Reconstructing Quality Management Implementation in Healthcare Organisations

Uche Nwabueze, Professor, Maritime Administration Texas A&M University

Quality management improvement programmes is being implemented in a vacuum, for example in a piecemeal fashion due to the fact that managerially and strategically many hospital systems lack the time required for detailed thinking, planning and execution, thus quality management programmes is seen as a political, reactive activity rather than an integrated approach to improving the quality of patient care and caring.

Evidence from a structured interview of twenty healthcare quality managers suggests a lack of managerial understanding, but more importantly, the belief in the holistic nature of quality management and improvement programmes in achieving improved standards of patient care. There seems to be continued confusion as to what constitutes the implementation variables that would ensure success in driving the operations, people and strategic alliances required in a quality culture. For example, many hospitals focus on the quality assurance requirements of standard setting and monitoring and then think that by so doing they are implementing quality management. However, what these hospitals are actually doing is installing methods to inspect, correct and elevate medical performance rather than embarking upon an organisation-wide strategic initiative to improve quality of care and caring for patients.

The paper presents a model for the time constrained manager; a model that offers an understanding of the essential requirements for the success of quality management be it Six sigma or Total Quality Management in healthcare organisations.


It is in pursuit of making quality management philosophy manifest, in making it operational and strategically useful in the modernisation of the delivery of care that practicing managers need a definitive model for guidance and for successful implementation. To date, there are remarkably few, if any, empirical attempts made to offer an holistic implementation model of quality management and improvement in healthcare organisations; a model that would help improve the structure, systems and processes of the delivery of quality patient care, but more importantly, make the provision of healthcare affordable for the consumer.

The paucity of such models has meant that managers informed only by the generalised and limited prescriptions of the work of the gurus of the quality management: Deming, Juran, Crosby, and a few business consultants like John Oakland have adopted their own individual approaches to the implementation of quality improvement. Whilst such personalised models have the merit of affording recognition to those unique characteristics which all organisations possess, and which provide each with its own particular culture, they have the demerit of failing to ensure continuity of implementation with successive quality managers adding their own preferred definitions and approaches to what should be a comprehensive, coherent and sustained drive for enhanced quality throughout the organisation. The obvious consequence is a loss of direction and momentum and ultimately, the lack of constancy of purpose and focus. In addition, the continued use of strategically challenged models based on subjective, and by definition, the idiosyncratic experiences of managers who have a poor understanding of the theoretical underpinnings or might one add, the tenets of operations redesign of work systems and employee engagement has invariably given rise to a fragmented internal work culture incapable of dealing with process and systems re-alignment with strategy and structure of the organisation.

Furthermore, claims are often made that if an organisation steadily improves quality, consumer satisfaction will increase and everything else will take care of itself. This assertion has given rise to the situation where organisations concentrate mainly on process improvement efforts that over treat symptoms and ignore root problems in inputs, throughput, and in the delivery of medical services (Eskildson, 1994). Despite the fact that the quality management literature emphasizes the need to improve patient valued outcomes, a large number of hospital systems focus instead on creating a quality management culture through organisation-wide training, self-managing teams, vision and value statements. The result is a state of confusion, long implementation time frames, frustration, resistance, and the abandonment of the program ultimately follows.

The findings of this paper are that the failure of quality in hospital systems is down to cultural, behavioural and strategic challenges because when change in how the organisation delivers care occurs, work relationships become strained and ambiguous. Furthermore, longstanding behavioural issues as it relates to poor employee attitudes and negative emotions impact job satisfaction, the ability of staff to engage with patients, and overall performance. Strategically, due to the lack of a clan culture and employee buy-in that is required to achieve commitment and engagement of minds, hearts and souls to the visionary aspiration of ‘patientfocused’ service, quality management is cornered sadly to the mysterious graveyard of panacea that never quite delivered the goods.

Quality Gaps in Hospital Systems

Parasuraman et al (1985) and Speller (1993) identified seven gaps in their service quality model and suggested that if these gaps exist in the quality management implementation programme of an organisation that organisation is failing in the delivery of quality services to its customers. It is in this way that the paper utilised a structured questionnaire based on the Parasuraman etal (1985) model to identify service gaps in 20 hospital systems in Texas, USA. Twenty quality managers were asked to rate their organisation on each of the seven gaps by circling a code of 3, 2, or 1 in which 3 stands for high ranking (“we are good at this; I’m confident of our skills here”); 2 for medium score (“we are spotty here;  we could use improvement or more experience’’); and 1 for low score (“we  have problems with this; this is new to our organisation).

What the analysis of the twenty returned questionnaires revealed was that medical services provided at the hospitals fell short of patient expectations and they were stumbling in the dark with regard to the successful implementation of quality management. This is not surprising given that the respondents noted that they need help with external communication with their patients and that internal communication within and between work teams, and between management and employees were a problem. Zemke and Schaaf (1989) note that “the success of an organisation depends on how you treat, relate to, engage, motivate and reward your contact employees who deal directly with customers” (Zemke and Schaaf, 1989).

