Quality management in

healthcare and industry

A comparative review and emerging themes
Alexander Komashie and Ali Mousavi
Systems Engineering Research Group, School of Engineering and Design,
Brunel University, London, UK, and
Justin Gore
The North West London Hospitals NHS Trust, London, UK
Abstract
Purpose The purpose of this paper is to review the historical development of quality assessment
methods in manufacturing industry and healthcare. It examines the gap between methods across the
two sectors, as well as the extent to which industrial techniques have been successfully adopted in
healthcare. Finally, a proposal for a new approach is presented.
Design/methodology/approach Firstly, a review of the evolution of quality assessment was
conducted, based on books written by prominent experts in the eld. Secondly, a study of the current
approaches in healthcare was undertaken. Publications from varied sources, including worldwide
operations research and healthcare sources were selected according to criteria and reviewed.
Findings While, the concept of quality has a long history, quality management in healthcare is not
as advanced as in industry. There are a number of reasons for this, such as differences in concerns and
processes across the two sectors. Further, quality researchers have differing views towards the best
approaches. It was deduced that the way forward in healthcare quality is the enhancement of staff
ownership and pride in a way akin to the era of the craftsmen, but with the use of new technology.
Practical implications The ndings provide a picture of how far quality management has
advanced in industry and healthcare. There is a note of caution for the use of industrial techniques in
healthcare, which may provide useful direction for further research and implementation.
Originality/value This work uniquely examines the origins of the concern for quality, and follows
the changes in demand and supply in industry and healthcare. It argues that understanding this
historical review, and the nature of processes across both areas, is key to the future of healthcare
quality. Finally, a new approach based on discrete event simulation is proposed.
Keywords Quality improvement, Quality management, Manufacturing industries, Health services
Paper type General review
Introduction
The quality of healthcare has been a major problem in many countries for over half a
century, and its origins go back much further. Finding a denition, methods of evaluation,
monitoring and quality improvement have been key issues for both researchers and
healthcare professionals (Idvall et al., 1997). Donabedian (1966) noted that the quality of
healthcare is a remarkably difcult notionto dene. Based ona denition offered by Lee
andJones (1933), he concludes that the criteria of qualityof care are mere value judgements
that are applied to varying aspects of a process called healthcare.
In the industrial context, Deming (1986) cites and shares W. A. Shewharts view that
the problems around dening quality emanate from the difculty in translating future
requirements of the user into measurable characteristics, so that the product or service
The current issue and full text archive of this journal is available at
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QM in healthcare
and industry
359
Journal of Management History
Vol. 13 No. 4, 2007
pp. 359-370
qEmerald Group Publishing Limited
1751-1348
DOI 10.1108/17511340710819598
can be designed to satisfy the user. Regarding the quality of healthcare, Deming states
that a denition is a perennial problem. He adds that healthcare quality has been
dened in many ways and each way seems to serve a special type of concern. In spite of
the denition problem, there has always been the need to measure and improve quality.
Moreover, it is evident that better quality has been achieved at different levels in
different industries or organisations. For example, Young et al. (2004), Merry (2004),
Laffel and Blumenthal (1989) and Mohammed (2004) provide evidence that healthcare
practitioners can adopt some of the quality improvement techniques found in other
industrial systems, mainly in the manufacturing sector. Currently, there are several
attempts being made to apply some industrial systems improvement techniques in a
healthcare environment (Komashie and Mousavi, 2005; Moore, 2003; Dodds, 2005).
This paper attempts to provide a comparative analysis of quality improvement
methods in manufacturing industry and healthcare and to suggest some directions for
further study. It is primarily concerned with the general concepts of quality assessment
within these areas at various points in time and how such concepts have changed.
It should be noted that as there are volumes of publications on quality, it is not possible
to provide an exhaustive review here. However, it is believed that the sources selected
are representative of the major trends in quality across the two domains, particularly in
the UK and the USA.
Methodology
Firstly, a review of the evolution of quality assessment in industry and healthcare was
conducted. This was based on books written by prominent authors in the eld of
quality. Secondly, a study of current approaches in healthcare was undertaken.
Publications from varied sources were selected and reviewed. The literature consulted
includes worldwide operations research and healthcare sources found via the internet
and reference lists of relevant paper. Some of the sources used were MEDLINE, Science
Direct and INSPEC.
Journal papers and conference proceedings were selected according (but not limited)
to the following criteria: Objective: the study shouldbe aimedat measuring or improving
quality or both. It could also be aimed at developing newways of measuring healthcare
quality; Method: observational studies, experimental trials or systematic reviews.
Results and discussion
Concern for quality
Understanding the basics of quality is an important part of our attempts to improve it.
