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From QA to TQM.

Medical audit" was the first of the two dominant medical quality processes to appear in the medical literature. The concepts of medical audit were described by Lembcke [1], Payne [2], Williamson [3], Brown [4] and others in the late fifties and sixties. In itself, medical audit was a sound statistical quality evaluation tool. Unfortunately, inherent limitations prevented its meeting the expectations of its supporters. Though a limited tool, it was elevated to a process for quality and cost control by both the government (PSRO) and the Joint Commission on Accreditation of Hospitals (now the Joint Commission on Accreditation of Healthcare Organizations), a process for which it was not designed.

Forced upon an unprepared profession in a cultural climate that applauded the discomfiture of all established institutions, medical audit failed to get the professional support it needed, failed in its objectives, and was discarded in 1980 by the PSROs and the JCAH. In addition to its cultural inadequacies, there were structural flaws [5]. First, too much was expected of the developing data industry, including indiscriminant choice of data, lack of data availability, and problems with processing. Second, with focus limited to professional behavior, medical audit did not address all systems within an institution. Moreover, there was no commitment by management to make changes in response to findings. In addition, the continuing focus on finding and correcting problems restricted the vision of all participants from the more important objective of institutional improvement. The total failure of this dismal 10-year experience caused a lingering and profound skepticism regarding all so-called "quality" efforts.

The "total quality management" process was introduced and developed in Japan by W. Edwards Deming and Joseph Juran. Although credited with the outstanding success of post-WWII industrial growth in Japan, it was not recognized by U.S. industry until about 1980. With the airing of a documentary about Deming by NBC, America took notice. The process has now been implemented successfully by the Ford Motor Company, Harley Davidson, Boeing, Xerox, and other manufacturing companies and by a service company, Florida Power and Light, the first company outside Japan to win the Deming Prize. Nevertheless, the success of this management process in both manufacturing and service industries continued to be ignored by a health industry overwhelmingly pre-occupied with JCAHO and its quality assurance emphasis on performance evaluation.

Characteristics of Total Quality


The industrial system of quality management developed by Deming and Juran is a process of institutional change for improvement. It requires sound, knowledgeable commitment by top management and a clear portrayal of management's vision and values, as defined in a concise corporate mission statement. This mission statement becomes the vehicle for strategic planning and deployment of resources, or "Policy Deployment." It should be prominently displayed, understood by employees, and recognized by the public.

Foremost in the understanding of employees and management should be commitment to meeting the needs and expectations of customers. These needs can be both technical and perceptual. Recognizing them requires a break from the customary assumptions of health professionals and readiness to explore new areas in new ways.

Because this system is applied to the institution as a whole, it is concerned with the interaction of systems and processes and is data driven. The process of meeting the needs of customers, both internal and external, becomes the structure for this continual evaluation.

An important implementational feature of this management process is the training and empowerment of employees. Extensive training is required of all employees, including top and middle management. The curriculum includes statistical processes, quality tools, and interpersonal communication skills. Emphasis is placed on training employees to achieve quality at the time work is done, which contrasts to correcting errors through inspection. Special training is provided to team leaders and facilitators.

Because the process recognizes that there is an immense reservoir of untapped knowledge within the organization, this resource is developed through "Quality Improvement Teams." A structure is designed for these teams, using data to address special themes for improvement to engage in formal problem solving. The results are incorporated in recommendations for implementation of innovative solutions. This is supported by an extensive reward and recognition system.

Progress of TQM in the Health


As in other areas of innovation, the health industry has generally lagged behind the manufacturing and service industries. Nevertheless, there were some early entries, including Alliant Health Systems of Louisville, Ky; Hospital Corporation of America; Harvard Community Health Plan; and others. Characteristic of early health organizations implementing TQM is the coincidental recognition by top management of the need to respond to external challenges and the awareness of the modern quality management process. Personal exploration and study proceeded to a presentation of the concepts to senior executives. Typically, a steering committee or research committee was formed and spent up to a year in reading, seminars, and site visits. This usually included a survey of potential consultants. Gradual implementation was then designed and organized. Early entries in the field were large organizations with staff model HMOs.

Rapid expansion began in 1988, stimulated by articles appearing in Modern Healthcare, [6] Business Week, [7] and other periodicals. Berwick [8] introduced the concept to the medical literature in the New England Journal of Medicine the following year. Interest spread to the federal government as well. TQM was stated to be a priority for FY 1990 for the V.A. Western Region, and in 1991, 12 pilot facilities within the Veteran's Service and Health Research Administration will be chosen for TQM implementation.

