Source: The New Healthcare Market by P. Boland (1988) Cited in Lanning (1990)
However, as identified by the author, there are different definitions as to the meaning of quality in the NHS. This has inhibited a ‘systems view to the services provided. In one particular hospital visited by the author, there were four different definitions of quality in use:
3. To the Chief Executive, ‘quality is low cost’.
4. To the Quality Manager, ‘meeting every patients’ needs is ridiculous, the hospital cannot afford that, we can only try to provide the patient with what is medically advisable’. This means what the patient actually needs.
In one other hospital an employee defined quality as ‘Auditing’. This means ‘checking me to see whether I do my job well’. Another employee in this particular hospital asked the Quality Manager, ‘When is this quality thing going to finish?". What was evident in this latter hospital was that whilst TQM was in full swing, most employees felt that this "quality thing" was unnecessary after all, ‘we do our job well’; confirming the fact that in a professional setting, once an employee feels he or she is carrying out a job within the confines of professional requirements he is providing a quality service, it does not matter whether the patient is satisfied. Whereas in the private sector, employees provide services in order to ensure repeat customers. Thus, in most cases with private sector, the needs of the customer are met.
These findings are congruent with the study by Kogan et al151, who noted a "lack of a common definition of quality in the NHS, due to the diverse professional groupings". Whilst Dailey and Mclver152, also identified a parallel mixture of definitions of quality. They noted a mixture of both Donabedian and Maxwells’ definitions in the NHS. However, the author disagrees with the assertion of Dailey and Mclver because, in the NHS, many managers are not familiar with the quality literature to know about Donabedian’s or Maxwell’s definitions. Whilst their actions might portray these definitions, the Quality Managers with whom the author spoke all defined quality from a basic premise of "meeting customer needs"; rarely did they mention a definition offered by any particular writer. Although it could be suggested that Crosby’s definition of quality, ‘meeting customer requirements’, is more widespread than any other definition of quality. But, if the members of a typical Trust Hospital’s Board were to be asked for their definition of quality, the question would generate answers revealing different and varying aspects of the definition of quality, whereas in a commercial organisation, say Miliken Europe, the Board would have one consensual
as to what quality means is as a result of the failure of Quality Managers to adopt an organisation-wide definition of quality.
One Quality Manager noted that the definition of quality is implicit, "everyone knows that quality is about meeting customer needs. Hence, it is not important to adopt an organisation-wide definition of quality". In the author’s opinion, the failure of most NHS hospitals to adopt a specific definition of quality has contributed to the lack of a systematic approach to the implementation of TQM. A commonly held definition by all employees is a good starting point for TQM because it provides the organisation with the ultimate ‘focus* for TQM. For example, Juran’s definition of quality, ‘Fitness for Use’, as an organisation wide definition informs the workforce explicitly that the services we provide should be ‘fit for purpose’ of our customers. Thus, providing the opportunity for every employee to adopt the new philosophy. An organisation-wide definition of quality is a must for the successful implementation of TQM.
WHAT IS TOTAL QUALITY MANAGEMENT?
One of the difficulties in the discussion of Total Quality Management is the apparent lack of consensus as to what it means153. There seems to be confusion as to what different commentators mean when they discuss TQM, although certain buzzwords are common in the literature, for example, ‘Zero defects’, ‘Right first time’, ‘Plan-do- check-act’ and ‘Fitness for use’154. However, Oakland, tries to ease this confusion by arguing that while the so-called quality ‘gurus’ (Deming, Juran, and Crosby) seem to present "different solutions to the problems of quality management and control, their solutions only reflect differences in dialect rather than language"155. The British Quality Association (BQA) have put forward three definitions of TQM156. The first focuses on the ‘soft’ qualitative characteristics; customer orientation, culture of excellence, removal of performance barriers, teamwork, training, employee participation and competitive edge. From this perspective, TQM is seen as consistent with open management styles, delegated responsibility and the empowerment of staff157.
an obsession with quality, the need for a scientific approach and the view that all employees are part of one team158. However, these definitions are rather arbitrary and it is unlikely that the practising manager would have much time for the ‘soft’ side of TQM given their emphasis on tools, measurement and bottom-line performance159. For Oakland, "TQM is a ‘way of managing to improve the effectiveness, flexibility and competitiveness of the business as a whole’, meeting customer requirements both external and internal to the organisation"160. TQM is conceptualised in the form of a triangle - with the three points representing; ‘management commitment’, ‘statistical process control’ and ‘teamworking’ - and a chain, indicating the interdependence of customer - supplier links throughout the organisation. The concept of a quality chain is central to Oakland’s view of TQM. His concern is that the chain can be broken at any point by one person or piece of equipment not meeting the requirements of the internal or external customer, and that this failure usually finds its way to the interface with external customers. By focusing on internal customer expectations all along the supply chain to the final customer in the market place, the intention is to build up an internal customer environment161. But, Oakland does not tell us explicitly how this internal customer environment will be built. He also tends to forget about the external customer environment and throughput process of the organisational environment. For Collard, quality management represents "a systematic way of guaranteeing that all activities within an organisation happen the way they have been planned. It is a management discipline concerned with preventing problems from occurring by creating the attitude and controls that make prevention possible"162. Furthermore, Collard draws attention to the fact that everything that is done within a company depends on people and it is essential to motivate everyone within the organisation with the commitment to quality163. However, Collard forgets that no matter how motivated ‘people’ are to the TQM process within an organisation, it is only the top management that can effect changes. Thus, it is imperative that top management is the first to be motivated and to exhibit commitment, in order for TQM to work; because it is the responsibility of top management to effect 98 percent of the changes required in the system whilst employees are only able to make 2 percent change which is inadequate in creating an environment of continuous quality improvement.
