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Combining total quality management and simulation with application to family therapy process design.

This case study shows how a new combined total quality management and simulation procedure was used to design, test, and implement a unique clinical process for brief systems family therapy. A process design procedure was developed that combines total quality management and simulation strategies and tactics. The six strategic check-points of the new procedure emphasize the use of both designed experimentation and process modeling and simulation to find process faults, evaluate process improvement alternatives, and test selected process improvements. Other information needed for process design was gathered from families in therapy, the family therapy literature and observations of student and experienced therapists. Simulation helped identify and compare alternative sequences of therapy process steps. Designed experimentation revealed improvements resulting from the new Brief Systems Family Therapy process as used by doctoral-level family therapy practicum students in a university clinic.

Clinical Clerkship↗

Total quality management: lessons learned from the medical practice environment.

Experience in dealing with the application of total quality management (TQM) to the medical practice environment suggests some generic lessons that can be helpful in applying TQM in other health care settings. These lessons focus on the need to address the motivation for TQM and its potential value; understanding the barriers created by the organizational and industry culture; identifying the structural barriers within the organization; clearly stating the guiding principles of the TQM effort; implementing the correct management tools for implementation; and allowing users of TQM to create new ideas for the application of TQM in their organizations.

Guidelines as Topic↗

Total quality management in a hospital.

The adaptation of the management philosophy and tools of total quality management (TQM) to the modern American hospital, its staff, and physicians is a major challenge facing health care today. The TQM "bandwagon" is one that hospitals both want to--and are required to--jump on, insofar as TQM is now part of the revised Joint Commission standards [Ed note: The standards encourage hospitals to adopt TQM, continuous quality improvement, or a similar approach to improve performance]. TQM holds out the promise of improving clinical quality while simultaneously reducing the "cost of poor quality." Although the actual realization of cost savings through TQM remains to be seen, the author provides an exceptionally clear overview of the issues involved in TQM implementation at the hospital level. This article is noteworthy in its practical and experienced approach to the necessary groundwork for a successful TQM program, including strategic commitment, human resource issues, and oversight of the TQM process as it unfolds. Quality review professionals may still wonder how to merge hospital and medical staff quality assurance efforts with TQM initiatives in the near future.

Consumer Behavior↗

Total quality management in the HMO environment.

Increasing numbers of healthcare organization are turning to total quality management (TQM) to contain costs and improve quality. This article describes the implication of TQM for health maintenance organizations.

Consumer Behavior↗

Adapting total quality management for general practice: evaluation of a programme.

OBJECTIVE: Assessment of the benefits and limitations of a quality improvement programme based on total quality management principles in general practice over a period of one year (October 1993-4). DESIGN: Questionnaires to practice team members before any intervention and after one year. Three progress reports completed by facilitators at four month intervals. Semistructured interviews with a sample of staff from each practice towards the end of the year. SETTING: 18 self selected practices from across the former Oxford Region. Three members of each practice received an initial residential course and three one day seminars during the year. Each practice was supported by a facilitator from their Medical Audit Advisory Group. MEASURES: Extent of understanding and implementation of quality improvement methodology. Number, completeness, and evaluation of quality improvement projects. Practice team members' attitudes to and involvement in team working and quality improvement. RESULTS: 16 of the 18 practices succeeded in implementing the quality improvement methods. 48 initiatives were considered and staff involvement was broad. Practice members showed increased involvement in, and appreciation of, strategic planning and team working, and satisfaction from improved patients services. 11 of the practices intend to continue with the methodology. The commonest barrier expressed was time. CONCLUSION: Quality improvement programmes based on total quality management principles produce beneficial changes in service delivery and team working in most general practices. It is incompatible with traditional doctor centred practice. The methodology needs to be adapted for primary care to avoid quality improvement being seen as separate from routine activity, and to save time.

England↗

Case study: the implementation of total quality management at the Charleston VA Medical Center's Dental Service.

Total Quality Management (TQM) is an evolving management philosophy which has recently been introduced to the health care industry. TQM requires the use of a continuous process improvement methodology for delivered services. It was implemented at Charleston VAMC's Dental Service as a study to determine its effectiveness at the grassroots level. A modified Quality Circle was established within the clinical service under the guidance of Dr. Edward Deming's 14 principles. Top management support was not present. Many lessons were learned as process improvements were made. The overall success was limited due to the inability to address interdepartment process problems.

