TQM: Towards better productivity

TQM: Towards better productivity

TQM is a success mantra for operational industries, but healthcare needs it the most. Sushmi Dey explores the dimensions of this management strategy

At the George Washington University Medical Center, in Washington, DC, cancer patients used to wait 11 hours or more for chemotherapy treatments. Today, the average wait is less than two hours.

At Overlake Hospital Medical Center, near Seattle, a new fast-track system for handling emergency room cases gets people with simple injuries in and out the door in half an hour.

These are a few instances of implementation of Total Quality Management (TQM) which has resulted in improved time management and greater patient satisfaction index.

“In order to control the cost, fundamental changes in the
healthcare sector are taking place”

– Dr CP Kamle,

Dr Kamle’s Prescription, Boston

The International Organisation for Standards (ISO) defines TQM as, “…a management approach for an organisation, centered on quality, based on the participation of all its members and aiming at long-term success through customer satisfaction, and benefits to all members of the organisation and to society.” TQM acts an umbrella under which everyone in the organisation can strive for customer satisfaction, reduce costs and wastage and increase the efficiency of services.

“The main focus of TQM is to analyse,” say Dr CP Kamle, Chief-de-Consortium, Dr Kamle’s Prescription, Boston (USA). TQM is a management-oriented strategy which aims at embedding awareness of quality in all organisational processes. TQM, which originally hails from the Japanese shoe industry, saw the 1980’s bring it to the healthcare domain. Says Vikram Anand, General Manager, Operations, Hosmac India Private Limited, “When TQM initially came up in hospitals, quality circles or groups were formed who suggested measures of quality control. It is these quality circles which gradually gave way to TQM in healthcare.”

Importance of TQM in healthcare

“QM implementation brings in process re-engineering, increased staff competence”

– Dr Umesh Gupta,

Vascular Surgeon and Head of Quality and Accreditation Indraprastha Apollo Hospital

As India’s healthcare establishment undergoes a paradigm shift from being a welfare activity to a revenue-driven model, it is focusing more on greater efficiency in its operations. According to experts, managing the quality of healthcare services is just as critical as managing the quality of manufacturing operations. In fact, healthcare being a service industry, quality management becomes tougher at times. Says Anand, “TQM should be made a habit among employees – only then one can expect to render quality services.” Therefore, no longer is it enough to look after patients that walk in because now most of the time, a patient goes to the hospital not just with the idea of treatment but to get the best of treatment.

Consequently, hospitals of today need to keep a tab on complete supply chain management. “Equipment, manpower and infrastructure – these are the three most important areas which determines quality standards for a hospital and standards and guidelines ought to be formulated in these areas,” asserts Anand. Probably, this is one reason that hospitals, in the recent past, have converted into swanky five star hotels. Also, it is important to note that corporate hospitals narrate the success stories of healthcare business. For most corporate hospitals, superior quality is at the core of their business strategy. The objective is to attain the most perfect quality possible in each of the department.

A huge portion of the increased annual healthcare expenditure is attributed to waste and inefficiency in hospitals. There are costs associated with product and service quality. While some costs are associated with prevention of poor quality, there are others that occur after poor quality occurs. “In India, costs in the healthcare sector have increased significantly throughout the past 25 years, and this trend is expected to continue. More than 50 per cent of these costs arise in hospitals. In order to control the cost, fundamental changes in the healthcare sector are taking place,” says Dr Kamle.

The healthcare industry can benefit from TQM both in cost and care. The fundamental changes that are taking place in Indian healthcare industry are therefore based on the implementation of TQM. “TQM implementation brings in process re-engineering, increased staff competence leading to efficient work methods hence reduced wastage and actual expenditure,” opines Dr Umesh Gupta, Vascular Surgeon and Head of Quality and Accreditation, Indraprastha Apollo Hospital.

Non-compliance of TQM gives place to “waste” which is astronomical. “At least 20 percent of the lab tests are unnecessary. Every infection is waste. Every complication after open-heart surgery is waste-and triples the bill,” informs Dr Kamle.

There are several components that work to provide a quality management process that functions like a feedback loop.

Quality Laboratory Processes (QLP) refers to the policies, procedures, personnel standards, and physical resources that determine how work gets done in the laboratory. Laboratory method manuals describe the standard operating processes for producing test results.

