Implementing TQM in a medical school department - total quality management

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

Given a long history of quality concerns, it seemed important to shake up the system and persuade the department that change was possible. The new Director of Clinical Affairs began by initiating a number of informal discussions with faculty, residents, and staff about the FMC practice. The idea was to find a few easily resolved problems--"squeaky wheels" that had everyone concerned-so that some "quick hits" on quality could be implemented quickly.

Some quick hits did succeed. For example, a persistent physician complaint concerned the nonavailability of nurses to assist with patient examinations and procedures. Simple dialogue revealed that nurses spent considerable time on nonnursing work. The practice received an average of 60 phone calls daily requesting prescription refills. Responding to these calls occupied one nurse for half a day each day--mostly because the physician's intention about refills could not be discerned from the medical record. The solution was a new medication list for patient charts that included specific refill instructions. This cut the time per refill request from approximately four minutes to one minute and eventually allowed management to turn this task over to a nonclinically trained staff member. A switch from mercury to electronic thermometers turned a four-minute task into a 40-second one. This, too, improved nurse availability.

Not all of the attempted quick hits were successes, however. Among the early failures was an attempt to improve the handling of telephone calls in the FMC. Meetings were held, scripts for telephone etiquette were written, and nothing happened. Exhortative management seemed to be a losing proposition. It also proved difficult to hold gains made elsewhere in the practice. The fledgling quality improvement effort became stalled.

The Dawning of CQI

At about this time, the concepts of continuous quality improvement and total quality management began to appear in the health care literature.(2) Now there was an explanation of why the gains were not held. The analysis of problems in the FMC had been superficial; quick-hit methods could not address root causes. As a result, solutions still appeared to be imposed from the top.

The first formal QI project in the department quickly followed. FMC staff and physicians complained that it took too long for new patients to register and complete health history forms. A time study confirmed a mean of 25 minutes for this process. The participants in the practice meeting, which was slowly transforming itself into an ongoing quality improvement meeting, then worked out a process flow diagram. They discovered that the registration process required FMC staff to handle seven separate pieces of paper, some of which contained redundant information. But it was completion of the health history questionnaire that consumed the single largest fraction of the 25 minutes. Three separate versions were in use (for adult males, adult females, and children), and only those staff members with long institutional memories recalled that one form had been transformed into three to support a long-forgotten experiment. A faculty member drafted a new, simpler form applicable to both sexes and all age groups. After several months of negotiation with other faculty, it was approved and put into use. This step promptly cut 10 minutes from the time needed to complete patient registration, thereby improving patient flow.