UNIT 4 FUNDAMENTALS OF QUALITY.

MANAGEMENT
Structure
4.0
4.1
4.2

Objectives
Introduction
Historical Background

4.3

Concept of Quality Care and Quality Management

4.3.1
Concept of Quality Care
4.3.2
Concept of Quality Management

4.4

Present Indian Scenario

4.5

Organisation of Quality Management System

4.5.1
Organisational Analysis
4.5.2
Awareness Campaign and Development of Quality Culture
4.5.3
Training
4.5.4
Development of Quality Manual
4.5.5
Development of Hospital Information System
4.5.6

4.6
4.7
4.8
4.9
4.10

Formulation of Criteria and Standards

Approach to Measurement of Quality

4.6 1
A Framework for Measurement of Quality
Review
Let Us Sum Up
Answers to Check Your Progress
Further Readings

4.0 OBJECTIVES
After going through this unit, you should be able to:
identify the problem areas, and their causes and effects relationship;
describe the concepts of quality care and quality management;
enumerate the needs and benefits of quality system of management;
list the steps involved in organising a quality management programme; and
examine and analyse various methods required to be adopted to assess delivery of
efficient and adequate quality of medical care.

4.1 . INTRODUCTION
This unit aims at making you aware of the problems associated with deliveryof
medical care services by various health care establishments; we will a l $ discuss
~
the
problems encountered by the recipients of care. It also highlights latest concepts of quality
mariagement system which can be adopted and implemented by administrative authorities
at various levels, to be able to provide efficient and adequate medical care.
You are aware that with the advancement of medical sciences and technology in recent
years there has been a growing sense of discontent amongst the people. The cause of this
discontent in the society is the.failure of the health care delivery system in India to meet
the expectations of people. During the last decade the quality of medical care and hospital
services have come under heavy scrutiny from the consumers and the community at large.
The rising cost and scarcity of resources have added a new dimension to the problem.
Patient considers health care as a basic human need and right, and he is vitally interested

Challenges in Hospital
Management

not only in the availability of care but in the quality of care as well. He has also started
questioning providers of care about the quality and cost of care and, in a number of cases,
have gone to court of law or consumer fonun for justice.
The massive investment made by the society in health care has had mixed results, in that
some people have been benefited whereas majority of people do not have access to the
quality health services. The inequities that require M e d i a t e attention are inaccessibility,
fragmentation, and high cost of health services combined with lack of concern with total
well being of the individual.
You will appreciate that the present situation calls for efficient and economic management
of medical care delivery system, capable of providing adequate medical care, both in
quality and quantity, at minimum cost, to the satisfaction of the consumers. This implies
proper organisation and efficient management of the hospital system for better utilisation of
physical facilities, staff, equipment, clinical services, and diagnostic and therapeutic
facilities. Quality management strategies introduced during early 90's aim at optimum
utilisation of available resources, focus on cost effective methods, and introduction of
hospital-wide systematic on-going quality control and quality assurance programmes to
continuously monitor and evaluate the performance, to improve the quality of care rendered,
and to increase productivity of the health care organisation.

HISTORICAL BACKGROUND
You have already learnt that Modem medicine in a large way is indebted to Hippocrates,
known as the "father of medicine", who lived and worked in Greece some 400 years before
,
Christ. He was a modem type of scientist physician in that he observed closely with a
surprisingly open mind; he described what he saw, he recorded his failures as well as his
successes. Much of what wrote so long ago is still of interest and value today. He required
his students to swear to an oath that the care a h n i s t e r e d to patients by them would
always be to the best of their ability. This was to ensure quality care.
The great names in Hindu Medicine are those of Sushruta in the 5th Century before and
Charaka in the 2nd Century after Christ. Sushruta, the professor of medicine in the Banaras
University wrote down in Sanskrit a system of diagnosis and therapy whose elements had
descended to him from his tutor Dhanwantari. He described many surgical operations, such
as, cataract, hernia, amputations, setting of fractures etc. Medical record keeping stands
today as proof of quality care ensured in those days.
Coming to the medieval period, we find that patient records were kept in St. Bartholomow's
Hospital, London, the only hospital still exists (1 137).
In nineteenth century, establishment of the famous Massachusetts General Hospital, Boston
USA is regarded as the landmark in the development of quality care concept, by ensuring
proper medical record keeping.
Tribute must be paid to Florence Nightingale, pioneer in modem nursing. She advocated
that "no harm should be done to a patient under care", and she was responsible for laying
down the standards of nursing care in 1859.
In twentieth century the idea of enforcing quality care by medical audit may be traced back

td 1900, when education leaders in the medical profession in the USA were trying to cope
with the problems of commercialismand general lack of skill of the profession. Consequently
American College of Surgeons was formed in 1913. Its Board of Regents decided that the
objective of "proper care of the sick and injured" could be achieved by a continent-wide
standardisation of hospitals. Thus a "Hospital Standardisation" programme was
inaugurated in 1918. One of the major requirements of the hospital standardisation was the
regular review and analysis of the clinical work of the hospital by the medical staff through
the medical staff conferences. In 1928, Thomas R. Ponton, MD presented a plan for
"Professional Service Accounting" and "Medical Auditing" based on the procedures used
by financial accounts.
Quality Assurance activities began with the formation of Joint Commission on
Accreditation of Hospitals JCAM in USA, in the 1960s. A document specifying "Standards
for Hospital Accreditation" was published jointly by the American College of Physicians,

