Joseph P.McClain Walter Reed Army Medical Center
In today’s complex health care environment, quality improvement and team building must go hand in hand. This is especially true for Clinical Engineers and Biomedical Equipment Technicians as the diversity of the field increases and technology moves so rapidly that no one can know all that needs to be known without the help of others.
Therefore, it is important that we work together to ensure quality improvement. Ken Blachard, the author of the One Minute Manager series, has made the statement that “all of us are smarter than any one of us”—a synergy that evolves from working together.
Throughout this chapter we will look closely at defining quality and the methods for continuously improving quality, such as collecting data, interpreting indicators, and team building. All this will be put together, enabling us to make decisions based on scientific deciphering of indicators.
Quality is defined as conformance to customer or user requirements. If a product or service does what it is supposed to do, it is said to have high quality. If the product or service fails its mission, it is said to be of low quality. Dr. W.Edward Demings, who is known to many as the “father of quality,” defined it as surpassing customer needs and expectations throughout the life of the product or service.
Dr. Demings, a trained statistician by profession, formed his theories on quality during World War II while teaching industry how to use statistical methods to improve the quality of military production. After the war, he focused on meeting customer or consumer needs and acted as a consultant to lapanese organizations to change consumers’
perceptions that “Made in lapan” meant junk. Dr. Demings predicted that people would be demanding lapanese products in just 5 years, if they used his methods. However, it only took 4, and the rest is history.
5.1 Deming’s 14 Points
1. Create constancy of purpose toward improvement of product and service, with an aim to become competitive and to stay in business and provide jobs.
2. Adopt the new philosophy. We are in a new economic age. Western management must awaken and lead for change.
3. Cease dependence on inspection to achieve quality. Eliminate the needs for mass inspection by first building in quality.
4. Improve constantly and forever the system of production and service to improve quality and productivity and thus constantly decrease costs.
5. Institute training on the job.
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6. Institute leadership: The goal is to help people, machines, and gadgets to do a better job.
7. Drive out fear so that everyone may work effectively for the organization.
8. Break down barriers between departments
9. Eliminate slogans, exhortations, and targets for the workforce.
10. Eliminate work standards (quota) on the factory floor.
11. Substitute leadership: Eliminate management by objective, by numbers, and numerical goals.
12. Remove barriers that rob the hourly worker of the right to pride of workmanship.
13. Institute a vigorous program of education and self-improvement.
14. Encourage everyone in the company to work toward accomplishing transformation.
Transformation is everyone’s job.
5.2 Zero Defects
Another well-known quality theory, called zero defects (ZD), was established by Philip Crosby. It got results for a variety of reasons. The main reasons are as follows:
1. A strict and specific management standard. Management, including the supervisory staff, do not use vague phrases to explain what it wants. It made the quality standard very clear: Do it the right way from the start. As Philip Crosby said, “What standard would you set on how many babies nurses are allowed to drop?”
2. Complete commitment from everyone. Interestingly, Crosby denies that ZD was a motivational program. But ZD worked because everyone got deeply into the act.
Everyone was encouraged to spot problems, detect errors, and prescribe ways and means for their removal. This commitment is best illustrated by the ZD pledge: “I freely pledge myself to make a constant, conscious effort to do my job right the first time, recognizing that my individual contribution is a vital part of the overall effort.”
3. Removal of actions and conditions that cause errors. Philip Crosby claimed that at ITT, where he was vice-president for quality, 90% of all error causes could be acted on and fully removed by first-line supervision. In other words, top management must do its part to improve conditions, but supervisors and employees should handle problems directly. Errors, malfunctions, and/or variances can best be corrected where the rubber hits the road—at the source.
5.3 TQM (Total Quality Management)
The most recent quality theory that has found fame is called TQM (Total Quality Management). It is a strategic, integrated management system for achieving customer satisfaction that involves all managers and employees and uses quantitative methods to continuously improve an organization’s processes. Total Quality Management is a term coined in 1985 by the Naval Air Systems Command to describe its management approach to quality improvement. Simply put, Total Quality Management is a management approach to long-term success through customer satisfaction. Total Quality Management
includes the following three principles: (1) achieving customer satisfaction, (2) making continuous improvement, and (3) giving everyone responsibility. TQM includes eight practices. These practices are (1) focus on the customer, (2) effective and renewed communications, (3) reliance on standards and measures, (4) commitment to training, (5) top management support and direction, (6) employee involvement, (7) rewards and recognition, and (8) long-term commitment.
