Implementing TQM in a medical school department - total quality management

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

The conventional wisdom was that we ran late because our patients came late. To our surprise, the time study showed that most patients arrived early, but only 43 percent of them were ready for the doctor by the scheduled time. Most of the prephysician time was occupied by nurse preparation--getting the patient weighed, laying out needed equipment, and so on. We confirmed that different nurses prepped patients differently. We quickly learned that they had no formal orientation to their jobs or any guidelines to which they could refer. The DCA and the nurses met to draft such guidelines. Because the physicians were the nurses' customers, their requirements were identified by circulating the draft guidelines to them for comment. A final version has become part of the orientation of new nurses. Certain other changes also were made in nurse prep routines. We did a followup study a few months later that showed that the percentage of patients ready on time had climbed to 67 percent. Organizational Change at Work Changes in clinical routines have been the most difficult changes to make. They require the consent of the faculty, which constitutes the senior clinical leadership. No major change was advanced without discussion at faculty meetings and circulation of background papers for comment. Some topics went through several rounds of comments and rewrites in order to achieve faculty wide agreement. And no discussion of change was initiated without a series of informal, behind-the-scenes conversations among the DCA and the faculty.

Prenatal care provides an example of our "push-and-pull" approach to organizational change. Our department delivers approximately 180 babies a year. This is an average obstetric load for an academic family medicine department. Many of our pregnant patients are at high risk for adverse perinatal outcomes. Some faculty members had become concerned about how effectively residents were managing their obstetrical patients. In response, the DCA and the department's Quality-of-Care Committee authorized an audit of the practice's prenatal charts. Deficiencies were noted in the documentation of patients' due dates. The Quality-ofCare Committee then proposed the creation of a prenatal care working group to address and solve these problems.

In effect, the group functioned as an ad hoc QI team. Its membership included faculty members (physician and nurse practitioner), residents, FMC staff, and a private obstetrician who frequently consulted on the FMC's patients. Residents noted the conflicting advice they received from faculty about how to establish patients' due dates when their menstrual histories were uncertain. The group quickly decided that the prenatal forms in use did not provide adequate guidance to documenting patients' due dates and that the practice needed a uniform approach to the establishment of due dates. Its members reviewed several existing recordkeeping systems, selected their favorite, and circulated all the forms to the faculty for their review and comments; the working group made its preference clear. Simultaneously the Quality-of-Care Committee approved the form. Faculty members were lobbied individually by the DCA, with each physician hearing how the working group had reasoned its way to its choice of form. When the official vote came, there was unanimous faculty support for the form the group had selected.