TOTAL QUALITY MANAGEMENT (TQM) and it's relevance in healthcare (A potential question under health care management topic) CONTENTS: 1. Definitions 2. Milestones of TQM 3. Rationale for quality in healthcare 4. Five attributes of quality 5. Dimensions of quality 6. Quality measurement 7. Quality management and it's principles 8. TQM view in areas of conflict 9. Deming's 14 points 10. PDCA/ Deming's cycle 11. Quality in health care organization 12. Implementation of quality improvement. 13. Quality assurance process 14. Clinical applications of TQM 15. Success story (chokpot PHC) Happy learning!!

1. TOTAL QUALITY MANAGEMENT
and its relevance in Healthcare
Dr. Immanuel Joshua. E
Junior Resident
Community Medicine
Banaras Hindu University
Email: immanuel2346@gmail.com

2. "TQM is a comprehensive strategy of organizational and attitude
change for enabling personnel to learn and use quality methods, in
order to reduce costs and meet the requirements of patients and
other customers"
"Maximization of patient’s satisfaction
considering all profits and losses to be faced in
a healthcare procedure"
"TQM/CQI – Continuous Quality Improvement – is
about two things: a management philosophy and a
management method"
(Donabedian, 1989).
D
E
F
I
N
I
T
I
O
N
S
(Ovretveit, 2000)

3. 1920s
1930s
1946
1950s
Today
TQM
MILESTONES
1968
Scientific management
principles
Shewhart develops
SQC methods
ASQ formed
TQM and Quality
concepts developed
Quality standards
and QMS
Quality Management
Systems

4. Everything the healthcare organization undertakes to
fulfill the needs of its customer, be it the patient,
the payer, the admitting doctor, the employer, or an
internal customer within the organization
Quality can refer to the technical
quality of care, to nontechnical aspects
of service delivery such as clients’
waiting time and staff’s attitudes, and to
programmatic elements such as policies,
infrastructure, access, and management.
“Quality is doing the
right things for the
right people at the
right time, and doing
them right first time
and every time.”
Indian Journal of Public
Health, Volume 57, Issue 3,
July-September, 2013

5. RATIONALE for Quality in health care
There are numerous reasons to improve quality in healthcare:
Enhances the accountability of health practitioners and managers
Resource efficiency
Identify and minimize medical errors
Maximize the use of effective care
Improves outcomes
Aligns care to what users/patients want in addition to what they need
Indian Journal of Public
Health, Volume 57, Issue 3,
July-September, 2013

6. Five broad attributes have been identified
for understanding quality:

7. Dimensions of
Technical performance
Choice
Relevance
Amenities
Interpersonal relations
Access
Efficiency
Effectiveness
Degree to which the tasks by
health workers and facilities
meet expectations of technical
quality
The degree to which desired
results (outcomes) of care are
achieved
The ratio of the outputs of
services to the associated costs
of producing those services
The degree to which healthcare
services are unrestricted by
geographic, economic, social,
organization, linguistic barriers
Trust, respect, confidentiality,
courtesy, responsiveness, empathy,
listening, and communication
between providers and clients
As appropriate and feasible,
treatment.
Physical appearance of the
facility, cleanliness, comfort,
privacy, and other aspects that
are important to clients
client choice of provider,
insurance plan
Indian Journal of Public Health, Volume 57, Issue 3, July-September, 2013

8. QUALITY
Measurement
Measurement of the quality is critical for improvement of processes and outcomes.
This area of concern has four standard measures for quality (measurable indicators)
Productivity Service quality
Clinical Care
Efficiency
Utilization indicators
o Bed occupancy
o C-Section rate
o Efficiency of processes
(such as turnaround time)
o Efficiency of human
resource
(surgery per surgeon)
o Average length of stay
o Death rates
o Patient satisfaction
o Waiting time
o LAMA rate.
http://qi.nhsrcindia.org/national-quality-assurance-standards

9. Quality management is that aspect of the
overall management function that determines
and implements the quality policy
 Strategic planning,
 Allocation of resources,
 Systematic activities for quality
(such as quality planning,
operations, and evaluations)
It includes:

