TQM IN HOSPITALS AND "HE ROLE OF INFORMATION SYSTEMS

IN PROVIDING QUALITY SERVICES

Rem Khorramshiahgol'
Jamal Al-Bard2
Robert W. S t a b g s '

1 Associate Professor
Department of Computer Science m d Information System
The American University, Washington, D.C. 20016 U.S.A

2 Director of Information Systems Department

Mount of David Hospital, Bethlehem, West Bank

3 Director of Information Systems

Kaiser Permanente, 11961 Bournefield Way
Silver Spring, Maryland, 20904 lJ.S.A

ABSTRACT There is an increasing interest adds to the dissatisfaction. However, it is of

in hospitals in the U. S. to apply total quality
management (TQM) principles to improve
service quality. This is due to the fact that in
recent years healthcare has been criticized for
its low quality service at high costs which are
continuously increasing. Another motivation
for utilizing TQM in healthcare is the success
that TQM has had in other service industries.
Based on interviews with TQM and
information systems officials in some U.S.
hospitals, this study identifies and discusses
some critical issues in providing high quality
service in hospitals and explores the crucial
role that both TQM and Hospital Information
Systems @IS) can play in this endeavor.
INTRODUCTION
Providing quality service and increasing
' information systems can play in making TQM
customer satisfaction while reducing costs is
a challenging task for any healthcare
organization. Patients are often impatient
with long forms that they have to fill out and
many repetitive questions they have to
respond when in need of service. In addition,
duplicate efforts and long waits for service
utmost importance for any hospital to attend
to the patients in real time: or near real time.
This is due to the fact that it is human nature,
when physically ill, to be impatient and need
immediate attention and care. To these
problems we should addl the continuously
rising prices of heilthcare and the
unacceptable error rate which at times have
been fatal to patients whiclh also leads to high
cost litigation.
Based on personal intewiews with some
officials in charge of TOM and information
system in some U. S. hospitals, this study
aimis at identifying some: critical issues in
providing quality service to patients and the
role of TQM in this endeavor. The study
thein focuses on the crucial role that
a siiccess.
TQM I N HOSPITALS
Like any other industry, healthcare has also
recognized that TQM is, inevitable. The
question facing the healthicare industry today
is not whether or not to implement TQM, but

