International Journal of Health Care Quality Assurance

Total quality management in European healthcare

John Øvretveit
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John Øvretveit, (2000),"Total quality management in European healthcare", International Journal of Health Care Quality
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Ali Mohammad Mosadeghrad, (2013),"Obstacles to TQM success in health care systems", International Journal of Health
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 Total quality management in European healthcare
Keywords
Total quality management,
Evidence, Europe, Health care,
Teams, Kaizen
Downloaded by West Virginia University At 12:06 11 March 2015 (PT)
Abstract
Total quality management (TQM)
promises much for service indus-
tries yet it has been little used in
European healthcare. Of those
hospitals and services which have and higher costs to healthcare. Total quality
implemented TQM, few have had
great success and many have
found difficulties sustaining their
programmes. This paper defines
TQM in healthcare and considers
examples and results of TQM in
European healthcare. It distin-
guishes between team projects
using TQM methods and organiza-
tion-wide TQM programmes, and
finds more evidence for the suc-
cess of projects than for pro-
grammes. The paper discusses
whether the differences between
healthcare and many other indus-
tries explain the mixed results,
and considers the prospects for
future TQM programmes in Eur-
opean healthcare.
This paper was originally
presented to the Japanese
Society of Quality Control,
Tokyo, July 1999
International Journal of Health complex systems of care.
Care Quality Assurance
13/2 [2000] 74±79
# MCB University Press
[ISSN 0952-6862]
[ 74 ]
John évretveit
Professor of Health Policy and Management, The Nordic School of Public Health,
Goteborg, Sweden, and Faculty of Medicine, Bergen University, Norway
Introduction
Across Europe, patients, payers and
governments are increasingly concerned
about the quality of health services. Different
approaches are being used to ensure and
improve quality. Not all have been successful,
and some may have only added bureaucracy
management (TQM) is one approach which
promised to both improve quality and reduce
costs. Some European hospitals have applied
TQM ideas and have found some success,
given certain conditions.
Patients are expecting more from
healthcare and are increasingly dissatisfied
with long waiting times and the way they are
treated, especially the post-war generation.
Those paying for healthcare ask why health
services cannot use quality methods which
are used in some other industries to reduce
the rising costs of healthcare. However,
improving patient satisfaction and reducing
costs are perhaps the least important reasons
for using TQM methods in healthcare.
Research has found that 4 per cent of hospital
patients suffer an avoidable injury (Brennan
et al., 1991), 7 per cent experience a medication
error (Leape, 1994; Bates, 1995), and 45 per cent
experience some medical mismanagement
(Andrews et al., 1997). In a recent study, 8 per
cent of anaesthetic errors were found to be
due to human error and 92 per cent due to
system errors (Lagasse et al., 1995).
These findings show that there is room for
improvement in clinical quality. They also
show that traditional methods for quality
assurance are not sufficient in the
increasingly complex and multidisciplinary
systems of modern healthcare services. The
promise of modern quality methods is that
they make it possible for professionals and
managers to understand and develop these
The current issue and full text archive of this journal is available at
http://www.emerald-library.com
The purpose of this paper is to give an
overview of TQM initiatives in Europe. It
first describes why there has been a rise in
interest in health quality and quality
methods in Europe in the last 15 years, and
describes different initiatives. It then shows
how TQM is different from other approaches
and its strengths and weaknesses for
healthcare quality improvement. The paper
finishes with a summary of lessons for health
organizations introducing TQM which arise
from the European experience.
Are there pressures to improve
quality in European healthcare?
Why have European health organizations
increasingly used TQM methods in the last
ten years?
Interest in, and concern about the quality of
healthcare is not new for patients,
professionals, and governments. Patients have
always been careful to choose a healthcare
professional or facility which they think will
cure their health problem, which will not
harm them, and which will not cost them too
much money. Where there has been no choice,
patients often decide not to use healthcare, or
turn to alternative medicine (Zollman and
Vickers, 1999). In making their choices,
patients have used their own experience, but
are increasingly using published quality
indicators such as the UK league tables and
the Norwegian quality indicators.
