Quality management in healthcare: The pivotal desideratum (2023)

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  • J Oral Biol Craniofac Res
  • v.9(2); Apr-Jun 2019
  • PMC6561897

Quality management in healthcare: The pivotal desideratum (1)

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J Oral Biol Craniofac Res. 2019 Apr-Jun; 9(2): 180–182.

Published online 2018 Jun 30. doi:10.1016/j.jobcr.2018.06.006

PMCID: PMC6561897

PMID: 31211031

(Video) "5Ws” of Quality Improvement in Neonatal Care by Prof Prakesh S Shah, University of Toronto, Canada

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Health care is very complex sector and delivery of service is the fragmented care. Quality can be a common paradigm to address the need of all groups in health care. Quality improvement is the process approach to the organization’s operational challenges. The initiative to address the quality in health care has become a global phenomenon. A quality revolution for delivery of service with patient at the center and services around it is the demand of the time. This article comprehensively reviews the quality management in health care service and aims to sensitize the health care professionals towards achieving total quality.

Keywords: Continuous quality improvement, Health care organization, Quality, Total quality management

1. Introduction

A Health Care Organization (HCO) is a complex organization by nature owing to the intangible outcome of service and a blend of diverse professional personnel. Quality management in healthcare is a critical requirement in health sector. The principles of quality have been implicit in health care. However, quality is not a physical attribute service. Use of the term ‘Health Care Service’ in place of ‘Medical Care’ further defines the field and puts it as an entity that can be assessed, monitored and improved. A quality healthcare system can be defined as “one that is accessible, appropriate, available, affordable, effective, efficient, integrated, safe, and patient related”.1 Health care is delivered by practitioners in allied health services, dentistry, midwifery, obstetrics, medicine, nursing, optometry, pharmacy, psychology and other care providers.

Quality management in health care is a wide term. Initially it was perceived as directing the healthcare personnel to what to do. However, its current interpretation is to manage the process of care.2 It refers to observing the organizational functions as an interaction of procedures and processes that can be addressed individually and collectively. Although various models have been put forth, however, the concept of triad of structure, process and outcome proposed by Donabedian remains the foundation of quality assessment today.3

(Video) 5Ws” of Quality Improvement in Neonatal Care by Prof Prakesh S Shah, University of Toronto, Canada

Quality management has emerged as the dire need more fiercely than ever in light of the new definition of the quality with patient satisfaction as the outcome of service. The quality of services being provided to patients is highly crucial. The traditional view of quality control aimed at defect detection while the current concept aims at the defect prevention, continuous process improvement, and outcome driven system guided by patients’ needs. Hence there is a crying need to bring about a paradigm shift in quality of health care delivery.4 The authorities need to step forward to get involved in quality.5 Currently, the quality has been addressed more in medical field than in the allied fields such as dentistry and nursing and also more in the developing country context.

2. Quality

‘Quality’ has different definitions, ranging from traditional to those that are strategic. The American National Standards Institute (ANSI) and American Society for Quality (ASQ) defines quality as the totality of features and characteristics of a care or service that bears on its ability to satisfy given needs. W Edwards Deming, the father of concept of TQM has defined quality as a strategy aimed at the needs of the customer. This strategic definition has received widest international acceptance. Joseph M Juran, another authority on quality, has defined quality as conformance to requirements.

Quality is a unit less value system interpreted as diverse view-points. It has been conceived as superiority of excellence or lacing patient care and service defect or conformance to requirements i.e. zero defects. The precise meaning of quality of care in HCO is ambiguous. It involves more than the earlier perception of ‘clinical quality’. The technical component is also included. The content quality in health care is determined and evaluated by the expectations of the health care professionals. The delivery quality of the health care service is determined by the patient satisfaction, is based on the patient expectations and linked with training and human interpersonal relations.6

2.1. Quality in health care

Medicine is a learned profession and it decides its own content quality. The focus for quality in health care is on simple preventive maintenance rather than total service maintenance. Donabedian proposed the use of triad of structure, process, and outcome to evaluate the quality of health care.3 The structure component includes the infrastructure, skill and qualifications of health care professionals and administrative systems to deliver the health care. The process encompasses the individual components of care and their interactions. The outcome is the recovery, restoration of function, and survival.