Hospitals, Veterans↗

Total quality management in the public sector--issues for implementation.

The Quality Matters Article is reprinted from the Australian Association for Quality in Health Care (AAGQHC) Newsletter (Vol 4, No 2). Researched and written by Sharyn White (Senior Planner, Southern Health Advancement Planning Unit, with the South Australian Health Commission) it is an excerpt from a qualifying dissertation for for a Masters in Policy and Administration at Flinders University. Written when the author was the Quality Co-ordinator, Noarlunga Health Services, SA, the article examines the literature related to some of the differences between the public and private health sectors, and explores the use of Total Quality Management systems in public health care facilities in light of the literature. Many of the issues around the use of Total Quality Management in health care remain unresolved. Will it achieve better results than other quality approaches? Can an industrial model achieve improvements in patient care? Is it more appropriate in teh public or private sectors? Is TQM appropriate in health care? Is it just a jargonistic name change? What's the difference, when all is said and done, between TQM and other ways of addressing quality? Does the cost of implementing TQM justify the results? Sharyn White's research addresses some of these issues from a refreshing perspective. My thanks to the author, and to the editors of the AAQHC Newsletter for their permission to reprint the article in Health Information Management Journal.

Industry↗

Total quality management: administrative and clinical applications in nursing homes.

OBJECTIVE: Describe the application of the Total Quality Management (TQM) model to the unique work force, resident population, and regulatory issues that characterize long term care settings. DESIGN: The key differences between TQM and current management and training practices in nursing homes are described. A specific data-based example is provided of a successful TQM application to health care involving clinical work processes related to incontinence care. CONCLUSION: Significant organizational and clinical obstacles must be overcome if TQM is to improve the quality of life and satisfaction of nursing home residents and their families as it has improved the efficiency and product quality in hospital and non-health-care settings.

Clinical Competence↗

The perceived effectiveness of total quality management as a tool for quality improvement in emergency medicine.

OBJECTIVES: To describe the perceived effectiveness of using the Total Quality Management (TQM) approach to quality improvement in both academic and nonacademic EDs, and to discuss some important barriers to effectiveness of TQM programs. METHOD: A mail survey of 100 EDs was conducted with telephone follow-up. Hospitals were randomly selected from three subgroups: university teaching hospitals, nonuniversity teaching hospitals, and private nonteaching hospitals. ED physician directors or nonphysician administrators with knowledge of departmental quality improvement initiatives were surveyed. RESULTS: The overall response rate was 60%. Of the respondents, 54 (90.0%) used TQM techniques as part of their quality improvement initiatives. TQM techniques were used more frequently and for a longer duration in academic programs. ED staff participation in TQM projects was relatively low; less than 25% in the majority (79.6%) of all EDs. TQM initiatives were ranked least effective in university settings, of which 11 of 13 (84.6%) rated their TQM programs as ineffective or having no effect. More mature programs (>5 years old) had a significantly higher ranking for effectiveness than those programs less than 2 years old. CONCLUSIONS: Total Quality Management is being utilized in a large number of EDs. TQM initiative is perceived as having little or no positive effect. This is particularly the case in academic EDs.

Emergency Medicine↗

Integrating Six Sigma with total quality management: a case example for measuring medication errors.

Six Sigma is a new management philosophy that seeks a nonexistent error rate. It is ripe for healthcare because many healthcare processes require a near-zero tolerance for mistakes. For most organizations, establishing a Six Sigma program requires significant resources and produces considerable stress. However, in healthcare, management can piggyback Six Sigma onto current total quality management (TQM) efforts so that minimal disruption occurs in the organization. Six Sigma is an extension of the Failure Mode and Effects Analysis that is required by JCAHO; it can easily be integrated into existing quality management efforts. Integrating Six Sigma into the existing TQM program facilitates process improvement through detailed data analysis. A drilled-down approach to root-cause analysis greatly enhances the existing TQM approach. Using the Six Sigma metrics, internal project comparisons facilitate resource allocation while external project comparisons allow for benchmarking. Thus, the application of Six Sigma makes TQM efforts more successful. This article presents a framework for including Six Sigma in an organization's TQM plan while providing a concrete example using medication errors. Using the process defined in this article, healthcare executives can integrate Six Sigma into all of their TQM projects.

Data Collection↗

[Online infection recording within the scope of total quality management].

