The American health care system has serious problems with quality and safety.

One effective way to attack these problems is through the methods of quality improvement (QI). Over the past several decades, the American healthcare system has moved from a quality assurance (QA) model to one focused on quality improvement (QI). The difference between the two concepts is that QA models target currently existing quality; QI models target ongoing and continually improving quality.

The term QI refers to activities that use data-based methodssome developed in manufacturing industriesto bring about immediate improvements in health care delivery. Change has always been an intrinsic part of medical practice, as clinicians and managers adapt to new medical knowledge, new technology, and new patterns of disease. QI methods enable them to make change in a systematic way, measuring and assessing the effects of a change, feeding the information back into the clinical setting, and making adjustments until they are satisfied with the results.

Model for Quality Improvement

The Model for Improvement is a simple but powerful framework for structuring any quality improvement project. First, every project should be able to answer three fundamental questions: 1. What are we trying to accomplish? This question is meant to establish an aim statement for improvement and focuses the organizations effort. The aim statement should be time specific, measurable and as concise as possible. It helps to focus on specific actions or elements of the Care Model and to define which patients and providers will participate. 2. How will we know a change is an improvement? Measures and definitions are necessary to assess and understand the impact of changes designed to meet the aim.

When shared aims and data are used, learning is further enhanced because it can be shared with other organizations. In this way, superior performance and best practices are more quickly identified and disseminated through benchmarking. 3. What changes can we make that could lead to an improvement? Testing by way of the Plan-Do-Study-Act cycle is necessary to conclude that a result is an improvement. The P-D-S-A cycle is a trial-and-learning method to discover what is an effective and efficient way to change a process. Studying the cycle is analyzing the outcome measurements and deciding if the intervention was an effective and efficient way to change a process. The cycle is modified and repeated as necessary until the change is ready for broader implementation.

Second, quality improvement teams should test their ideas for improvement in small but frequent tests of change, using Plan-Do-Study-Act (PDSA) cycles.

Two models that emphasize the ongoing nature of QI include total quality management (TQM) and the Toyota Production System (TPS).

Total Quality Management (TQM) This is the original QI model based on the Plan-Do-Study-Act (PDSA) cycle. TQM, also referred to as Continuous Quality Improvement (CQI), is a philosophy developed by Dr. W. Edwards Deming

Dr. W. Edwards Deming:

(October 14, 1900 December 20, 1993) was an American statistician, professor, author, lecturer and consultant, considered the Father of the Modern Quality. Edwards Deming strongly influenced Japanese industry post WWII with Statistical Process Control (SPC) and Total Quality Management (TQM)

TQM is one of the hallmarks of Japanese management systems. It assumes that production and service focus on the individual and that quality can always be better. Thus, identifying and doing the right things, the right way, the first time and problem-prevention planning not inspection and reactive problem solvinglead to quality outcomes.

Because TQM is a never-ending process, everything and everyone in the organization are subject to continuous improvement efforts. No matter how good the product or service is, the TQM philosophy says that there is always room for improvement. Customer needs and experiences with the product are constantly evaluated.

Workersnot a central QA/QI department do this data collection, thus providing a feedback loop between administrators, workers, and consumers. Any problems encountered are approached in a preventive or proactive mode so that crisis management becomes unnecessary.

Another critical component of TQM is the empowerment of employees by providing positive feedback and reinforcing attitudes and behaviors that support quality and productivity. Based on the premise that employees have an in-depth understanding of their jobs, believe they are valued, and feel encouraged to improve product or service quality through risktaking and creativity, TQM trusts the employees to be knowledgeable, accountable, and responsible and provides education and training for employees at all levels.

Although the philosophy of TQM emphasizes that quality is more important than profit, the resultant increase in quality of a well-implemented TQM program attracts more customers, resulting in increased profit margins and a financially healthier organization.

14 Total Quality Management Principles of TQM

1) Create a constancy of purpose for the improvement of products and service. 2) Adopt a philosophy of continual improvement. 3) Focus on improving processes, not on inspection of product. 4) End the practice of awarding business on price alone; instead, minimize total cost by working with a single supplier. 5) Constantly improve every process for planning, production, and service. 6) Institute job training and retraining. 7) Develop the leadership in the organization.

8) Drive out fear by encouraging employees to participate actively in the process. 9) Foster interdepartmental cooperation, and break down barriers between departments. 10) Eliminate slogans, exhortations, and targets for the workforce. 11) Focus on quality and not just quantity; eliminate quota systems if they are in place. 12) Promote teamwork rather than individual accomplishments. Eliminate the annual rating or merit system. 13) Educate/train employees to maximize personal development. 14) Charge all employees with carrying out the total quality management package.

The Toyota Production System

Another more contemporary, customer-focused quality improvement model is the Toyota Production System (TPS). TPS is a production system built on the complete elimination of waste and focused on the pursuit of the most efficient production method possible (Toyota Motor Company, 2010).

Lean thinking, which was developed by Toyota in the 1950s, aims to achieve waste reduction and efficiency while simultaneously improving product quality. The core principle in lean thinking is the need to provide what the internal or external customer wants, i.e., to provide value to the customer, with minimal wasted time, effort, and cost. Correcting or removing any actions or processes that do not create value (i.e., waste) will lead to additional capacity and hence enhanced performance.

Healthcare organizations that use TPS would have caregivers not only attempt to directly solve problems at the time they occur, but it would also have them determine the root cause of the problem, so that the likelihood of the problem recurring would be minimized. TPS argues that solving individual problems this way, one at a time and where, when, and with whom they occur, prevents larger problems. Thus, management decisions are based on a long-term philosophy, even at the expense of short-term financial goals.

Implementing TPS, however, is not easy. It usually requires a change in organizational culture, values, and roles since responsibility and accountability for solving problems is so decentralized. In addition, eliminating problems at their root is far different from solving an immediate problem at hand. Thus, adopting TPS in an organization requires a substantial commitment of leadership time and resources. It also requires a tremendous amount of staff preparation and involvement.