Professionals have for some time sought to
prove their competence to patients and to
other professionals and to improve their skills.
The government role in public and private
healthcare has increased this century and
governments have acted to protect patients
from poor quality health professionals and
facilities, and formed an alliance with
professionals to regulate practice.
However, these traditional concerns and
methods have changed in recent years because
of changes in healthcare and in society. First,
healthcare has become more complex. A
 John évretveit
Total quality management in
European healthcare
International Journal of Health onset through to diagnosis, treatment,
Care Quality Assurance
13/2 [2000] 74±79
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patient suffering a heart attack will come into
contact with many doctors and other
professionals in their episode of care from
rehabilitation and after care. There is an
increasing specialization of medicine and of
professions, increasingly complex treatments
and equipment, and more service units run by
different organizations. This division of health
labour needs coordination if the patient is to
benefit from the different specialist expertise.
The patient has to be carefully assessed and
the right specialists have to be found and
enabled to bring their expertise and
treatments to bear on the patient. There is
more risk of things going wrong with this
professional specialization, the complexity of
treatments and medical equipment, and the
number of different organizations involved.
A second change is evident in patients'
expectations. Traditional authority relations
in society have changed and there is
increasing consumerism and choice. Patients
increasingly expect the same service from
healthcare which they have grown to expect
in shops and other services. The media both
respond to and fuel the growing interest in the
demand for healthcare, as well as publicizing
the newsworthy examples of poor quality.
Third, those paying for health services
have become more concerned about rising
healthcare costs and possible inefficiencies.
Governments which pay for health services
find that there is no limit to the money
demanded by healthcare. There are more
medical interventions which could help more
people. The public and professionals demand
that these be made available. With rising
standards of living health has become a
political issue. Employers are increasingly
aware of the costs of healthcare in higher
taxes or in higher payments. They are also
aware that healthcare services often do not
serve their employees well, with waits for
treatment and delays before people return to
work. In a global economy, poor healthcare
quality damages the competitiveness of a
nation's industries.
Parallel to these concerns about health
quality there has been, in other industries, a
growth in the use of quality methods.
European manufacturers have learnt and
applied quality methods and this has helped
them compete in global markets by reducing
costs and enabling them to better meet
customer demands (Edvardsson et al., 1994).
These same companies ask why healthcare
does not use these methods, especially when
the company owns the healthcare
organization or views healthcare as a
supplier like any other industry.
Improving healthcare quality
As a result of different pressures there have
been a number of initiatives in Europe to
ensure and improve healthcare quality. Below
is a list demonstrating some of these initiatives.
. Professional initiatives, such as self-
regulation, education, standard setting,
and professional audit methods.
. Promoting evidence-based medicine (EBM)
and evidence-based protocols (promoted by
professions and some governments).
. The use of audit: setting standards and
comparing practice to standards (uni-
professional, multidisciplinary, and
organizational (e.g. UK Kings Fund).
. Government regulation (licensing and
inspection).
National quality strategies (e.g. Norway,
Denmark, the UK).
. Quality prizes and awards.
. Quality data collection and comparisons
(confidential and public).
. Benchmarking.
. Patient information, participation, and
rights.
. Pathway and re-engineering methods.
. Total quality management (TQM).
With regards to TQM there is great potential
to resolve quality problems in healthcare
because the methods and ideas help managers
work with health professionals to improve
systems of care. Furthermore, TQM enables
different professionals to work together in
teams. Yet this potential has not often been
realised, a reason for which may be that there
is some confusion around the term TQM.
What is TQM?
Outside of healthcare, quality is defined as
exceeding customer expectations. In applying
TQM in healthcare, many have viewed
customer satisfaction as one of three
dimensions of quality:
1 Patient quality: whether the service gives
patients what they want.
2 Professional quality: professionals' views of
whether the service meets patients' needs
as assessed by professionals (outcome is
one measure), and whether personnel
correctly select and carry out procedures
which are believed to be necessary to meet
patients' needs, (process).
3 Management quality: the most efficient
and productive use of resources to meet
client needs, without waste and within
limits and directives set by higher
authorities (évretveit, 1992).