Thus, this section briey examines the main concerns that led to the pursuit of quality
both in manufacturing industry and healthcare.
Juran (1999), Ellis and Whittington (1993), Berwick and Bisognano (1999), Maguad
(2006) and Dooley (2001) all agree that the concept of quality is timeless both in
industry and healthcare. However, a close examination of the literature shows that
there has been a difference in the concerns underpinning quality improvement across
these contexts. In the days of the village market place, the caveat emptor, which means
let the buyer beware was the norm. The producer supplied the goods but the buyer
was responsible for assuring the quality of the goods before making a purchase. Juran
(1999) explains that the buyer looked closely at the cloth, smelled the sh, thumped
the melon, and tasted the grape. It can be deduced from this evidence that the primary
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concern for quality in that era was the need to obtain value for money. Thus, the buyer
did everything to avoid any dissatisfaction that may arise after paying for goods. This
value for money principle remains inherent in some quality techniques or methods
today, for example customers are allowed to try on clothes in the shop before buying.
Consumers of healthcare on the other hand have not had much choice until in recent
years. There is therefore little historical evidence of healthcare consumers demanding
any level of quality. Bull (1992) noted that from 1854 to 1870, the motivation for
systematic quality evaluation in healthcare was primarily of a professional nature in
Great Britain. The Hippocratic Oath and the work of Ignaz Semmelweis and Florence
Nightingale were all cases of professional concern. Thus, it can be hypothesised that
the pursuit of healthcare quality came out of a concern for better health or lost lives as
perceived by individual professionals. In recent years, however, it is evident that the
primary concern for quality comes from a pressing need to satisfy the customer
(or patient) both in industry and healthcare. This has become the prerequisite for
staying in business and most of the experts (Deming, Juran, Crosby, Feigenbaum) in
the eld have argued that focusing on quality is more benecial than focusing on
prot. Top management involvement is regarded as vital in this context.
Another observation is the demand and supply of quality over the years which
summarises the argument in this section. Figure 1 shows that the level of quality
around the time of the Caveat Emptor was relatively high and could be beyond
the customers expectations. There was a direct contact between the producer and the
buyer. Ellis and Whittington (1993) relate that in such a context, it was possible for an
individual customers wishes to be designed into the product at anytime. On the
contrary, the industrial revolution ushered in an era of production that led to the fall of
the craft system and degradation of quality of products (Maguad, 2006). Productivity
became the goal of industry and the demand of consumers for quality began to rise
above its supply from industry. Then, the technological explosion in the latter part of
the twentieth century further degraded quality by the complexity of the resulting
systems and products. With the consumerism of the twenty-rst century, it has become
even more difcult to satisfy customers as the demand for quality goods and services
continues to rise.
Figure 1.
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In contrast, consumers of healthcare did not have much choice and were less informed
about health issues around the time of the village market place. Thus, the quality of
healthcare was supplied by professionals and improved gradually as they sought
ways to avoid unnecessary deaths and errors. Berwick and Bisognano (1999) noted
rather arguably that the modern era of quality in healthcare, particularly in USA,
began at the turn of the twentieth century. This may have been due to some of the
forces of social change related to industrial and technological advancement, as well as
increased patient education. This demand for quality care rose very quickly to levels
that left healthcare organisations in search of new ways of assuring quality (Ferlie and
Shortell, 2001). As a result of this difference in fundamental concern, the tools and
methods used to manage quality have also changed considerably.
Use of quality tools and methods
Quantifying and improving quality requires the use of specic methods or tools. In this
study, it has been observed that though it may appear that several methods are common to
healthcare andindustry, the majorityof techniques have their origininindustry. According
to Montgomery, though quality has always been an integral part of almost every product
andservice, our awareness of its importance andthe introductionof systematic methods for
its control have been an evolutionary process. Table I provides a comparison of this
evolutionary process in industry and healthcare and shows that developments in quality
methods have occurred in quite distinct ways across the two sectors.
The development of control charts in the early part of the twentieth century by W. A.
Shewhart shows the rigour with which industry approached the problem. As Hare
(2003) states, faced with the problem of process variability, Shewhart had to nd an
answer to the question How much of a scientic observation is deterministic and how
much is random? Shewhart concluded that the answer was in the application of
statistical methods and began to dene the notion of quality control:
A phenomenon will be said to be controlled when, through the use of past experience, we can
predict, at least within limits, howthe phenomenon may be expected to vary in the future. Here,
it is understood that prediction within limits means we can state, at least approximately, the
probability that the phenomenon will fall within the given limits (quoted in Hare, 2003).
