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Quality has become the focus for many healthcare organisations in the world. The economic and organisational benefits such as increased customer satisfaction, improved processes and efficiency can be derived from quality management. The implementation of Quality Management strategies provides the framework for the establishment of systems; procedures and activities needed to achieve quality. The implementation of quality management in health care organisation provides an opportunity to deliver consistent, high quality and cost effective health care to customers.
In its Health Sector Reform programme for Trinidad and Tobago, the Ministry of Health (MoH) identified Quality of health care services as a key issue to be addressed .The MoH strategic direction for quality was presented in their guiding document Quality 2001 A Reality which was geared in the direction of making quality a priority. The strategy was broad and aimed towards improving quality of health care services, creating a quality culture and emphasising value for money as goals for improving health care services. One of their specific key objectives was the introducing of framework for developing a Total Quality Management system at the public healthcare institutions.
The decentralisation of health services and the enactment of the Regional Health Authorities (RHAs) Act No.5, 1994 represented the Government's intention to institute efficient health care systems for Trinidad and Tobago. The MoH would retain responsibility for policy, planning and regulation of health care. The formation of five (5) Regional Health Authorities (RHAs) would have responsibility for the provision of health care services and implementation of management strategies to achieve improved performance. The North Central Regional Authority (NCRHA) is one of the largest statutory bodies providing healthcare services in the country. Its remit includes three (3) major hospitals, two (2) district health facilities and fourteen (14) health centres.
1.3 Problem Definition:
The public confidence in the quality of health care services delivered by the public health sector is very low. The NCRHA in recent years has been the centre of media attention due to matters allegedly related to medical negligence. The increase in adverse events and medical care complaints at its hospitals has been disturbing. According to MoH data there were at least seventeen (17) reported Adverse Events occurring at our nation's hospital for the period 2004 to 2011 which resulted in patient injury, disability or death.
Health care trends such as rapid advancements in public health management, shifts in customer demand for health service delivery and population health concerns have changed the national social landscape.These trends have resulted in a more informed customer accessing services therefore demanding reduced waiting time for services, improved medical care, enhanced facilities and overall quality health care from their service providers.
The recent change in government in May 2010 has also brought about strategic transformation. The Government's Seven Development Pillars (Pillars 1, 6) emphasizes the bringing together of all stakeholders to ensure that public services, especially essential services like health care, are affordable, accessible and of the highest quality.
These current issues have strategic implications for public health sector organisations such as the RHAs. Therefore current TQM strategies should be critically assessed and a new structured approach to the implementation of Quality Management must be proposed.
Medical Care related complaints data received at the health care facilities NCRHA for the period 2008-2010:
Arima Health Facility
Chaguanas Health Facility
Eric Williams Medical Sciences Complex
Mt Hope Women's Hospital
Primary Care Health Center
Figure 1 NCRHA Complaints Data
Source: NCRHA Quality Department
The strengthening of public confidence in the quality of health care services at NCRHA is critical to the organisation's future survival. The MoH is currently in its final drafting of legislation for the Establishment of a Health Service Accreditation Bill (2009), that would provide the framework for health care quality and accountability. The Act would facilitate the institution of the Health Services Accreditation Council Trinidad and Tobago (HSACTT) which is a pre-requisite to the introduction of National Health Insurance. The MoH in its policy statements to inform legislation for the HSACTT identified that both RHAs and private hospitals must be complaint with this Act. The MoH made further recommendations in its document, that the state would not provide funding or enter into any arrangements for procurement with un-accredited health facilities. The financing of public health sector organisation is highly dependent on government funding therefore RHAs must deliver quality healthcare to access public funding and gain a competitive advantage.
The World Health Organisation (WHO) has also set targets and key indicators to monitor quality of care in developing countries as part of their Millennium Development Goals (MDGs) 2015, examples such as the MDG (4) improved maternal healthcare and MDG (5) reduced infant mortality rates. The NCRHA has recently received negative publicity from alleged medical care negligence complaints regarding quality of maternal and infant care at their medical facilities. The MoH has mandated that a critical strategic issue for all RHAs is the improvement of maternal and infant health care; this is part of their efforts towards achieving MDGs target for Trinidad and Tobago.