TQM and CQI (continuous quality
improvement) have emerged in Europe over
the last ten years as a distinct approach to
[ 75 ]
 John évretveit
Total quality management in
European healthcare
International Journal of Health First, TQM can be viewed as an organization-
Care Quality Assurance
13/2 [2000] 74±79
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improving quality which may be more cost-
effective than other approaches. It is useful to
distinguish between two aspects of TQM.
wide approach and philosophy, with a
strategy for organization and personnel
development, and a quality management and
information structure. An example of this
aspect of TQM is the Baldridge quality award
framework and its many variations;
European Foundation for Quality
Management (EFQM), Quality Development
Leadership (QDL), Norsk Kvalitetsprisen
(NKP) and Finnish Quality Award (FQA) to
name but a few.
Second, TQM involves quality team methods
and frameworks for process improvement. In
European healthcare many different activities
. Change implementation (the most difficult of
these components to carry out in healthcare,
because of complexity and because of the
power and autonomy of many professions).
Some theorists take the view that TQM should
also involve a system perspective, working to
control unwanted variation in process
performance using statistical process control
(SPC) methods, as well as quality function
deployment to match customer needs to
organizational capability (Ishikawa, 1985).
What could TQM offer European
healthcare?
Why, in theory, might TQM be a suitable
approach for improving healthcare quality?

One reason is that training in TQM methods

are carried out under the name of total quality
management. Two definitions distinguish TQM
from other approaches. One is that TQM is, ``A
comprehensive strategy of organisational and
attitude change, for enabling personnel to learn
and use quality methods, in order to reduce
costs and meet the requirements of patients
and other customers'' (évretveit, 1997).
A second definition given by US theorists
emphasizes that TQM is a management method:
``TQM/CQI is simultaneously two things: a
management philosophy and a management
method''. They propose four ``distinguishing
characteristics or functions'', which are ``often
defined as the essence of good management'':
1 empowering clinicians and managers to
analyse and improve process;
2 adopting a norm that customer preferences
are the primary determinants of quality
and the term ``customer'' includes both the
patients and providers in the process;
3 developing a multidisciplinary approach
which goes beyond conventional
departmental and professional lines; and,
4 providing motivation for a rational, data-
based cooperative approach to process
analysis and change (McLaughlin and
Kalunzny, 1992).
Main components of TQM
Another way to define TQM is in terms of
different ``components'', and this type of
definition can help to assess the degree to
which an organization has adopted TQM. For
instance, the components of TQM are seen as
including:
. Customer focus ± internal and external
. Process analysis.
. Quality project teams.
. Simple methods used in a systematic way
to analyse quality problems, plan change,
and evaluate the results.
. Data to identify and analyse problems and
to evaluate the results of change.
[ 76 ]
and principles could help to develop healthcare
managers, especially clinical professionals
occupying management positions. For TQM to
succeed in any organization, all theorists agree
on the need for top management commitment
and their persistent attention to ensuring TQM
methods are used. TQM requires a change from
a controlling style of management to a
facilitating and empowering role. It is this
change in the role of management and
increasing the ability of doctors and other
employees to take control of quality in teams
which has the greatest implications for most
healthcare organizations. The scientific
philosophy of TQM applied to management and
organization is one which doctors find natural
± so long as it presented in a way which shows
the compatibility with medical research, and
shows how they can take a greater and more
significant part in hospital management.
Another reason is that TQM methods gives
a way to involve different professions in
analysing and then agreeing changes to
complex care organizations. This is both a
technical and political process. The rationale
is as follows:
1 Coordination of specialist activities: as
specialization and complexity increase in
healthcare there is a need to coordinate the
different specialists and activities to
ensure that they combine to benefit the
patient. Unfortunately our methods for
coordination have not kept pace with the
increase in the variety of specialists and
treatments. A patient passes through
different departments and sees many
different professionals who may not
communicate, or coordinate their work.
2 One method to coordinate is to conceptualize
and analyse healthcare as a process.
3 A good way to improve processes is to
form a team of people who work in
different parts of the process and for them
to describe and analyse the process.