The continuous and exact recording of infections is a condition sine qua non for total quality management. Therefore, at the Diakoniekrankenhaus Rotenburg (Wümme) a program which offers the possibility of online recording of data was integrated into the hospital intranet. The recording is done with network clients. The recording of data is supported by a series of plausibility controls. The advantage consists in immediate evaluation of up to date and extensive statistics of infections. By integration into the existing system, relevant influences and consequences such as the prolongation of hospitalisation, use of material, and frequency of reoperation can by recognized and immediately considered with high validity.

Cross Infection↗

Total quality management and shared governance: synergistic processes.

"Synergism" accurately describes the gains that can be made when total quality management (TQM) and shared governance are employed for reciprocal development. This article explores the relationship between TQM and shared governance from a systems perspective. Systems thinking is the fundamental framework that must be learned by nursing managers. An example of this synergistic process is described from the National Institutes of Health nursing department's experience in implementing TQM and shared governance. The idea that structure is fundamental to problems and solutions when implementing change and focusing upon interdependency issues are the systemic competencies nursing managers need to develop in order to become strong nursing leaders.

Decision Making, Organizational↗

Information management in the age of managed competition.

BACKGROUND: Today's information requirements differ from those of the past, in terms of both the internal and external reporting needs of health care organizations. Demands for information are currently generated by physicians, quality managers, total quality management (TQM) teams, marketing staff, financial managers, regulators, insurance plans, accreditation agencies, purchasers, coalitions, and other customers. DISCUSSION: Health care organizations respond to these demands in different ways, depending on their size and type. Six aspects of information needs that would be relevant under managed competition are analyzed: standardization, linkages among data banks, risk adjustment, comprehensive institution-based indicators and information systems, comprehensive population-based indicators and information systems, and methods for protecting confidentiality of patient records. RECOMMENDATIONS: Six recommendations to hospitals/managed care plans that decide to establish information management systems are made: set goals, set priorities, describe current system, identify external data sources, develop (a plan), and check back (reassess).

Centers for Medicare and Medicaid Services, U.S.↗

W. Edwards Deming and total quality management: an interpretation for nursing practice.

The purpose of this article is to introduce nurses to W. Edwards Deming and the 14 points of his management philosophy, the basis of total quality management (TQM) (Deming, 1986). Each of Deming's points has been subject to in-depth analysis from business executives for the past 40 years. Quality improvement is at the very center of TQM. To adopt TQM will require a major thought transformation for many nursing leaders, but the benefits that nurses and the profession as a whole can reap from this revolutionary style of management make the effort to change worthwhile. If you are not satisfied with the status quo and are looking for a better way to conduct business, the information in this article will begin to define quality improvement and will help you strive for the highest possible level of service to your ultimate customer--the patient.

Japan↗

Total quality management strategies in mental health systems.

This paper introduces the concept of total quality management (TQM) to top managers of mental health systems. While TQM is a philosophy of management at the cutting edge of U.S. business, it has only recently entered the vocabulary of health care managers. To our knowledge, TQM has yet to be systematically applied to the state mental health service delivery system. After introducing some key concepts and techniques, we develop two extensive examples of how TQM can be integrated into the already existing management structure of the psychiatric hospital.

Hospital Units↗

Total quality management (TQM) in a hospital library: identifying service benchmarks.

Hospitals are turning to total quality management (TQM) to lower costs of providing care. A hospital library in a TQM environment needs to embrace corporate goals while maintaining its accountability as a contributor to quality patient care. Alliant Health System (AHS) Library at Norton Hospital and Kosair Children's Hospital in Louisville, Kentucky, conducted a study to establish TQM benchmarks and to examine the significance of its role in clinical care. Using a methodology designed to allow both library user and nonuser to respond, 2,091 surveys were distributed to physicians and nursing and allied health personnel. Areas surveyed included frequency of library use, impact of information received on clinical judgments, cognitive value of the information, and satisfaction with library products and services. Results confirm that the library has a substantial clinical role. Eighty-eight percent of reporting physicians agreed that information from the library contributed to higher quality care. Nursing and allied health were less convinced of the importance of the library's clinical role. Sixty-nine percent of nursing personnel and 58% of allied health personnel agreed that the library contributed to higher quality care. Nursing and allied health personnel also used the library less frequently than physicians. With these results as benchmarks, improving the clinical role of the library will take commitment to the TQM process and a willingness to change.

Attitude of Health Personnel↗