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Transcript of 14 15Solinap&Somongcad D.
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QUALITY STANDARD IN HEALTH CARE ORGANIZATION
IMPROVING PERFORMANCE
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Presented to
Dr. Betty T. Polido
Faculty of the College of Nursing
Central Philippine University
In Partial Fulfillment
for the Requirement in the course
N 414- F
By
Solinap, Lady Juelaine M.
Somongcad, Denevieve P.
July 10, 2012
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The report is about improving performance in health care organizations specifically it aims
to:
identify important events and people in the history of quality care;
describe factors influencing performance of health workers and strategic performance;
discuss about ineffective performance and factors related to it;
determine the influence of motivation as a performance indicator
identify strategies that influence, competence and responsiveness among health care
organizations;
compare the benefits and drawbacks of performance appraisal
describe what is Total Quality Management (TQM);
explain the relevance of TQM in Quality of Health Care.
OBJECTIVES:
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Qualityis a more complicated term than it appears. Dictionary definitions are
usually inadequate in helping a quality professional understand the concept. It seems
that every quality expert defines quality somewhat differently, and there are a variety of
perspectives that can be taken in defining quality. This report focuses in improving
performance of health care provider organizations in quality standard.
Improving performance is a very relevant topic in the health care
organization since our clients deserve the best quality of care. We, as the providershave to be fully equipped with knowledge, skills and attitude in order to be considered
as competent in our field.
INTRODUCTION
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The quality movement can trace its roots back to medieval Europe, where
craftsmen began organizing into unions called guilds in the late 13th century.
Until the early 19th century, manufacturing in the industrialized world tended
to follow this craftsmanship model. The factory system, with its emphasis on product
inspection, started in Great Britain in the mid-1750s and grew into the Industrial
Revolution in the early 1800s.
In the early 20th century, manufacturers began to include quality processes in
quality practices.
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After the United States entered World War II, quality became a critical
component of the war effort: Bullets manufactured in one state, for example, had to
work consistently in rifles made in another. The armed forces initially inspected
virtually every unit of product; then to simplify and speed up this process without
compromising safety, the military began to use sampling techniques for inspection,
aided by the publication of military-specification standards and training courses in
Walter Shewharts statistical process control techniques.
The birth of total quality in the United States came as a direct response to
the quality revolution in Japan following World War II. The Japanese welcomed the
input of Americans Joseph M. Juran and W. Edwards Deming and rather than
concentrating on inspection, focused on improving all organizational processes
through the people who used them.
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By the 1970s, U.S. industrial sectors such as automobiles and electronics
had been broadsided by Japans high-quality competition. The U.S. response,
emphasizing not only statistics but approaches that embraced the entire
organization, became known as total quality management (TQM).
By the last decade of the 20th century, TQM was considered a fad by
many business leaders. But while the use of the term TQM has faded somewhat,
particularly in the United States, its practices continue.
In the few years since the turn of the century, the quality movement seems
to have matured beyond Total Quality. New quality systems have evolved from the
foundations of Deming, Juran and the early Japanese practitioners of quality, and
quality has moved beyond manufacturing into service, healthcare, education and
government sector (http://asq.org/learn-about-quality/history-of-
quality/overview/overview.html).
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Poor performance of service providers leads to inaccessibility of care and
inappropriate care, which thus contribute to reduced health outcomes as people are
not using services or are mistreated due to harmful practices. Poor performance
results from too few staff, or from staff not providing care according to standards and
not being responsive to the needs of the community and patients. As Hughes et al.
state: Most performance problems can be attributed to unclear expectations, skills
deficit, resource or equipment shortages or a lack of motivation (Hughes et al., 2002).
These causes are rooted in a failing health system, low salaries, difficult working and
living conditions and inappropriate training.
FACTORS INFLUENCING PERFORMANCE OF HEALTHWORKERS AND STRATEGIES FOR IMPROVEMENT
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This framework was designed using a systemic approach to health worker
performance: situational analysis, intervention (input/process), outputs, effects,
outcome and impact.
The framework shows that determinants of healthworkers behavior (in the workplace) are rooted in
factors relating to:
macro level, or the overall health system, such as resources allocation, planning
and deployment of health workers, current regulatory framework, communication and
decision-making processes, and accountability mechanisms. These can be influenced by
policy-makers and planners in the health sector, as well as other stakeholders at
national level, such as the ministry of finance, ministry of education, professional
associations, civil society groups and funding agencies (health systems level).
