Quality Management – Global

context

Dr. Syed Aftab Rahim

syedaftabrahim@hsa.edu.pk
 Quality health services – WHO Fact sheet
• Between 5.7 and 8.4 million deaths are attributed to poor quality care
each year in low- and middle-income countries (LMICs), which
represents up to 15% of overall deaths in these countries.

• Sixty per cent of deaths in LMICs from conditions requiring health care
occur due to poor quality care, whereas the remaining deaths result
from non-utilization of the health system.

• Inadequate quality of care imposes costs of US$ 1.4–1.6 trillion each

year in lost productivity in LMICs.

• In high-income countries, 1 in 10 patients is harmed while receiving

hospital care, and 7 in every 100 hospitalized patients can expect to
acquire a health care-associated infection.
 ..Quality care
• It has been estimated that high quality health systems
could prevent 2.5 million deaths from cardiovascular
disease, 900 000 deaths from tuberculosis, 1 million
newborn deaths and half of all maternal deaths each
year.

• Globally, the essential structures for achieving quality

care are inadequate: one in 8 health care facilities has
no water service, one in 5 has no sanitation service,
and one in 6 has no hand hygiene facilities at the
points of care.
 Healthcare and Quality
• Health Care Organizations (HCO) are complex organization by nature owing to
the intangible outcome of service and a blend of diverse professional personnel

• Health care is delivered by practitioners in medicine and allied health services;

dentistry, midwifery, nursing, optometry, pharmacy, psychology, rehabilitative
services and other care providers.

• The healthcare traditionally revolved around the medical model, where the
physician played the major role in deciding what treatment is required for the
patient

• Quality care in health sector took its cue from the quality systems introduced in
production industries and adopted in service industries
 History of Quality Management
• It is widely recognized that consumers only buy the goods with good
quality, desired functions, and accepted price

• Enterprises usually adopt some quality practices to control the product

quality during the manufacturing process in order to assure the delivery of
qualitative good products to customers

• The concept of quality has been evolving;

• In the first three decades of the last century, quality was defined as
“conforming to the standards and specifications of a product”

– So the commonly adopted quality practices by industries were the

standardization of quality, inspection, and rework
– The quality inspectors checked the dimensions and characteristics of products,
detected the errors and failures, and took the necessary actions to improve the
product quality.
 ..evolution
• It was realized that quality assurance could not be achieved by
placing the control just on production processes. Thus, the concept
of total quality control, TQC, was introduced in 1950s -
Feigenbaum, Juran, Deming & Crosby

• In 1960s, Japan took the lead in employing the practices of zero

defect, total quality and executing tasks right first time

• It was called Company‐Wide Quality Control (CWQC) which later

evolved into TQM in US & Europe
• From the mid‐1980s onward, several important quality programs
were launched:
– The development of TQM, the ISO 9000 system, the Six‐Sigma program
(which was initiated by Motorola) & Lean management by Toyota
Quality Management

Quality Assurance

Quality
Control
 Japan’s Quality drive
• The Japanese TQC possessed several critical characteristics:
• customer‐focused and quality‐first as the quality policies,
• full participation and teamwork,
• education and training of quality for all employees,
• realization of “do the right thing first time,”
• concept and materialization of a “zero defect” culture,
• “continuous improvement” as the key quality activity,
• everyone is responsible for achieving high quality levels,
• emphasizing on the prevention activities and quality
assurance,
• cultivating a quality culture environment.
 Quality – Customer focus
• Customer’s satisfaction
– customers’ satisfaction is the result of the fulfillment of their
explicit needs
• Customer’s loyalty
– customers’ loyalty cannot be assured by grossly satisfying
customers as competitors will satisfy the explicit needs and
provide better value products
• Customer’s delight
– “Customer delight” is a new quality concept
– To identify customers’ latent needs and to create customer
value by developing the innovative products and attractive
services in order to fulfill these.
Quality Management Systems
Quality Management System - HCO
• A QMS is defined as a formalized system that documents the
structure, responsibility, and procedures required to achieve
effective quality management that is focused on the quality policy
and quality objectives in order to meet customer requirements
• In healthcare, a QMS specifically describes the process for
improving all aspects of patient outcomes and operating
performance
• A system by which an organization aims to reduce and
eventually eliminate non-conformance to specifications,
standards, and ensures patients expectations in the most cost
effective and efficient manner
• Poor quality of health services waste resources that could be used
to treat more patients
 Quality Management Systems in HCO
• TQM
• Kaizen (Continuous Quality Improvement)
• Six Sigma
• Lean Management
• Pareto Analysis
• ISO 9001
• Accreditation
• Clinical Audits
• Health system Risk Management
• Adverse Events reporting systems
 History of QMS & TQM
• Before the WWII the principal focus in quality
management was on the quality of the
finished product
• The tools used were of acceptance sampling,
inspection plans, and control charts
• The ideas of Frederick Winslow Taylor
dominated.
• The birth of total quality in the United States
was in direct response to a quality revolution
in Japan following World War II
 ..QMS
• Japanese manufacturers converted from producing military
goods for internal use to producing civilian goods for trade