 John évretveit 4 Teams need to use methods in a
Total quality management in disciplined way to investigate complex
European healthcare problems and implement solutions.
International Journal of Health 5 A fact-based and scientific approach is
Care Quality Assurance essential for significant and sustained
13/2 [2000] 74±79
improvement (e.g. to collect data to
analyse the problem, to measure quality
before and after the change).
TQM in practice
It is useful to distinguish TQM as an
organization-wide philosophy and a way of
working, from TQM to team projects, the
latter being a set of methods used by teams
for complex problem solving and process
improvement. In the last five years more
European hospitals have been influenced by
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the US quality improvement movement
which takes a more liberal and flexible
approach to quality and tends to emphasize
process improvement and team projects. The
following gives an example of a TQM team
project and an example of a TQM programme
in a European hospital.
Example of a TQM project
This project illustrates a simple nine-phase
sequence which a team worked through to
analyse and implement a solution to a quality
problem (the T-QIS framework). An
anaesthetist working in a Norwegian hospital
believed that the number of cancelled and
delayed elective surgical operations was
unnecessarily high. He had attended a course
on TQM methods and the hospital had
recently started a quality programme. He got
support from the managers of surgery and the
operating room to start a team project. A team
was formed which met every two weeks.
The team specified the problem and
investigated the possible causes of delays.
They did this by listing possible causes and
then collecting data over three months about
the different causes. Examples of the causes
were: patient too unwell for surgery, surgeon
unavailable, and patient records unavailable.
The change intervention which they made
was simply to present the data about the
number of cancellations and delays at
meetings of the personnel who managed and
worked in the operating room. They
described the measurement system they had
developed and how it would continue to be
used to collect the data.
Table I shows how the number of cancelled
operations was reduced. Collecting and
presenting data to the personnel had
motivated them to make changes.
This work then laid the basis for further
work by the team to describe and analyse the
operating room process. This was necessary
Table I
Reduction of cancelled operations
1 March ± 30 1 January ± 31
May 1997 March 1998
Total elective
procedures 1,045 1,125
Cancelled operations 100 (7.6%) 83 (7.4%)
Avoidable
cancellations 78 (7.5%) 54 (4.8%)
because, over time, the simple problems
which caused cancellations and delays had
been solved by personnel. However, the more
deep-seated problems needed a more detailed
analysis and change programme which is
described in évretveit and Aslaksen (1999).
Example of a hospital-wide TQM programme
Probably one of the most successful TQM
hospital programmes has been that of the
Reiner de Graaf Gasthuis, in The Netherlands.
The hospital director describes the decision to
introduce TQM methods and associated
cultural norms in 1992 as being due to the lack
of success in solving chronic problems
characteristic of hospitals in general.
Examples of common aspects of poor quality
are: long waiting times, lost X-ray pictures and
records, poor service attitudes towards
patients, blame-shifting between departments,
employees and/or doctors, and inefficiencies.
There were also gradually reducing budgets,
and a need to cut costs. The hospital started
with seven demonstration projects, which
were only partially successful. In 1994 it
started a strategic quality planning process to
concentrate on key strategic areas, and
focused on eight key processes in the hospital.
The project teams used a 12-step Juran TQM
approach within the four phases of: project
definition and organization, diagnosis,
planning, and holding the gains.
Some of the lessons emerging from this
experience were that:
. Cooperation between specialists' and
departments does not come naturally or as
a result of exhortation.
. Process analysis by a multidisciplinary
team develops specialists understanding of
how their work interrelates, and of where
the problems occur. If the specialists take
part in mapping the process and then in
redesigning it, it makes it easier for them
to agree changes which they would
otherwise find inconvenient.
. A structured team improvement process
makes it possible to work methodically
through the necessary stages to achieve
measurable improvements.
[ 77 ]
 John évretveit
Total quality management in
European healthcare
International Journal of Health
Care Quality Assurance
13/2 [2000] 74±79
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[ 78 ]
. Team facilitation by an expert is
important if the team is to follow the steps
and to use the methods correctly.
