The Role of Total Quality Management in the National Health Service - Essay Example

The Role of Total Quality Management in the National Health Service Introduction In the last couple of decades, there has been an increasing interest in the application of quality management into healthcare organisations around the globe (Carman et al, 1996:48; Zairi and Jarrar, 2001:882). It appears that the healthcare system, in general, have largely embraced total quality management. This is, perhaps, a fall out of the assumption that this concept will ensure an improvement in both the quality and efficiency with which health services are delivered (Carman et al, 1996; Watson et al, 1992). Thus, many health organisations have realised that if they would remain functional and in tune with the present trend, they must be in the fore front of the new drive for quality (Zairi and Jarrar, 2001:882). In the UK, the National Health Service (NHS) has not been left out of this new drive for quality. The drive for total quality management began early in the 1980s as a fall out of the Griffiths Report (Nwabueze, 2001: 658). Since then, and over the following years, ‘quality’ has become a buzz word in the NHS. Much time, energy and effort has been put into the pursuit of quality (Dalley, 1992). Furthermore, the zeal for quality improvement in the UK health services was further heightened by the explicit endorsement of the Department of Health that total quality management (TQM) was "the desirable way forward to improve the provision of healthcare" (Nwabueze, 2001: 657). According to this author, the implementation of total quality management in the NHS was initiated through the setting up of twenty three trusts as demonstration sites and the provision of adequate funding for this purpose. This article intends to look at this developing importance of total quality management in the healthcare sector. And using the NHS as a guide, this article will review the critical elements of total quality management; the different factors that come to play in promoting these elements and how these can be better put to use to improve the overall quality of service delivery in the NHS. The next section of the essay will attempt a detailed explanation of the term total quality management, to establish a background understanding of the topic at hand. This will be followed by a look at the several elements of TQM, the factors driving these elements and how they inter-play to enhance service delivery and improve competitive advantage. How total quality management has affected the NHS will be discussed in the last section of the assay and in the concluding part recommendations will be offered on how healthcare delivery could be better improved through total quality management. Total Quality Management The term total quality management has been defined in different lights, by different authors, however, considering the vast amount of literatures available on this topic, it is surprising that very few authors have provided meaningful definition of TQM (Nwabueze, 2001). For example, Carman et al (1996), simply defined TQM as an ongoing effort to provide services that meet or exceed customer satisfaction through a systematic process for creating participation and implementation of quality improvements (199:49). Nwabueze and Kanji, on the other hand, believe that TQM represents the unending search for "continuous quality improvements in the product or services offered to both internal and external customers" (1997:265). McAdam and Henderson (2004), however, argue that total quality management has gone pass these narrow and often mechanistic definitions assigned to it; they argue that TQM has come to encompass more subjective and broader organisational philosophy, that it can better be explained with respects to its constituent theoretical constructs, rather than attempting a simplistic definition. According to these authors, TQM could be better defined as encompassing the following constructs: TQM is strategically linked to organisational goals Customer satisfaction and understanding is vital within the organisation Employee participation and understanding at all levels is required within the organisation There is need for management commitment and consistency of purpose within the organisation The organisation is perceived as a series of processes, which incorporate customer-supplier relations (2004:52). Putting all these constructs into perspective, the authors concluded that total quality management is better defined as a "continuum of theories touching on the soft and hard aspects of organisations" (Dale et al (2001) quoted in McAdam and Henderson, 2004). This argument is complemented by Nwabueze (2001), who observe that TQM has three complementary views: the first is that it is an organisation wide process involving every member of an organisation, from post room to boardroom; the second view is that it involves establishing quality goals for each and every element in the process of product or service delivery, so as to meet customer needs and expectations first time and on subsequent occasions; the third is that it involves, not just the management commitment to quality goals, but their active involvement in the pursuit of the goals. Critical Elements and Drivers of TQM Irrespective of ones view on TQM, what is apparently undisputable is that total quality management has played, and is still playing crucial roles in helping companies become more competitive and customer friendly (Motwani, 2001). In this regards, proponents of TQM argue that there