American College of Surgeons, American Hospital Association and American Medical

Association.
The Joint Commission on Accreditation of Hospitals (JCAH) was renamed as Joint
Commission on Accreditation of Health Care Organisations (JCAHO). They have revised
the document in 1995 and published as "Accreditation Manual for Hospitals". The
mission of the JCAHO is to improve the quality of care provided to the public.
The Geneva based International Organisation for standardisation was raised in 1946 with
India as a founder member amongst 25 countries at that time. IS0 9000 series of standards
have generated maximum interest world wide and already 90 countries have adopted
these so far, includmg all developed countries. The prime role of quality system is to
provide effective means to assuring that the customer requirements are met fully. The
system is aimed to achieve, sustain and improve the quality of product or service.
In India, quality assurance programme or medical care standards for hospitals are nonexistent. Bureau of Indian Standards (BIS) have adopted the concepts of total quality
management advocated by International Standards Organisation (ISO) as applicable to
services provided by health care organisations. However, the progress made by BIS in
laying down standards is very slow. A few corporate hospitals have made remarkable
progress in adopting IS0 standards for accreditation.
Check Your Progress 1

1)

2)

reat at names of Hindu Medicine are those of

ii)

Charaka in .........................................................................

To check problems of commercialism in medical practice ..................... was

introduced in 1900 in USA to ensure quality care.

ii)

Hospital standardisation programme was inaugurated in ............. :....

3) The following stands for

i)

JCAH

......................................................................................

ii)

JCAHO

.....................................................................................

iii) BIS

......................................................................................

iv) IS0

.....................................................................................

4) JCAHO is composed of:

4.3 CONCEPTS OF QUALITY CARE AND

QUALITY MANAGEMENT
-~>

You are already aware of that health is considered as physical, mental, spiritual and social
well being and also enjoyment of highest standard of health is fundamental human need
and right. Society as a whole has some responsibility to provide care of the sick and to
prevent the occurrence of disease among its members. In the previous block you have
also learnt that hospital is an institution evolved round the concerned care for sick among
the population.
What is that the average patient really wants from health professionals? Patient wants
someone who beside being a primary physician and an expert in diagnosis, can also give
advice, allay fears and educate; secondly, patient is vitally interested not only in the

Fundamentals o f
Quality Management

Challenges i n Hospital
\lanagemen1

availability of care but in its quality as well, and is also concerned with the cost of care;
thirdly, he is interested in well patient care, i.e. promotive and preventive care; fourthly,
he expects personal attention as OPD or in-patient.
Health care services include a wide variety of quality aspects all of which are important.
In case of medical services, the sellers are doctor, hospital, nursing home, clinic etc.?
because they offer health services at stipulated prices. The buyer, i.e. the patient as a
customer wants acceptable quality services which must be commensurate with what he is
paying to the seller. Acceptable quality services not only indlude the quality of direct
medical services, .such as, diagnosis, medicines, surgery, and treatments, but indirect
operations, such as, administration, purchasing, stores, house keeping, linen services and
so on, are also included as their costs are reflected in what the buyer pays. It may also
include quality of performance that is directly connected and closely related to health care,
such as, food, housing, safety, security, attitude of employees, and other factors which
arise in the context of hospitals and nursing homes.

4.3.1 Concepts of Quality Care

You will appreciate that the key person for whom all activities are performed is the patient
and the key word related to health care services is quality, which is understood as
customer satisfaction. Therefore, the quality of service should always be in line with the
customer's needs and expectations.
The "Quality of Service" may be defined based on I S 0 8402 as, "Totality of features and
characteristics of service that bear on its ability to satisfy stated and implied needs of its
patients."
In this definition the "features and characteristics" refer to specifications relating to
standards for various dimensions of quality, such as. accessibility, appropriateness,
continuity, effectiveness, efficiency of care and so on. As regards the customers "stated
and implied needsn his main aim of caning to a hospital is to get totally cured of his
ailment. His implied need may be treatment in the shortest time at most reasonable cost,
and possibly physical and emotional security.
The quality of care generally means the degree of excellence of the med~calcare delivered,
whether it meets or exceeds accepted standards. Criteria necessarily changes with
improved efficiency related to technological advancement; therefore, standards of quality
change with time. For example, in 1960s a cardiac patient was satisfied with an ECG test but
now with newer technology the patient probably expects a Tread Mill test or an Echo
Test. Achievement of satisfactory quality involves implementation of quality needs at
all spges of process of care, like diagnosis, treatment and post treatment follow up and
monitoring.
Quality of care has been defined by JCAHO as LLThe
degree to which health services for
individuals and populations increase the likelihood of desired health outcomes and are
consistent with current professional knowledge". Dimensions of quality include the
following: Patient perspective issues, acceptability, continuity, effectiveness, equity and
efficiency.