Reflecting on four years of the TQM
programme, the hospital director
emphasized the following lessons for others:
. Earlier project teams failed because they
did not have trained facilitators or good
team leaders, they met infrequently
rather than for one hour every week, they
did not follow the structured methods and
jumped to conclusions too early, and
doctors did not attend.
. Each project team needed to have a
sponsor from the high-level quality
council, who supervised the team and
helped them with problems.
. It was important to develop quality
measures, for the projects and also
routine indicators.
. Developing good training materials in a
recognizable language was important, as
was using consultants early on.
. It took time to change attitudes and
resistance had to be expected and
welcomed as it showed people were taking
the ideas seriously.
Discussion ± does TQM work?
The above examples are from a growing
number of reports of successful individual
projects and of hospital-wide programmes,
mostly written by enthusiasts rather than
objective independent researchers. After ten
years of applying TQM the question needs to
be asked as to whether there is evidence that
TQM works in European healthcare,
especially public healthcare services.
In the US there are different views about
whether TQM works. The earlier positive
reports by enthusiasts (Berwick et al., 1990;
Melum and Sinioris, 1992; Gaucher and Coffey,
1993) have been followed by studies which found
little evidence of success, using different
criteria of success and different sources of
evidence (Bigelow and Arndt, 1995; Motwani et
al., 1996). It has been argued that it is impossible
or difficult to evaluate TQM, and that TQM has
rarely been properly implemented.
What is the European experience?
There is even less evidence from European
healthcare. Conclusions from the main studies
are that: there is evidence of improvements
made by projects, but unclear results from
programmes. Many hospitals adapt TQM
principles, making it questionable whether
they are applying TQM or something else.
After ten years there is still no clear evidence
about which types of TQM programmes are
most successful, especially compared to other
approaches to quality improvement, or when
combined with such approaches.
Problems applying TQM
In Europe, the biggest problems introducing
and using TQM ideas have been:
. Cost of investment: TQM has to compete
with other investments such as information
technology or medical equipment.
. Uncertain returns for an organization-
wide programme and for some projects
the evidence of success is mixed.
. Management resistance towards
empowering employees and to taking
them away from direct care work for
training or working in quality teams.
. Professional resistance: towards teamwork,
learning new methods and language, and a
belief that other methods may be as good.
Also, there is no time (due to the patient
demands and need to keep professionally
up to date), and a fear of loss of autonomy.
. Sustaining continuous improvement where
there are no market competition incentives
to do so, or quality measurement is poor.
. Time: there is little time for managers and
professionals to concentrate on long-term
projects, with reforms and frequent
changes in healthcare.
Successes and future directions
There have been successful programmes
from which we can learn, and there are new
ways in which TQM methods are being used
in combination with other approaches:
. There is a convergence between TQM and
evidence-based medicine; both emphasize
a fact-based systematic approach and care
pathway or protocol development.
. Computer support: intranets for access
and updating of pathways, procedures and
data gathering and analysis.
. Knowledge about how to make team
projects more effective, including
frameworks for simple and complex
problems (e.g. T-QIS), problem selection,
team reporting and team sponsors, team
facilitation and leadership.
. Better training for doctors and doctor
managers.
. Showing similarities between TQM and
medical research.
Main lessons
The main lessons which have been learned
about introducing quality methods are:
. Quality leadership: the need for heads of
departments to lead quality. How to
develop heads of departments' competence
and motivation to do this?
. Resistance and opposition: the need to work
with resistance through understanding and
dialogue, not fight resistance; this
approach communicates quality principles.
 John évretveit . Development: do not rely on a training
Total quality management in programme to provide the personnel and
European healthcare organization development needed. For
International Journal of Health managers, even the best quality education
Care Quality Assurance alone is not sufficient. They need to be
13/2 [2000] 74±79
exposed to a variety of experiences and to
be helped in different ways if they are to
apply quality ideas in teams and in
everyday work, and to lead by example.
Knowledge is not know-how.
. Doctors: their involvement is essential,
and special training for them is required,
which connects quality methods with
applied medical research.
. Training: do not train people who are not
working on quality projects, unless it is
general awareness training.
