Princess Margaret Hospital is one of the leading hospitals in the Bahamas in terms of both quality and quantity of patient care services. The hospital started in 1963 after commissioning by the government of the Bahamas for the delivery of extensive non-discriminatory healthcare services to all populations. The hospital has over the years evolved to a premier hospital in the country. The hospital’s hallmark of service delivery is in the ability to offer healthcare services to patients without consideration of the patients’ ability to pay. With over two million patients that have been treated in the emergency department alone, the hospital has continued to show stellar performance in terms of quality of patient and service delivery. In order to effectively deliver its promise to the customers sustainably, the hospital has been focused on providing low-cost services whose payments go beyond tax-payer obligations hence it is constantly in need of additional funding. The hospital seeks to develop total quality management (TQM) plan for improvement in patient safety and quality based on the organizational goals.
Hospital Mission and Vision
The mission and vision of the hospital are all centered on providing valuable, high-quality care to patients through the commitment of professionals, organizational distinction as a leader in healthcare service delivery, and ensuring customer satisfaction (1). To achieve the organizational mission and vision, Princess Margaret Hospital operations are guided by a principle described as QUEST, namely quality healthcare, unselfish attitude, excellence in service delivery, service with a smile, and timely response to patient needs (1). The practices presented by the QUEST acronym are aimed at fostering the consistent and effective delivery of quality healthcare services. The hospital also has clear policies on care quality and a patient care manual that provides guidelines into the measures that are to be taken by healthcare professionals in carrying out various healthcare procedures at the hospital (1). The combination of the clear commitment to quality as described in the hospital mission and vision statements and in the QUEST principle and the organizational patient care manual has been sufficient towards sustaining quality service delivery. While the hospital clearly communicates its commitment to healthcare service quality, there is no clear communication of commitment to patient safety in the organizational mission and vision statements. It is, therefore, possible to suggest that gaps in quality management and effectiveness are inevitable at the hospital. Implementation of TQM at the hospital will therefore consider the gaps that still exist in quality service delivery and be aimed at sustaining quality care over the long term.
Background to the problem
Princess Margaret Hospital has developed a set of strategic goals and objectives that are expected to result in more significant outcomes in inpatient quality. The hospital’s set of strategic goals are categorized under 6 pillars, which are aimed at facilitating the realization of effective and patient-centered care. The first of these pillars is that of clinical quality and patient safety. This pillar entails goals such as patient monitoring and evaluation, strengthening the hospital’s risk management practices, planning and development of systems for quality improvement, and auditing and assessment of patient safety and clinical quality practices (1). The second pillar is service, in which the hospital aims at improving patient satisfaction. In the third pillar on people, the hospital focuses on improving staff training and development, enhancing employee relations and incentives, and the management and training of human resources. The fourth pillar relates to financial stewardship and is presented through the goals of strengthening of financial management and control systems for internal use, enhancement of revenue, and strengthening of preventive maintenance programs (1). The fifth pillar is on growth and includes the goals of strengthening the health system and supporting infrastructure development (1). The last (sixth) is on community relations, under which the hospital works towards strengthening both internal and external communication (1). The clearly stated goals of the hospital confirmed the hospital’s commitment to quality care and to patient safety. The implementation of TQM in the organization will therefore be aimed towards supporting continuous improvement through effective documentation of changes made in various areas including in HR management, financial management and control, and in monitoring and assessing the quality and patient safety practices.
The situation at Princess Margaret Hospital does not present a specific area of challenge. Rather, it gives an impression of the intention to develop a system that would support continuous improvement. The hospital has not recorded negative performance in any of the areas in which the goals are set, indicating that the goals are aimed at moving towards a better position relative to what the hospital currently exhibits. As part of this TQM planning process, the focus will be on improving patient safety and quality. Finding the right solution for improving both care quality and patient safety requires an examination of the gaps that currently exist in the hospital’s policies on patient safety and quality care delivery. Specifically, gaps have been identified in the organizational mission, vision, and values statements, which do not emphasize the role of patient safety as a practice that is mandatory in service delivery.
For effective planning, the objective can be broken down into two goals namely, improvement of care quality and improvement of patient safety. There are specific indicators given by the AHRQ for care quality and different ones for patient safety, therefore it will be possible to assess progress in each of the two areas separately. Patient safety indicators are a subset of the broader care quality indicators set. The provider-level patient safety indicators include pressure ulcer rate, postoperative hip fracture rate, and postoperative sepsis rate among others (2). The other categories of care quality indicators include preventive quality indicators such as short-term complications admission rates for diabetes patients; inpatient quality indicators such as esophageal resection volume; and pediatric quality indicators such as neonatal mortality (3). The TQM plan developed for the hospital will therefore take into consideration all these indicators as metrics for performance evaluation with the goal of improving each area. Implementing TQM with the objective of attaining continuous improvement in quality care and patient safety will result in improved patient care outcomes in the hospital.