10. Principles for
good Quality
Management
PATIENTS FOCUS
LEADERSHIP
INVOLVEMENT
OF PEOPLE
PROCESS
APPROACH
SYSTEM
APPROACH
CONTINUAL
IMPROVEMENT
Healthcare org. depends on the patients and must understand
patients’ needs, meet requirements and exceed their expectations
To establish unity of purpose & direction of the org.
To create the internal environment so people can
become fully involved in achieving the objectives
People at all levels are the essence of an
organization and their full involvement enables
their abilities to be used for the organization’s benefit
A desired result is achieved more efficiently when
activities and related resources are managed as a process
Continual improvement of the organization’s overall performance
Identifying, understanding, and managing interrelated processes
Indian Journal
of Public
Health, Volume
57, Issue 3,
July-September,
2013

11. 7
8
Fact based decision making
Effective communication
PRINCIPLES
(contd…)

12. Total quality management (TQM) incorporates the concepts of service
quality, process control, quality assurance, and quality improvement
It is the control of all transformation processes of an organization
to better satisfy customer needs in the most economical way

13. PROFESSIONAL VIEW TQM VIEW
Area of Conflict
RESPONSIBILITY
Individual Collective
LEADERSHIP
Individual Managerial
PLANNING
Rigid Flexible
FEEDBACK
Response to complaints Benchmarking
PERFORMANCE
APPRAISAL
Retrospective Continuous
AUTHORITY
Administrative Participative
Science Journal of Public Health
2016; 4(4): 271-278

14. D
E
M
I
N
G
'
S
P
O
I
N
T
S
Create purpose for improvement
1
Involve all workers in transformation 14
Drive out fear 8
Education and Self improvement
programs 13
Remove ratings or merit system 12
Break down barriers between staffs 9
No quotas or numerical goals 11
No unclear slogans 10
Leadership
7
Job Training
6
Continuous improvement
5
Work with one supplier to reduce cost
4
Don’t depend on inspection
to achieve quality
3
Adopt the new philosophy
2
14

15. PLAN
Identify the problem.
Discover where and
why it started.
Plan the improvements
Create a plan of action
DO
Involve everyone and
execute the plan
CHECK
Analyse to see if everything
went as planned and if the
expected result occurred
ACT
It worked?
Didn’t it work?
 Standardize the process
 Share the learning
Reflect on what can be changed
Restart the cycle
Problem solved
PDCA Cycle

16. QUALITY IN HCO
Benefits
To HCO
To Patients
To Healthcare Personnel
Institutional development
Patient Safety
Risk Management
Quality Control
CHECK
DO
ACT
PLAN
Process for quality
Self Assessment
Organizational gap analysis
Quality assurance
TOTAL QUALITY MANAGEMENT
Quality Recognition
International Accreditation
DEMING CYCLE

17. Steps In Implementation Of Quality Improvement
Creating a supportive environment
Focus on the user (of services)
Adaptive change in the organization
Motivation in the organization
Data collection & analysis
Supervision
Building teams: An overview
Problem solving cycle
1
3
5
7
2
8
6
4
Indian Journal of Public Health,
Volume 57, Issue 3, July-
September, 2013

18. Users
Assess
Analyze
Plan
Action
Improve
-ment
Reassess
Monitor
Implement
Find Gaps
Prioritize and
Suggest solution
Quality
Assurance
Process
Indian Journal of Public Health,
Volume 57, Issue 3, July-
September, 2013
Audits
SOP
Critical Incident Technique

19. State Health Mission
District Health Mission
District Quality Assurance Group
DQAG Teams
QA Nodal Officer
DHO/Civil Surgeon
District Quality Assurance
Coordinator
State QA Nodal Officer
Structure of Quality Assurance in Healthcare

20. A. Provider availability Staff is not trained, Vacancies,
Not performing,
Conduct training
Fill vacancies
State/regional director
B. Infrastructure Minor/major repairs, facility
dirty, deficient amenities for
client, nonfunctional OT, citizen
charter not displayed, signage
poor, vehicle not used for referral
Undertake repairs , provide
amenities for clients, put up
citizen charter, proper signage,
use vehicle for referral, and
make OT functional
Local and district
C. Essential protocol
and guidelines
Essential protocols and guidelines
not available, not used
Ensure protocol and
guidelines are available to
staff
District
D. Infection prevention
practices
Poor infection prevention
practices, hospital waste not
disposed as per guidelines
Train local staff and follow
Infection prevention and proper
disposal of hospital waste
Local level
CHECKLIST OBSERVATION ACTION SUGGESTED LEVEL FOR ACTION
Common observations during QA – Case Study
NRHM of the Ministry of Health and Family Welfare (MOHFW), Population Council, and UNFPA in 2007