1.5 Research Question:
How can NCRHA use their Quality Management Strategy to deliver quality health care and gain competitive advantage?
1. To critically evaluate current Quality Management strategies used at the NCRHA to deliver quality health care to their customers
2. To ascertain any gaps by benchmarking current strategies against theoretical framework for TQM implementation
3. To design a framework for the implementation of a total quality management strategy for NCRHA
To synthesize a comprehensive Quality Management Strategy to enable the NCRHA to progress from a state of quality awareness to quality readiness, thus enabling NCRHA to improve quality health care and gain competitive advantage in the Public Health Sector.
2.0 Literature Review
2.1 Quality Management Defined:
The concept of quality revolves around meeting and exceeding the customer expectation. The customer's needs are ever changing and the demand for high quality requires a systems approach towards improved quality. The idea of quality management is not derived from one single source but is a collection of ideas that has been called by various names. According to lynch (2003) Total Quality Management (TQM) can be define as the modern strategic approach to quality management. ASQ (2006) has indicated that the term TQM has lost its flavor and in recent years has been subsumed under the term Quality Management. This can be further argued by Hannagan (2002) who suggest that the approach can be recognized by either title of TQM or strategic quality management. However it can be agreed that TQM is a strategic approach to achieving quality and a sustainable competitive advantage for an organization. There have been many theorists who have contributed to the quality movement and has also has influenced the TQM philosophy.
2.2 TQM Theories:
TQM can be described as a management philosophy, characterized by a common set of principles, practices and techniques Dean &Bowen (1994) however it tends to be examined by numerous authors from different perspectives. The perspectives of three main founding TQM philosophers or Quality gurus would be discussed and their supporting TQM methods. It is theorised by Crosby (1979) that quality is conformance to requirements therefore one arrives at the concept of zero defects. He also focuses on organisational factors such as leadership, culture and training. Deming (1986) was considered one of the founders of TQM his philosophy can be summarised in his fourteen management principles. These would include management commitment to quality; raise quality awareness, employee empowerment and training. The underpinning theory being that quality is a process and not a program therefore it should be ongoing in the organisation. Juran (1989) focuses on quality planning, quality control and quality improvement. There can be three levels of quality management defined which are strategic quality management, operational quality and workforce that concerns its self with work process (Juran 1989). The philosophies of these quality gurus can be summarised as a management system that involves management commitment for a customer focused organisation in which all employees participates in continual improvement. The system integrates the use of strategy, culture, training and effective communication to achieve TQM.
2.3 TQM Elements:
ASQ(2006) identified essential elements to TQM that organisations must define either in their core values or principles on which the organisation operates. These elements would be discussed with the purpose of understanding the key concepts that must be considered in quality management implementation. An analysis of literature provides an exhaustive list of key elements however critical components would be discussed. While TQM is viewed through different perspectives what is written about TQM is based on a common set or sub-set of key components (Harris, 1995).
The fundamental assumption of TQM is planning for the design and delivery of products and services that fulfil the needs of the customers (Dean and Bowen 1994). The customer ultimately decides whether the efforts are worthwhile. According to Waldman (1995) in order to create a quality culture all members of the organisation must be involved in the quality process. The involvement of employees in the quality process is critical to its success in the organisation. The formulation of a strategic plan which encompasses the systems approach to quality management is a core component. The TQM process is supported by continual process improvement in the organisation.