It was also ascertained through face-to-face interviews with the twenty quality managers other contributing factors to the difficulties encountered during implementation. The factors include:

  1. Top management lacked understanding of patient’s expectation of service, which showed poor management perception (Gap 1)
  2. Systemic failure in translating knowledge of patients’ expectations into service quality specifications, service standards and patient informed guidelines (Gap 2)
  3. Structurally, the delivery of services failed to adhere to set quality guidelines (Gap 3)
  4. Process alignment –failure to map the cycle of patients throughput (Gap 4)
  5. Perception is the reality of most people and staff felt like pawns of faith (Gap 7)

Evidence from the questionnaires and the structured interviews with the twenty quality managers suggest that these organisations are structurally complex, in which can be found different managerial patterns. The main patterns include: management by formality; a reliance on procedures and rules; management by committees; settlement and decisions by negotiation; and turf battles for resource deployment and allocation. As a consequence, it can be argued that what is required to successfully implement quality management in healthcare organisations is a comprehensive, industry specific model to avoid the fate of previous management systems that promised revolution and true reform and failed. A process led strategy will have the advantage of enabling hospitals to focus on its main purpose: arranging care, delivering care, and managing care. However, the problem across many hospitals in the United States is that the delivery of medical care and nursing care processes are task-oriented, impersonal, out-dated, and unresponsive to the changing needs of today’s patient.

For example, one worker takes the patient’s registration information, another staff takes vital signs, and yet another staff moves the process forward. This represents the antithesis of efficiency and effectiveness of work performance. A process-led model will reorganise and reorient work activities so that when a staff member is arranging care for a patient, he or she follows the patient all the way through the provision of care, thus ensuring that there  is no loss of communication, no missed opportunities and that the entire system works much more efficiently to the patient’s advantage.

The essential elements of the model include:

Top management must demonstrate its commitment and leadership to the strategic, operational and cultural effort by becoming process, employee and patient champions. This would require the development of a vision for the organisation, identification of organisational values and beliefs, and the development of a social learning culture. The signals senior management sends with its daily behaviour, actions and decisions will change and ultimately improve the attitude and behaviour of staff members. The implementation of quality management in a healthcare environment is not nembutsu –repeating prayers to obtain salvation.

In Japan, examples of successful implementation of quality improvement are led by top management who acknowledge the importance of quality control and then implement it by leading from the front lines. Management must show, engage, inspire and lead the way. Management must be seen by all employees to reach and scream from the mountain top about the virtues of quality and its focus on delighting the customer. It is imperative to move from the ‘prescribed perspective of professional quality to the ‘felt perspective’ i.e., rendering services according to patients’ felt needs and expectations rather than to the professional’s ordainment. The key to effective patient care resides in: identifying the specific requirements, needs and expectations of patients’ and their families, continuous improvement, redesign and rightsizing of all organisational business and support processes; delighting the patient; and continuously managing and updating the patient/staff interface.

If quality management is introduced with a focus on process identification, process streamlining, process improvement, and process optimisation then it is reasonable to expect benefits to be delivered over a period of three years. Therefore, organisations should tackle the obstacles to process discipline through training, education, communication, participation and facilitation. These must be supported by a slow, planned, purposeful approach that engages top management and capitalises upon bottom-up involvement.

Based on what the author of the paper calls the ‘SMEP’, which means the Single Minute Exchange of Patients, a typical hospital must fast track patients through the system by reducing service lead times and also by employing the S:P ratio to better route patients to various medical cells. S –the total throughput time, the time it takes to arrange, deliver, and manage medical care. P –the clinically determined patient waiting time; the time between diagnosis and receiving treatment

  • If S>P=refer to medical cell
  • If S<P=refer to focused hospital
  • If S=P=use CA/PA


Overall, the paper would surmise that quality management implementation in healthcare requires: No waste of movement –trading fat for muscle

  • Modifying and simplifying work processes
  • Process refinements –use of appropriate medical technology
  • Quality improvement –the utilisation of the right people

However, the first reaction in a situation of disarray that is the fictional implementation of quality management in hospital systems is always to reach out for the short-term measure of ‘patching’ and ‘spot-welding’ here, there, and yonder. Achieving improved organisational performance is only possible when there is dramatic change in structure, organisation, and management; and succeeds when all employees fanatically participate.

--Issue 50--

Author Bio

Uche Nwabueze

Uche Nwabueze is a Professor of Maritime Administration at Texas A&M University, Galveston Campus, Texas, USA. Dr. Nwabueze’s research focuses on Healthcare process improvement strategies. Dr. Uche as he is fondly called by his students has served as faculty member across four continents.

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