is a universal set of practices that ensures success with TQM if implemented, and failure, if not. These practices contribute to the success or otherwise of TQM efforts, they are therefore identified as critical elements of total quality management (Youssef and Zairi, 1995). It is important to assert that the elements of total quality management have been numerously developed through Crosbys 14 steps, Deming’s 14 prescriptive points and Juran trilogy. Each of these quality authors has long identified set of key variables that each claim is vital for the success of TQM efforts (Motwani, 2001). Motwani (2001) and Youssef and Zairi (1995) maintain that the philosophies of Deming, Juran and Crosby provides the fundamental elements on which total quality is based. Through a review of several empirical studies on TQM, Motwani (2001) identified seven critical elements of total quality management, these included: i). top management commitment; ii). Quality measurement and benchmarking; iii). Process management; iv). Product design; v). Employee training and empowerment; vi). Supplier quality and management and vii). Customer involvement and satisfaction (2001:28). However, Nwabueze (2001), added fostering team work and improved communication and information sharing as the eight and ninth elements of TQM. Elaborating on these elements, Youssef and Zairi (1995) explained that for TQM to be successfully implemented in any organisation, top management commitment must be demonstrated through active involvement, setting of clear goals and vision for the organisation, and integrating TQM into the strategic quality planning process. They also maintain that TQM is a long term process, and as such can only succeed if there is a concerted effort towards changing methods, ways of working, ideas, and technologies. In a sense, a fundamentally new culture would is required (Youssef and Zairi, 1995). This is in line with Jabnoun (2001) contention that cultural change is a necessary pre-requisite for quality and excellence (Jabnoun, 2001). While the aforementioned elements of TQM are critical to the success of TQM implementation, they are also subjected to the influence of some factors regarded as the drivers of total quality management. McAdam and Henderson (2004) broadly divided these factors into two categories; internal and external factors. They explained that internal drivers refer to issues within the TQM movement while external drivers refer to issues within the environment in which TQM is placed. According to McAdam and Henderson (2004), the internal drivers of TQM can be seen as the paradigm shift in culture, management and processes that ensures the success of TQM in any organisation. They identified the development of human resources and empowerment concepts; the improvement in productivity management and supply chain management; the award process; the institution of business process and business process re-engineering; cultural change and change management; new approaches to strategic management and development of innovation approaches as internal drivers for the present and future success of total quality management (McAdam and Henderson 2004:55). On the other hand, technology, market and environment were identified as drivers that influences total quality management from the outside. TQM in the NHS In the last two decades, the NHS has witnessed a plethora of continuous and substantial changes which has impacted greatly on its structure, organisation and management. A lot of effort has been put into, not just clinical outcomes and effectiveness, but also managerial effectiveness (Jones and Jenkins, 2006; Zairi and Jarrar, 2001). As a result of efforts geared towards TQM, in todays NHS, performance matters; and providing high quality service is recognised as an important goal of the NHS. Though, in a complex organisation which is steeped in tradition and bureaucracy, like the NHS, the implementation of TQM cannot be expected to be a straightforward success (Watson et al, 1992; Zairi and Jarrar, 2001). Jones and Jenkins (2006), Joss (1994) and Nwabueze (2001) reports that the implementation of total quality management became a pivotal concern across the NHS in the mid 1980s following the Griffiths report of 1983 that looked into the managerial inefficiency of the NHS. According to Nwabueze (2001), the Griffith report was critical of the NHS on tow major counts: i. The failure of the NHS management adequately to take responsibility for continuous assessment of performance against such measures as level of service, quality, budgeting control, productivity, motivation and rewarding staff. ii. The lack of a clearly defined general management functions throughout the NHS. General Management in the report alluded to the responsibility drawn together in one person at different levels of the organization for planning, implementing and control of performance (Nwabueze, 2001:658). Moreover, `working for patients’ further drew the attention of the NHS management to the need for a more business-like approach and the need to place more emphasis on improving the quality of care provided to patients. The implementation process of TQM in the NHS began early in the 1990s, when funding was made available for the use of twenty-three hospitals as demonstration sites for the implementation of TQM (Nwabueze, 2001). Apparently, the NHS has embarked on implementing TQM over the last two decades, assessing how the implementation of total quality management has influenced or affected management efficiency and quality of services provided