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micro level, or the workplace itself (district or facility, etc.), such as availability of
equipment, drugs and supplies, teamwork and human resources management activities.
In principle these can be influenced by local managers, colleagues, patients and other
local partners (health facility level)4.
individual characteristics and living circumstances, such as living in conflict areas or
being a woman or a newly graduated professional. These require specific group
strategies and can be developed locally by managers or nationally by policy-makers and
planners together with other stakeholders (individual level).
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Interventions are designed based on an analysis of the determinants that
influence health workers performance. Implementation of these interventions (inputs
and process) provides outputs (expected results) in terms of improved working
conditions, improved motivation, improved staff retention, etc. These, in turn, result
in the effects of the intervention in terms of measurable improvements on availability,
productivity, competence and/or responsiveness of health workers. The effects
positively influence performance, i.e. the outcome of the intervention, for which the
intervention is not totally accountable. Improved performance in turn contributes to
improved health status.
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There is no linear relationship between determinants and outputs, between
outputs and effects, and between effects and outcomes. Health worker performance is
a complex issue to address, as a variety of determinants influence staff behaviour at
different levels. Various authors have regrouped the determinants (Rowe et al., 2005;
Hongoro & Normand, 2006; WHO, 2006), suggesting four main areas:
health worker characteristics (individual level)
health system and facility characteristics (macro and micro levels)
characteristics of the wider political and socioeconomic environment (contextual
factors)
community/population characteristics (contextual factors)
(www.who.int/hrh/resources/improvinghw-performance.pdf).
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Job performance is ineffective when productivity falls below a standard
considered acceptable at a given time. Ineffective performers consume considerable
managerial time. The causes of poor job performance can be rooted in the employee,
the job, the manager, or the organization. Usually ineffective performance is caused by
a combination of several factors.
Factors contributing to ineffective performance
Employees are or become ineffective performers for many different reasons.
The cause of poor performance can be rooted in the person, the job, the manager, or
the company.
INEFFECTIVE PERFORMANCE
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Insufficient mental ability and
education
Insufficient job knowledge
Job stress or burnout
Low motivation and loafing
Technological obsolescence
Absenteeism and tardiness
Emotional problem or personality
disorder
Alcoholism and drug addiction
Tobacco addiction or withdrawal
symptoms
Conducting outside business on the
job
Family and personal problems
Physical limitations
Preoccupying office romance
Fear of travelling, especially flying
FACTORS RELATED TO THE
EMPLOYEE:
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Inadequate communication about
job responsibilities
Inadequate feedback about job
performance
Inappropriate leadership style
Bullying or intimidating
FACTORS RELATED TO MANAGER :
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Ergonomics problems and repetitive
motion disorder
Repetitive, physically demanding job
Built-in conflict
Night-shift work assignments
Substandard industrial hygiene
A sick building
FACTORS RELATED TO JOB:
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Organizational culture that tolerates
poor performance
Poor ethical culture
Counterproductive work environment
Negative work-group influences
Intentional threats to job security
Violence or threats of violence
Sexual harassment
FACTORS RELATED TO THE ORGANIZATION:
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Define performance standards.
Detect deviation from acceptable
performance
Define and assess the cause
Communicate with the substandard
performance
Set improvement goals
Select and implement an action plan
Reevaluate performance after a time
interval
Continue or discontinue the action plan
(Dubrin, 2006).
APPROACH IN IMPROVING INEFFECTIVEPERFORMANCE:
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Understanding why people do the things they do on the job is not an easy
task for the manager. All important work behaviors are motivated. Managers need to
motivate employees to join and remain in the organization and to exhibit highattendance, job performance, and citizenship.
Motivation refers to forces that energize, direct, and sustain a persons
efforts. All behavior, except involuntary reflexes like eye blinks is motivated. A highly
motivate person will work hard toward achieving performance goals. With adequate
ability and understanding of the job, such a person will be highly productive (Bateman,
2007).
MOTIVATION AS PERFORMANCE INDICATOR
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The Nature of Motivation.