1)

Dimensions of Quality in Health C a r e

Patient perspective issues (patient focused functions) Patient Rights, organisatiol~al
Ethics.
-Rights

to information

---Considerate and respectfd care

--Right

to privacy, Safety

-Right

to choose and t o be heard

-Right

to Consumer education

Acceptability includes
a) accessibility
b) the patient-practioner relation
c) amenities

d) patient preferences as to effects of care

e) patient preferences as to the cost of care
Effectiveness-Degree to which the care proposed would achieve the expected
outcome, given the present condition of patient and current science and
technology of health care.
Equity-Conformity to a principle that determines what is just or fair in the
distribution of health care and its benefits among the members of a population.
Efficiency-Work of the services as a whole, not the end itself but the way the end
is achieved; concerned with systemic efficiency of various facilities which put
together contribute towards quality of care at minimum cost.
Efficacy-The degree to which the care of the patient has been shown to
accomplish the desired or projected outcome(s).
You might wonder if an assessment of quality is at all possible, seeing the multiplicity of
dimensions or attributes relevant to the concept of quality, and the possibility the
goodness in one might conflict with goodness in another. Fortunately, the principles
of "Contextuality" offers a way out of the difficulty. You will appreciate that in any
given situation certain dimensions are more in~portantand relevant; other components
can be left out, although in a different situation, those excluded components would be
the very ones to include.
2)

Conceptual Issues Relating to Quality Care and Cost

From the foregoing description you will appreciate that prime focus in quality management
is not on providing the best possible care at any cost. The whole emphasis is on making
available care of an acceptable standard as per needs of each patient, at the least cost. The
following factors are relevant for consideration:
i)

Preventive Versus Curative Care

Past research findings have undoubtedly established the fact that promotive and preventive
health care schemes are definitely more cost effective than curative and rehabilitative care
for the population. However, at a micro level, where an individual patient is concemed if
appropriate care is rendered at OPD level it is possible that inpatient admission may be
avoided. Again, as inpatient prevention of nosocomial infection becomes important to
avoid extra length of stay, which add to the hospital cost.
ii)

Manpower Substitutability

It means allocation of right job needing particular skill to the right person. Delivery of
health care.involves series of activities ranging from the highly skilled sophisticated
activities to the most ordinary repetitive ones. It is necessary to identify which health
worker can perform each task efficiently at minimum cost. For example routine BP can be
recorded easily by a nurse for which doctors' time should not be wasted.
iii)

Quality Care Versus Costs

It is commonly believed that emphasis on quality means generous use of sophisticated

technology, which of course. result in escalation of costs. Quality care means need based
care, which should ensure nothing less nor anything extra done than is essentially
required. Aim should be to provide the best under the given circumstances and whatever
diagnostic and therapeutic procedures are necessary are carried out with maximum
efficiency. effectiveness and economy.
iv)

Quality Care and Productivity

Efficient utilisation of resources will ensure better quality which in turn will reduce cost
and increase productivity. Marketing sb-ategies are required for ensuring optimum bed-..
occupancy and maximum use of costly sophisticated diagnostic-and therapeutic equipment.
W o ~ kstandards are necessary for quality performance by minimum staff and to monitor
labour productivity on regular basis. Clear cut policies, value analysis, adoption of
inventory control techniques, proper preventive and breakdown maintenance, control over

Fundamentals o f
Quality Management

C'hallenges i n Hospital
Management

misuse, overuse of resources like drugs, Lab, imaging facilities will add to the quality care
and increase productivity by reducing cost. .
Check Your Progress 2

1)

What an average patient wants from health professionals?

..................................................................................................
2)

Acceptable quality services include the following:

..................................................................................................
3)

List the dimensions.ofquality in health care:

4)

How a balance between quality care and cost can be maintained.

4.3.2 The Concept of Quality Management System

With liberalisation and globalisation of Indian economy, quality has become a buzzword for
survival in the competitive world market. It is obvious that health care costs are escalating
at a dizzying pace. When cost in manufacturing environment reaches a dangerous
proportion the same is efficiently controlled by quality management techniques. To
understand the coplexities of introduction of quality management in health care services
it is necessary to understand the functioning of hospital system.
1)

Hospital System

In Block 1 of this course you have learnt about the concept of hospital as a system. .You
have learnt that a system is a hierarchical chain of system and subsystems, interconnected
and interdependent, having clear objectives at each level of the system or subsystem,
obtains enough inputs from the environment to offset its output; it operates with varying
processes or methods to achieve the ultimate objective of the system.
You will appreciate that for efficient management of hospital, the administrator should
have a conceptual model of a hospital which functions as a system, consisting of various
service areas as subsystems, to achieve ultimate objective of patient care. A large hospital
may have 40-70 departments, which may be functionally grouped under following heads:
a)

Clinical and Nursing Services: such as OPD, OT, Inpatient, Emergency Servlces
Supportive Services: X-ray, Laboratory, Blood Bank, Records, Dietary etc.

'1-

6)

Utility Services: Laundry, CSSD, Engineering, Transport, Communication, Security

etc.

d)

Business Services: Personnel, Finance, Materials, Administration etc.

