Managing Service Quality: An International Journal

TQM implementation for competitive advantage in healthcare delivery

Satya P. Chattopadhyay Steven J. Szydlowski

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To cite this document:
Satya P. Chattopadhyay Steven J. Szydlowski, (1999),"TQM implementation for competitive advantage in healthcare
delivery", Managing Service Quality: An International Journal, Vol. 9 Iss 2 pp. 96 - 101
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Introduction

Case studies
TQM implementation
for competitive
advantage in
healthcare delivery

The market for delivery of healthcare services

has been steadily moving into the private
sector as part of a global phenomenon. The
markets where socialized healthcare services
are predominant are also beginning to realize
the potential for increasing the productivity of
systems as well as the quality of services provided. In almost every corner of the globe, the
realization has dawned that healthcare organizations, like any other, have to make a conscious effort to competitively meet customer
requirements. Unless the customer is satisfied
that he/she has been conveniently provided
with quality care at a reasonable cost, and risk
of adverse outcomes have been minimized,
healthcare organizations run the risk of going
out of business sooner rather than later. The
demise of the individual organization can
come about from the lack of willing customers
in a competitive marketplace, and/or from
increased exposure to liability arising from
human, technological or procedural failures
that may occur in the course of delivery of
healthcare services.
Application of performance control and
quality assurance techniques in medicine have
begun to be documented (Farber, 1988).
However, there have been some persistent
problems that have plagued implementations.
Lopez-Fresno and Fernandez-Gonzales
(1998) identified misunderstanding
between management and medical professionals in healthcare delivery as a primary
impediment to successful implementation of
total quality management (TQM) systems.
Peters (1998) finds that non-medical management professionals are unable to prescribe
how medical professionals will act, even in the
name of quality. This makes implementing
TQM principles in an integrated system that
includes physicians, other healthcare professionals and business managers very difficult.
This paper presents case studies that describe
successful TQM implementations in a healthcare delivery setting. The link between competitiveness in an increasingly demanding
marketplace and the range of improvement
makes a case for systematic implementation of
TQM in healthcare services delivery.
The next section provides brief outlines of
five quality improvement projects undertaken
in healthcare delivery in northeastern Pennsylvania, USA. All of these projects were
under a semi-formal umbrella initiative to

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Satya P. Chattopadhyay and

Steven J. Szydlowski

The authors
Satya P. Chattopadhyay is an Associate Professor of
Marketing and Steven J. Szydlowski is a Master of
Health Administration candidate at the University of
Scranton, Scranton, Pennsylvania, USA.
Keywords
Community planning, Health care, TQM, USA
Abstract
An examination of total quality management implementation projects in the healthcare industry is reported.
Illustrations of the projects show how projects are predominantly managerial issues-oriented, rather than
emphasizing medical/clinical aspects. The issue of competition between healthcare and managerial perspectives is
raised. The five cases reported were undertaken as part of
a Community Excellence Initiative in north-eastern
Pennsylvania which aimed to make the region more
attractive to relocating business. Looks at implications of
the projects for the future.

Managing Service Quality

Volume 9 Number 2 1999 pp. 96101
MCB University Press 0960-4529

96

TQM implementation for competitive advantage in healthcare delivery

Managing Service Quality

Satya P. Chattopadhyay and Steven J. Szydlowski

Volume 9 Number 2 1999 96101

make the region more attractive to relocating

businesses by improving quality of services
and quality of life using a TQM approach.
The Community Excellence Initiative (CEI)
provided subsidized support quality improvement projects that were implemented in
manufacturing, service businesses and nonprofit sectors including education, healthcare
and community services.
The paper concludes with a discussion of
the results and implications of the projects for
the future.

during the day of the nursing staff was recorded to identify the reason why the call bell
response was unsatisfactory. The staff were
charting in medical records, giving showers,
or talking on the telephone. This often left
only one nurse on each nurses station at
certain times throughout the day. The variation was equally distributed throughout all
three shifts at the care center.
Process implementation
Nursing staff were tracked as to whether call
bells were answered in a timely manner,
maintaining facility operational standards
(which meets government regulations) to
improve quality. All breaks were scheduled to
maintain sufficient staff on each of the three
nurses stations. Staff were instructed to
answer the call bells when needed and delay
on the medical charting if necessary. Staff
assured residents needs were met before
giving them showers.

