Total Quality Management : the development, application and analysis of a Total Quality Management paradigm in healthcare
The research programme focuses on Total Quality Management adoption and application. TQM which is established in a number of businesses and industries has more recently been introduced into healthcare. TQM definition and eclectic paradigm has been developed and tested for establishing quality performance and distinguishing radical change and continuous improvement approach. A number of critical elements and variables concerning implementation and application are identified which pertain to organisations which through size and bureaucracy operate with diverse missions, a wide range of systems and are characterised by degrees of rigidity from an employee mix of multiple knowledge, understanding competences skills and hence commitment. Research was conducted in healthcare provider organisations, which involved eighty-three NHS hospitals/Trusts, wherein two pilot, twelve TQM demonstration and sixty-nine sites were involved. The main focus concerned a case study Trust, which although demonstrating keen interest in quality management had not reached the formative stages of developing TQM definition or paradigm. The research framework is based on a number of approaches in that methods selected for evaluation were appropriate both to the situation and the context of TQM strategies being examined. Intention was to identify successes and failures of the TQM processes applied, establish similarities and distinguishable differences and determine extent to which TOM objectives were achieved and the impact of the processes on specific groups. The investigation was undertaken using longitudinal analysis which involved in-depth interviews with top managers and clinicians and a mix of employees, customers, potential customers and purchasers in the form of managers, consultants, hospital doctors, nurses, support services personnel, patients, members of the public and GPs. TOM Awareness and Action Seminars and Workshops involving personnel from a variety of international healthcare organisations provided an additional source of data. Self-completion questionnaires were also used. Data analysis compares and contrasts varying TQM models, processes, activities and results from degree of emphasis placed on critical elements and variables. Stage predictions and resulting outcomes are presented and quality of care improvements suggested from analysis of customer perceptions of quality and value. The findings show significant variations in approach between the hospitals/Trusts in matters which concern organisation, management and culture issues, resulting in a high proportion viewing TOM process as evolution from quality assurance to radical change, hospital process re-engineering and patient focused care A minority only included such processes in their application of TQM. Key conclusions result from attempt at establishing some measure of success and failure from TQM implementation and application. Findings contribute to the extant literature specifically in that beyond top management and clinician commitment to high level strategic focus is a combination of facilitator-led culture change, motivation and shared values directing attention to exceeding that of merely doing enough for reducing poor quality and customer complaints. Patient involvement in TOM is more problematic than literature suggests from both the patients and professionals perspectives of patient empowerment. Bottom-up action focused TQM paradigm working simultaneously with top down support and commitment requires barrier breaking, culture transformation and the establishment of internal/external customer and supplier chains and seeking to establish opportunities for continuous improvement and radical change in advance of attempts at in-depth implementation and evaluation. It is not over-statement to conclude that the majority of managers and clinicians were unaware of the costs of getting things wrong. Despite TOM being acted upon as driving force for competition most had limited knowledge of how much non-quality cost them, suggesting that they had not earlier thought it necessary to measure the costs of none or low quality. Research results, irrespective of applications definition or paradigm, question the views that TQM is long-term process. Whether these may be concluded as desire to integrate TOM with other foci or vacuum sucking in panaceas was unclear. It was clear however that although quality in healthcare is sacred total quality management is not.