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How to make CQI work for you.

While the benefits of continuous quality improvement (CQI) done right are extraordinary, organizations implement CQI with a huge variation in skill and commitment. More than half of about 1,200 corporate employees who answered a Gallup survey for the American Society for Quality Control say their companies claim that quality is a top priority. But only about one third say their companies follow through with effective programs. In health care, where CQI is relatively new and where there is often a tendency to implement short-term fads, the quality of CQI implementation is very uneven. Physician executives are in an excellent position to become the champions of CQI and to play a lead role in ensuring that it is done right in their organizations. This opportunity involves two major actions:

1. Become educated on what CQI is and how it works.

2. Help lead the hospital's CQI process.


The CQI education plan should focus on at least three areas: the concept, the process, and the tools.

The Concept

It is helpful to learn how other organizations define CQI and to develop a definition that is most meaningful to you. Most definitions stress:

* Meeting (or exceeding or anticipating) customer expectations.

* Internal and external customers.

* CQI as a continuous way of doing business.

* Improving processes.

It is important to get a sense of the magnitude of the results of CQI in Japan and in America's leading companies, such as Motorola, Corning, 3M, Federal Express, IBM, etc. It is also helpful to learn about the early health care pioneer's experience with CQI, including the experiences of Rush-Presbyterian-St. Luke's Medical Center, HCA, Harvard Community Health Plan, and Park Nicollet Medical Center. Site visits to these organizations can be extremely helpful to gain first-hand exposure to CQI and insights from peers.

To develop your own philosophy of CQI, you should be exposed to the major teachers of and developers of CQI theory, and to each one's unique contributions. Shewhart, Deming, Juran, Feigenbaum, and Crosby have all been major contributors to CQI. Well-known books by these gurus include Out of the Crisis by W. Edwards Deming (the major book by one of the most respected CQI leaders), Quality Is Free by Philip Crosby (an influential book describing the benefits of CQI and a 14-step plan for its implementation), and Juran's Quality Control Handbook by Joseph Juran (a major reference book on quality planning, improvement, and control). A good introductory book is The Deming Management Method by Mary Walton. A bibliography of articles is included at the end of this article.

Your CQI education plan should leave you with a clear sense of significant differences between CQI and QA. Through specific examples, you should gain an understanding that:

* CQI assumes the best in people; it focuses on continuous improvement for the good guys, not on weeding out the bad apples.

* CQI brings about systematic improvement in processes by addressing the root causes of process problems rather than by focusing on symptoms or individuals.

The Process

Once you understand the theory of CQI, it is critical to learn why CQI is successful at some organizations and at others never seems to get off the ground. Your education plan on the CQI process should start with the six Key Success Factors (KSFs) for CQI:

KSF 1 Visionary Leadership

KSF 2 Commitment to Customers

KSF 3 Trained Teams

KSF 4 Physician Particiaption

KSF 5 TQM Process

KSF 6 Alignmnet of Management Systems

These KSFs may sound like a blinding flash of the obvious, but I urge you to resist the temptation to belittle them. In many health care organizations, gaining active management leadership of CQI, through a commitment to personal behavior change, is a major hurdle. Gaining substantial physician commitment and adapting organizational support systems such as MIS, recognition programs, and budgeting are also common challenges.

The process to implement CQI includes both a CQI management process to ensure that CQI is institutionalized as a long-term way of doing business and a CQI improvement process to solve specific problems (figures 1, above, and 2, page 5). There are differing views on how the processes should be phased into an organization. Some health care organizations build the broad management strategy and structure for CQI before specific improvement projects are initiated. Other organizations start with a few pilot improvement projects to gain experience in and support for CQI before expanding it throughout the organization. Education on the improvement process should include at least an introduction to statistical process control.

The Tools and Techniques

The major tools and techniques used to implement CQI include:

The Shewhart Cycle

This is a cycle of action steps, based on the scientific method, to bring about continuous improvement in a process.

* Plan a change.

* Do the change on a small, test scale.

* Check the results of the test.

* Act upon the results to either sustain the improvement, abandon it, or revise and retest it.

The 7 Quality Control Tools

Graphical techniques can be particularly helpful in determining the root causes of a problem. The seven quality control tools are caused and effect diagrams, flow charts, Pareto charts, run charts, histograms, control charts, and scatter diagrams.

The 7 Management and

Planning Tools

These graphical tools, many of which were developed by Japanese quality leaders, can be helpful in organizing and depicting relationships among data and can assist in planning, including development of critical paths and timelines. The tools are affinity diagrams, interrelationship digraphs, tree diagrams, prioritization matrices, matrix diagrams, process decision program charts, and activity network diagrams.

Quality Function Deployment (QFD)

QFD, a technique to address customer demands when designing a service, uses matrices that depict key aspects of a service and areas for "breakthrough" improvements.

Hoshin Planning

Hoshin Planning, a process of organizationwide quality planning, focuses on achieving the quality plan by deploying it throughout the organization. This is done by building a clear understanding of each person's role in implementing the plan.


While most hospitals endorse a physicians' central role in CQI in theory, it is very common for there to be only minimal physician involvement in the early stages of a hospital CQI process. If you are committed to effectively shaping your hospital's CQI effort, you need to take the initiative to ensure that you and other physician leaders are centrally involved in four phases of CQI.

Phase 1--Plan the Strategy

Go on hospital-sponsored site visits of CQI pioneers. Help to set the agenda for these site visits to ensure that your questions are addressed.

Participated in any quality improvement needs assessment.

* Ensure that appropriate physicians are interviewed or surveyed.

* Be briefed on the findings of the needs assessment and communicate these results to the medical staff.