. Facilitators: train more team facilitators
than you think you need; you will need
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more and you will lose many.
. Project management: select quality
projects which are strategically
significant, and manage them for results.
Get the right balance between bottom-up
initiatives and centrally-initiated
projects.
. Structured teamworking: ensure quality
projects working on complex subjects
follow the steps of a structured team-
working process.
. Measurement: develop the skills to design
and use measures of quality; what gets
measured gets attention.
. All services: do not neglect those services
which are doing little to address quality
problems; the inverse quality law acts to
expose patients to unnecessary risks.
. The soul and spirit of quality: the need to
engage with professional values, enable
people to use and develop their potential
and awaken the hope and belief they can
make things better.
Conclusions ± lessons from Europe
Since 1990, TQM methods have been applied
in a number of hospitals, clinics and health
organizations in Europe. Towards the end of
the 1990s the approach has become more
widespread, but most hospitals and health
organizations still do not use TQM methods.
TQM means many things to many people, but
there is a common agreement that it involves
team-based process improvement projects
and a customer orientation across the
organization. The approach has not been
easy to implement. Nevertheless, there have
been many lessons learned from the
European healthcare organisations applying
quality concepts and principles. If everyone
considered these lessons before or during
their TQM journey there is great potential for
ensuring that healthcare organisations
Europe-wide reflect the characteristics
associated with a quality service.
References
Andrews, L., Stocking, C., Krizek, T., Gottlieb, L.,
Krizek, C., Vargish, T. and Siegler, M. (1997),
``An alternative strategy for studying adverse
events in medical care'', The Lancet, Vol. 349,
pp. 309-13.
Bates (1995), ``Errors in medication administration'',
Journal of the American Medical Association,
Vol. 274.
Berwick, D., Godfrey, A. and Roessner, J. (1990),
Curing Healthcare: New Stratgeies for Quality
Improvement, Jossey Bass, San Francisco, CA.
Bigelow, B. and Arndt, M. (1995), ``Total quality
management: field of dreams?'', Health Care
Management Review, Vol. 20 No. 4, pp. 15-25.
Brennan, T., Leape, L., Laird, N., Hebart, L.,
Loralio, A. and Lawthers, A. (1991),
``Incidence of adverse events and negligence
in hospitalised patients'', New England
Journal of Medicine, Vol. 324, pp. 370-6.
Edvardsson, B., évretveit, J. and Thomasson, B.
(1994), Service Quality ± A TQM Perspective,
McGraw-Hill, Maidenhead.
Gaucher, E. and Coffey, R. (1993), Total Quality in
Healthcare, Jossey Bass, San Franciso, CA.
Ishikawa, K. (1985), What is Total Quality
Control?, Prentice Hall, London.
Lagasse, R., Steinberg, E., Katz, R. and
Saubermann, A. (1995), ``Defining quality of
perioperative care by statistical process
control of adverse outcomes'',
Aneasthesiology, Vol. 82 No. 5, pp. 1181-8.
Leape, L. (1994), ``Error in medicine'', Journal of
the American Medical Association, Vol. 272
No. 23, pp. 1851-7.
McLaughlin and Kalunzny (1992), Continuous
Quality Improvement in Healthcare, Jossey
Bass, San Francisco, CA.
Melum, M. and Sinioris, M. (1992), Total Quality
Management: The Healthcare Pioneers,
American Hospital Publishing, Chicago, IL.
Motwani, J., Sower, V. and Brasier, L. (1996),
``Implementing TQM in the health care sector'',
Health Care Management Review, Vol. 21 No. 1,
pp. 73-82.
évretveit, J. (1992), Health Service Quality,
Blackwell Scientific Press, Oxford.
évretveit, J. (1997), ``Learning from quality
improvement in Europe and beyond'', Journal
of the Joint Commission for Accreditation of
Healthcare Organizations, Vol. 23 No. 1, pp. 7-22.
évretveit, J. and Aslaksen, A. (1999), The Quality
Journeys of Six Norwegian Hospitals,
Norwegian Medical Association, Oslo.
[ 79 ]
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