All key activities in the organisation should be measured so that their improvement can be demonstrated and the benefits achieved. According to ASQ(2006) in times of organisational change, effective communication plays an important role in maintaining employee morale and motivation Training and education play a critical role in the TQM organisation, Juran (1986) postulates that training is required when undertaking a quality effort in an organisation in order to teach employees how to think about quality
Figure 2 Elements of TQM in the organisation
2.4 TQM Implementation Approaches:
The ASQ(2006) states that there is no one solution for implementing TQM for all situations therefore organisations TQM strategies would vary since culture, management practices are unique however the key elements discussed must be present in some format also there is a suggested generic model for implementation.
Generic model for implementing TQM
Top management learns about and decides to commit to TQM. TQM is identified as one of the organisation's strategies
The organisation assess current culture, customer satisfaction and quality management system
Top management identifies core values and principles to be used and communicates them
A TQM master plan is developed on basis of steps 1, 2 and 3
The organisation identifies and prioritizes customer demands and aligns products and services to meet those demands
Management maps the critical processes through which the organisation meets its customers' needs.
Management oversees the formation of teams for process improvement efforts
The momentum of the TQM effort is managed by the steering committee
Managers contribute individually to effort through hoshin planning, training, coaching, or other methods.
Daily process management and standardisation take place
Progress is evaluated and the plan revisited as needed
Constant employee awareness and feedback on status are provided and a reward/recognition process is established
Figure 3 Model for implementing TQM
The review of literature on TQM revealed that an attempt towards TQM will not succeed unless the discussed elements are applied and maintained in the TQM strategy. There is extensive literature that provides an understanding of the ideal TQM program however more research is needed to determine how all its factors fit together to form a theory that provides a maximum understanding of what TQM really is (Waldrnan 1993). This is further supported by Powell (1995) that although TQM became part of business theory, its role as a strategic resource seems to have remained virtually unexamined in strategic management.
2.5 TQM in Healthcare:
The issue of quality has become even more pressing for healthcare organisations. In a time of economic slowdown and financial constraints by government, the NCRHA is now faced with budget cuts and increased workload for human resources. There is a growing demand for quality in health care and for mechanisms such as quality management strategies and accreditation programs to maintain quality health services. The direct implications of poor quality in healthcare such as medication errors, increased infection rates and deaths are severe. According to Segonin (2005) developing countries are adapting quality management and accreditation standards in healthcare in order to work towards standardising healthcare services and to ensure high quality of healthcare for citizens. Vretveit (2001) suggest that some countries are conducting programs that consist of quality strategies and accreditation however little research is available to show evidence of efficacy. The available research on TQM implementation in public healthcare systems in developing countries is sparse and provides anecdotal information.
2.7 TQM Healthcare Best Practices:
The implementation of TQM in healthcare organisations is important for improving quality of clinical care to patients but also to satisfy accreditation requirements. Mayer et.al (1994) suggests benchmarking is the practice of regularly comparing oneself to other performing similar activities for continuously quality improvement (CQI). It is postulated by Campbell (1994) that until recently benchmarking has scarcely been used in the clinical setting primarily because of a limited knowledge of TQM methods and lack of support for initiatives.
Underwood (1994) refers to a case study of Lloyd Noland Hospital continuous quality improvement initiatives in clinical management of pneumonia patients using benchmarking process with a TQM approach in an effort to achieve improved outcomes for pneumonia patients. The hospital formulated a cross functional team in order to successfully benchmark and develop a total patient care process. The team utilised quality tools such as brain storming, flowcharting clinical pathways, monitoring and documentation. The teams findings on the quality improvement process were clinical benchmarking is a TQM tool that attempts to improve patient outcomes which is a data driven TQM/CQI practice in healthcare that is current and a future reality.
Based on the literature reviewed conducted thus far the researcher would attempt to critically assess the TQM practices at the NCRHA using the above theoretically implementation framework. The findings of this analysis would be synthesised and gaps would be identified. This data would assist in a design of a strategy for TQM implementation at the NCRHA. This study would provide fresh insights in the areas of total quality management in public health sector organisations in developing countries.