In order to estimate the present impact of TQM in the health industry, questionnaires were sent to 400 randomly chosen hospitals represented in the College's membership. The questions were designed to determine the penetration of TQM into the health organizations, the sophistication of implementation (teams and practice guidelines), and variation within provider staffs (independent private practitioners vs. house staffs vs. full-time employees). A response rate of 34 percent, 134 questionnaires, was obtained. Of these, 57 (42 percent) said they were involved in implementing TQM; 38 of the 57 were using teams and 36 of them were using clinical guidelines, critical paths, or algorithms (figure 1, above). Fifty-eight respondents indicated that their facilities were staffed by independent private practitioners (IPPs) (figure 2, above). (This question was not answered by 35 of the respondents, and 19 indicated a combination of IPP, employed physicians, and house staff.) Of the 58 respondents using the staff model, 31 (53 percent) were implementing TQM. Of these, 15 (50 percent) were using teams and 10 (32 percent) were using some form of clinical guidelines.

Fifteen of the respondents represented hospitals with house staffs. The medical staffs of 13 were composed of IPPs. Eight reported involvement in TQM, two using teams and six using clinical guidelines. Among teaching hospitals, those contacted by phone indicated an overwhelming enthusiasm for the process. Residents, in particular, appreciated clinical guidelines because of the structure for clinical care they offer. Unfortunately, we have no information regarding university hospitals.

Although the institutions that have been utilizing TQM for three to four years are reporting measurable improvement in employee satisfaction, reduced costs per DRG, increased market share, and improved measures of quality outcomes, it is too soon to evaluate the results of hospitals that have begun implementation more recently. Characteristically, more recent entries appear to represent a broader range in size, are predominantly staffed by independent private practitioners, and are using established consulting firms that have adapted their organizational development package to the characteristics of TQM. A number of the hospitals responding to phone interviews also said that the igniting energy may have come from lower down on the management ladder or that mild interest at the CEO level had led to delegation of information gathering to a staff person. Time will tell how these arrangements succeed.

The application of the quality management methods of Deming and Juran to health care provides management with a tool to expand critical evaluation to include all the systems that clearly contribute to physicians' and the organization's effectiveness. They expand the concept of quality assurance from a performance evaluation system previously limited to clinical behavior to the incorporation of all management tools for improvement of organizational outcomes. The implications for patients, for third-party payers, for JCAHO, and for physicians are significant. Total quality management is a process for change. It is moving QA out of the basement and into the board room.


[1] Lembcke, P. "Medical Auditing by Scientific Methods." JAMA 162(7):646-55, Oct. 13, 1956.

[2] Payne, B. "Continued Evolution of a System of Medical Care Appraisal." JAMA 201(7):536-40, Aug. 14, 1967.

[3] Williamson, J. "Priorities in Patient-Care Research and Continuing Medical Education." JAMA 204(4):303-8, April 22, 1968.

[4] Brown, C., and Fleisher, D. "The Bi-Cycle Concept--Relating Continuing Education to Patient Care." New England Journal of Medicine 284(7, Suppl.):88-97, May 20, 1971.

[5] Anderson, O., and Shields, M. "Quality Measurement and Control in Physician Decision Making: State of the Art." Health Services Research 17(2):125-55, Summer 1982.

[6] Perry, L. "The Quality Process." Modern Healthcare 18(14):30-4, April 1, 1988.

[7] Nussbaum, B., and others. Smart Design: Quality Is the New Style." Business Week, April 11, 1988, pp. 102-7.

[8] Berwick, D. "Continuous Improvement as an Ideal in Health Care." New England Journal of Medicine 320(1):53-6, Jan. 5, 1989.

Russell D. Tyler, MD, FACP, FACPE, is Clinic Director, Department of Veterans Affairs Outpatient Clinic, Santa Barbara, Calif.
COPYRIGHT 1991 American College of Physician Executives
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Title Annotation:quality assurance, total quality management and the medical audit
Author:Tyler, Russell D.
Publication:Physician Executive
Date:May 1, 1991
Previous Article:What is quality, and how is it measured?
Next Article:Developing an in-house physician advisor program.

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