21. E. Availability of
equipment and supply
Some equipments not available,
emergency drugs not available,
lab equipment and consumables
in shortage
Procure or indent Local
F. Family planning Contraceptive stock out, record
not proper, counseling not proper
Indent supplies, maintain
proper record and train staff in
counseling
Local and district
G. Maternal Health Screening and counseling of ANC
poor, incomplete records, newborn
baby corner not established,
newborn care protocol not adhered
Train/orient LHV/Staff in ANC
screening and counseling, keep
proper record and set up new
born corner and follow protocols
Local and district level
H. Immunization and
child health
Micro-plan not available, vaccine
not available, drop outs not
followed, record keeping poor,
waste management poor,
counseling poor and vaccine not
administered at proper age
Prepare micro-plan, indent
vaccine on time, use counterfoil
of card for follow-up, train staff
in counseling, improve record
keeping, waste management
Local level
CHECKLIST OBSERVATION ACTION SUGGESTED LEVEL FOR ACTION

22. TQM and Clinical Applications
TQM is not only for Administrative functions but also for Clinical Care
Department of clinical Epidemiology at Latter Day Saint's Hospital, Salt Lake City used TQM to
reduce the rate of post-operative wound infection from 1.8% to 0.4%
(Koska MT. Using CQI methods to lower post surgical wound infection. Hospital ;66:62-4)
Northern New England Multi hospital project used quality improvement techniques to reduce
mortality among patients undergoing cardio-vascular surgery by 24% in 3 years
(O'Connor GT. Plunne SK. Olmsteal EM et al. A regional intervention to improve the hospital mortality
associated with coronary bypass graft surgery JAMA;275:841-6)
Another study has shown a 30% decrease in frequency of patient morbidity due to
antibiotics by process-improved computerised guidelines
(Pestatnik, SL. Classen DC. Evans S. Burke JP. Implementing. antibiotic practice guidelines through
computer assisted decision support : clinical and financial outcomes. Ann Intem Med;124:884-90)

23. Success in Adversity: Chokpot CHC
 Chokpot CHC is situated in Chokpot village in South Garo Hills of Meghalaya.
 South Garo Hills is remotest corner of the country & most backward district.
 Chokpot CHC is the major health provider for 158 villages under Chokpot Block.
 It caters to a population of 26435 and has 5 subcentres.
http://qi.nhsrcindia.org/national-quality-assurance-standards

24. In 2016, Chokpot CHC has started working for Kayakalp, baseline score of facility was quite low
due to poor infrastructure, insufficient funds & lack of support from certain section of society.
To sustain cleanliness in Hospital staff started mass cleaning of the
facility on Holidays which includes cleaning of toilets, open area etc.
MO I/C of facility motivated staff for Kayakalp activities & jointly they aimed for commendation award.
Facility team thought to involve community to help them for Kayakalp. So on
Sunday/ Holiday they start inviting people from adjacent villages, Schools, Church

25. 1 Dust Bin for General Waste Staff along with community weaved local type baskets & paint them in green.
2 IEC material for Hygiene Staff has drawn IEC material in posters
3 Infection Control Practices Training is given by Mo I/C & started monitoring on daily basis
4 Liquid waste Management Locally design liquid waste management system as per Karnataka Model
5 Work place Management
All the areas like Pharmacy counters, stores & kitchen etc. are re-arranged &
sustained by monitoring
6
Boundary Wall of the
Hospital
Hospital Boundary was the biggest challenge for CHC, few sections of society
did not want to construct boundary wall of the Hospital. Hospital & RKS
members convinced them about importance of boundary wall & construct it.
Later Hospital got notice from the court.
7 Infrastructure Maintenance
Infrastructure maintenance was also a challenge for facility as Handymen
involved in repair work usually took holiday every alternate day. So MO I/C
before OPD hrs go to their home to ensure they will come for repair work.
CHALLENGES
SN HOW THEY OVERCOME

26. But TQM is not an
Aladin's lamp. It
has to be
understood,
incorporated and
nurtured and then
only the fruit
tasted
It will not give any
quick fix solutions
and will indeed be
time consuming
and rigorous

27. THANK YOU…!!!