3.0 Research Design
3.1 Research Paradigm:
Epistemology is concerned with what constitutes acceptable knowledge and the nature of knowledge itself (Saunders, 2009). In contrast ontology can be define as being concerned with the nature of reality and the assumptions the researcher have about the way the world operates and a commitment to a particular view (Saunder,2009). This study would be based on subjectivism epistemological or interpretative stance in that the researcher would be eliciting the views and opinions of senior management, operational managers, medical staff and support staff in the organisation. The researcher would adopt a phenomenological paradigm since it would require understanding the point of view of the research subjects.Considering the relatively new development of TQM research, in Trinidad and Tobago public health care as well as the applicability of private sector research, an inductive approach was chosen. According to Saunders (2009) inductive approach is particularly concerned with the context in which the event takes place. A qualitative approach would be followed since a case study research design would be adopted this is supported by Yin (1989) who advocates that variables under study cannot be manipulated but somewhat observed and data extrapolated from them.
3.2 Research Methodology:
The exploratory approach was found to be most suitable for this study given the lack of research regarding TQM implementation in the public health care sector (Eisenhardt, 1989b). The utilization of a case study strategy is proposed to evaluate the TQM practices of NCRHA. The NCRHA constitutes three (3) tertiary hospitals, two district health facilities and fourteen (14) health centres, this research would be examining the sub-units within the organisation and an embedded case study would be constructed. This approach would give the researcher an opportunity to study and evaluate a phenomenon that few have considered. The design described would provide the advantage for real life issues to be brought to the forefront. The NCRHA was chosen for the case study since there are current TQM strategies implemented in the organisation. Once the organisation's ethic committee gives approval for the research and the Quality Department Manager is informed a letter of request would be forwarded requesting facilitation by the various health facilities Quality Coordinators (QC). The researcher would use a triangulation method since different data collection techniques would be used in this study to ensure the data telling what is being said. The combination of interviews, focus groups, archival documentation and observations techniques would be utilised by the researcher. There would be interviews conducted with senior managers and hospital administrator focused on TQM leadership and current status of initiatives. Documentation would be reviewed such as accreditation plans, quality plans and vision, mission of the company. Since TQM must have employee involvement a focus group would be administered to gauge employees' awareness and observation would be conducted outside of these activities. Due to time constraints for this study a cross sectional studies would be conducted over a stipulated period time. Saunders (2009) postulates that cross sectional studies may be used in qualitative methods since many case studies data techniques such as interviews are conducted over a short period of time.
3.3 Research Technique/Method:
3.3.1 Data Collection:
3.3.2 Primary Data Sources:
The data source of this research would include semi-structured interviews with hospitals administrators and senior executive team. This approach was taken to allow the researcher an opportunity to explore necessary issues without inhibiting the interviewee to volunteer important information. Data would be collected on areas such as organisation leadership, culture and quality management systems for qualitative analysis.
Documentation would be reviewed from to verify involvement in TQM process. This would include accreditation plan, quality plans, vision and mission. Finally material substantiating a TQM initiative would be reviewed. These documentations would be sourced from quality department and CEO's office.
There would be researcher observations conducted to find evidence of TQM such as posters, banners and customer service interactions. This would serve to corroborate the interview and documentation findings.
The researcher would conduct employee focus groups to obtain views on TQM implementation activities in the organisation since employee involvement and awareness is critical to its success. These groups would be interviewer-led structure and kept to 6-8 persons to allow for moderator /researcher control to maintain focus. This technique would be conducted several times with similar participants to establish trend and patterns for data collection and analysis.
3.3.3 Secondary Data Sources:
The literature review for this research proposal thus far used several secondary data sources. This data was assessed for authority and reputation of the source. The review of written materials from industry experts or "gurus', journals, organisation's records and government publications would be accessed and referenced as part of this study. This approach would allow for more time for analysis and interpretation of data.
