International Journal of Applied Public Sector Management (ISSN: 1742-2655) Volume 1 Issue 1
All systems include inputs, processors, and outputs (Lanning 1990). Taking the NHS, as an example of the largest public sector organisation, the human and capital resources and the patient population serve as outputs (1). This characterisation of system overlaps with the classical categories of structure, process, and outcome developed by Donabedian (2). System component linkages are identified as efficiency, appropriateness, and effectiveness. Efficiency is defined as the attainment of a desired result at minimum cost; it links resource inputs to hospital service processes. Appropriateness considers service suitability with respect to a patient’s specific health requirements and links patient inputs to service processes. Effectiveness, doing the right things in relation to the result that is sought, links service processes to outputs defined as improved or maintained health status (3).
Traditional health care quality models have focused on health status as the end result, but more recent models have considered the human element and consumer perceptions of quality (4). In these approaches, structure still relates to physical facilities, personnel, and organisation but process has been redefined to refer to the interaction between provider and consumer. This interactive view of process focuses on how well the service employee delivers functional quality, how the patient experienced health care, as well as on technical quality and medical and clinical competence. The extent to which the service interaction meets the patient’s perceived expectation of health care is of primary importance as an outcome measure (5).
Despite the availability of such models, the current reality within the NHS
is that they have been disregarded and that managers, who are charged with responsibility
for the maintenance and enhancement of quality in health provision, have instead
opted for individualised models based upon their own personal experience. This
means that quality managers within the NHS are working to evaluate the benefits
that TQM can bestow upon their organisations on the basis of an idiosyncratic
understanding of past, intra-organisationally determined experience. Inevitably,
this has impacted upon the process through which TQM has been introduced within
the NHS, with the quality managers’ definitions of TQM directly determining
the way in which the tenets of TQM are implemented.
Whilst such a personalised approach has the merit of affording recognition to those unique characteristics which all organisations possess and which provides each with its own organisation, the obvious consequence of this is a loss of direction and momentum. Such deficiencies could be surmounted if a specified, generic model for the implementation of TQM was to be put in place throughout the NHS. Were this to be done, constancy of purpose, as advocated by Deming, would be an attainable goal (6).
Currently, in the absence of such a generic model, there is within the NHS, no clear agreement on what constitutes quality health care, nor is there any clear agreement as to the way in which TQM should be implemented in a health care context. Ad hoc approaches to the delivery of some national standards of health care abound, with each different approach being legitimised and deemed to be valued on the basis that it makes some contribution to the drive for a largely unspecified and ill-defined quality improvement.
That this is the current state of play with regard to the introduction of TQM into the NHS can be demonstrated by recourse to two case studies. It should be pointed out at this juncture that these case studies are derived from two of the flagship hospital units within the NHS and that these units have been chosen, not because they are atypical, but for the very opposite reason, namely, that they exhibit practices with regard to the introduction and implementation of TQM which are widespread throughout the NHS. In both cases, the role that definitions of quality play in determining the implementation of TQM is in evidence.
Whilst such a personalised approach has the merit of affording recognition to those unique characteristics which all organisations possess and which provides each with its own particular culture, it has the demerit of failing to ensure continuity of implementation; with successive quality managers adding their own preferred definitions and approaches to what should be a comprehensive, coherent, and sustained drive for enhanced quality through the organisation.