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Case I. Improving the health status of a

population
Organization
Mountain X Care Center: Skilled nursing and
rehabilitation care.
Description
This long-term care facility has 180 beds and
maintains a 97 percent occupancy rate.
Improving quality of care is a constant issue
facing administration and staff. Problems are
identified, and processes are adapted to produce quality outcomes.

Health outcomes/quality outcomes

Complaints by residents and family members
decreased dramatically following implementation. Follow-up was conducted in resident
counsel meetings and one-to-one visits. At the
resident counsel meeting, residents and family members praised administration and staff
for eliminating the problem area.

Monitoring
Call bell response time as perceived by
patients.
Problem identification
For approximately two months before this
survey was conducted, residents and family
members were complaining to administration
about the timeliness of responding to call bells
by the nursing staff. The policy for responding to call bells in the facility is five minutes
maximum. Not only was policy neglected, but
also quality of care suffered. Residents would
often wait for nurses to assist them with toilet,
ablutions, eating, etc. This was a major
concern for residents, family members,
administration, and staff.

Case II. Improving the health status of a

population
Organization
Health Care Center Y: Skilled nursing and
rehabilitation care
Description
This long-term care facility has 273 beds and
is currently maintaining a 71 percent occupancy rate. An Alzheimers unit was opened
on April 1, 1998, which is reflected in the
occupancy rate at this time. Improving quality
of care is a constant concern for administration and staff. Problems are identified, and
processes are adapted to produce quality
outcomes.

Survey results
Administration conducted a response survey
by ringing selected resident call bells and
recording the exact time it took for nursing
staff to respond. The total number of team
monitoring checks conducted was 44. Of the
44 test rooms, eight of the nursing responses
were delinquent. This is a high rate for skilled
nursing care. The average response time for
negative responses was 11 minutes with a
median of 9.5 minutes. The exact shift time

Monitoring
Management of caloric intake of elderly
patients to avoid medical complications.
Problem identification
The nutritional needs of certain residents
were not met. Some residents were receiving
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TQM implementation for competitive advantage in healthcare delivery

Managing Service Quality

Satya P. Chattopadhyay and Steven J. Szydlowski

Volume 9 Number 2 1999 96101

too much calorie intake, while others were not

receiving enough. This is a critical issue for
health providers dealing with the elderly
population. Lack of calories can lead to
skin/tissue breakdown. Since many residents
in skilled nursing facilities spend much time
lying down or sitting, tissue breakdown results
in pressure sores. These open sores can cause
serious infection and severe discomfort. Too
many calories for certain residents can lead to
unacceptable levels of fat and obesity. This
decreases the residents functional capabilities
and increases his/her dependency. Respiratory
problems and circulatory problems are soon
to follow.

Description
This agency is funded by the federal government. The area has a large population of aging
veterans whose medical needs are met in a
large part through this facility.
Monitoring
Identifying and improving the patient medical
record handling by reducing the number of
errors in documentation of patient treatment
and service received.
Problem identification
Physicians as well as patients have complained
and expressed dissatisfaction with current
medical records system. Cases have been
reported where delays and errors in treatment
have occurred due to incomplete and/or
inaccurate documentation of patient medical
record. Such events have the potential of
putting patient safety in jeopardy.

Findings
Quality assurance personnel, members of the
nursing staff, and the facility dietitian
reviewed 20 resident medical charts to find
reasons for this deficiency. After reviewing the
medical charts, the participants discovered
that communication was the sole reason for
this problem. Nurses were documenting the
changes in residents conditions appropriately; however, the dietitian often did not review
the documentation until two or three days
after at the weekly interdisciplinary meeting.
For those days the dietary department
was sending the same food tray before the
condition change took place.

Findings
A cross-functional team of physicians, clinical
staff and administrative personnel was put
together to study the existing system of producing and maintaining medical records. The
group systematically implemented TQM
principles and tools to study the situation and
identified problem areas in the existing inputs
and processes. A control chart was used to
study the operating characteristics of the
system under stable conditions, providing
evidence of an unacceptable level of inaccuracies. The study of the inaccuracies revealed
that a high percentage of them were caused
when the service provider did not update the
patient record, even as they recorded the test
reports at the next scheduled appointment
after the tests were requested.