The system concept as applied to a hospital will imply collection of departmental

subsysten~components, which operating individually and collectively perform a set of
operations in the acconlplishn~entof defined objectives of the hospital system, i.e. delivery
of patient care services.
.The 'System Concept' In n~anagementis only a tool, which the administrator can use to
correct the disorganised resources of men, machines, materials and money into a useful
and effect~veinstitution. Management is the process whereby those unrelated resources
are integrated into a total system of objective accomplishment.
Before you proceed further let us examine a simple model of hospital system as shown in
Fig. 4.1. In this figure you will see that the patient information obtained and fed to the
decision centre which represents the doctor, who makes the diagnosis. He in turn orders
certain supplies and services for diagnosis and therapy. These supplies and services are
checked, and administered by the doctor or his representative, the nurse. The second
decision centre as well as the first decision centre regulates the flow of patients stay in
the hospital. Statistical data obtained from medical records of discharged patient provides
further information to the decision centres for planning of the future services. The
regulatory function is acconlplished by decision centres through their control on action
centres. i.e. all departmental sub-systems in the organisation, involved in patient care.
For sin~plicity,it is not possible to show all the action centres, but their existence is apparent
by the fact that there is recovery or output rate, which is possible only with the assistance
of all supportive, utility and business seivices.
You may have observed the following salient features in the model of hospital system,
which are very relevant for the quality management system:
a)

There is a continuous flow of information from the time of patients' admission till
after discharge which are essential for decision making.

b)

Each sub-system (ward unit as shown) has a clear objective, obtains input from
its environment (both internal and external) and operates with varying processes
or methods to achieve an output or ultimate objective of the system.

C)

There are decision centres (both doctors and administrators) who control input and
output rate of patients, supplies and services.

d)

A clear cut feedback system is available for the users for planning, monitoring
evaluation and decision making.

e)

Medical records play a vital role in providing patient care related data for both
professional and admlnistrative management.

2)

ISO-9000 Quality Management System

Quality Management is concerned with "All activities of the overall management function
that determine the Quality Policy, Objectives and responsibilities, and implement them by
means such as quality planning, quality control, quality assurance and quality
improvement." Quality management is the responsibility of all levels of management but
must be led by the top managen~ent. Its implementation involves all members of the
organisation.
As dready stated earlier, the ISO-9000 series of standards for quality management system
have generated n ~ a x i m ~ uinterest
~l
world-wide and already 90 countries have adopted,these
so far. 1SO-9004 is a guide for application of quality management system. It is in two parts,
Part- 1 for manufacturing sector and Part-2 for service sector, like health and hospital
services.
This quality system is based on the principle that prevention is better than cure. The
prime role of quality system is to provide an effective means to assuring that the customer
requirenients are met fully. The system is aimed at firstly, to achieve, sustain and improve
the quality of product or service; secondly, assurance to the management that internal
controls are effective, and thirdly, assurance to the customer that the service conforms
to his requii-enlent.
The main emphas~sof 1SO-9000 series of standards is on the following:
Every man is involved in maintaining the quality of the activities that he performs
apart from the centralised quality checks.

Fundamentals o f
Quality Management

Challenges in Hospital
Management

Input
.........................

information of
objectives
established
admitting
Feedback

Decision centre
(Doctor)

..........

"

..

"

...........

"

(Hospital)
..

lnput
Ward Unit

,Patient Discharge :

Patient on
Undergoes
Treatment

and Services

Recovery

Actual Performance

Records

...........................................
.

Material
Input Rate

.. ..........................................

Medical Records
Department
Statistical
Data admn.
and
Clinical

Output
Rate

- Flow of Materials and

Patient

....... Flow of Informaton

\ Value to Indicate that

Fig. 4.1 Simple Model of Hospital System

*
*

Decision Function
Controls Flow

Importance of customer which has been sub-divided into external and internal
customer. In the case of hospital the external customer is the patient or his relations.
whereas the internal customer may be an employee or a department receiving
product or service from another employee or department. For example, employees or
departments receiving stores from CSSD, Laundry, Medical stores etc. are
considered as customers of the issuing departments.
Utilisation of intellect of the operator : As a matter of fact Japanese have "quality
circles" in which all members of the team are invited to suggest improvement of the
existing system or working procedures. This shows total involvement of all
employees working in organisation.
"Continuous improvement" is yet another important aspect that the Japanese call
"Kaisan". Quality management system incorporates various methods like
management review, internal audit and statistical techniques for measuring and
assessing the quality of the system on a continuous basis to correct deviations.

You have come across the terms like 'quality control' and 'quality assurance' in the
definition of the term quality management.
~uality'control refers to "the operational techniques and activities that are used to fulfil
requirements of qualityn. It will therefore be clear that quality control techniques applied
in quality management are concerned both m monitoring and evaluat~onof the system

implemented to eliminate causes of unsatisfactory perfokance at all stages i.e., during

input, process and output stages, in order to achieve standads of quality and economic
effectiveness.
Whereas, "quality assurance" is concerned with "All the planned and systematic activities
implemented within the quality system and demonstrated as needed, to provide
adequate confidence both internal and external customers as explained above that an entity
(i.e. service or product) will fulfil requirement for quality".
In fact some quality control and quality assurance actions are intemlated and are
complimentary to each other.
The latest terminology used in quality management is "Total Quality Managementn(TOM),
which has a wider base and is a all pervasive approach to quality management. It is defmed
as a "management approach of an organisation, centered on quality, based on
pamcipation of all its members, and aiming at long term success through customer
satisfaction, and benefits to all members of the organisation and to society". You will
note that it has the following elements:
The approach is centered on quality.
. The expression "All its members" designates personnel in all departments and at all
levels of organisation structure.