To understand quality the key features are reliability, assurance and responsiveness. The seven pillars of quality as presented by Donabedian are efficacy, efficiency, optimality, acceptability, legitimacy, equity, and cost. According to the Institute of Medicine, services are of quality, when they are safe, effective, patient centered, timely, efficient, and equitable.7

Quality management in health care has observed a paradigm shift from expecting errors and defects to considering that perfect patient experience is achievable. Philip Crosby supports the same principle that the system for causing quality is prevention and not the appraisal. Literature indicates that the cause of death for a large number of patients in hospitals is medical negligence and nosocomial infections. These deaths can be easily avoided by incorporating quality assurance programs.

System designs are important but are not enough in health care management. High value clinical care results from the most efficient expenditure of resources to achieve an established high level of clinical quality. Six Sigma design produces a yield of virtually zero defects. No single model has been established as superior to others in quality management. However, any mechanism would work if top management and the team are committed to quality.

Patient satisfaction is the desirable outcome of quality assurance program that requires patient-centered care delivery and also compliance with the standards and efficient protocols. The Institute of Medicine defines patient-centered care as a type of care that is respectful of and representative to individual patient preferences, needs, and values ensuring that patient values guide all clinical decisions. Another approach is the shared decision-making where clinicians and patients make decisions together using the best available evidence.

Patient satisfaction, a blurred term that lacks a clear and agreed-upon definition, is a multidimensional entity and is subjective to great extent.2 Majority of the studies to understand the intricacies of relationship between the three key components of service quality have been carried out in the developed country context, which cannot be generalized in the developing country context due to culture differences. The overall quality of the service provided is one of the key factors that patients consider important when choosing a dentist.8

Tools can be utilized to continually improve the effectiveness of quality management system. These include internal quality audit, subject feedback and corrective/preventive actions to meet applicable standards. IT-Integrated Health Management Information System and committed leadership facilitates the implementation. The four-step quality model, the plan-do-check-act (PDCA) cycle, also known as the Deming Cycle, is the most widely used tool for continuous quality improvement (CQI). (Fig. 1) Other methods are Six Sigma, Lean and total quality management (TQM). The Kano model has been adopted to identify patient requirements or enhance their satisfaction with healthcare services. Well defined protocols following standard operating procedures and continually trained staff are the internal measures to control quality, while accreditation is the external evaluation of quality.

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Fig. 1

Quality Control Flow Chart in Health Care Organization.

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2.2. Total quality management

The aim of the quality assurance programs in HCOs is to implement a system that is capable of managing the health care service to deliver a high quality service in a measurable way. The answer lies in TQM, a system that can address all the challenges of the organization. Total Quality Management (TQM) is defined as a management philosophy concerned with people and work processes that focuses on customer satisfaction and improves organizational performance.9 It encompasses Content Quality and Delivery Quality both. It decreases burden of errors, ensures optimal utilization of infrastructure and medical personnel and manages quality control.

The key principles of TQM are customer focus, obsession with quality, scientific approach, long-term commitment, teamwork, continual improvement systems, education, and training, freedom through control, and unity.10 It addresses not only the direct medical services of diagnosis and treatment but indirect operations as administration and purchase also. The nurses are the main personnel that contribute to achieve the success of implementation of this program.11

The TQM implementation is strengthened by the specific quality department.12 Various instruments have been developed to measure the healthcare service quality. Improved quality benefits all, reduces cost and it identifies problems before they actually cause harm. TQM helps reduce quality waste and imparts a continuous improvement of quality services and the employees. Research on the implementation of TQM has been limited, particularly in developing countries including India.13

2.3. Conclusion

Health care is a sacred and scientific enterprise and not fundamentally a commercial one. The competent authorities should enforce the responsibility for ensuring high quality standards and quality of care in healthcare facilities. The authority should consider shaping the curricula to ensure training of future professionals to increase patient satisfaction. To gain the desired momentum, HCOs need to initiate a new Quality Movement to achieve total quality in health care service. It is the need, the challenge and the future direction.