Quality Control (QC) refers to procedures for monitoring the work processes, detecting problems, and making corrections prior to delivery of products or services. Statistical process control or statistical quality control is the major procedure for monitoring the analytical performance of laboratory methods.

Quality Assessment (QA) refers to the broader monitoring of other dimensions or characteristics of quality. Characteristics such as turnaround time, patient preparation, specimen acquisition are monitored through QA activities. Proficiency testing provides an external or outside measure of analytical

Quality Improvement (QI) is aimed at determining the causes or sources of problems identified by QC and QA. Some problems may require a team of people and a team problem-solving process and team problem-solving tools such as the flowchart, Pareto diagram, Ishikawa cause and effect diagram, force field analysis, etc.

Quality Planning (QP) is concerned with establishing and validating processes that meet customer needs. The selection and evaluation of new methods and instruments as well as selection and design of QC procedures are part of this component of TQM.

Quality Goals represent the requirements that must be achieved to satisfy the needs of customers. For analytical quality, the requirement is to provide test results that are correct within stated limits.


The prominence in product quality in business strategy for many firms has come from the painful knowledge that business can be lost to lower priced products, but they can win it back with superior product quality. “However, as Indian hospitals have not gained much experience in dealing with business issues, for many of them the implementation of TQM is a major barrier,” says Dr Kamle.

There are several elements that form the core of implementation of TQM.

Involvement and commit-ment of Management: The involvement of top management is important. “Motivation should trickle down from the top management to the grassroot level. Efficient leadership is an important ingredient in any organisation,” opines Anand. The management should stay involved in not just setting business strategy based on using product quality as a weapon to capture market share but also in rewarding employees for achieving excellence in product quality. “Employees are unlikely to behave in a responsible way if they see management behaving irresponsibly,” says Dr Kamle.

Participation of employees: Participation of employees in all activities is another important element of TQM since making TQM work rests with employees. To avoid poor quality in services or products it is important that employees, who are involved in the process of producing quality, are made to feel that they are responsible for customer satisfaction.

Training: Training is an essential element to implement TQM. Employees must be trained, organised, motivated, and empowered to produce services of quality. “Training should be visible in their daily duties. They should have ownership for their quality improvement program only then TQM shall succeed,” says Dr Gupta. A protocol-based training is essential for employees so as to minimise deviation from processes and reduce number of complaints.Customer

Involvement: Customer- wants drive the TQM system. It is therefore important to value customers’ opinion.
However, experts complain that India lacks a proper system of guideline. “TQM implementation in the healthcare industry requires government support and commitment. The big players need to develop quality standards for different segments of the healthcare industry keeping in mind the smaller players also,” suggests Dr Gupta. According to experts, the government should develop and implement standards of service delivery, like set by NABH. “The government should also carry out assessments of service quality so as to identify the gap against national/international standards and improve planning,” suggests Dr Gupta.

1. The first step is to define the problem.

2. The next step is to seek the root causes of the problem. There is a tendency to jump to the first cause that comes to mind. This is hazardous as it can focus on the wrong cause or simply correct a symptom. In many situations, the root cause can be found by brainstorming. More complex problems require more sophisticated techniques, such as cause/effect diagrams or system failure analysis.

3. Once the likely causes of the problem have been found, one should identify a variety of potential solutions and select the best to implement.

4. The final step in the problem solving sequence is to evaluate the effectiveness of the solution. This is done after it has been implemented to ensure that the solution really does work. It is also a learning experience for the organisation so that people can learn from the successes and pitfalls experienced by others.

Maintaining continuity

To develop benchmarking standards is one thing and to maintain the standards is another. While TQM helps an organisation to manage its resources and bring in customer satisfaction, it is even more important to manage the continuity of those quality services as well improve them. The standards set by TQM become the basis for long-term continuous improvement. TQM was felt by experts as a one time effort put in by an organisation, but quality standards should be improved upon and updated on a regular basis. That is when Continuous Quality Management (CQM) plays a pivotal role.

CQM is a calculated vision, which depends on people having good problem solving skills. According to Dr Kamle, it is through the continuous process of identifying problems, and solving and implementing solutions that the business is improved. Problem solving consists of identifying the root causes of a problem and implementing actions to correct the situation.

With inputs from Nayantara Som