5.4 CQI (Continuous Quality Improvement)
Step 8 of the total quality management practices leads us to the quality concept coined by the Joint Commission on Accreditation of Healthcare Organizations and widely used by most health care agencies. It is called CQI (Continuous Quality Management). The principles of CQI are as follows:
Unity of Purpose
• Unity is established throughout the organization with a clear and widely understood vision.
• Environment nurtures total commitment from all employees.
• Rewards go beyond benefits and salaries to the belief that “We are family” and “We do excellent work.”
Looking for Faults in the Systems
• Eighty percent of an organization’s failures are the fault of management-controlled systems.
• Workers can control fewer than 20% of the problems.
• Focus on rigorous improvement of every system, and cease blaming individuals for problems (the 80/20 rule of J.M.Juran and the 19th-century economist Vilfredo Pareto).
Customer Focus
• Start with the customer.
• The goal is to meet or exceed customer needs and give lasting value to the customer.
• Positive returns will follow as customers boast of the company’s quality and service.
Obsession with Quality
• Everyone’s job.
• Quality is relentlessly pursued through products and services that delight the customer.
• Efficient and effective methods of execution.
Recognizing the Structure in Work
• All work has structure.
• Structure may be hidden behind workflow inefficiency.
• Structure can be studied, measure, analyzed, and improved.
Freedom through Control
• There is control, yet freedom exists by eliminating micromanagement.
• Employees standardize processes and communicate the benefits of standardization.
• Employees reduce variation in the way work is done.
• Freedom comes as changes occur, resulting in time to spend on developing improved processes, discovering new markets, and adding other methods to increase
productivity.
Continued Education and Training
• Everyone is constantly learning.
• Educational opportunities are made available to employees.
• Greater job mastery is gained and capabilities are broadened.
Philosophical Issues on Training
• Training must stay tuned to current technology.
• Funding must be made available to ensure that proper training can be attained.
• Test, measurement, and diagnostic equipment germane to the mission must be procured and technicians trained on its proper use, calibration, and service.
• Creativity must be used to obtain training when funding is scarce.
• Include training in equipment procurement process.
• Contact manufacturer or education facility to bring training to the institution.
• Use local facilities to acquire training, thus eliminating travel cost.
• Allow employees to attend professional seminars where a multitude of training is available.
Teamwork
• Old rivalries and distrust are eliminated.
• Barriers are overcome.
• Teamwork, commitment to the team concept, and partnerships are the focus.
• Employee empowerment is critical in the CQI philosophy and means that employees have the authority to make well-reasoned, data-based decisions. In essence, they are entrusted with the legal power to change processes through a rational, scientific approach.
Continuous quality improvement is a means for tapping knowledge and creativity, applying participative problem solving, finding and eliminating problems that prevent quality, eliminating waste, instilling pride, and increasing teamwork. Further it is a means
for creating an atmosphere of innovation for continued and permanent quality improvement. Continuous quality improvement as outlined by the Joint Commission on Accreditation of Healthcare Organizations is designed to improve the work processes within and across organizations.
5.5 Tools Used for Quality Improvement
The tools listed on the following pages will assist in developing quality programs, collecting data, and assessing performance indicators within the organization. These tools include several of the most frequently used and most of the seven tools of quality. The seven tools of quality are tools that help health care organizations understand their processes in order to improve them. The tools are the cause-and-effect diagram, check sheet, control chart, flowchart, histogram, Pareto chart, and scatter diagram. Additional tools shown are the Shewhart cycle (PDCA process) and the bar chart. The Clinical Engineering Manager must access the situation and determine which tool will work best for his or her situational needs.
Two of the seven tools of quality discussed above are not illustrated. These are the scatter diagram and the check sheet. The scatter diagram is a graphic technique to analyze the relationship between two variations and the check sheet is simple data-recording device. The check sheet is custom designed by the user, which facilitates interpretation of the results. Most Biomedical Equipment Technicians use the check sheet on a daily basis when performing preventive maintenance, calibration, or electrical safety checks.