• Japan had a reputation for shoddy exports, and their goods

were shunned by international markets

• This led Japanese organizations to explore new ways of

thinking about quality

• The Japanese welcomed input from foreign companies and

lecturers, to improve the quality of their products
It came and it conquered
 So what was the change?
Joseph Juran’ Trilogy Edward Deming’ Principles
 Juran’s Quality Trilogy
• The Juran Trilogy is a quality improvement cycle that is meant
to reduce the cost of poor quality by planning quality into the
product/process
• Quality Planning
– it is critical to know who your customers are and find out their needs
– you will able to define the requirements for your product/service
– design and develop it as per the customer need
– planning should be a multidisciplinary activity and done with all the
stake holders
• Quality Control
– determine what you need to measure (what data do you need to
know if your process is working?)
– set a goal for your performance
 Juran’s trilogy
– measuring actual performance, and act on the gap between
your performance and your goal
– Root cause of deviation
• Quality Improvement.The strategies for this stage are: 4
Rs
– Repair: Reactive; fix what’s broken
– Refinement: Proactive; continually improve a process that isn’t
broken
– Renovation: Improvement through innovation or technological
advancement
– Reinvention: Most demanding approach; start over with a clean
slate
Total Quality Management

TQM
 Deming
• Dr Deming was an engineer & statistician who used
statistical process control tools to determine sources
of variation that led to waste in manufacturing
• He is responsible for introducing the quality systems
that drove the industrialisation of Japan following
the Second World War
• His approach to improvement shifted focus from
individuals to underlying processes as the primary
source of error and variation
• This concept of process improvement helped pave
the way for today’s view of QI
 Deming’s concepts
• He emphasized the concept of total quality management and
the importance of understanding the type of variation in a
process
• The more variation, the more waste and inability to
consistently produce the outcomes desired
• He believed that each organization is composed of a system of
interrelated processes and people which make up system’s
components.
• The success of all workers within the system is dependent on
management’s capability to orchestrate the delicate balance of
each component for optimization of the entire system
• His 14 principles tell us what can be changed to bring in quality
 Deming’s 14 Principles
• “Create constancy of purpose towards
improvement.”
– Think long-term planning, not short-term reaction
– What are we doing and why we are doing it?
– To stay in business requires that leaders spend
time on innovation, research and education
– They must constantly improve the design of their
product and service
 The principles…
• “Adopt the new philosophy.”
– Management as well as the workforce should actually
adopt this philosophy
– We are in a new economic age, created in Japan
– We can no longer live with commonly accepted levels of
delays, mistakes, defective materials and defective
workmanship
– We cannot accept today, the levels of error that could
be tolerated yesterday
– Defective products and services are a cost to the system
• “Cease dependence on mass inspection.” If
variation is reduced, there is no need for
inspection since defects (errors) will be
reduced or eliminated.
– Quality doesn't come from inspection, but from
improvement of the process. Improve the process
so that defects aren’t produced in the first place.
– This eliminates the need for inspection on a mass
basis.
• “End lowest tender contracts.” End the practice
of awarding business on the basis of price tag
alone
• Minimise total cost, not the initial cost
– Move toward a single supplier for any one item, on a
long-term relationship of loyalty and trust
– Lowest bidder means low quality & high cost
– Multiple suppliers mean variation
– Build mutually beneficial relationship with your
supplier
• “Improve every process.” Focus on continuous
quality improvement.
• Nothing is ever good enough, every process is
subject to improvement and change
– Finding what’s wrong & plugging leaks is not
improvement
– Don’t look at outcomes or defects, instead look at
what produces the defects
• “Institute training on the job.”
• Lack of training leads to variation among workers
– imparting the necessary skills, through systematic
instruction, to enable people to carry out a given job
efficiently
– Provide learning and development for all including the
management
– Training for new skills
• A trained workforce has more productivity and
quality
 …principles
• “Institute leadership.” The aim of management
should be to help people to do a better job.
– The leader is a coach, not a judge
– The emphasis of management must be changed from
sheer numbers to quality.
– Improvement of quality will automatically improve
productivity
– The management allows the organization to be successful
by providing for the needs of the employees & delighting
customers
– The aim of leadership is not merely to find and record
failures of men, but to remove the causes of failure: to
help people to do a better job with less effort
Where there is fear, there will be
wrong figures
• “Drive out fear.” Management through fear is
counterproductive and prevents workers from
acting in the organization’s best interests
• By nature, people are afraid of change and any
attempt to make things different that they
used to be will lead to fear of the unknown
– Effective communication systems is of great help
• Employees should have confidence in their
management
 “Eliminate slogans.”
• Eliminate slogans, warnings and targets for the
work force asking for zero defects, doing it
right first time and new levels of productivity
– Such urging only creates hostile relationships
– Posters ask people to do what they can not do
– Normally all a slogan does is result in blaming
people for not delivering what the
slogan promises
• “Remove barriers.” Break down barriers between
departments. People in research, design, sales,
technology and production must work as a team
– This leads to increased worker satisfaction
– Regular HoDs meeting
– Social interaction
– Common rooms
– Gym/Libraries
– Tea & lunch
• “Eliminate arbitrary numerical targets.”
– Production targets encourage shortcuts and the
delivery of poor-quality goods
– Traditionally quantity rules over quality
– The focus is not on how many you make, it is
on how well you make them
– Companies that use production targets eventually
lose focus on production improvement
 ..the principles
• “Permit pride of workmanship.” Remove the
obstacles and barriers that deprive workers, and
people in management, of their right to take pride and
joy in their work.
– This implies abolition of the annual merit rating (appraisal
of performance) and of Management by Objective, all of
which creates conflict and competition
– Fixing points for employees, and ranking them inside the
company, infuses competition within that organisation. We
want collaboration not competition
The greatest waste in America is failure to use the ability of
people - Deming
 ...13 & 14 principles
th th

• “Encourage education and self improvement.”