Solution: Total Quality Management as a Culture
Total Quality Management (TQM) is a practice that requires the development of a long-term cultural change process. TQM is itself a complex process that can fail in case an effective strategy is not developed for the shift from the bureaucratic culture that characterizes most of the operations in a healthcare environment to one that embraces continuous improvement towards intended objectives (4). A healthcare environment such as Princess Margaret Hospital is in a continuous state of change due to the evolutions in healthcare practice. Healthcare technology and practice standards change continuously as more effective approaches to sustaining patient safety and care quality are discovered. In such an environment, therefore, the first step towards sustaining change through TQM is recognizing that the process is not reactionary but is an evolutionary one since it deals with both individual and collective behaviors (5). These behaviors in TQM are aimed at ensuring customer satisfaction through continuous identification of customer needs and ensuring continuous improvement.
For the hospital, the solution to the quality and patient safety improvement challenges will be the development of a culture of TQM. TQM will require laying down ground-works for the establishment of a quality-oriented culture. During the recommended TQM process, the three elements of TQM, which include employee orientation, customer orientation, and continuous progress (6), will be pursued with the customer orientation as the leading element. Implementing TQM is expected to result in improved communication between the employees and the patients, enhanced adaptation of the employees to patient safety and quality care culture, increased job satisfaction among the hospital’s employees, and an overall improvement in the hospital’s reputation (7). Each of these outcomes is desirable for the hospital.
Implementing the proposed solution will require a strategic and systematic approach to decision-making. In this context, it is necessary to realize that the TQM process is a systematic one that has to be carried out simultaneously across the entire organization. As such, there will be no departmental operations. Instead, the plans laid down will be applicable to all departments since TQM requires an integrated approach to implementation, in which all departments are connected by horizontal processes that are the basis for TQM implementation (8). Employee commitment will be pursued from the onset beginning with the managers as recommended by (9). The process will also be strategic in that there will be no distinction between the handling of outpatient clients and inpatient clients (all clients are the same) as recommended by (10), the implementation of different treatment approaches will be aligned to stipulated industry standards (one of the principles of TQM is a process-approach to problem-solving through which the right actions are taken at the right time to ensure consistency and speedy delivery (11)), there will be an emphasis on a customer-centric approach to healthcare service delivery based on the study by (12), and clear documentation for all the healthcare processes will be developed for monitoring and evaluation purposes (13). These specifications are based on the recommendations given by (14) towards effective strategic management of healthcare organizations. Additionally, the TQM process itself is generally customer-centric hence customer-centered operations can be considered the core of strategic decision-making in implementing this solution.
Besides the conventional process recommendations provided by entities such as the WHO, the implementation of this solution will also require a fact-based approach to decision-making. Hospital operations are quite dynamic and performance statistics vary from day today. Therefore, making informed decisions at each stage will require the hospital to rely on data that is gathered and analyzed through reliable methods, accurate, and sharable with the stakeholders (15). The data obtained from the hospital records on progress with respect to various quality and patient safety indicators and the implementation of standardized protocols will be used to provide guidelines to employees on the next courses of action in the continuous improvement process. Through the entire process, communications, which is a principle of TQM, will be paramount. Zehir et al. (16) assert that in the implementation of TQM, there is a greater risk of failure if communication is ineffective as indicated by lack of involvement of all staff, absence of an official communications line for the process, and lack of role clarity among staff. To prevent such failure, the communication aspect will be managed effectively from the beginning of the process.
The implementation plan for the recommended solution is provided in Table 1 below.
Table 1. Implementation plan for TQM at Princess Margaret Hospital
|Identification of deficiency areas in patient safety and care quality.
|Nurse leaders from all departments.
|Hospital data on key patient safety and quality care indicators.
|Development of protocols for patient safety based on WHO guidelines
|Hospital administrative personnel such as clerks and secretaries guided by nurse leaders and registered nurses (RNs).
|WHO guidelines on patient safety
|Development of patient care protocols for chronic conditions based on WHO guidelines.
|RNs and advanced practice care nurses (APRNs)
|WHO guidelines on care quality and the hospital’s patient handbook.
|TQM leaders in collaboration with physicians and nurse leaders.
|Educative resources on TQM
|Intermittently for 3 months and refreshers every 6 months.
|Actual onset of TQM documentation
|Nurse leaders in respective departments.
|Templates for progress recording for outcomes in each of the indicators.
|Continuous from 1 month.
The implementation of TQM at Princess Margaret Hospital will require a cultural change in the organization from a bureaucratic operations culture to a strategic and systematic decision-making culture oriented on the quality. The hospital has indicated positive performance in various aspects of quality but is set to improve its performance on patient safety and quality based on the AHRQ standards. To achieve this, a TQM implementation plan is recommended for continuous improvement. Effective implementation of the plan is expected to result in positive outcomes in patient safety, job satisfaction among employees, customer satisfaction, and financial performance in the hospital.
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