Process implementation
Information flow sheets were designed. On
the change in a residents condition, the
attending nurse would fill out the sheet (as
well as document in the medical record), drop
it in an interdepartmental communication
box, and the dietitian would pick them up.
Food trays are served with the appropriate
calorie intake for each resident.

Process implementation
The project improvement team, in the short
term, decided to dedicate a printer in the file
room to automatically print computer reports
for inclusion in patient records as they were
received from the laboratories. In the long
term, a search was initiated to locate a high
performance comprehensive software package
that would automate the receipt of test results
and subsequent updating of patient records,
producing hard copy reports on a real time or
batch mode at appropriate locations.

Health outcomes/quality outcomes

The amount of pressure sores decreased from
13 (September 1997) to ten (November
1997). The information flow sheets also
enabled nursing staff to notify the dietary
department of likes/dislikes of certain
residents on a continual basis.

Case III. Improve availability of patient

medical records
Organization
A veterans administration medical center
providing care to veterans of the armed forces
of the USA.

Health outcomes/quality outcomes

The average proportion of deficient patient
records dropped from 49 percent to 27 per98

TQM implementation for competitive advantage in healthcare delivery

Managing Service Quality

Satya P. Chattopadhyay and Steven J. Szydlowski

Volume 9 Number 2 1999 96101

cent and stabilized over a 20-week period

following the implementation of the improvement ideas. Patient and physician satisfaction
with accuracy and completeness of patient
records improved by approximately 8 percent
in a follow-up survey.

developed and incorporated in structured

room inspection form (RIF) and items were
assigned priority codes based on criteria
agreed upon by the team. The process was
identified and represented on flow charts and
a control chart was created showing time
required for completion of work orders over a
ten-week period. The team used tools such as
Pareto diagram, cause and effect diagram,
relations diagram, nominal group technique
force field analysis to identify communication
and co-ordination between personnel as the
primary cause of delays in refurbishing patient
rooms.

Case IV. Improving physical plant

condition at multidisciplinary healthcare
facility

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Organization
A multidisciplinary healthcare facility providing rehabilitation care to outpatients and
residents recovering from trauma, surgery and
other conditions.

Process implementation
The team, with support from the vice president operations introduced mandatory meetings of RPMS personnel on a bi-weekly basis
and preparation of advance assessment of
refurbishing needs of the patient room inventory on a regular cycle.

Description
The plant-engineering department of this
major rehabilitation care provider in northeastern USA describes its mission as: To
provide the patients, residents, clients, and
staff with a quality maintained facility at a
reasonable cost.

Health outcomes and quality

outcomes
The implementation of the improvement plan
resulted in a 50 percent reduction in completion times for patient room maintenance as
recorded over a six-week period that followed.
Complaints from patients and their
relatives/friends were down 15 percent from
the preceding period.

Monitoring
To improve the Room Preventive Maintenance System (RPMS), as measured by
man-hours to refurbish a room and the
number of defects after completion.
Problem identification
The physical plant upkeep at this facility has
been of a high standard in general, but time
constraints (fast turnaround of patient rooms)
have resulted in pushing back ongoing maintenance until a crisis level has been reached.
Assembling the required material and labor
and completing a thorough evaluation of the
rooms with subsequent restoration to acceptable standards has not happened consistently.
This has resulted in significant complaints
voiced by patients themselves and/or their
relatives and visitors.

Case V. Improving the health status of a

population
Organization
Area Agency on Aging: Providing service to
the elderly
Description
This government agency, a branch of the
Department of Aging, is mainly funded
through Pennsylvania State Lottery dollars. It
sub-contracts with many organizations to
provide services to the elderly. Improving
quality of care and service to the elderly is
continuous. Needs of the elderly community
are identified, and processes and programs
are developed to produce health outcomes.