– No organisation can survive with just good people,
they need people that are improving with
education
• “The transformation is everyone’s job.” Put
everybody in the organisation to work to
accomplish the change.
– Develop a critical mass that will bring about the
change; a critical mass including top management
 Other Quality gurus
• Ishikawa
• Dr. Ishikawa developed the
Ishikawa diagram, also known as
the fishbone or cause-effect
diagram
• He was known for popularizing
the seven basic tools of
quality and the philosophy of
total quality.
• Dr. Walter Shewhart
• US engineer, father of Statistical
Quality Control
• Deming used to quote him a lot
• Philip Crosby
• Philip B. Crosby developed the
idea of Cost Of Poor
Quality (COPQ) to explain how
“quality is free”
• He believed implementing quality
improvement pays for itself
through the savings from the
improvement, increased revenue
from greater customer
satisfaction, and the improved
competitive advantage that
results. He popularized the
concept “zero defects”
 Quality is possible
• Ask ‘why’ at least five times until you find the
root cause
• Better the “wisdom” of ten people then the
“knowledge” of one
• Improvements are unlimited. Don't substitute
money for brains
• Improvement is made at the workplace not
from the office.
TQM
 TQM
• TQM is a management philosophy concerned with
people and work processes that focuses on
customer satisfaction who is the judge of quality and
improves organizational performance
• It believes in Continuous Quality Improvement,
continually seeking improvement on a process or
system
• It applies analytical and behavioural techniques to
improve those processes within an organization
• Improvement is based on both outcome and process
 Total Quality Management
• W. Edwards Deming, Joseph M. Juran, and Armand V.
Feigenbaum helped in developing the concept of total quality
management
• Total Quality Management originated in the manufacturing
sector, but is now applied to almost all organizations
• It is defined as a continuous effort by the management as well
as employees of organizations to ensure long term customer
loyalty and customer satisfaction
• Total quality management ensures that every single employee is
working towards the improvement of work culture, processes,
services, systems and so on to ensure long term success
• One happy and satisfied customer brings ten new customers
along with him
 Elements of TQM
• Leadership
–Top management vision, planning and support
–The management to provide an inspiring vision, make
strategic directions that are understood by all and to instill
values that guide subordinates – walk the talk
–Commitment and personal involvement is required from top
management in creating and deploying clear quality values
and goals consistent with the objectives of the organization
and in creating and deploying well defined systems, methods
and performance measures for achieving those goals.
• Employee involvement
–They must be sufficiently trained and given the proper
resources to complete tasks
–All employees assume responsibility for improving the
quality of their work
–Create an environment where employees can openly discuss
problems and suggest ways to solve them
–Increased employee retention because employees are
motivated, committed, and actively involved in working
toward customer satisfaction
 Elements…
• Process/Product Excellence
–Improve Processes which ensure consistency and speed up
production
–More consistency and predictable outcomes
–Improve product design quality and monitoring the process
for continuous improvement
–Poka-yokes are devices that prevent defects from being
produced
–to reduce defects from mistakes through the simplest and
lowest-cost manner possible