Motivation encompasses the psychological forces within a person that
determine the direction of the persons behavior in an organization, the persons levelof effort, and the persons level of persistence in the face of obstacles. Mangers strive
to motivate people to contribute their inputs to an organization, to focus these inputs
in the direction of high performance, and to ensure that people receive the outcomes
they desire when they perform at a high level.
THEORIES IN MOTIVATION
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Expectancy Theory
According to expectancy theory,
managers can promote high levels of
motivation in their organizations by taking
steps to ensure that expectancy is high
(people think that if they try, they can
perform at a high level, they will receive
certain outcomes) and valence is high (
people desire these outcomes).
THEORIES IN MOTIVATION
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Need Theories
Need theories suggest that to motivate their workforces, managers should
determine what needs people are trying to satisfy in organizations and then ensure that
people receive outcomes that satisfy these needs when they perform at high level and
contribute to organizational effectiveness.
Equity Theory
Managers can promote high levels of motivation by ensuring that people perceive
that there is equity in the organization or that outcomes are distributed in proportion to
inputs. Equity exists when a person perceives that his or her own outcome-input ratio
equals the outcome-input ratio of a referent. Inequity motivates people to try to restore
equity.
THEORIES IN MOTIVATION
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Goal-setting Theory
Suggests that managers can promote high motivation and performance by
ensuring that people are striving to achieve specific, difficult goals. It is important for
people to accept the goals, be committed to them, and receive feedback about how
they are doing.
Learning Theories.
Operant conditioning theory suggests that managers can motivate people to
perform highly by using positive reinforcement or negative reinforcement. Managers
can motivate people to avoid performing dysfunctional behaviors by using extinction
or punishment. Social learning theory suggests that people can also be motivated by
observing how others perform behaviors and receive rewards, by engaging in self-
reinforcement, and by having high levels of self-efficacy.
THEORIES IN MOTIVATION
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Pay and motivation
Each of the motivation theories discussed
alludes to the importance of pay and
suggest that pay should be based on
performance. Merit plans can be
individual,- group-, or organizational
based and can entail use of salary
increases or bonuses (Jones, 2006).
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Various strategies have been developed to improve productivity, competence
and responsiveness of health workers: these range from specific interventions (such as
the provision of performance-related allowances) to more comprehensive approaches
that combine aspects such as training, supervision and the provision of drugs and
guidelines. Success depends not only on identifying and addressing root causes but also
on the process of implementation. Although there was no conclusive evidence, single
interventions often had limited success (Rowe et al., 2005).
STRATEGIES TO INFLUENCE PRODUCTIVITY, COMPETENCE
AND RESPONSIVENESS
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A performance appraisal (PA) or performance evaluation is a systematic and periodic
process that assesses an individual employees job performance and productivity in relation to
certain pre-established criteria and organizational objectives.
A central reason for the utilization of performance appraisals (PAs) is performance
improvement (initially at the level of the individual employee, and ultimately at the level of the
organization). Other fundamental reasons include as a basis for employment decisions (e.g.
promotions, terminations, transfers), as criteria in research (e.g. test validation), to aid with
communication (e.g. allowing employees to know how they are doing and organizational
expectations), to establish personal objectives for training programs, for transmission of
objective feedback for personal development, as a means of documentation to aid in keeping
track of decisions and legal requirements and in wage and salary administration.)
PERFORMANCE APPRAISAL: PROS AND CONS
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Additionally, Performance
Appraisals can aid in the formulation of
job criteria and selection of individuals
who are best suited to perform the
required organizational tasks. A
Performance Appraisal can be part of
guiding and monitoring employee career
development (www.wikipedia.com).
PERFORMANCE APPRAISAL: PROS AND CONS
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Potential Benefits of ConductingPerformance Appraisals
Facilitate communication Enhance employee focus by promoting
trust
Goal setting/reinforcement of desired
behavior/performance
Performance improvement
Determination of training needs
PERFORMANCE APPRAISAL: PROS AND CONS
Drawbacks of Formal PerformanceAppraisals
Detrimental to quality improvement Negative perceptions
Errors
Legal issues
Performance goals Derail merit pay or performance-based
pay
POTENTIAL BENEFITS OF CONDUCTING
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Facilitate communication:
- recognized as an important skill for managers and leaders in organizations (Kikoski,
1999).