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(Video) Community of Practice Session I Canadian Neonatal Network - Key Learnings

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Articles from Journal of Oral Biology and Craniofacial Research are provided here courtesy of Elsevier

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What is the importance of quality management in healthcare? ›

Improved quality benefits all, reduces cost and it identifies problems before they actually cause harm. TQM helps reduce quality waste and imparts a continuous improvement of quality services and the employees.

What are some challenges of quality management in healthcare? ›

Six challenges to delivering quality healthcare
  • Lack of interoperability. ...
  • Optimizing clinical workflows. ...
  • Personnel shortages and burnout. ...
  • Keeping up with advances in medical science and information. ...
  • Advancing health equity. ...
  • Patient safety.
6 Sept 2022

What are the 6 IOM aims? ›

Its follow-up report, Crossing the Quality Chasm: A New Health System for the 21st Century (2001), introduced the IOM Six Aims for Improvement: care that is safe, timely, effective, efficient, equitable and patient-centered (STEEEP).

What are the 3 components of quality health care? ›

Effective – providing evidence-based healthcare services to those who need them; Safe – avoiding harm to people for whom the care is intended; and. People-centred – providing care that responds to individual preferences, needs and values.

How can we improve quality of healthcare? ›

5 Ways to Improve the Quality of Healthcare
  1. Collect Data and Analyze Patient Outcomes. If you can't measure it, then you can't manage it. ...
  2. Set Goals and Commit to Ongoing Evaluation. ...
  3. Improve Access to Care. ...
  4. Focus on Patient Engagement. ...
  5. Connect and Collaborate With Other Organizations.
9 Sept 2019

What is the biggest challenge facing healthcare? ›

Major Challenges Facing the Healthcare Industry Today
  • Cybersecurity Threats.
  • Telehealth Implementation.
  • Invoicing and Payments.
  • Price Transparency Mandate.
  • IT Healthcare Investments.
  • Patient Experience.
  • Effective Payment Models.
  • Healthcare Staffing Shortages.
24 May 2022

What are the factors affecting quality management? ›

The external factors like politics, competitors, economy, customers, and weather are beyond your control but can make a huge impact on your organization's performance and success. On the other hand, internal factors like processes, staff, culture, and financial situation can be controlled by you.

What are the two most significant challenges facing healthcare managers today? ›

The respondents pointed to increasing operating expenses, rising staff costs, and slow and inadequate reimbursement rates as among the most significant financial challenges facing healthcare administrators today.

Which 4 factors contribute to quality of care? ›

Factors Influencing the Quality of Healthcare Services
  • Clinical competence of the hospital staff. ...
  • Physical ambience of the hospital. ...
  • Amenities provided by the hospital. ...
  • Expertise of the physicians. ...
  • Behaviour of the staff. ...
  • In-patient experience. ...
  • Patient satisfaction.
11 Jul 2019

What are all the 6 key elements of high quality care? ›

The six domains of healthcare quality outlined by the Institute of Medicine are patient safety, effectiveness, patient-centred, timeliness, efficiency, and equity. Each of these is important for ensuring that patients receive high-quality care.

What are the 5 IOM core competencies? ›

A strategy for successful care coordination includes an understanding and implementation of the core competencies for all healthcare professionals as described by the Institute of Medicine (IOM, 2003) to include: 1) patient-centered care, 2) teamwork and collaboration, 3) evidence-based practice, 4) quality improvement ...

What's the most important aspect of healthcare quality? ›

Patient-centeredness - High-quality care is respectful of and responsive to individual patient preferences, needs, and values and ensures that patient values guide all clinical decisions.