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 when and how soon to do it? Healthcare has
realized that TQM implementation is the
means for survival. In today's competitive
world, more and more hospitals are turning to
TQM's wish fulfilling tree: provide high
quality service and at the same time reduce
waste, become more cost efficient and cost
effective, make customers happy, increase the
productivity. "Both the American Hospital
Association and the Joint Commission on
Accreditation of Healthcare Organizations are
implementing initiatives for quality
improvement, Additionally, many payers and
preferred provider organizations are
establishing rigorous quality standards for
preferred healthcare providers" [Andrew,
19911.
However, implementing TQM in a hospital
and applying its principles is quite different
than TQM in any other industry. This is due
to the fact that hospitals usually have two
distinct lines of authority, namely, the
administrative staff and the medical staff.
This duality can easily cause some problems
in applying TQM in a hospital environment.
As a result, the interviewees strongly
suggested that for TQM to succeed in
hospitals a close cooperation between these
two authorities is of utmost importance and
they mentioned that a happy marriage
between them can be made possible by the
help of an integrated information system. For
example, by combining and integrating a
various administrative and operational
information systems in a hospital, information
can be captured and given to physicians in the
form of a medical record abstract, thus
improving the care they provide to the
patient. Such a system can significantly
improve the communication between the
administrative and the medical staff and it can
assist greatly in reducing conflicts.
Some other problem areas peculiar to
hospitals are operations and the perception of
quality. There is usually a fuzzy connection
between inputs and outputs in hospital
9 5 ENGINEERING MANAGEMENT CONFEKENCE
operations--i.e., it is not always clear to see
exactly which activities lead to what results.
In addition, patients tend to give better
judgment of quality they perceive over an
extended period of time. Both, the fuzzy
input-output connection and the perception of
quality make data collection and any
measurement for process improvement a
d ifficu 1t task .
The participants in our interviews
unanimously believed that top-down approach
was the most appropriate method for
implementing TQM in hospitals and the
support of top management was extremely
crucial for TQM success. To gain the
commitment and the support of the senior
management as well as all other employees, a
massive organization-wide training and
educational program was suggested as a
'definite must" and a "prerequisite" for TQM
implementation. Interviewees suggested that
through training, initially an awareness must
be created throughout the hospital about
TQM: What is TQM? Why are we doing it-
-i.e., what are the strategic and tactical
goals/objectives? What are the anticipated
benefits? What are the penalties of non-
compliance? These questions emphasize two
points: (1) A well defined plan as well as well
established objectives are of utmost
importance and (2) It can be a fatal mistake to
start TQM with immediately identifying
problemslopportunities for improvement and
trying to solve them. TQM awareness must
be the initial step. Another factor affecting
the failure of TQM in many organizations as
well as in hospitals is the over zealous use of
TQM to solve everything rather than looking
for those opportunities that provide the
greatest return relative to the organizational
objectives.
A comprehensive survey of customers
(internal as well as external) must be the
second step. A customer is anyone who
interacts with processes. Some typical
customers of a healthcare system are:
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 patients, doctors, nurses, pharmacists,
supplierdvendors, facultyhdents.
Among other TQM implementation tasks
suggested by the interviewees are the
following:
-- A well defined organizational process for
cultural change
-- An assessment of the hospital’s current
position in the industry
-- An evaluation of the hospital’s relationship
with its external and internal customers as
well as its suppliers
-- A self assessment of the current standing
with quality (it will be very useful to use the
criteria specified in Malcolm Baldrige Award
(whenever such criteria becomes available for
hospitals) for self-assessment. Such an
assessment can be helpful in determining
where the hospital is today and where it ought
to be).
-- An external assessment of quality.
THE ROLE O F HOSPITAL
INFORMATION SYSTEM
In simple terms, HIS can be defined as a
system (preferably integrated) that is used for
storing, retrieving, and communicating
information about all different components of
a healthcare system. Ideally, the HIS should
assist a healthcare organization to achieve its
long-term and short-term goals and objectives.
In addition, an ideal HIS should extend its
boundaries to include external customers as
well as suppliers/vendors. Such a system can
be of invaluable assistance in making TQM
dream come true and in realizing its benefits.
HIS can have a significant impact on the
quality of the services provided and can
drastically improve the communication among
various players.
Most hospitals surveyed in this study were
mainframe based and the HIS in most of them
was a collection of a few isolated (non-
integrated) systems. The following are some
suggestions for making HIS a success and for
making it accepted by all users:
95 ENGINEERING MANAGEMENI CONFEIZENCE
-- Mign the objectives of HIS with those of
the arganization. Remember that the mission
of HIS is to help the hospital to achieve its
goals and objectives. To this end,
continuously keep in mind that providing
quality service to external customer (i.e., the
patient) is the ultimate goal.
-- Integrate all subsystems of HIS. The
integration of all subsystems is a critical
element in providing support for an effective
TQM program. Much of what is provided
from TQM occurs only after extensive
analysis. Obtaining clinical information from
an integrated system facilitates this analysis.
-- Make sure that HIS has; a user friendly
interface. For this purpose, a Graphical User
Interface (GUI) can be very helpful. A user
friendly interface for HIS will make it much
easier to sell to users.
-- The major resistance to using HIS will
come from doctors and nurses. To make HIS
acceptable to these users (i.e., to successfully
sell HIS to this group of users) involve them
in all stages of HIS development. In addition,
it will1 be a good idea for the project manager
to team up with a medical doctor@) who is
well respected by hidher colleagues and can
represent their information needs. Other
doctors and nurses will accept HIS and will
believe in its benefits if another doctor sells
HIS to them rather than a technical (non-
medical) person such as HIS director or
project manager.
-- HIS should, among others, provide TQM
related information (e.g., information about
customer satisfaction, clinical outcomes).
-- Training programs must be offered to
educate the end users about the services HIS
can provide. In addition, it is very crucial to
educate IS personnel in TQM methods and
practices.
_ _ Migrating some applications to
ClientlServer environment may result in some
(possibly substantial) cost yavings. This in
turn can significantly reduce the cost of
providing services.
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CONCLUSION
In recent years healthcare has been criticized
for its low quality service at high costs.
Unfortunately, these two elements are directly
related--i. e., providing high quality services
requires increased costs. But customers are
demanding a high quality service at low costs.
TQM which has had success in other
industries may be able to do the magic in
healthcare too. Consequently, TQM has
attracted the attention of hospital
administrators. However, one major player
in a successful TQM implementation and its
subsequent acceptance is a Hospital
Information System (HIS) that will go far
beyond a simple "patient record keeping and
billing system". Ideally, HIS should be an
integrated system capable of making any
information available in a timely manner.
Such a system must serve external (e.g.,
patients) and internal (e.g., nurses, doctors)
customers as well as suppliers and should
improve communication among them. The
contributions of this study were twofold: (1)
it identified some critical issues in providing
high quality service in hospitals and (2) it
explored the crucial role that both TQM and
Hospital Information Systems (HIS) can play
in this endeavor. For this purpose personal
interviews with some hospital officials in
charge of TQM and information systems were
conducted. Through these interviews, factors
contributing to TQM's success and the role of
HIS in this effort were identified.
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