Influences on the implementation of TQM in health care organizations: professional bureaucracies, ownership and complexity

TQM is introduced into many organisations in an attempt to improve productivity and quality. There are a number of organisational variables that have been recognised as influencing the success of TQM implementation including leadership, teamwork, and suppliers. This paper presents findings of a study of the implementation of TQM in Australian health care organisations. Structural factors were observed to affect the progress of TQM. Professional bureaucracies were less successful than machine bureaucracies. Private organisations were more successful than their public counterparts.

EBM in healthcare: management and policy

The nature of policymaking often precludes a significant role for formal evidence-based practice. Management practice is also bereft of formal evidence and appears unlikely to change because of the methodological constraints on collecting good evidence. Despite this, policymakers and managers are keen to promote evidence-based clinical practice. This, in part, reflects rational management's desire to standardise the clinical process and develop the profession's accountability to the management hierarchy. To the extent that clinical practice is dependent on organisational settings, this push is inevitable. Widespread and persistent small-area variation in clinical practice, and concern over apparent high levels of avoidable error, make doctors vulnerable to these efforts to standardise clinical practice.

The effect of genomics on health services management: ethical and legal perspectives

The growing use of genetic testing for diagnostic and predictive purposes, and for the purpose of selecting therapeutic regimens with better risk-benefit ratios for patients, raises numerous legal and ethical challenges. Researchers and institutional review boards must pay careful attention to the need to obtain informed consent from subjects. The FDA will face increased pressure to more carefully regulate the accuracy of genetic testing. Clinicians will need to safeguard the privacy and confidentiality of sensitive patient information, especially when testing is performed in settings in which the information may be readily accessible to insurers and employers. Novel genomic treatments may increase liability for drug manufacturers, but physicians and other healthcare providers, including health plans' drug formularies, will bear the primary liability risk. Difficult questions of distributive justice also must be faced if third-party payers resist covering genomic services because of their cost. Down the road, more aggressive gene therapy techniques and the ability to test for non-disease traits will tax our notions of fairness, equality, and the limits of professional authority.

Compliance programs: beyond billing and coding

Ensuring the success of your compliance program means keeping your eye on more than billing and coding. The author highlights some issues on the horizon for compliance officers.

Conflict of interest: organizational vs. executive ethics in health care

This survey of 207 senior- and mid-level administrators from across the U.S. details the surprising level and type of ethical conflicts and unethical practices they face on the job and how their organizations create and respond to these challenges. The findings suggest widespread ethical conflict caused by situational and environmental factors, financial incentives, boards of directors, and stakeholder pressure. Particularly poignant is the apparent inability of executives to alter the ethical environment. Substantial differences were found between nonprofit and proprietary sector administrators as well as gender and age groups.

[Accreditation: the outcome is worth the time and money]

When the Canadian Council on Health Services Accreditation adopted the Client-centered Accreditation Program (CCAP), we had to assess our methods and results and encourage the staff at all levels and the users to be involved. A complete change, considerable benefits: improved staff knowledge of the organisation, support and understanding within the teams, improved training through team meetings, more room for the patients and their families. Is accreditation costly? One cannot put a price on the degree of satisfaction experienced by the staff within a team who listens to their opinions and strives to make the daily routine as rewarding as possible.

Organizational justice principles and large-scale change: the case of program management

Many of the barriers to implementation of large-scale change in healthcare organizations seem to be related to a lack of attention to the human change that needs to occur. One element of this human dimension that change agents overlook is the role that perception of fairness to employees plays in implementing large-scale organizational change. This article uses program management (an organizational design that has been implemented in many healthcare facilities across Canada) as an example of large-scale structural change and demonstrates the importance of applying procedural and interactional justice principles to enhance the implementation of organizational change.

IOM committee calls for complete revamping of health care system to achieve better quality

The health care system can no longer deliver quality care the way it is currently organized, according to a new report, Crossing the Quality Chasm, released March 1 by the Institute of Medicine's Committee on Quality of Health Care in America. Instead, the committee says that it is time to reinvent the system.

Community and consumer participation in Australian health services--an overview of organisational commitment and participation processes

This article briefly describes recent initiatives to improve consumer participation in health services that have led to the establishment of the National Resource Centre for Consumer Participation in Health. The results of a component of the needs assessment undertaken by the newly established Centre are presented. They provide a 'snapshot' of the types of feedback and participation processes mainly being utilised by Australian health services at the different levels of seeking information, information sharing and consultation, partnership, delegated power and consumer control. They also allow identification of the organisational commitment made by Australian health services to support a more coordinated approach to community and consumer feedback and participation at different levels of health services such as particular emphasis on determining the presence of community and consumer participation in key organisational statements, specific consumer policies and plans, identifiable leadership, inclusion into job descriptions, allocation of resources, and staff development and consumer training. Discussion centres around four key observations and some of the key perceived external barriers.