to patients, Dalley (1992) maintain that the results has been a blend of success and failure. Dalley (1992), highlighting the influence of TQM implementation on the NHS explain that the supply chain management or purchaser/provider split has radically changed the internal structure of district health authorities (1992:42), with purchasers specifying quality standards in contract and providers managing the production of that quality. Also, in the NHS, managerial power has been transferred from district level to units (i.e. directly managed units or trusts) and the lead on quality management no longer resides with the district general manager. Moreover, another interesting influence of TQM on the NHS is the great variety of quality activities going on in different areas of the service. As noted by Dalley, several professional and occupation groups- from district general managers to clinic clerks, from consultant surgeons to supplies officers, from health visitors to porters, from hospital nurses to medical electronics technicians, and from hospital chaplains to the cleaners are all involved in quality activities. This multiplicity is reflected in the sorts of activities in which they are all engaged. Generally speaking, though, these activities divided into those which were general management-led, to do with ‘cultural change’ and customer relations; those which were about clinical standards; and those which were to do with technical improvements. Some had been promoted at the very highest levels; others took place at ground level stimulated by the enthusiasm of particular groups of staff (Dalley, 1992). However, TQM implementation in the NHS suffers several setbacks, most usually as a result of the peculiarity of the health service. For example, effective communication and information sharing regarded as one of the critical element of total quality management is flawed in the NHS. According to Nwabueze (2001), this is because patients move horizontally across hospital functions, whereas communication within hospital is vertical. In this regard, this author maintains that for TQM to work best in the NHS there must first be an agreed meaning of quality. Unfortunately, this is not the case (Nwabueze, 2001:662). Another problem with implementing TQM in healthcare services is whether customer (patients/clients) should be provided what they want or with what they need. For instance, if a patient prefers ‘home stay’ during a course of treatment, but the medical professional recommends that the patient be admitted into a ward for effective monitoring; given the emphasis on customer satisfaction in TQM, the hospital may have to decide between what is medically right for the customer and what the consumer actually wants. Most hospitals are more likely to go for the medical option, irrespective of the customers choice (Nwabueze, 2001). Apparently, the peculiarity of health services requires that the NHS adopt a specialised approach to the implementation of TQM. This approach should be built on the following principles: clear purpose and shared values, led from the top, patient and client focused, investment in staff, continuous, fact-driven action, organization-wide, and built in, not inspected out (Brooks, 1992 quoted in Nwabueze, 2001). Also, for TQM to work better in the NHS, measurement of quality is an essential tool. According to Haigh and Morris (1991), what cannot be measured, cannot be managed. Thus, in the NHS, quality standards will have to be identified throughout directorates and units and the associated standards need be evaluated and monitored continuously. In sum, to make TQM work more effectively, the NHS must develop a strategy that will emphasise quality as an integral part of every individual’s task, encourage the commitment and consistency of all involved, from staffs down in the hierarchy to district managers, and finally an organisational structure that focuses on quality clinical care and customer satisfaction must be established (Dalley, 1992; Joss, 1994; Nwabueze, 2001; Jones and Jenkins, 2006). Finally, for any effort towards effectively implementing TQM in the NHS to be effective, Dally (1992) identifies three main issues. First, this author believes that building on the present staff commitment, efforts towards overcoming in-built tendencies towards staff scepticism has to be a major strategy. He argues that systems of communication within the service must be improved and staff must be made to be confident that their voices are being heard and listened to. Secondly, leadership should be improved. Leaders recognised as agents of change or product champions should be identified and encouraged to motivate others to follow in the line of cultural change towards effective and quality management. And lastly, considering the difficulty in imposing managerial control on professional performance, peer review processes should be facilitated and encouraged to ensure that quality of professional activity is maintained. Conclusion Total Quality Management is an important tool for any organisation that intends to remain functional and competitive in the ever-changing business world of the twenty first century. It is an attempt to better manage the resources and business process of an organisation to be able to meet and exceed customer satisfaction. The customer is the rallying point of total management. However, the peculiarity of the national Health Services places it in a difficult position with respect to total quality management implementation. 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