Implementing TQM in a medical school department - total quality management

Physician Executive, March-April, 1993 by Robert A. Fried

In a modest way, our medical school department has succeeded in applying continuous quality improvement and TQM methods to its ambulatory practice. We are close enough to our experience not to have forgotten what Rosabeth Moss Kanter calls the "messy, mistake-ridden, muddling stage."(1) This article is a narrative of some of our stumbling attempts to change the way our practice works. The lessons we have learned are relevant to other ambulatory practices, both inside and outside the academic world.

Those who would implement a total quaility management approach in an academic medical setting face unique challenges. TQM concepts challenge physicians to think in different ways. The special attributes of the medical school environment create additional barriers to this new view of quality improvement.

To succeed, TQM must engage the energy and imagination of all members of the health care organization. But in the academic world, most physicians necessarily are part-time clinicians. Frequently, patient care is seen by medical school faculty as a burden to be endured, not as a central part of professional identity. Faculty are the top clinical leadership, but attracting and holding their attention on quality problems in patient care can be difficult.

The demands of the training environment also work against the implemenration of TQM. Incompletely trained physicians--housestaff and students--have their hands full learning the mechanics of patient care. They rarely are willing participants in a quality improvement effort. Faculty, residents, and students all rotate through outpatient clinics and inpatient wards. Few physicians will serve on a quality improvement team that concentrates on a clinical service they will soon leave.

TQM requires an analysis of waste, complexity, and rework, but some inefficiencies are inherent in the academic world. Patient flow through outpatient clinics, for example, must include enough time for teaching and review of trainees' work by faculty attendings. Some tests are ordered "for completeness"--that is, because they illustrate a teaching point, not because the diagnosis really is in doubt.

Even the culture of the academic medical center is a barrier to TQM. As noted above, rewards in medical school come from research and teaching, not from patient care. Superior clinical performance is assumed, not evaluated and certainly not rewarded. The presumption of excellence can interfere with the honest self-assessment that TQM requires.

In recent years, competition has shrunk the patient care bases of many academic medical centers. Patients naturally seek health care they perceive to be of the highest quality, but the university hospital no longer is perceived automatically as the best. Paradoxically, then, academic medical centers must emphasize quality to attract patients, even though patient care has not been a priority for them.

The Crisis

The Department of Family Medicine (DFM) of the University of Colorado School of Medicine operates a Family Medicine Center (FMC) in which faculty and residents see approximately 15,000 patients a year. For many years, the practice was ignored. Overworked faculty were always willing to cancel their own patient care hours whenever they needed discretionary time. Residents behaved like their teachers. The practice literally was held together by its nursing and clerical staff. During the 1987-88 academic year, there were signs that the patient base was eroding. Faculty realized this not only would mean a loss of service for many patients, but also would hinder the educational and research agendas of the department.

In response, the faculty approved a plan to address quality-of-care concerns. An important change concerned the physician management of the FMC. Traditionally, the medical director had been a junior faculty member with no management training and no mandate for change. The incumbent had responsibility for the most mundane details of running the practice. Inexperienced physician managers behaved like physicians instead of managers; they gave orders and expected them to be carried out. Not surprisingly, medical directors came and went, and the practice went on as before. The 1988 practice revision plan created a new Division of Clinical Affairs within the department, with a more senior faculty member as its director. The first Director of Clinical Affairs (DCA) had experience in management and was given an unmistakable mandate for change. Day-to-day responsibilities for running the practice were transferred to a full-time practice manager, leaving the director free to concentrate on a quality assessment and improvement program.

The practice revision plan did more than redraw the organizational chart. It created a weekly "practice meeting' in which residents, faculty, and staff met to discuss patient care issues. Over time, this meeting, which had a vague agenda when conceived, became a forum for internal customers and suppliers to work out problems.