The strong and persistent leadership of top management and the education and
training of all members of the organisation are essential for the success of this
approach.
In his the concept of quality relates to the achievement of all managerial objectives.
The concept "Benefits to Society" implies, as needed, fulfilment of the requirements
of society.
Total Quality Management (TQM) or parts of it are sometimes called ''Total Quality"
or "Company Wide Quality Control " (CWQC), or "Total Quality Control" (TQC) and
SO on.
After going through the concept of quality management system and various terminologies
used in this connection, you will learn about the expected effects and benefits of IS0 9000
quality management system.

Effects and Benefits of ISO-9000 Quality Management System

3)

3 Effects
Clarity of customer requirement of product or service, as the service is designed
based on market study to fulfil customer needs.
.Clarity of roles and responsibilities at all levels through system analysis and process
study.

Cleas business objectives and targets and clarity of service to be delivered at each
point.
Control over quality of operations, through decentralised individual check for
quality and centralised quality check by quality control team.
Assurance of quality of supplies and service at all stages-input, process and output.
Continued Education and training of petsonnel. This is to ensure that every man
remains confident of his capability to provide results expected thereby
motivated to work.
'

Efficient and effective working methods, as the new procedures and works
instruction are based on quality model, prepared by employees themselves.
Independent Audit of all operations to ensure that the quality system covers all
aspects, being implemented in the desired manner, and provide continuous feedback to
the management for timely corrections, if required.

Fundamentals o f
Quality Management

Challenges i n Hospi t a l
Management

ii)

Benefds

Competitive advantage in the market and increase of image and credibility

Expanded and continued market share, due to favourable publicity by satisfied
customers.
Higher productivity and profitability proportionate for reduction of cost of operation by
improving eficiency.
8

Higher potential for growth.

Baseline information for planning future services and initiating improvement.
Safeguard interest of both providers and recipients of care, due to improved quality
care, and supporting documentation/data base-to meet the challenges in cases of
complaints registered with consumer court.

Check Your Progress 3

1)

What do you understand by "System Concept" in Management?

.....................................................................................................................................
2)

What are the aims of Quality Management System'?

3)

What are the main emphasis of ISO-9000 series of standards'?

4)

List five benefits of ISO-9000 quality management system.

The print media has been repeatsdly bringing out the state of the nursing homes as also the
public and private hospitals. As per reports public hospitals turn into 'illness factories' and
going to the hospital remains a 'nightmarish experience', as can be seen from the
following findings:

Big crowds, long queues

Conhsing maze like layout
Incomprehensible instructions and tedious procedures
Casual diagnosis
Rude physicians, rough handling by sullen staff
Bribe taking by touts
Complete absence of accountability
Unjustified delays
Gross negligence due to callousness and incompetence
Malpractice, like un-indicated surgery.
The private hospitals and nursing homes have been labelled as "Shrine to Mammon".
Mammon is known as God of Riches. These institutions are thriving in spite of glaring
inadequacies in facilities provided therein. As per survey reports on nursing homes in
cities like Bombay, Delhi, Calcutta, Patna, Lucknow, Bangalore, gross inadequacies have
been noticed with some variation. In Delhi for instance it has been reported that out of
estimated 2000 private nursing homes, over 1SO0 are unlicensed.
Some major centres of learning do have some appraisal activities, such as, periodical
publication of statistics relating to patient load, mortality and morbidity; clinical
conferences, clinico-pathological reviews, analysis of fatal cases and enquiry into
major cases of negligence. These, however, focus on technical aspects, such as,
accuracy in diagnosis, investigation reports, treatment regimen and so on. The
legitimacy of the diagnostic and therapeutic procedures adopted, related to the cost of
care, the problems encountered during the patients stay, the professional and
administrative lapses and so on, are never examined in detail for remedial measures.
In general, except a few, the Indian hospitals do not have any quality assurance programme
to regularly monitor and evaluate the standard of care delivered.
You will appreciate that considering "the health is a basic human need and right" the
hospital Board or Trustee or an Owner of any health institution has the following
obligations:
Moral-Patient

interest to be protected

Legal-Appropriate

measures to ensure quality and patient safety

Contain the cost of care

Identify inadequacies in the system
Regulate activities to ensure quality and efficiency by maximumutilization of
resources
Assess effectiveness of delivery of services rendered.
The causes of the present malady are multidimensional and the remedy lies in introduction
of quality management system,. to provide efficient and adequate services both in quality
and quantity, at minimum cost to the best satisfaction of customers and the society.

4.5 ORGANISATION OF QUALITY MANAGEMENT

SYSTEM
According to quality guru W. Edward Deming, an organisation should focus not on bad
employees but on bad systems. Deming estimates that 94 per cent of all errors are system
errors. not en~ployeeerrors. He further estimates that only 15 per cent of quality.

Fundamentals o f
Quality Management

Cballcnges i n Hospital

Management

improvement opportunity lies in focusing on the performance of people, with the

remaining 85 per cent of impedimentsto quality coming from systemic factors that are
optimally addressed by involving everyone in the system in the quality improvement
activities.
One of the most crucial factors for success of any quality system is the commitment of
the top management of the organisation.
At the outset it is necessary to take a decision by the top management that Quality
Management System should be introduced in the organisation. Once this crucial
decision is taken in consultation with members of the governing body, medical staff and
administration, the following steps are necessary before introduction of the quality
management ProIPmme-

4.5.1 OrganisationalAnalysis
Review organisationsrelationship with its external environment. Today, successful
health care organisations must be able to anticipate, understand, and proactively and
flexibly respond to change in the dynamic health care environment.
Examine organisations internal characteristics and functions. Excellence in patient care
requires state-of-the-art professional howledge: clinical, Management, Governance
and Support expertise; and Competent technical skills integrated and co-ordinated
organisation wide to effectively and efficiently respond to patient and family needs.
The existing characteristics that is, its strengths and weakness can be assessed
through a review of systems, policy, rules and procedures and operational statistical
data of each department in the organisation.
Thirdly, identifying problem areas and analysis of problems to understanding cause
and effect relationship. This will help in systematically assessing and improving
important functions and work processes and their outcome.