Ensure that there are strong physician representatives on the hospital's CQI Steering Committee or Quality Council. This key group will direct the organization's CQI process. Participate in, either directly or through your representatives, key Steering Committee decisions.

* What should be the organization's quality vision statement and goals?

* How will quality improvement progress be evaluated?

* What should be the specific CQI implementation plan and budget?

* What should be the strategy for broad medical staff involvement in this effort?

* What should be the criteria for selecting quality improvement projects?

* What specific departments and projects should be targeted for improvement and when? What will be the pilot projects?

* Who, including which physicians, should serve as facilitators, the internal CQI change agents, team leaders, and trainers?

Be sure that a strong evaluation system is set up to measure results associated with CQI. Track incremental results, at least every three months, to maintain momentum.

Phase 2--Support CQI

Communicate relevant CQI decisions and progress to the rest of the medical staff through:

* A CQI report at all Medical Staff Executive Committee meetings.

* A regular column on CQI in the physician newsletter.

* CQI reports at full medical staff meetings and department meetings.

* CQI videos, progress reports, and informal discussions in the physicians' lounge and dining room.

* Participation in the hospital's training sessions on CQI. Most organizations will hold a CQI planning and training retreat for the Steering Committee. In addition, more in-depth training sessions are commonly provided for facilitators and department heads. Prior to these training sessions, you can work to ensure that the previously discussed education plan will be adequately covered.

* Providing input on how management systems (performance evaluation and compensation, recognition programs, training and professional development programs, communication, strategic planning process, budgeting process, quality assurance, management information systems, organizational structure, and decision making process) should be adapted to better support CQI. Adapting these systems to fit with CQI is critical to sustaining CQI long term and preventing it from being just another program.

Phase 3--Improve


* Assist in the selection of quality improvement projects (QIPs), including pilot projects.

* Assist in the selection of quality improvement teams to work on the QIPs. In addition to recommending physicians for team participation, this can include advocating that all teams be cross-functional to be maximally effective.

* Help to keep your team on track in working through the CQI improvement process. For example, you may want to help the team avoid the common pitfalls of focusing on symptoms instead of root causes of problems, or of moving to solutions before the problem is adequately understood. Many teams would benefit from a physician champion to keep the team focused on understanding and meeting customer expectations, avoiding the common tendency to assume the team has all the answers.

* Continually seek out opportunities for personal improvement to better meet your customers' expectations.

Phase 4--Advance CQI

* Assist in evaluating how the CQI process is working and in developing improvements to it.

* Work to better integrate CQI with related physician efforts, such as quality assurance, JCAHO accreditation, outcomes projects, clinical protocol/pathway developments, etc.

* Help to develop CQI into a marketing strategy to maintain and increase business.

* Identify additional training needs, for example in the areas of statistical process control, benchmarking, or team building.


The preceding discussion assumes that you are affiliated with an organization where, at a minimum, the CEO or some other senior executive is committed to embarking on a CQI process. But what if you are out there on a CQI quest by yourself? The starting point for your quest remains the same: to become well educated about CQI. Then you need to share relevant highlights of your CQI education, and your resulting enthusiam, with the CEO, key executives, and other physician leaders. If all of your support building efforts fall flat, you may want to consider the following:

* Start the process on a small scale on some clinical issues.

* Try again to generate enthusiasm in 90 days, or after the current crisis abates.

* Seriously evaluate whether this health care organization can be a long-term winner without CQI.

Physicians are key to the success of any health care organization's CQI process. Nevertheless, for a variety of reasons, physicians are playing only minor roles in the CQI process of many hospitals. Your leadership in CQI will result in wins for you, your employees, the health care organization, and patients.


[1] "Adopting Deming's Quality Improvement Ideas: A Case Study." Hospitals 64(13):58-60,62,64, July 5, 1990.

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

[3] "Data Spin Debate on Hospital Quality." Wall Street Journal, May 24, 1990.

[4] Francis, A., and Gerwels, J. "Building a Better Budget." Quality Progress 22(10):70-5, Oct. 1989.

[5] Laffel, G., and Blumenthal, D. "The Case for Using Industrial Quality Management Science in Health Care Organizations." JAMA 262(20):2869-73, Nov. 24, 1989.

[6] Melum, M. "Total Quality Management: Steps to Success." Hospitals 64(23):42, 44, Dec. 5, 1990.

[7] Melum, M., and Sinioris, M. "The Next Generation of Health Care Quality." Hospitals 63(3):80, Feb. 5, 1989.

[8] Merry, M. "Total Quality Management for Physicians Translating the New Paradigm." QRB 16(3):101-5, March 1990.

[9] Nolan, T., and Provost, L. "Understanding Variation." Quality Progress 23(5):70-8, May 1990.

[10] Scholtes, P., and Hacquebord, H. "Six Strategies for Beginning the Quality Transformation, Part II." Quality Progress 21(8):44-8, Aug. 1988.

Mara Minerva Melum is President of Mara Melum and Associates, Inc., a health care management consulting firm based in St. Paul, Minn., that pioneered the use of TQM in health care. She has served as Special Consultant to the 3M Corporation on its work on quality management and is author of an upcoming American Hospital Association book on health care pioneers in total quality management.
COPYRIGHT 1991 American College of Physician Executives
No portion of this article can be reproduced without the express written permission from the copyright holder.
Copyright 1991, Gale Group. All rights reserved. Gale Group is a Thomson Corporation Company.

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Title Annotation:continuous quality improvement of health care
Author:Melum, Mara Minerva
Publication:Physician Executive
Date:Nov 1, 1991
Previous Article:The Hay Group Guide to Executive Compensation.
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