Error Proofing
• Customer focus. Your customers determine the
quality of your product
– You need to give something extra to your customers to
expect loyalty in return
– Research and understand your customers’ needs and
expectations.
– Align your organization’s objectives with customer
needs.
– Communicate with customers, measure satisfaction, and
use the results to find ways to improve processes.
– More sales, increased revenue & market share
• Continuous Improvement
–Optimal efficiency and complete customer satisfaction
doesn’t happen in a day—your business should continually
find ways to improve processes and adapt your products and
services as customer needs shift
–Quality improvement is a journey with no end – PDCA Cycle
–Implement policies to establish product, process, and system
improvements as measurable goals for individuals, teams,
and departments
–Recognize, acknowledge, and encourage innovation to
improve processes and development
 TQM in Hospitals
• Many hospitals are using TQM to achieve optimum health outcomes,
i.e. high quality services, patient satisfaction and better performance
• TQM has to be tailored to the special needs of the organization
• The success of TQM depends on various variables, which are specific
to the organization’s environment, structures, cultures, processes
and procedures
• Applying zero errors to all patients services
– maintaining a continuous error prevention program
• Rendering acceptable, quality health services to patients
• Training employees in medical care on such aspects as;
– error prevention
– reducing delay time
– prompt response to patients needs
 Hospitals with TQM
• Most hospitals that have implemented a successful quality
improvement program have built on the foundation of an
excellent ongoing quality assurance and quality
management program
• Attributes of Hospitals in which the Total Quality
Management/CQI has been successful are:
– willingness to make behavior changes in all aspects of how
hospitals do business
– reliable data hospital information system
– very significant investments in time & effort
– most important—top management and medical staff
commitment
 The Deming cycle
•An iterative four-step management method used for the control
and continuous improvement of processes and products
•People do the same thing over and over again in the hopes of
obtaining different results
•The 3rd step; ‘check’, if done properly will ensure the desired
result
 Skeptic view
• TQM in healthcare came from industrial experience,
but the healthcare industry is uniquely different from
a production plant or even from a service industry
due to;
– Its complex, highly departmentalized and bureaucratic
structure
– Differences in the perceptions, values and work ethic of
the healthcare providers
– Highly specialized division of labour
– Culture of hospitals and leadership styles
– Patient satisfaction alone can not decide appropriate
treatment
 Refrences
• What are the best strategies for ensuring quality in hospitals?
WHO Regional Office for Europe’s Health Evidence Network
(HEN) November 2003
• The Evolution of Quality Concepts and the Related Quality
Management by Ching-Chow Yang
• Total Quality Management; Volume 6, Issue 3, published online
2010.
• Total Quality Management Techniques. Boundless
Management. Boundless, 26 May. 2016
• Deming’s 14 Points, Posted on July 15, 2011 by dpjoyce
• http://asq.org/learn-about-quality/history-of-quality/
overview/total-quality.html
 References
• Six Sigma in Healthcare: Concept, Benefits and
Examples, DRMAHEY, September 30, 2018
• https://www.lucidchart.com/blog/8-total-
quality-management-principles
• Going Lean in Healthcare. Gary Kaplan, MD
John Toussaint, MD
• What is Lean Healthcare? NEJM, Article · April
27, 2018