4.5.2 Awareness Campaign and Developmentof Quality Culture

Corporate culture is the basic pattern of shared belief, behaviours, attitudes and
assumptions acquired over time by members of an organisation. Corporate culture
impacts on the organisational performance and productivity. For this it is necessary to
create a system of values, beliefs and behaviours (individual and team) for the success.

4.5.3 Training
Training of top management to help them in decision making regarding
implementation of the quality system. These senior managers are generally the
heads of departments and will subsequently form the steering committee.
Training of senior and middle level managers who will form the task force on the
project team to design and develop the quality system best suited for the organisation.
Training of all other members of the organisation to familiarise them with the
quality system requirements, and their role in its implementation.

4.5.4 Development of Quality Manual

Quality manual is a document stating the mission and vision of the organisationsas to the
quality, the quality policy and describing the quality system of an organisation (ISO8402). The document should reflect the following:
The mission and vision of the organisation.
The approach of the organisation for compliance of the quality system elements.'
The organisational structure, defining broad responsibilities and methodology of
organising various activities.
The policy guidelines as to how the system would operate.
The indicator measurement system for measurement/overviews, which involves both
routine, ongoing data collection for processes or functions performed by
individuals or multidisciplinary teams or groups, as well as time specific, focused data
collection.
A self comined measurement system includes important.dimensions of performance,

collects data about relevant processes, outcomes, resource consumption, and

satisfaction levels, and taps into patients, practitioners, and employee perceptions of
quality. The quality cube shown in Fig. 4.2 presents a model for assessing quality that
illustrates the relationship of dimensions of performance and important functions to a
range of patient populations and services provided. The cube is a tool that can help
stimulate thought about. and focus measurements related to, important priorities.
Fig.4.2 below explains the forms of Quality Assurance (QA) studies applying the quality
control technique.
StaadardslCriteria

/
Input
Personnel Equipment
Supplies
Space Technology
Finance
Rules + Procedures

Process

output

Inter-pers. Relations,
Techniques& Procedures

Quality

Art of Care

Quantity

Technical Management
Efficiency of Care
Documentation

Consumer
SatisfaFtion

(-)

Error Cornpliqations

Error of Treatment

Input Control

process Control

output Control

Fig. 4.2: Quality Control (Moaitoriag & Evaluatioa--A Tool for QA)

The dimensions of performance, as shown in Fig. 4.2, are patient centred activities involving
hnctions of all the services. Systematic assessment and improvement of performance is a
continuous process which involves:
a) Study of problems to identify process weakness and not individual incompetence;
b) Careful co-ordination of work and collaboration among departments and professional
groups;
C) Seeking judgements about quality from patients and others and using such judgements
to identify areas of improvement; and
d) Setting priorities for improvement of performance of all important functions, and
maintaining stability of these functions.
You will now learn about the dimensions of performance as given by JCAHO.
Doing the Right Thing

Efficacy

The degree to which the care (procedure or treatment) of the patient

has been shown to accomplish the desired or projected outcome(s).

Appropriateness

The degree to which the care provided is relevant to patient's

clinical needs, given the current state of knowledge.

Fundamentals o f
Quality Management

Challenges in Hospital
Management

Doing the Right Thing Well

Availability

The degree to which the appropriate care (needed test, procedure,

treatment or service) is available to meet the patient's needs.

Timeliness

The degree to which the needed care is provided to the patient at

the most beneficial or necessary time.

Effectiveness

The degree to which the needed care is provided in the correct

manner, given the current state of knowledge, to achieve the
desired or projected outcomes for the patient.

Continuity .

The degree to which the needed care for the patient is

coordinated among services, practitioners, and providers and over
time.

Safety

The degree to which the risk of an intervention and risk in the care
environment are reduced for the patient and others, including the
health care providers.

Efficiency

The relationship between the outcomes (results of care) and the

resources used to deliver patient care.

Respect and Caring:

The degree to which the patient or a designee is involved in his or

her own care decisions, and to which those providing services do
so with sensitivity and respect for the patient's needs, expectations,
and individual differences.

4.5.5 Development of Hospital Information System

The framework of the hospital information system should be so organised that there is
rapid and regular feedback of information, related to the quality ofpatient care rendered
by clinical departments and also overall performance of all services including Supportive,
Utility and Business Services of the organisation.
The information based upon the "hospital" is called the "Hospital Operational Statistics"
which can be grouped as under:
Resources of the hospital, e.g., bed, diagnostic and therapeutic facilities, staff
available, supportive services etc.
Utilisation of hospital resources including statistics of:
-Patient

movement, days of care, bed occupancy etc.

-Outpatient

visits

-Operations, deliveries
-Number

and type of Laboratory and radiological investigations and so on.