-help reduce employee uncertainty, while promoting more effective communication
between supervisors and subordinates (Spinks, Wells, and Meche, 1999; Wells and
Spinks, 1999).
-absence of feedback leaves employees to play a guessing game concerning whether to
continue on the current path of workrelated behavior or to chart another course.
-encouraging employees to continue on a positive trajectory or to guide employees in
improving problem areas.
POTENTIAL BENEFITS OF CONDUCTING
PERFORMANCE APPRAISALS
POTENTIAL BENEFITS OF CONDUCTING
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Enhance employee focus by promoting trust:The existence or the lack of trust among organizational members and
structures affects performance (Argyris, 1964). Behaviors, thoughts, or issues thatdistract the employee from the work task reduce task performance (Kanfer andAckerman, 1989, p. 659). Their reasoning suggested that issues that consume anemployees limited capacity to focus would necessarily lessen the employees ability tofocus on activities that contributed to the achievement of organizational goals.Performance appraisals,properly structured and applied, can be used to help minimizeenvironmental distractions (Mayer and Gavin, 2005), promoting an increased level oftrust within the organization.
Goal setting/reinforcement of desired behavior/performance:
Ideally, organizations strive to match individual goals and performance to theoverall objectives of the organization. This may help reduce uncertainty about job-related expectations (Pettijohn et al., 2001). Performance appraisals also provide aforum for collaboration in setting goals for the employee (Kikoski, 1999). This
collaborative effort in goal setting is desirable because it results in greater acceptanceand satisfaction with appraisal results (Cawley, Keeping, and Levy, 1998).
POTENTIAL BENEFITS OF CONDUCTING
PERFORMANCE APPRAISALS
POTENTIAL BENEFITS OF CONDUCTING
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Performance improvement:
Performance appraisals are an important tool for communicating with
employees about how well their job-related performance meets organizational
expectations (Spinks et al., 1999). Well structured appraisals should directly relate to
noted improvements in any weak areas (Broady-Preston and Steel, 2002). At the
organizational level, numerous studies have reported positive relationships between
human resource management (HRM) practices, including performance appraisal and
organizational performance (e.g., Arthur, 1994; Delery and Doty, 1996; Guthrie, 2001;
Juselid, 1995; MacDuffie, 1995).
POTENTIAL BENEFITS OF CONDUCTING
PERFORMANCE APPRAISALS
POTENTIAL BENEFITS OF CONDUCTING
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Determination of training needs:
Employee training and development are crucial components in
helping an organization achieve strategic initiatives (Twomey and Harris,
2000). Seldon et al. (2001) argue that the key to an effective performance
appraisal system is providing individuals with an opportunity to pursue
training and development directly related to problem areas identified in the
appraisal. Appraisals systems can serve as an effective conduit for identifying
training needs, particularly for new employees (Broady-Preston and Steel,
2002). Further, performance appraisals may be useful in establishing and
monitoringemployees career goals (Spinks et al., 1999) (www.asq.org.).
POTENTIAL BENEFITS OF CONDUCTING
PERFORMANCE APPRAISALS
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Despite all the potential advantages of formal performance appraisals (PAs),
there are also potential drawbacks. It has been noted that determining the relationship
between individual job performance and organizational performance can be a difficult
task. These includes:
Detrimental to quality improvement:
It has been suggested that the performance appraisal systems of
organizations are an impediment to the pursuit of quality (Soltani, 2005). Kikoski
(1999) acknowledged the belief among some scholars and practitioners that total
quality management eliminates the need for formal performance appraisals.
DRAWBACKS OF FORMAL PERFORMANCE
APPRAISALS
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Negative perceptions:
Deming (1986), advocated that organizations take steps to create an
organizational environment that was free from fear, thus enhancing the overall quality
of performance. Quite often, individuals have negative perceptions of performance
appraisals (Pettijohn et al., 2001). Indeed, receiving a performance appraisal can be an
unnerving and even frightening experience for some employees (Spinks et al., 1999).
Performance appraisals can also create tension between supervisors and
subordinatesm(Jenks, 1991). This could be why some managers dread or even avoid
conducting them (Kikoski, 1999).
