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TQM: a paradigm for physicians.

Change, even when for the better, is always accompanied by apprehension and even outright fear. It is therefore not surprising to hear health care workers, especially physicians, expressing their concerns about this "new" management philosophy through a spectrum of reactions that vary from skeptical or grudging acceptance to outright dismissal of all of the new "alphabet soup" associated with TQM.

Application of the continuous quality improvement cycle popularized by W. Edward Deming and Joseph Juran to American health care processes in the form of total quality management (TQM) is bringing constant and accelerating change into our hospitals and clinics. The threatening nature of change, in and of itself, is the most likely explanation for the resistance to the "new" management philosophy of TQM that has been demonstrated by many physicians, because physicians have cheerfully brought a management style indistinguishable from that of total quality management to their day-today professional activities for years. We need only look at a typical doctor patient interaction to see that this is true.

A patient usually presents to a physician with a collection of symptoms defining a chief complaint and other, lesser complaints. These complaints suggest "opportunities for improvement" in the patient's health. The physician, after taking a history and performing an examination to obtain a preliminary database, establishes priorities in diagnosis and treatment that further refine the "opportunity statement" originally presented by the patient. The physician then often involves colleagues with specific expertise as consultants, there by "organizing a team" to address the patient's problems in a logical sequence.

Next, the physician coordinates the efforts of this team in "clarifying" all that is known about the patient's overall health status, identifying dysfunction, and guiding the patient through a further diagnostic journey frequently involving very technical special examinations and studies. These steps lead to a more refined "understanding" of the exact nature and extent of the underlying disease that is the root cause of the patient's symptoms. Thorough understanding of the underlying disease process permits the physician and the health care team to "select" the most appropriate specific interventions from the many alternatives usually available.

This classic diagnostic and therapeutic approach exactly parallels the FOCUS methodology of TQM, in which an organization's management Finds an opportunity for improvement, Organizes a team to address that opportunity, Clarifies knowledge of the underlying process, Understands that process, and Selects a specific intervention designed to improve the outcome of the process. Furthermore, the similarities between TQM and the daily activities of a physician do not stop there. After selecting the indicated therapeutic interventions, the physician applies them and then follows the patient closely to determine if those interventions are, indeed, appropriate ones. As the patient improves, the physician may repeat the entire process to refine treatment. If the patient fails to improve, the physician and the consultant team may very well revisit their previous findings and determinations to look for a flaw in their analysis that would suggest an alternative approach. This is exactly the same as the "Plan-Do-Check-Act" management sequence popularized by TQM.

Of course, the basic physician-patient interaction, while resonating with the principles of TQM, already offers many opportunities for improvement. For example, data collection in actual clinical practice seldom follows the complete and carefully organized paths espoused by TQM, and the current level of technology does not permit full understanding of the root causes of many diseases. Art, therefore, enters into the equation far more than would be the case in the study of most industrial processes. However, improvements in clinical information management systems will help most physicians refine the evaluation processes that they apply to their patients and to follow their patients better over time. Also, improved diagnostic modalities will lead to fuller understanding of disease. There will still be a place for the art of medicine, but it will not serve as often as a proxy for knowledge and understanding.

There is one final, crucial similarity between the orientation of the physician and that of management dedicated to the continuous quality improvement engendered by TQM. Both are trained to look at process and to seek out the root cause of disfunction, accepting the axiom that-- in physicians' terms--"an ounce of prevention is worth a pound of cure." The all-too-frequent medical emergencies seen in clinical practice do indeed mandate "firefighting" to deal with "special causes," but the astute physician strives to seek the underlying currents of faulty process in evaluating the whole patient and in searching for root causes of disease. Through evolving concepts of wellness rather than intervention in the course of disease, physicians will proactively assist people in "planning for quality" in their lives by helping them to choose life-styles that foster health rather than illness. A physician ultimately succeeds by planning for health and by defining and treating underlying disease rather than by merely treating symptoms when health fails. So, too, does management succeed by planning for quality and by correcting root causes of organizational disfunction when disfunction occurs, rather than by constantly firefighting special causes.

TQM, therefore, is nothing more and nothing less than good medicine applied to ensure the health of organizations and institutions rather than that of individual patients. Moreover, TQM works best when it is used as preventive medicine, planning for quality rather than seeking out and correcting dysquality arising from faulty processes that have been poorly planned in the first place. TQM is a perfect physicians' paradigm, and physicians who realize and accept this simple fact will add to their arsenals a powerful tool to improve both their patients' well-being and their own professional lives.

Further Reading

The following additional sources of information on total quality management and continuous quality improvement were obtained through a computerized search of databases. Copies of articles are available from the College for a nominal charge. For further information on citations, contact Gwen Zins, Director of Information Services, at College headquarters, 813/287-2000.

"An Annotated Bibliography: Total Quality Management." Healthcare Information Management 6(1):18-9, Winter 1992.

"Glossary of Total Quality Management Terms." Journal of the American Health Information Management Association 62(12):60-1, Dec. 1991.

Appel, F. "From Quality Assurance to Quality Improvement: The Joint Commission and the New Quality Paradigm." Journal of Quality Assurance 13(5):26-9, Sept.-Oct. 1991.

Berwick, D., and others. "The State of Quality Management in HMOs." HMO Practice 6(1):26-32, March 1992.

McCabe, W. "Total Quality Management in a Hospital." QRB 18(4):134-40, April 1992.

Pelling, M. "Total Quality Management: a New Challenge for Quality Assurance Professionals." Journal of the American Health Information Management Association 62( 12):32-6, Dec. 1991.

Schaffer, R., and Thomson, H. "Successful Change Programs Begin with Results." Harvard Business Review 70(1):80-9, Jan.-Feb. 1992.

Whetsell, G. "Total Quality Management." Topics in Health Care Financing 18(2): 12-20, Winter 1991.
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Title Annotation:total quality management
Author:Snyder, David A.
Publication:Physician Executive
Date:Mar 1, 1993
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