Quality management targets health care – Total Quality Management applied to hospital administration

Elaine Zablocki

At The George Washington University Medical Center, in Washington, D.C., cancer patients used to wait 11 hours or more for chemotherapy treatments; today, the average wait is less than two hours.

At Overlake Hospital Medical Center, near Seattle, a new fast-track system for handling emergency room cases gets people with simple injuries in and out the door in half an hour.

In each case, the same quality-management techniques that have produced performance breakthroughs in other industries are being applied to hospital management, with encouraging results.

Perhaps no American industry could benefit more from adoption of Total Quality Management (TQM) techniques than health care. Experts maintain that a huge portion of the nation’s annual healthcare expenditures can be attributed to waste and ineffciency. Spending on health care nationwide last year hit a record $838.5 billion, equivalent to 14 percent of the nation’s total economic output, according to the Commerce Department. Health plans purchased by businesses account for about one-third of total health expenditures.

“The waste is astronomical,” says A. Blanton Godfrey, chairman and CEO of the Juran Institute, a consulting firm based in Wilton, Conn. “At least 20 percent of the lab tests are unnecessary. Every infection is waste. Every complication after open-heart surgery is waste–and triples the bill.”

While health-care reform is a priority of the Clinton administration, congressional debate in the past has focused on overhauling the delivery system, making sure all Americans have access to affordable care. TQM would complement that effort by focusing on improving the processes involved in delivering quality service, often with the benefit of cutting costs.

“By reducing the number of infections, which means improved quality for patients, a hospital also saves a bundle of money,” says Godfrey. “There are wonderful synergies. In many cases, high-quality care actually costs less.”

Although quality techniques have been applied for over a decade in manufacturing industries, TQM is a relative newcomer to hospital management. Interest in the idea increased in the late 1980s after 21 hospitals participated in a project designed to demonstrate the application of TQM to health-care delivery. The hospitals reported the results of their efforts in June 1988. An extended version of their reports was published in 1990 in a book titled Curing Health Care: New Strategies for Quality Improvement (Jossey-Bass).

Not all the hospitals produced success stories, but many did. Subsequently, more and more hospitals have decided to try quality-management techniques, though they remain the exception, not the rule.

The George Washington University (GWU) Medical Center, for example, has successfully applied TQM techniques in a number of departments. Not long ago, patients often didn’t get medicine delivered in a timely fashion. Prescriptions sometimes got lost. As a result, “there was a major war between nursing and pharmacy,” says Roger Chaufournier, assistant vice president for quality. “It rivaled Desert Storm.”

When an interdisciplinary TQM team of GWU staff members studied the problem, it found no one was at fault, he explains; it concluded that the system just didn’t work. Physicians wrote prescription orders on patients’ charts, but since so many people needed the charts, the instructions reached the pharmacy hours later or never arrived at all. The pharmacy was then blamed for losing the doctors’ orders.

Once the team discovered the real problem, it was relatively easy to develop a system to speed prescription orders directly to the pharmacy.

There were similar problems within the GWU oncology unit, where patients would arrive at noon to begin elective chemotherapy. Sometimes they had to wait until midnight or later before treatment started.

“We dissected the process of admitting a patient to the hospital, and it turned out to be much more complicated than anyone had imagined,” says Dr. Robert Siegel, medical director of the oncology department.

A TQM team found ways to improve the process. Today, the patient’s doctor faxes the chemotherapy prescription to the hospital at least 24 hours before the patient arrives. All the admissions paperwork is done ahead of time, rooms are prepared in advance of patient check-in, and attending physicians try to discharge patients early in the day.

“Advance planning for elective admissions has made a big difference,” says Siegel. “The average time between admission and start of chemotherapy decreased from 11 hours to less than two hours.” This often cuts a full day from the patient’s hospital stay, trimming the bill by more than $1,000.

TQM stresses the importance of listening to customers–patients, in the hospital setting–and trying to meet their needs.

When Overlake Hospital Medical Center, near Seattle, found that emergency room patients with cuts and fractures felt they were waiting too long for treatment, a TQM team came up with creative solutions.

“Now we care for patients’ needs first and do the paperwork afterwards,” says Overlake’s president and CEO, Sanderson Jeghers. “We set up a triage desk at the front door, with a ‘fast-track’ care unit. Patients with simple injuries used to wait for an hour or two; now they’re out the door in half an hour.”

A TQM team, including doctors and nurses, also got involved in designing the new maternity center. After listening to patients’ concerns, the team suggested that all new mothers should have private rooms with sufficient space to accommodate visiting family members. The rooms also have a reclining chair for fathers who want to spend the night.

Because Overlake emphasizes customer satisfaction, the hospital regularly invites a select number of patients to take notes on how they are treated during their stay. “They’re our ‘mystery patients,’ “Jeghers says. “Retailers and the airline industry have used this concept for years. No one on our staff knows who the mystery patients are. After they recover, we take them out to lunch and debrief them about ways we could improve our performance.”

Another basic quality-improvement principle is good communication. Overlake believes in it so much that the hospital has a computerized communications center in the cafeteria. Any employee, patient, or visitor can key in a question, or make a comment, says Jeghers. “We review their feedback every day.”

The hospital also uses the system to disseminate the latest internal news and information. “We try to post our most important news every day, so if someone hears gossip through the rumor mill, they can easily check it on the computer,” says Jeghers.

Overlake’s emphasis on meeting the needs of patients and employees has been good for the bottom line. “In 1991, we cut our operating costs by 10 percent, using TQM teams,” Jeghers says. “Seattle has some of the lowest health-care costs in the country, but our operating costs are 31 percent below any comparable hospital in this market.”

Although relatively few hospitals have well-established TQM programs in place today, quality-management programs may be a requirement in the near future. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO), an influential body that accredits 90 percent of U.S. hospitals, is revising its standards to include quality-improvement methods.

“In the past, there has been a tendency to focus on problems and the individuals supposedly responsible for the problems,” says Dr. Paul M. Schyve, JCAHO vice president for standards and research. “In the future, our focus will shift to systems and processes.”

The JCAHO accreditation standards for 1993 ask whether hospital leaders, including the CEO and senior managers, are developing plans to assess and improve hospital processes. The 1994 standards, which have not yet been published, most likely will include more-specific requirements for data collection and performance improvement, says Schyve.

In addition, JCAHO is developing a national database of performance indicators, such as cancer-survival rates, death rates after coronary bypasses, the number of patients who develop infections after surgery, and the time it takes to transport accident victims to the hospital. By 1996, hospitals will be required to gather this data as part of JCAHO accreditation. Eventually, JCAHO will give each hospital regular reports comparing its performance with the performance of other hospitals.

Chip Caldwell, president and CEO of West Paces Medical Center, in Atlanta, says even up-to-date statistics are not enough. “The business community should ask the quintessential TQM questions: ‘Show me how you achieved your results. Show me that you weren’t just lucky. Most importantly, show me the process you plan to use to achieve even better results in the future.'”

At Caldwell’s hospital, small-business owners are invited to drop in for informal talks with the director of corporate health services and the vice president for medical affairs. “We’re 1001dng for ways to improve the health system from within,” says Caldwell.

Right now, hospitals such as West Paces, Overlake, and The George Washington University Medical Center are industry leaders in quality-management improvement. Most hospitals are just now beginning to learn about the benefits of TQM. But as news about TQM spreads, and as JCAHO increasingly emphasizes quality improvement to achieve accreditation, TQM probably will be coming soon to a hospital near you.

COPYRIGHT 1993 U.S. Chamber of Commerce

COPYRIGHT 2004 Gale Group

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