Assessing the relationship between quality of care and the characteristics of health care organizations

In the past two decades, relationships among health plans, medical groups, and providers have grown more complex and the number of clinical management strategies has increased. In this context, determining the independent effect of a particular organizational strategy on quality of care has become more difficult. The authors review some of the issues a researcher must address when studying the relationship between organizational characteristics and quality of care. They offer criteria for selecting a research question, list organizational characteristics that may influence quality, and suggest sampling and study design techniques to reduce confounding. Since this type of research often requires a health care organization as collaborator, the authors discuss strategies for developing research partnerships and collecting data from the partner organization. Finally, they offer suggestions for translating research into policy.

The introduction of the frontline management initiative in South Western Sydney Area Health Service

This article provides an overview of the development and implementation of a management development strategy for the South Western Sydney Area Health Service (SWSAHS). The program, the Frontline Management Initiative (FMI), was introduced as a developmental tool which enabled managers to identify those competencies that they already possess and those which they need to develop. The FMI will be progressively implemented throughout the five sector health services of SWSAHS comprising approximately 1500 managers. This article outlines the introduction and experience of FMI in one sector health service, the development and assessment of a manager's portfolio, the pathway developed from FMI to university based health management courses, the lessons learnt and the future directions for management development.

Quality, CQI, and reengineering in health services organizations

Quality in health care is defined with a focus on satisfying customer needs. The contemporary management philosophies of continuous quality improvement (CQI) and reengineering are defined; attributes and applications of each are described. Criticism of reengineering appearing in the literature is presented. It is likely that CQI will remain a predominate management philosophy in health services, while reengineering may not endure in its form of radical change.

Making health care safer: a critical analysis of patient safety practices

OBJECTIVES

Patient safety has received increased attention in recent years, but mostly with a focus on the epidemiology of errors and adverse events, rather than on practices that reduce such events. This project aimed to collect and critically review the existing evidence on practices relevant to improving patient safety.

SEARCH STRATEGY AND SELECTION CRITERIA

Patient safety practices were defined as those that reduce the risk of adverse events related to exposure to medical care across a range of diagnoses or conditions. Potential patient safety practices were identified based on preliminary surveys of the literature and expert consultation. This process resulted in the identification of 79 practices for review. The practices focused primarily on hospitalized patients, but some involved nursing home or ambulatory patients. Protocols specified the inclusion criteria for studies and the structure for evaluation of the evidence regarding each practice. Pertinent studies were identified using various bibliographic databases (e.g., MEDLINE, PsycINFO, ABI/INFORM, INSPEC), targeted searches of the Internet, and communication with relevant experts.

DATA COLLECTION AND ANALYSIS

Included literature consisted of controlled observational studies, clinical trials and systematic reviews found in the peer-reviewed medical literature, relevant non-health care literature and "gray literature." For most practices, the project team required that the primary outcome consist of a clinical endpoint (i.e., some measure of morbidity or mortality) or a surrogate outcome with a clear connection to patient morbidity or mortality. This criterion was relaxed for some practices drawn from the non-health care literature. The evidence supporting each practice was summarized using a prospectively determined format. The project team then used a predefined consensus technique to rank the practices according to the strength of evidence presented in practice summaries. A separate ranking was developed for research priorities.

MAIN RESULTS

Practices with the strongest supporting evidence are generally clinical interventions that decrease the risks associated with hospitalization, critical care, or surgery. Many patient safety practices drawn primarily from nonmedical fields (e.g., use of simulators, bar coding, computerized physician order entry, crew resource management) deserve additional research to elucidate their value in the health care environment. The following 11 practices were rated most highly in terms of strength of the evidence supporting more widespread implementation. Appropriate use of prophylaxis to prevent venous thromboembolism in patients at risk; Use of perioperative beta-blockers in appropriate patients to prevent perioperative morbidity and mortality; Use of maximum sterile barriers while placing central intravenous catheters to prevent infections; Appropriate use of antibiotic prophylaxis in surgical patients to prevent postoperative infections; Asking that patients recall and restate what they have been told during the informed consent process; Continuous aspiration of subglottic secretions (CASS) to prevent ventilator-associated pneumonia; Use of pressure relieving bedding materials to prevent pressure ulcers; Use of real-time ultrasound guidance during central line insertion to prevent complications; Patient self-management for warfarin (Coumadin) to achieve appropriate outpatient anticoagulation and prevent complications; Appropriate provision of nutrition, with a particular emphasis on early enteral nutrition in critically ill and surgical patients; and Use of antibiotic-impregnated central venous catheters to prevent catheter-related infections.