What are 5 factors that identify quality healthcare? ›

External environment refers to the environment surrounding healthcare organizations that affects their performance and quality of services.
  • Patient socio- demographic variables. ...
  • Patient cooperation. ...
  • Patient illness (severity of illness) ...
  • Physician socio- demographic variables. ...
  • Physician competence (Knowledge and skills)

Who is responsible for quality in healthcare? ›

The Quality Director is basically the coach, facilitator, and mentor. His or her job is to instill principles of quality at all levels, helping everyone in the organization — every employee, executive, service user, caregiver, and consultant— feel driven to achieve excellence.

What is the best methods of improving quality? ›

PDSA Model:

Another important method of Quality Improvement is based on the PDSA model which involves a combination of building and applying knowledge. PDSA model comprises of Plan, Do Study and Act. This process runs as a cycle and needs to be repeated.

What are barriers to quality improvement in healthcare? ›

These include lack of funding, lack of staff training and resources, lack of support from management, lack of buy-in from clinicians, lack of leadership, poor communication, resistance to change and lack of data systems and analytics infrastructure.

What are the challenges of delivering quality care? ›

Faced with a barrage of regulations, there are several obstacles they face when trying to deliver quality care.
  • Budget Restraints. ...
  • Minimal Support for Staff. ...
  • Limited Buy-in. ...
  • Evolving Patient Needs.
14 Aug 2020

What are three barriers to receiving healthcare? ›

Physician shortages, poverty, a greater number of uninsured, and long travel distances add up to major discrepancies in healthcare equality between urban and rural America and pose a challenge to the national healthcare system that must be addressed.

What are the main principles of quality management? ›

What are the seven principles of quality management?
  • Engagement of people.
  • Customer focus.
  • Leadership.
  • Process approach.
  • Improvement.
  • Evidence-based decision making.
  • Relationship management.

What are the main components of quality management? ›

It has four main components: quality planning, quality assurance, quality control and quality improvement.

What are the 3 keys to total quality management? ›

TQM: 3 Principles of Total Quality Management
  • (i) Customer satisfaction:
  • (ii) Employee Involvement:
  • (iii) Continuous improvements in quality:

What is most important issue in healthcare today why? ›

1. The High Cost of Health Care. The problem: Perhaps the most pressing issue in health care currently is the high cost of care. More than 45% of American adults say it's difficult to afford health care, according to a survey by the Kaiser Family Foundation, and more than 40% have medical debt.

What is the biggest challenge for a healthcare manager? ›

The Top 5 Challenges Healthcare Managers Face
  • Working with Health Insurance Companies. ...
  • Finding and Retaining Qualified Healthcare Staff. ...
  • Controlling Your Overhead Costs. ...
  • Meeting Healthcare Safety and Compliance Regulations. ...
  • Providing Affordable Care To Patients.
29 Jul 2021

What is a new trend in healthcare management? ›

Some of the top health care technology trends to watch – both administrative and patient care initiatives – include: Artificial intelligence. Big data and analytics. Data security. Digital therapeutics.

How is quality measured in healthcare? ›

Quality measures are typically developed based on evidence generated through research and clinical practice, with most measures beginning as clinical guidelines. Developers of measures include: Public agencies (e.g., the CMS and the Agency for Healthcare Research and Quality [AHRQ])

What are the three main factors that determine quality? ›

Answer: The three Main Factors are following: Expected clickthrough rate, landing page experience, and ad relevance.

What are the 3 main factors that affect your health? ›

The determinants of health include: the social and economic environment, the physical environment, and. the person's individual characteristics and behaviours.

What are the 7 pillars of quality? ›

MeSH terms
  • Costs and Cost Analysis.
  • Efficiency.
  • Health Services Accessibility.
  • Patient Acceptance of Health Care.
  • Physician-Patient Relations.
  • Quality of Health Care*

What are the 5 C's in care? ›

According to Roach (1993), who developed the Five Cs (Compassion, Competence, Confidence, Conscience and Commitment), knowledge, skills and experience make caring unique.

