Business Management Articles
/ Quality Management


by Rene T. Domingo

Hospitals and other health care providers deal with a host of problems besides treatment of sick patients. This includes service delivery problems, management and people problems, logistics, maintenance and resource allocation problems. Unfortunately, very few tools are used by management and the medical staff in addressing these problems. Problems often recur or remain unsolved because of reliance on personal styles, subjective approaches, and purely qualitative approaches. Most of the methods and tools used by manufacturing and service industries to solve quality problems can be applied in problem solving in health care. These simple tools have proven effective in dramatically reducing if not eliminating defects, failures, wastes, and customer complaints in these businesses. Hospitals that have launched a Total Quality Management (TQM) program to improve their services use these tools on a regular basis.

These tools and methods, most of which are quantitative in nature, can help health care institutions achieve the following goals:

{ establish facts and objectivity through "management by fact"

{ clearly define, identify, and document a problem

{ clearly define, identify, and document an opportunity

{ facilitate problem analysis and problem solving by individuals or groups

{ enhance and simplify management reporting

{ facilitate communication, dissemination, and transfer of knowledge or technology by providing a common language for analysis and presentation

{ make meetings more organized, productive, and focused

{ help in developing countermeasures and preventive measures

{ measure the effectiveness of the solution to the problem and the amount of improvement

{ help in the formulation of standards and procedures

{ sustain the organization's TQM and continuous improvement programs

Among the simple yet effective tools that all health care personnel from management to employees can adapt and employ are: tables, tally sheets, flowcharts, bar chart, pareto diagram, fishbone diagram. There are other more sophisticated statistical tools like multivariate analysis that can be used to analyze for more complex problems. However, these may require computer assistance and extensive training in statistics.

The tools can be applied in almost any medical and non-medical operation and processes in the hospital or health care institution like: nursing services, medical services, radiology, laboratories, pharmacy, admissions, medical records, accounting, dietary, housekeeping and maintenance. Among the problems that the quality tools can address are: long queuing time or waiting time for the patient, slow response time to calls, errors in medication and records, cold meals, slow turnover of rooms and slow shift-turnover of nursing staff.

{ Tables and tally sheets

Well prepared tables contain critical and often numerical data that are clearly and effectively presented to highlight problems and opportunities. Tables can also show which problems should be given priority. A small clinic uses a table to highlight and compare the costs of rework of its major service providers. The table shows that the administrative staff is the most wasteful and costly for not doing their jobs right the first time. Training or retraining them may be one way to improve their performance.

Tally sheets can be used to measure, quantify, and locate improvements in quality. A hospital made a two-year tally of patient comments on all its services, medical and non-medical, using a rating scale from “VP” (very poor) to “VG” (very good). We may gauge success as the greatest improvement in the "VG" responses. We can recommend improvement for those units that had high "VP" scores, or had high increases in "VP" scores during the last two years. The tally sheet shows the improvement in the number, length, and types of patient calls received by a nurse station of a hospital after implementing a "kaizen" or work simplification project. For instance, between October and December, patient calls pertaining to air-con adjustment were reduced from 20 to 7 or by 65% after the hospital improved the air-con knobs and mounted a patient information campaign on how to adjust and use the air-con thermostat. Tally sheets can thus measure the effectiveness of any improvement program.

{ Flowcharts

Flowcharts can be used to clearly show the flow of people, services, and information in a hospital. A flowchart can show the flow of service in a hospital, starting with admission and ending with satisfied customers or patients. It also lists the types of services each unit must deliver for the hospital to create total customer satisfaction. The flowchart also conveys that message that everybody works towards a common goal. It shows the flow of services from one hospital unit- the department of laboratories - to the rest of the organization and eventually to the patients. The flowchart conveys the principle that any one failure in service to any department or internal customer will result in a dissatisfied external customer or patient.

Flowcharts can show areas of responsibility as well as areas for improvement. A flowchart in a clinic shows that a client registration process takes up 30 minutes. If the 30 minute registration time were to be reduced further, the flowchart can help analyze which step or steps to eliminate, combine, or simplify. A flowchart can show how nurses respond to a patient call. One hospital used flowcharts to indicate the improvement in charge card approval time of a patient of nuclear medicine from 1 hour to 7 minutes.

Flowcharts and any other problem analysis tool may be supplemented or supported by diagrams or pictures to clarify the work process or problem.

{ Bar charts, pareto diagram, fishbone diagram

Bar charts can help identify differences, gaps, priorities, and trends. They provide visual representation of numbers generated by tables and tally sheets. All tables and tallies can be graphed. Use line graphs to highlight trends, and bars charts to highlight differences among several items or factors. Another popular form of bar chart is the pareto diagram in which the items graphed are sorted from highest to lowest resulting in a stair-like shape. The pareto is used to set priorities or indicate which problem or problems to solve first. It enables us to have a systematic way of dealing with problems and prevents us from firefighting. The pareto rule is that 80% of problems are due to only 20% of the causes. The pareto will help us identify those vital few (the 20%) causes so that we can improve quality dramatically and quickly. A hospital made a pareto diagram on the types of patient calls that a nurse station receives. It shows that the most frequent (around 25%) is call for supplies - linen, blanket, tissue paper, etc. By improving housekeeping procedures and making sure supplies are always sufficient, the quality improvement team has almost eliminated this type of call and freed a lot of time for nurses to answer medical calls.

After the pareto has identified the most critical problem to attach, the fishbone or cause and effect diagram may be used to analyze it. The fishbone diagram looks like a fish. The head represents the problem to be eliminated, while the bones represent all its possible causes. The fishbone is a result of a structured brainstorming of all the members of the quality improvement team. It is usually best to have a cross-functional team to be able to identify all possible causes. A quality improvement team of a hospital made a fishbone analysis of delayed patient's discharge of a hospital. After constructing the fishbone, the team how discussed and decided which among the possible causes were the most probable ones, usually one or two items or factors. These causes were then validated, studied, and eliminated.

Problem solving in health care is too important to be left to chance, personal styles, and disorganized approaches. A thorough and organization-wide application of the tools described above will lead to better communication, teamwork, and faster solution of problems of any kind in the hospital, whether administrative or medical.


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