknesses (W) are considered to be internal factors over which you have some
measure of control. Also, by definition, Opportunities (O) and Threats (T) are
considered to be external factors over which you have essentially no control.
SWOT Analysis is the most well-known tool for audit and analysis of the
overall strategic position of the business and its environment.

2. Strengths

To identify strengths an analyst has to answer a few questions and list the
answers. What are the positive aspects of the systems, methods, techniques,
services and products of the institution? When does the institution do well?
What makes the institution different from other similar institutions? What is the
net worth of the institution TQM is not about product perfection alone. It is
about customer satisfaction as an objective in itself.

3. Weaknesses

To identify weaknesses an analyst has to answer a few other questions and list
the answers. What are the areas of work which could be improved? What is not
working effectively? Why is it not working effectively? Which are the jobs that
are badly done? Which are the offices that are not working to standard? What
actions are to be avoided? What is responsible for low productivity? Which
process is responsible for inferior quality production or performance?

4. Opportunities

To identify opportunities an analyst has to ask some other questions and list the
answers. What are the chances of improvement? Which are the places where one
could sell the products? What action can assure better quality of the product?
What new technology will guarantee quality? What policy will help increase
production? What are the new trends in the area of work? What area of the
organization needs improvement for producing better?

5. Threats

To identify threats an analyst has to ask different questions and list the answers.
What are the obstacles on the way to success? Who are the competitors in the
field? Are the standards set too ambitious? Are there people who are not
competent? Has the approach become out of date? Is the demand lesser? Is there
any value addition in the services or products? Is the gap between investment for
product and earning of sales getting reduced? Are the products performing badly
in their places of choice? Are there legal complaints from customers?

The following is a sample SWOT analysis of an educational institution.

Strengths
-Enthusiastic management team.
-Excellent examination results.
-Strong departments
-Strong parental support.
-Good staff morale.
- Good support from the Government.
Weaknesses
-Old buildings in poor condition
- High average age of staff.
-Inadequate budget
- Lack of play-grounds.
- Inadequate sports facilities.
-Inadequate library.

Opportunities
-Merger with local institutions with an
excellent infrastructure but mediocre
reputation.
- Develop sports status.
-The excitement of establishing a new
institution.
Threats
-Loss of identity, strengths.
- Risk of losing experienced teachers
who may take up early retirement or
move to other institutions.
-The philosophy of another institution,
in case of a merger, may change
-The opportunity to enlarge staff
expertise in order to increase the range
of activities.
-Willingness of the faculty to undergo
training and development.
- Possibility of help from old students.
existing culture.
- Large numbers that may make
handling unwieldy.
-Unexpected changes in work ethics
due to cross cultural behavior.

06. Analysis

Once a background is ready the analysts will have to divide it into external and
internal. They will also identify issues after which action plans will be drawn up
to ensure that something is done about every issue. Brainstorming sessions may
be needed. All Quality Control Tools become useful once the SWOT analysis is
ready. The SWOT analysis has to be reviewed from time to time to examine
whether anything has changed. This will also help in measuring achievements.

07. The 5 Ss

Any organization or institution which initiates a TQM movement has to go

through the 5 Ss.

 S No. 1 - Sorting ‫فرز‬

SWOT analysis would have brought up plenty of matter. There is a need
to separate the necessary from the unnecessary.
S No. 2 - Systematizing ‫ترتيب‬
Setting up systems is not enough. Right systems have to be in the right
places. Everything has a place and everything should be in its place.
 S No. 3 – Sanitizing ‫تلميع‬
However accurately any system may work, it needs spring cleaning from
time to time.
 S No. 4 - Standardizing ‫تحسين‬
Each institution or organization has to set its own process checks,
systems and standards for improvement. This process of development
from an existing standard to a higher standard has to have its own
parameters for checking improvements. Each time a standard is fixed
systems have to be developed and implemented to reach it.
 S No. 5 – Sustain ‫تثبيت‬
If or when the first four are taken care of in implementation, the
completion of TQM tasks becomes a habit and there is no need for
anyone else to pressurize people or groups to do what they are expected
to do. This becomes a discipline or habit
08. Top Management Initiative

It is the responsibility of the top management of any organization or institution

to take the initiative or recognize a demand for an initiative for total quality
management Once a core team consisting of the most efficient members of the
staff is ready, they should be given the task of environment building.
Discussions have to take place at every level right up to the last class of
employees, both as separate units and as cross sections. TQM means
participation of all involved.

09.Vision Statement

The institution or organization will have to make a vision statement. It is better

to make a vision statement by involving all the stakeholders. The vision
statement has to be ratified by every person who will join the TQM movement.
Once the vision statement is ready, several missions have to be defined. Each
mission may have several streams of tasks. Once the tasks are described,
methodology and techniques of implementation have to be identified and action
plans drawn up.
 10. Decision Making and Problem Solving

TQM involves plenty of decision making and problem solving. For achieving
both of these satisfactorily, identification and descriptions of tasks is the base.
Prioritization of problems and fixing teams to work on them will be necessary.
All these can happen only when a basic understanding of definitions of TQM is
available to all involved in the movement.

References

-Pillai. L., & Vallatharai. L., (2003). Total Quality Management Handbook.by
National Assessment and Accreditation Council (NAAC). Chapter 2. First Edition :
pages: 125:145. Pub- June, 2003. DOI: 6.2116 /237-2-4003/1000.

-Madu .C., (1998). Handbook of Total Quality Management. Quality management

in small and medium-sized companies and strategic management. Chapter5, 2nd
edition.. Pages: 33:55. ISBN 978-1-4615-5281-9 (eBook). DOI 10.1007/978-1-
4615.

-Definition of quality, available at :

http://www.shsu.edu/~mgt_ves/mgt481/lesson1/lesson1.htm. Retrieved on
10/1/2021.

:Wikipedia available at-

thttps://en.wikipedia.org/wiki/Health_administration, Accessed on 15 Jan, 2021

.
CBAHI. Central Board of Accreditation for Healthcare Institutions, 2013. [cited -
./16/01/2021; Available from: http://www.cbahi.org/apps