What are the 7 C's in care? ›

Consider the different headings that make up the Seven C's and try to think about what each one would represent.
Click on the headings above to reveal the correct description.
  • Communication. • ...
  • Co-ordination. • ...
  • Control of Symptoms. • ...
  • Continuity. • ...
  • Continued Learning. • ...
  • Carer Support. • ...
  • Care in the Dying Phase. •

What are the four 4 common competencies? ›

Answer: Some common competencies are: Personal competencies: creativity, determination, integrity, tenacity, emotional balance and self-criticism.

What are the six dimensions of quality by the IOM? ›

The IOM endorsed six dimensions of patient-centered care which stated that care must be: 1) respectful to patients' values, preferences, and expressed needs; 2) coordinated and integrated; 3) provide information, communication, and education; 4) ensure physical comfort; 5) provide emotional support – relieving fear and ...

What are the 4 key competencies? ›

The 4 skills:
  • Creativity…to find solutions.
  • Critical thinking…to think logically.
  • Cooperation and Communication…to work together.
5 May 2021

What are the 5 total quality management elements? ›

There are five major steps to TQM, and each are essential to successful implementation.
  • Commitment and Understanding from Employees. ...
  • Quality Improvement Culture. ...
  • Continuous Improvement in Process. ...
  • Focus on Customer Requirements. ...
  • Effective Control.
22 Jun 2012

What are the 5 steps of quality control? ›

Here are 6 steps to developing a quality control process:
  • Set your quality standards. ...
  • Decide which quality standards to focus on. ...
  • Create operational processes to deliver quality. ...
  • Review your results. ...
  • Get feedback. ...
  • Make improvements.
23 Jun 2019

What are the five 5 different quality control methods? ›

There are four types of quality control: process control, acceptance sampling, control charts, and product quality control.

What is the best definition of quality in healthcare? ›

The Institute of Medicine defines health care quality as "the degree to which health care services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge."

What are the benefits of quality healthcare? ›

Because high-quality care has a big impact on patients. When people are treated by top doctors and get care at great facilities, they benefit from: Better health outcomes such as faster recovery times, lower risk of complications and mortality, and improved long-term health.

Why is high-quality healthcare important? ›

Safe. Healthcare providers should prioritize their patient's safety in every interaction. Timely. High-quality healthcare allows patients to get the care they need without potentially harmful or costly delays.

What are the goals of quality management in healthcare? ›

The goal of quality management in health care is to reduce costs and improve patient outcomes – a win-win scenario for both health care organizations and patients.

What is the main goal of quality improvement? ›

Quality improvement seeks to standardize processes and structure to reduce variation, achieve predictable results, and improve outcomes for patients, healthcare systems, and organizations.

What are 4 risk and quality management tools in healthcare? ›

Tools include FMEA, SBAR, root cause analysis, daily huddles, and more. Download these ten essential quality improvement tools to help you with your improvement projects, continuous improvement, and quality management, whether you use the Model for Improvement, Lean, or Six Sigma.

What are the benefits of quality management? ›

Advantages of quality management systems
  • greater efficiency and less waste.
  • better and consistent control of major business processes.
  • a better understanding of customer needs.
  • regulation of successful working practices.
  • improved risk management.
  • increased customer satisfaction.
  • improved participation of employees.

What is the main purpose of total quality management? ›

TQM's objectives are to eliminate waste and increase efficiencies by ensuring that the production process of the organization's product (or service) is done right the first time.

What are the main objectives of the quality management process? ›

The primary goal of a quality management system is to improve the quality of the production process and final products. In such a system, there are 3 main objectives of quality control: enhance product quality and reduce risks, gain production efficiencies, and garner customer loyalty.

Why is quality so important? ›

Quality is critical to satisfying your customers and retaining their loyalty so they continue to buy from you in the future. Quality products make an important contribution to long-term revenue and profitability. They also enable you to charge and maintain higher prices.

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