Findings
A cross-functional team consisting of nursing
staff, mechanics, utility workers and the
director of engineering worked with a process
consultant to study and address the problem.
They defined the elements of the RPMS in
terms of process, material, equipment,
people, environment and information aids. A
comprehensive checklist of items was

Monitoring
Assessing elderly needs: Geriatrician services,
(May, 1998).
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TQM implementation for competitive advantage in healthcare delivery

Managing Service Quality

Satya P. Chattopadhyay and Steven J. Szydlowski

Volume 9 Number 2 1999 96101

Problem identification
Scranton, PA, has the second-largest elderly
population in the country. The availability of a
specialized geriatrician is non-existent. There
are four board-certified physicians in geriatrics in this area; however, none of them
practice in this field. The health needs of the
elderly population are not being met at the
present time.

clinical or treatment areas. This pattern has

been variously described as technical/
functional (Gronroos, 1984) or service
core/service surround (Peters, 1998). This
split is manifest across disciplines involving
professional services (education, business
services and law are good examples). Handy
(1985) makes the case that professionals
ultimately work for their professions, and
organizations they are affiliated with are
somewhat peripheral in terms of allegiance
owed. Peters (1998) suggests that the recognition of this differential is necessary before
quality improvement efforts in professional
services can take place across the spectrum.
Communication and negotiation on a regular
basis between the managerial and medical/
clinical staff is of course essential. The basis of
the negotiation can be outcomes that are
customer focused.
Future research in the area of TQM implementation in healthcare must give careful
consideration to developing a prescriptive
structure for such negotiations as described
above. It is most likely that the patient or
service client in healthcare delivery will eventually hold the key to the norms that will serve
as the basis for negotiation between the managerial and health professionals. Studies
consistently show that customers in healthcare perceive medical/clinical expertise as
disjunctive criteria in their decision making.
Put another way, absent clinical/medical
competency, the choice option falls out of the
evoked set being evaluated. Only when it is
perceived to be present is the option a viable
candidate. At this stage, patient-customers
develop a measure of utility for the service
surrounds beyond the core and choose the
option that appears to maximize value.
Shared understanding of the patients/clients,
as the focal point of the entire system is the
starting point of the norm development
process. While the managerial professionals
will lead in use of sophisticated tools that
measure utility in order to configure the
service surround and maximize customer
value, healthcare professionals will be indispensable as they develop the interface that will
allow packages and delivery systems that
maintain the integrity of the healthcare
core. These activities can only occur when
there is meaningful ongoing interaction and
exchange of thoughts and ideas among the
two groups.

Findings
Epidemiological statistics prove that the
unavailability of health care services to a
population result in an unhealthy community. This leads to more serious health conditions which eventually increase health care
expenditures due to more emergency care
entries.

Process implementation
Members of the Area Agency on Aging wrote
for, and received a grant to hire a full-time,
salaried geriatrician to serve the elderly population. Once established, the geriatrician will
provide services only to individuals 65 years
of age or older.

Health outcomes/quality outcome

It is expected for the health status of the
elderly population to improve dramatically in
the Scranton/Lackawanna County area.
Individual and community needs will be met
as this initiative comes to fruition.

Discussion of findings
The positive impact of engaging in total
quality management driven improvement of
quality in healthcare service delivery is
undeniable, as the above illustrations demonstrate. The through link to competitiveness
and wealth creation can be shown through the
Deming chain (Deming, 1986). The philosophy behind TQM is of a journey in continuous improvement rather than the achievement
of a terminal goal.
There are however concerns that have
been voiced as TQM implementation gains
ground in the healthcare industry. The overwhelming majority of improvement projects
documented are clearly being implemented in
the managerial/business aspects of the
industry and not in the quality of diagnostics,

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TQM implementation for competitive advantage in healthcare delivery

Managing Service Quality

Satya P. Chattopadhyay and Steven J. Szydlowski

Volume 9 Number 2 1999 96101

References
Deming, W.E. (1986), Out of The Crisis, MIT Center for
Advanced Engineering Study, Cambridge, MA.
Farber, S.J. (1988), Perspectives in quality assurance and
technology assessment, Report of a Forum of the
Council on Healthcare Technology, Institute of
Medicine, National Academy Press.

Lopez-Fresno, P. and Fernandez-Gonzales, F. (1998),

Cellular implementation of quality systems in
medical organizations, Proceedings of 3rd ICIT
Conference, Hong Kong, pp. 337-40.
Peters, J. (1998), Quality assuring professional practices
a case example from a cancer treatment center,
Proceedings of 3rd ICIT Conference, Hong Kong,
pp. 341-5.

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Gronroos, C. (1984), A service quality model and its

marketing implications, European Journal of
Marketing, Vol. 18 No. 4.

Handy, C. (1985), Understanding Organizations (3rd ed.),

Penguin Books, London.

101

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