3.3.4 Sample size and sampling method:
Since a case study approach was taken the use of non-probability sampling would be applied by the researcher so that sample selection can be made based on subjective judgement. This view is supported by Saunders(2009) that within business research such as case study this may either be not possible or appropriate for answering the research question. The use of purposive sampling technique would enable the researcher to use judgement in selecting cases that would enable the research question and objectives to be answered. According to Saunders (2009) is form of sample is often used in case study research and when a selection of cases would particularly informative. It is also further suggested for a general study a suitable sample size of between 25 to interviews are undertaken (Creswell 2007).
3.3.5 Data Analysis:
A qualitative analysis on this data would be conducted, this would require the condensing, categorising and also restructuring as narrative to support for significant analysis to be derived. The interviews with respondents would be audio recorded and reproduced via word processing. It would also be noted during transcribing the tone and non-verbal communication of the participants. A process of data sampling would be used to reduce time for audio transcribing since this would allow for the researcher to list sections pertinent to the study. The interviews conducted would be saved in separate word documents and filename maintained for confidentiality. The recommendation by Silverman (2007) on list of useful transcription symbols would be used for this study. The precise work format for NVivo software would be utilised to ensure accurate analysis can be conducted.
3.3.6 Qualitative Analysis:
Analytical induction approach was adopted since it would allow for an intensive explanation of the case study so as to empirically establish the causes of a specific phenomenon (Saunders2009). This would be most appropriate since the researcher case study sampling took a purposive approach which would allow for the phenomena to be explored. The use of thematic analysis would be utilised to identify data that relate to classified patterns these would be catalogued into sub-themes for emerging patterns. This would lead to building a compelling argument derived from the literature reviewed.
Research ethics is the defined as a question of how we formulate and clarify our research area, design, gain access to data and write up our research findings in a moral and responsible way (Saunder2009). The researcher proposes the following ethical issues during this study.
The researcher would have to submit a research proposal for approval from the NCRHA ethics committee before this study can be conducted.
Informed consent would be solicited from participant for possible privacy and confidentiality issues
Participants would be informed of its voluntary nature and the right to withdraw from the process.
The data generated during this study would have transcript symbols to maintain confidentiality
The researcher would be cognisant of the ethical concerns with regards to qualitative research since objectivity must be observed during analysis so the data is not misrepresented.
3.3.8 Reliability and Validation:
Validity in research must be considered when conducting a case study research since it is concerned with whether findings are really what they appear. The researcher must be careful of generalisabilty particular when the case study is conducted in one organisation (Saunders2009). The research design for this study incorporated triangulation so that different data techniques can be used within one study which allows for cross verification. The researcher would also consult peer consultation prior to final draft of the report. According to Yin(2003) construct validity is especially problematic in case study research and it can be a source of criticism due to its subjectivity it is further recommended the use of case study protocol to achieve reliability. The researcher prior to data collection would develop a case study protocol that includes more than one survey instrument and procedure to be followed in using the instrument.
3.3.9 Limitations to Methodology:
The researcher may not provide a representative population for the case study.
This research methodology can be time consuming and costly
There is a potential for researcher bias during the study
The study in also reliant on subject participation in the research data collection
3.3.10 Resources Required:
This study would require a number of resources such an audio recording device for interviews, purchase if NVivo software, internet and computer capabilities to complete this report. There would be a need to access secondary data such as journals, written text and peer view materials for further literature review.
The research study would require an ongoing literature review and write-up as the study progress. The research proposal would require ethics approval from the organisation and university ethics committee this would be key milestone in this project. The appointment of dissertation supervisor and the gathering of resources for this research should be completed. The planning of interviews, focus groups, documentation reviews have some schedule over lap since meeting with senior managers would require some coordination. Due to the time consuming process involved in qualitative analysis the researcher would plan to conduct most interviews with-in a 4 weeks time frame
The collation of data would be concurrent since interviews would be transcribed after being conducted. The data analysis would be key milestone in the project since critical analysis would be required for this study. The researcher would aim for a completed draft six weeks before submission to allow for editing and additional research work. This would allow supervisor review and approval prior to submission. Please attached Gnatt chart of activities and timescales.
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