The increase in public, professional and political interest in TQM is especially obvious in the United States of America. Reasons suggested for this interest in the USA (Graham, 1990) are probably true, if to a lesser extent, in Singapore. These are interrelated and include rapid advances in medical science, paradoxically demonstrated poor healthcare, rising costs of medical care, increased consumer education, expectations and power, the proliferation of service institutions and also increased Government involvement in healthcare provision and regulation.
As in many other countries, TQM in healthcare came from industrial experience in the development of TQM concepts, theories and practices. However, to implement the same concept into the healthcare industry would be a disaster. Although anecdotal evidence suggests that the healthcare industry is not uniquely different from any other organisation or industry; closer examination suggests that the healthcare industry is, in fact, uniquely different on five major counts:
i. its closer linkage to politics
ii. its complex organisational structure
iii. its inherent characteristics: intangibility, heterogeneity, inseparability, perishability, labour intensive, a credence product
iv. its objective is continually shifting, its environment is under siege from concurrent government changes
v. differences in the perceptions, values and work ethic of the healthcare
Recognising these differences is imperative to the successful implementation and development of a TQM system in healthcare. Whatever the differences and problems, TQM should not be directly transferred into the healthcare industry. It is up to the quality professionals in healthcare to define principles, philosophies and techniques that will determine the quality standards appropriate for their own industry. The authors in this paper establishes the principles of TQM in a hospital setting, as TQM is very complex when implemented through the many processes and areas within a healthcare facility. In the authors' opinion, the following definition of TQM sums up the principal elements of TQM:
TQM is the integration of a customer-focused, continuous improvement philosophy, analytical skills, people skills and a structure and organisation, within an internal and external culture affected by leadership (Gaucher and Coffey, 1993). Based on this definition, the principles of TQM are:
The Theme: TQM must be grounded in a continuous improvement philosophy. It is geared to the continuous improvement of quality in a hospital. However, the literature is devoid of suggestions as to how to sustain this never-ending journey. The authors are of the view that for TQM to actually constitute a never-ending process, it must deliver on performance. Therefore, TQM must be result-oriented in order for employees/management to believe it actually delivers a transformational strategy.
The Focus: TQM is customer-focused. It is based on customer expectations and on meeting customer needs. However, in healthcare, the identification of the customer is a relatively new concept. The patient is not traditionally viewed as the ultimate 'external' customer. The idea of the patient and the existence of other external customers such as the government, employers, third party payers have only been recently acknowledged. In addition, in an environment characterised by professional dominance, the identification of the customer and the anticipation of their needs is rather alien (Claus, 1991).
The Control: TQM requires analytical knowledge and skills and an organisation's long-term commitment. The use of analytical tools and techniques to evaluate and improve processes and in business decision-making are very important to the TQM process. Engineers, business managers, quality control staff and others have used measurement, graphs of data, control charts and other quantitative techniques for years. However, these skills have not been widely used by healthcare managers to improve organisational performance.
The Approach: TQM requires a structure and organisation that must be tailored to the unique internal and external culture and environment. A supportive culture and organisation should be established to ensure the success of a wide range of quality improvement efforts ranging from formal Quality Improvement Teams through daily quality improvement efforts of every employee. If quality improvement is to become an organisational focus, it must be management driven and be tailored to the unique internal and external culture and environment of the organisation. Applied to the hospital setting, with its dual line of authority, this means that both administrators and consultants will have to take the lead and move beyond 'advanced lip-service' in applying the principles and tools to their work setting (Claus, 1991). However, this is easier said than done.
The Scale: TQM involves interpersonal or people skills. As work is accomplished by people, the involvement of everyone in the organisation and the empowerment of staff are critical to success in a highly competitive healthcare environment. Better ideas are generated and changes implemented faster if staff closer to the process are involved in the analysis and decision-making process. However, in healthcare, empowerment of staff remains an illusion. Many senior managers are still not prepared for empowered subordinates.
The Scope: TQM's focal point is leadership and collaborative teamwork. Overtime, leadership drives the process and creates the pressure for cultural change within the hospital, which can significantly influence the external culture. Nevertheless, the TQM literature remains vague on how to achieve leadership and collaborative teamwork in a hospital setting, where consultants see themselves as better trained and more qualified than the rest of the staff.
However, the uniqueness and power of TQM is in the integration and balance of the above principles, not in the use of individual principle. The key to organisational goal achievement is PEOPLE, especially in a labour-intensive hospital environment. Inattention to people and cultural change are the most common reasons for failure in implementing TQM in hospitals. It is also important to recognise that very few healthcare professionals have a combination of analytical and people skills. Hence, training programmes with skill-building opportunities are essential to help healthcare professionals and practising managers to develop and combine these skills.
The TQM movement, while strong in many other industries, is still in its infancy in Singapore's healthcare services. Although the need for quality exists at all levels of healthcare provision, tertiary healthcare is of the greatest importance because the hospitals are where the medical technology is most advanced, where the greatest social and economic cost to society is incurred and where the opportunity for abuse and sub-optimal care is clearly present. Hence, the authors conduct an empirical study to determine the level of top management understanding of what is required to develop a TQM culture and the current TQM practices of Singapore hospitals. The policy implications formed through subjective and objective evaluation instead of data-mining would also be compared to the principles of TQM discussed earlier.
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