DRAWBACKS OF FORMAL PERFORMANCE
APPRAISALS
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Errors:
Performance appraisals should be based on a pre-established set of criteria
directly related to the employees job assignments (Amsterdam, Johnson, Monrad, and
Tonnsen, 2005). Thus, the ratings should provide an accurate reflection of the
employees performance. However, supervisors often give employees ratings that
exceed their true performance to avoid conflicts or avoid other unpleasant
consequences. Inflated ratings are a common malady associated with formal
performance appraisals (Martin and Bartol, 1998).
DRAWBACKS OF FORMAL PERFORMANCE
APPRAISALS
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Legal issues:
Performance appraisals that are not done well by supervisors can be costly to
organizationsfrom a legal standpoint (Jenks, 1991). This is important since
performance appraisals are becoming increasingly important tools in organizations
disciplinary programs (Spinks et al., 1999). Ratings on performance appraisals may also
be used by some organizations as a basis for promotion decisions. If the appraisals are
not donecorrectly, the resulting decisions may have negative effects on employees, thus
leading to legal action.
DRAWBACKS OF FORMAL PERFORMANCE
APPRAISALS
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Performance goals:
Performance or outcome goals are often used in conjunction with performance
appraisal systems. When performance or outcome goals are too challenging or
overemphasized at the expense of ethics, legal requirements, or quality, this can have
negative consequences for organizations (Loomis, 2003; Schweitzer, Ordonez, and
Douma, 2004). Furthermore, specific challenging performance goals have a deleterious
effect on employees effectiveness in the early stages of learning (Kanfer and Ackerman,
1989). Therefore, in organizational situations where the acquisition of knowledge and skill
is the primary focus, performance goals may be detrimental to performance (Seijts and
Latham, 2005). Learning goals, rather than performance goals would be more appropriate
in these situations.
DRAWBACKS OF FORMAL PERFORMANCE
APPRAISALS
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Derail merit pay or performance-based pay:
Some researchers argue that failure of merit-based pay and performance-
based pay can been associated with problems inherent in performance appraisal
systems (Selden, Ingraham, and Jacobson, 2001). As Milkovich and Newman (2005)note, performance measurement and performance management are the oil that
lubricates the human resources (HR) engine. To determine if HR efforts are working,
accurate performance appraisals are needed (http://asq.org/quality-
participation/2007/03/human-resources/critical-examination-performance-appraisals.pdf).
DRAWBACKS OF FORMAL PERFORMANCE
APPRAISALS
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The TQM concept was developed by a number of American management consultants, including W.
Edwards Deming, Joeseph Juran, and A.V. Feigenbaum. Originally, these consultants won few
converts in the United States. However, managers in Japan embraced their ideas enthusiastically and
even named their premier annual prize for manufacturingexcellence after Deming.
Total Quality Management is a philosophy or approach to management that is grounded on three core
principles:
1. A focus on the customer.
2. Participation and teamwork
3. Continuous Improvement
These principles are supported and implemented by an integrated organizational infrastructure, a set of
management practices, and a wide variety of tools and techniques, which all must work together
and support each other .
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Figure 3. The Scope of Total Quality Management
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The modern definition of quality
centers on meeting or exceeding customer
expectations. Thus, the customer is the
principal judge of quality. Perceptions of
value and satisfaction are influenced by
many factors throughout the customers
overall purchase, ownership and service
experiences.
CUSTOMER FOCUS
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When managers give employees the tools to make good decisions and the
freedom and encouragement to make contributions, they virtually guarantee that better
quality products and production processes will result. Employees allowed to participate-
both individually and in teams- in decisions that affect their jobs and the customer can
make substantial quality contributions. In any organization, the person who bestunderstands his or her job and how to improve both the product and the process is the
one performing it. By training, employees think creatively and rewarding good
suggestions, managers can develop loyalty and trust.
Another important element of total quality management is teamwork, whichfocuses attention on customer-supplier relationships and encourages the involvement of
total workforce in attacking systemic problems, particularly those that cross functional
boundaries.
PARTICIPATION AND TEAMWORK
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TQM requires horizontal coordination between organizational units.
Poor quality often results from breakdowns in responsibility that occurs when
an organization focuses solely on vertical structures, and fails to recognize the
horizontal interactions. Vertical structures lead to internal competition ratherthan promoting the good of the whole organization.