Administrative and Financial Data--organisation and analysis of data required for

utilisation review, performance review, cost analysis, patient satisfaction study to
assess and improve quality of patient care.
The information based on the "Patient" may be termed as " Hospital Morbidity
statistics". The statistica! unit is patient and the information is collected from medical
records. The report includes:
Personal characteristics of patients, age, sex, occupation etc.
Length of stay, overall and speciality wise
Presence of complications, consultations, infections
Type of investigations and treatment
Outcome of hospital stay-Patients
recovered and rehabilitated, pre-natal
mortality, surgical fatality, mortality for other causes and so on.
As you know the primary source of patient statistical data in hospital is the medical
records. Therefore, accurate and complete record keeping and good patient registration
system is essential.

Fundamentals of
Quality Management

4.5.6 Formulation of Criteria and Standards

All measurement requires something analogous to a yardstick. Criteria and standards are the
yardstick for quality assessment. The definitions, along with some examples are given in
the table below:
A) Definitions
Criterion

Attribute of structure, process or outcome capable of leading to an

inference about quality.

Standard

A specific, quantitative measure that defines goodness.

Structure

B) Examples
Criterion

Standard

Process

Outcome

Staffing of
Intensive Care
Unit

Blood Transfusion Casefatality

during surgery

Structure

Process

I
Not less than
One RN per two
occupied beds

Outcome

Not less than 5%

Not to exceed 0.1%
not more than 20% for a specified procedure.
of average cases

Criteria and standards may be derived in two ways: (a) "normatively", which means
from the scientific literature, supplemented by the opinions of recognised experts, and
(b) "empirically" which means, from examples of actual practice or behaviour.
Check Your Progress 4
1)

Enumerate the obligations of Hospital Board or Trustee of a health institution in

respect of patient care.

.......................................................................................................................................
2)

What are the steps involved in organisation of quality management programme?

.......................................................................................................................................
3)

List the dimensions of performance.

C'halleoges i n H o s p i t a l
Mattagemectt

.......................................................................................................................................

4.6 APPROACH TO MEASUREMENT OF QUALITY

The measurement of quality of care or service poses many problems as it is not possible
to establish accurate standards ofjudgement. Yet we need to have some indicators, i.e.
some kind of criteria and standards for evaluating the service; only then the efficiency of
performance and in turn the community benefit, can be assessed for further improvement.
In health care for the purpose of measurement of quality one needs to look at the entire
process, including the resources available, the setting in which the care is rendered, the
process of delivery of care, and the con~petencyof those delivering the care. Therefore
qualitative studies include studies of structure, process, and outcome of care. Quality
study of factors influencing quality care may be termed as "Resource Utilisation Study"
and actual performance appraisal may be termed as "Professional Activity Study" for
evaluation of quality care.

4.6.1 A Framework for Measurement of Quality

"Structure" deals with the resources associated with the provision of care and indirectly
influencing quality care, such as:
\

i)

Beds: number available and their utilisation

ii)

Personnel: adequacy, qualification, level of motivation etc.

iii) Equipment: adequacy, state of repairslreplacement

iv) Supplies: adequacy, supply breakdowns, pilferage
v) Space: does it meet minimum standards, state of maintenance
vi) Rules and Procedures: available or not for all areas
vii) Technology: appropriate or not
viii) Finance: adequacy, proper allocation and utilisation
"Process" aims to analyse the practice of care delivery. In clinical areas, it involves direct
observation of patient care and studies based on medical records (professional service
review).
i)

Physician-patient interaction
-Art

of care

-Technical

management of care i.e. proper utilisation of diagnostic and therapeutic

facilities
-Efficiency

of care relates to overall management of patients' problems consuming

minimum resources.
-Documentation
ii) Interpersonal relations-conflicts,

grievance procedure

iii) Techniques and procedures-available

and appropriate

In other areas, such as, supportive and utility services, it is necessary to study the
legitimacy of methods adopted to achieve the end-result.
"Outcome" Studies emphasize the resuits of care:
i)

Quality of work done-how

good is the service;

li)

Quantity of work done-is

it optimal, minimal or maximal;

iii) Cost of care to the patient and the cost of hospital operation;
iv) Consumer satisfaction with the type of attention received.
In outcome related to quality care the credit points are, number of lives saved, number
recovered and rehabilitated. Debit points are, deaths, complications d u e to drugs or
procedural el-rors, hospital infection and so on.

Check Your Progress 5

1)

What areas one should look for the measurement of quality?.

2)

What are the factors influencing quality care?

3)

At what level the quality control technique should be applied to maintain quality of
service ?

4.8 LET US SUM UP

In this unit you have learnt that considering the rising consumer awareness and
expectations, and the escalating cost of health care, the health organisations can no longer
remain insensitive to the need of quality management. Introduction of quality
management system in any health establishment, be a small or large, will be of
considerable benefit to the provider of care, and to the patient and community, as it
ensures delivery of efficient care of quality and quantity, at minimum cost, to the
satisfaction of customers.
Further you have learnt that the quality management system can be introduced at no cost
or ininimum cost, depending on the quality policy and approach, provided the organiser
of care is able to (a) design a mechanism for proper selection and training of all categories
of staff, (b) develop a quality culture related to cost, (c) maintain goodmedical records,
and (d) introduce a framework for hospital information system capable to meet the user
requirements in the system.
You also learnt that prompt attention to patients, courteous behaviour by staff, providing
reassurance and comfort to patient in a clean and safe environment, will provide best
satisfaction to the consunlers of care at no cost.
Subsequently you learnt that the productivity of a hospital can be increased while
maintain~ngthe quality, through the following steps:
Manpower utilisationwell.

right man for the right job, and ensuring doing right things

Maximum use of diagnostic and therapeutic facilities and maximum bed occupancy,
through dynamic marketing strategy.
Quality versus cost ensure nothing less or nothing more.