CONCLUSIONS

An evidence-based approach can help identify practices that are likely to improve patient safety. Such practices target a diverse array of safety problems. Further research is needed to fill the substantial gaps in the evidentiary base, particularly with regard to the generalizability of patient safety practices heretofore tested only in limited settings and to promising practices drawn from industries outside of health care.

Spirituality and healthcare organizations

In recent years, the place of spirituality in organizations has become increasingly discussed and advocated. On a personal level, this may involve achieving personal fulfillment or spiritual growth in the workplace. In the broader sense, spirituality is considered by many to be essential in an organization's interactions with employees, customers, and the community. This article describes a possible role for greater spirituality in healthcare organizations, whose cultures in recent decades have largely excluded spirituality or religiousness. This is the consequence of an analytical, scientific perspective on human health; a reductionist paradigm in biomedical research; and the inevitable bureaucratization occurring in large healthcare organizations. However, in recent decades, numerous scientific articles supporting a connection between faith or religiousness and positive health outcomes have been published. Because individuals seek meaning when experiencing severe illnesses, and humans universally respond to compassion and caring, spirituality among healthcare workers and managers appears highly appropriate. The article describes organizational barriers to the greater inclusion of spirituality in healthcare and presents several approaches to developing a more caring organization. These include eliciting extensive input from all staff and clinicians in identifying core or common values, ethics, and a philosophy of caring. Programs should ensure that the views of nonreligious staff and patients are respected and that clear guidelines are established for the extent and nature of affective or spiritual support for patients.

Application of activity-based costing (ABC) for a Peruvian NGO healthcare provider

This article describes the application of activity-based costing (ABC) to calculate the unit costs of the services for a health care provider in Peru. While traditional costing allocates overhead and indirect costs in proportion to production volume or to direct costs, ABC assigns costs through activities within an organization. ABC uses personnel interviews to determine principal activities and the distribution of individual's time among these activities. Indirect costs are linked to services through time allocation and other tracing methods, and the result is a more accurate estimate of unit costs. The study concludes that applying ABC in a developing country setting is feasible, yielding results that are directly applicable to pricing and management. ABC determines costs for individual clinics, departments and services according to the activities that originate these costs, showing where an organization spends its money. With this information, it is possible to identify services that are generating extra revenue and those operating at a loss, and to calculate cross subsidies across services. ABC also highlights areas in the health care process where efficiency improvements are possible. Conclusions about the ultimate impact of the methodology are not drawn here, since the study was not repeated and changes in utilization patterns and the addition of new clinics affected applicability of the results. A potential constraint to implementing ABC is the availability and organization of cost information. Applying ABC efficiently requires information to be readily available, by cost category and department, since the greatest benefits of ABC come from frequent, systematic application of the methodology in order to monitor efficiency and provide feedback for management. The article concludes with a discussion of the potential applications of ABC in the health sector in developing countries.

Performance appraisal: a primer for the lower level health care and rehabilitation worker

This article reviews the use of performance appraisal in health care and rehabilitation organizations, particularly as such an evaluation measure could be used to examine the results achieved by managerial and supervisory level personnel. This entails a reversal of the prevailing view, that is, appraisal of lower level workers by "superiors" to a counter view as seen from those at "lower levels" looking upwards. Hierarchies, of course, are facing increasing challenges. Performance appraisal can serve the needs of the people at the lower end as well as those defined as the "management." Ultimately, performance appraisal can assure that all people in an organization will achieve benefits, not just those at the managerial level.

Paul E. Plsek on creativity and innovation in organizational change. Interview by Paul L. Green

Mr. Plsek is an independent consultant with 20 years of diverse experience in the field of quality management. He has written numerous articles, presented papers at a variety of conferences, and led seminars for more than 10,000 managers and executives in diverse companies. His seminar, "Creative Thinking for Serious People," has taught people that there can be a serious approach to innovation. He also has served in a variety of engineering and management positions at AT&T and Bell Laboratories and is a senior fellow with the Institute for Healthcare Improvement. Mr. Plsek has BS and MS degrees in electrical engineering from Texas A & M University and the Polytechnic Institute of New York (Brooklyn).