Partnerships are an additional way of promoting teamwork.
Partnerships between a company and organized labor and between customers
and suppliers are common among companies practicing TQM.
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Continuous Improvement has its roots inthe industrial revolution. In the early 1900s, Frederick
Taylor, often called the Father of Scientific
Management, believed that management had a
responsibility to find the best way to do a job and
train workers in the appropriate procedures.
Continuous improvement is an integral
part of the management of all systems and
processes. Under TQM framework however,
responsibility for quality lies with the individual
worker and teams of workers and quality is the
principal focus. The process of continuous
improvement requires systematic planning, execution,
and evaluation.
CONTINUOUS IMPROVEMENT
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Improvement is a critical aspect of all operations and of all work unit
activities of a company. Improvements may take any one of several forms:
Enhancing value to the customer through new and improved products and
services
Reducing errors, defects and waste
Improving productivity and effectiveness in the use of all resources
Improving responsiveness and cycle time performance
Seven important principles of Total Quality
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1. Quality can and must be managed
2. Processes, not people, are the problem
3. Dont treat symptoms, look for the cure
4. Every employee is responsible for quality
5. Quality must be measurable
6. Quality improvements must be continuous
7. Quality is a long-term investment
(http://managementhelp.org/quality/total-quality-management.htm).
Seven important principles of Total Quality
Management as a foundation for all your activities
APPLICATION OF TQM IN QUALITY OF
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Total quality management (TQM) is originally a concept of manufacturing
management. It is first used in the enterprise management, and considerrd as one of effective
methods of managing in the management field because a good result is achieved on TQM.
One of the content of its core is based on the course of the total quality management.
The total quality management thinking applied to the management of hospital careis to focus on the hospital care management, improve work-related activities, and establish
apatient-centeredconcept of care, so that the management of all hospital care forms a
complete network of services, which will ensure and enhance the quality of care. Hospital
care is an important component of the overall curative work. The quality of care reflects the
work level of hospital care and the quality of hospital management, and directly relates to the
patients life and health, impacts the satisfaction degree of the patient on the care, and even
plays a vital role in the development of the hospital (http://www.res-medical.com/clinical-
medicine/81208).
APPLICATION OF TQM IN QUALITY OFHEALTH CARE
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Achieving quality care and improving performance is not an instantaneous job to do.
This two requires endless effort to be achieved. Before achieving that certain level of excellence
in patient care there are certain factors to consider.
In improving performance, various factors influencing staff retention and mobility
can be distinguished such as personal and lifestyle-related factors, including living circumstances;
work-related factors, related to preparation for work during pre-service education; health-systemrelated factors, such as human resources policy and planning; and job satisfaction, influenced by
health facility factors, such as financial considerations, working conditions, management capacity
and styles, professional advancement and safety at work. providers depends on the political,
socioeconomic and cultural environment.
As elements influencing performance are intricately related to each other,
interventions must be comprehensive and multifaceted and must take place simultaneously and at
different levels of the health system. While experiments have taken place using different types of
interventions to improve performance of health workers, substantive evidence of their
effectiveness is still limited.
LESSONS LEARNED
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Books
Bateman, Thomas S (2007). Management: leading & collaborating in a competitive world . The
McGraw-Hill Companies, Inc., 1221 Avenue of the Americas, New York,NY,10020 :p. 427-428
DuBrin Andrew J. (2006). Essential of Management, Seventh Edition . Thomson HigherEducation 5191 Natorp Boulevard Mason, OH 45040 USA: p. 513, 538
Evans James R., Lindsay William M. (1996). The management and control of quality ,West PublishingCompany 610 Opperman Drive P.O. Box 64526 St. Paul, MN 55164-0526: p.105-109
Jones,Gareth R (2006).Contemporary Management , The McGraw-Hill Companies, Inc., 1221 Avenueof the Americas, New York,NY,10020: p.484
Electronic Resourceswww.who.int/hrh/resources/improvinghw-performance.pdf (07-8-2012)
http://asq.org/learn-about-quality/history-of-quality/overview/overview.html (07-8-2012)
http://asq.org/quality-participation/2007/03/human-resources/critical-examination-performance-appraisals.pdf (07-8-2012)
http://www.res-medical.com/clinical-medicine/81208. (07-8-2012)
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