Fundamentals of
Quality Management

Challenges i n Hospital
Manaeement

Optimum utilisation of all available resources

Clear purchase policies, standardisation of equipment and value analysis.
Enforce inventory control procedures
Control overuse, underuse and misuse of resources
Reduce cost of poor quality, disquality, due to poor performance, nonperformance, in clinical and supportive services: such as, wasted x-ray films,
unjustified investigations, medication errors, misdiagnosis, hospital infection and
SO on.
Develop basic quality standards and criteria for all key performance areas, which
may be adopted as indicator for measurement.
Towards the end of the unit you learnt that development and management of information
system is an important function focused on meet~ng the organisation's informat~on
needs. Its goal is to obtain, manage, and use information to enhance and improve
individual and organisation performance in patient care, governance, management and
support processes.

Check Your Progress 1

1) i) SthCentury BC

ii) 2nd Century AD

2) i) Medical Audit
ii) 1918.

3) i) Joint Commission on Accreditation of Hospitals

ii) Joint Commission on Accreditation of Health Care Organisations

iii) Bureau of Indian Standards
iv) International Organisation for Standardisation
4) American College of Physicians. American College of Surgeons, American Hospital
Association and American Medical Association.

Check Your Progress 2

1) a) Reassurance and advice
b) Quality of Care and Cost of Care
C) Promotive and preventive Care
d) Personal attention
2) a) Quality of direct medical service, as diagnosis, treatment etc.
b) Appropriateness of indirect operations, such as, housekeeping, linen, stores,
adrmnistration etc.
C) Quality of utility services, such as, food, housing, safety, security, attitude of
employees and so on.

3) Patient perspective issues, acceptability, continuity, effectiveness, equity, efficiency,

efficacy and timeliness of care.
4) The whole emphasis is on making available care of an acceptable standard asper
needs of each patient, at the least cost. This could be achieved by:
a) emphasis on preventive careb) allocation of right job to right person
c) efficient utilisation of resources
d) Cost monitoring and cost management

Fundamentals of
Quality Management

Check Your Progress 3

1) It is only a tool, which the administrator can use to correct the disorganised
resources of men, machines, materials and money into a useful and effective
mstitution. Management is the process whereby those unrelated resources are
integrated illto a total system of objective accomplishment.

2) a) to achieve. sustaii~and improve the quality of product or service

b) to assure the management that internal controls are effective.
c) to assure the customer that the service conforms to his requirement.
3) a) maintaining quality through checks individually and centrally.

b) customer oriented service

c) utilisation of intellect of the operator- e.g. 'quality circle'.
d) continuous improvement. ;
4) a) Increase of image and credibiIity
b) Higher productivity and profitability
Higher potential for growth

C)

d) Baseline information for planning of services

e) Safeguard interests of providers and recipients of care.

Check Your Progress 4

1) a) Normal
b) Legal
c) Contain cost df care
d) Identify inaccuracies in the system
e) Regulate activities to ensure quality and eficiency
f ) Assess effectiveness of services rendered.

2) a) Organisational analysis by reviewing external environment, examining existing

characteristics of internal organisation to ascertain strengths and weakness, and
thereby identifying the problem areas for detailed analysis of cause and effect
relationship.
'

b) Awareness campaign and development of quality culture

C)

Training of all managers and other members of staff

d) Development of quality manual

e) Development of Hospital Information System
3) a) Efficacy

b) Appropriateness
c) Availability
d) Timeliness
e) Effectiveness
f) Continuity

9) Safety
h) Efficiency
i) Respect & Caring

Check Your Progress 5

1)

One should look at the entire process. including, the resources available. the

<'ballcnges i n H o s p i t a l
Vl'lnnagernent

setting in which the care is rendered, the process of delivery of care. and the
competency of those delivering the care.
2)

Beds, personnel, equipment, supplies, space, technology, rules and procedures. and
finance.

3)

At the level of (a) input. i.e. the quantity and quality of resources made available, (b)
process i.e. how efficiently the resources are utilised for delivery of care, and (c)
output or outcome, i.e. checks and measures applied to ensure quality at the time of
final disposal of the product or service.

JCAHO: Accreditation Manualfor Hospital, vol.1 Standards, 1995, One Renaissance

Boulevard, Oakhrook Tenace, Illinois- 6018 1. USA.
Raandi Schmidt, J.Trumbo, and R. Johnson: Quality Assumnce in Hecllth Care service^.
ASQC Quality Press.
Richard P. Wenzel. Assessing Quality Health Care: Perspectivesfor Clinicians,William &
W i b
Rosander, A.C.: Deming 's 14 Points Applied to Services, ASQC Quality Press.
Rosander, A.C.: The Quest for Quality in Services, ASQC Quality Press.
Vincent K. On~achonu:Total Quality and Productivity Management in Health Core
Organisations, ASQC Quality Press.