Dale and Plunkett suggest that for the implementation of TQM, "it is necessary to change behaviour and attitudes throughout the organisation"164. They suggest that, the key features of TQM are: "employee involvement and development and a teamwork approach to dealing with improvement activities". Although Dale and Plunkett accord a recognition to the role which must be played by employees in making TQM operate effectively, the principal focus of their work remains on the statistical and operational characteristics of the system165. However, the author would add that TQM is based on an understanding of a combination of organisational values, customer expectations and the granting to employees of the opportunity to deliver good service to the customer. This implies that a TQM programme centred around statistical control of processes would encounter difficulties because of the limited knowledge of statistical tools amongst many employees. This view is consistent with the work of Schaffer and Thompson who note that many organisations have failed to adapt Deming’s philosophy because of its emphasis on statistical control of processes166.
Furthermore, involving employees and undertaking a teamwork approach does not necessarily guarantee quality. In the author’s opinion, what makes quality work, irrespective of teamwork, is an optimised organisational ‘system’. A system designed to meet both external and internal environmental needs and expectations. Thus, without an optimised system which works under a hundred percent statistical control, any TQM initiative will falter.
For Crosby quality has no qualifiers. He defines quality management as a systematic way of guaranteeing that organised activities happen the way they are planned. ‘It is a management discipline concerned with preventing problems from occurring by creating the attitudes and controls that make prevention possible’167. TQM advocates zero defects in the products and services produced by an organisation. It is about driving quality into all aspects of a company’s operation and perhaps, even more importantly, it is about doing things ‘right first time’; an approach which adds nothing to the cost of a company’s product or services168. The author questions Crosby’s idea
TOTAL - Organisation-wide process involving everyone from post room to the board room.
QUALITY - Establishing quality goals for each and every element in the process of product or service delivery so as to meet customer needs and expectations fir time and on every subsequent occasion.
MANAGEMENT - Not just commitment of senior management to quality goals but senior management’s active involvement in pursuit of them.
They go further to suggest that TQM is a process which embraces the conscious striving for zero defects in all aspects of an organisation’s activities or management with workforce co-operating in the processes developing, producing and marketing quality goods and services which satisfy customers’ needs and expectations first time and every subsequent time170.
Whilst for Macdonald and Piggot171 quality management is not a fixed body of truths but a process that is evolving and which will take different forms to meet the needs of individual companies. Whereas Atkinson172, taking a proactive stance, sees TQM as a preventative strategy replacing rework, fire-fighting and crisis management by planning, coordination and control. TQM, he suggests, is the umbrella under which a great number of quality initiatives can be managed. However, Sinclair notes that such definitions as put forward by MacDonald and Piggot and Atkinson are limited because of the failure to recognise the role and place of the workers within organisations. It is this failure which has been responsible for the failure of many programmes of TQM173.
Lesley and Malcolm Munro-Faure define TQM as ‘a proven, systematic approach to the planning and management of activities’174. They state that the objective of TQM is to satisfy customer requirements as efficiently and profitably as possible. In a total quality environment all employees must strive to:
(i) do the right things - only the activities that satisfy the requirements of customers should be encouraged, all other activities are to be analysed or discontinued if they are considered unnecessary
(ii) do things right - all organisational activities should be performed correctly to ensure that output meets customer requirements
(iii) do things right first time, everytime - if this is possible, then money should not be wasted on checking, and scrapping output or correcting errors.
They go further to suggest that TQM can be successfully applied to any type of organisation provided it integrates certain components175:
FIGURE 9
TOM: COMPONENTS OF TOM MEETING CUSTOMER REQUIREMENTS AT MINIMUM COST Understanding Cutomers - external -internal Continuous quality improvement - management commitment - employee involvement education team work Quality Mangt systems - BS 5750 - ISO 9000 AQAD measurement error prevention Understanding the business - functional analysis quality costs Quality tools -SPC - OFD - Benchmaning - Problem solving
Source: Lesley & M.M. Faure. Implementity TQM. 1992
The author agrees with the components of TQM as advocated by Lesley and Malcolm Faure but would suggest that any model of TQM should establish clear, customer- oriented performance standards and the meticulous measurement of performance against those standards. A commitment to TQM without a commitment to standards and
measurement would be a dedication to lip service, not customer service. Only with customer-focused standards and customer-based satisfaction measurements is it possible to create and maintain a quality focused organisation.
Hagan notes that the underlying theme of most discussions on TQM is two fold176: the need for sufficient cultural changes in industry to support the concept of continuous quality improvement, and the need to carry this concept beyond traditional quality assurance applications into work processes, ultimately including management:
FIGURE 10
A CLOSEP-LQQP NOTION OF TWO UNDERLYING THEMES OF TOM