This is evidently a focus on the process and can be claimed to mean that the quality of
the product is in the process. The concept of reduced variability (control), resulting in
improved quality, has been shown to be effective over the years and still remains the
fundamental principle in some modern quality philosophies like six sigma. Shewharts
work laid the foundation for industrial quality methods for the subsequent years.
The quality control approach was soon being taken up in the healthcare context,
although this was of a reactive nature to begin with. About, the same time of
Shewharts work, a survey was undertaken by Groves (1908), cited in Bull (1992).
According to Bull, Groves, a British Physician, surveyed 50 hospitals, each having over
200 beds, to assess patient mortality from surgical procedures. He was able to use this
survey approach to show that mortality ranged from 9 per cent for appendectomies to
44 per cent for procedures related to malignancies. Other efforts to monitor quality
around the time were professional certication and legislations (Bull, 1992; Berwick
and Bisognano, 1999), nursing standardisation (Bull, 1992) and Dr Codmans
recommendation to review all patients one year after surgery (Sale, 2000). In contrast to
industry, while informing healthcare understanding and strategy, these efforts were
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based within the professionals domain and lacked an assessment of quality at the level
where it matters most. If care is to be patient or user-centred, then the most
important level is, as Donabedian (1966) said, that of the physician-patient
interaction. It was not until the latter part of the twentieth century and into the new
millenium that the notion of consumerism was more fully adopted within healthcare.
These historical differences in approach across industry and healthcare can quite
reasonably be attributed to the difference in processes (product-prot based vs
service-based, respectively) and concern for the pursuit of quality as discussed
previously. However, the methods and principles around quality improvement across
the two sectors appear to be converging. The end of Table I (period of 2000 and
beyond), shows that automation (which could perhaps be regarded as an extreme
result of standardisation) is becoming the order of the day. It appears that whenever an
Period Industry methods Healthcare methods
Up to 1900 Guilds membership
Inspection
Standardisation
Supplier certication
Physician licensing
Specialty societies
Individual efforts (record keeping)
1900-1920 Systematic inspection and testing
Experimental design
Control charts
Survey, e.g. E.W. Groves (1908)
Professional certication
Legislations
Nursing and hospitals standardisation
Follow-ups, e.g. Dr Codman (1914)
1920-1940 Acceptance sampling
Statistical methods
Professional regulation
Studies on nursing conduct
Health insurance legislations
Government legislation and standards
1940-1960 Training in statistical control
Quality societies
Quality publications
Total quality control
Experimental design
Top management involvement
Industrial standards
Awards, e.g. Deming prize
Regulatory bodies formed
Landmark publications
Internal and external inspection
Professional standards
Performance measures
Accreditation of hospitals
1960-1980 Quality circles
SPC widespread
More quality societies/publications
Introduction of TQM
Rapid increase in literature
Focus on process and inspection oriented
More surveys, e.g. Drew
Supervisory and record audit
Hospital accreditation
Audit tools, e.g. Phaneufs audit, rush
Mediscus, qualpacs
1980-2000 Spread of experimental design and SPC
National and international certication
Six sigma QFD TQM more widespread?
Increase in published standards
Publications on indicators
Focus on measurement and monitoring
More regulatory bodies
Government involvement raised
2000, beyond New international standards, e.g.
ISO 9000:2000, ISO 14000
Automation of quality
Enterprise quality systems
New and tighter standards
Consumer societies
Consumer surveys and involvement
Import of industrial techniques
Table I.
A comparison of quality
methods in industry and
healthcare
QM in healthcare
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363
organisational task can be effectively automated, it eventually will be (Dooley, 2001).
Dooley used this argument to predict that quality methods in industry will eventually
be automated, and Montgomery sees this period as one in which quality improvement
will break traditional boundaries into healthcare, insurance and utilities. This, together
with the advent of consumer involvement in healthcare, may be representing a real
shift in the way in which quality is managed.
However, although healthcare has been adopting certain industrial techniques for
example, Sale (2000) reports that the introduction of the Salmon Report (DoH) caused
an enormous change in British nursing by its introduction of industrial management
techniques it is still not sufciently evident what the effectiveness of these
interventions are and which are the most appropriate. Therefore, it is important to
understand the difference between industry and healthcare in terms of product and
service orientations as discussed in the next section.
Product and service quality
The difference between a product and service is not always very obvious. The term
product is used in a number of service industries such as travel and hospitality and
nancial services (Mene, 1999; Aubrey II and Hoogstoel, 1999). These broad uses of the
term make it sometimes difcult to distinguish its classical meaning as applied to
manufactured products. Both Deming (1986) and Di Primio (1987) (cited in Ellis and
Whittington (1993)) agree on the distinguishing factor that service provision involves a
direct transaction or face-to-face interaction with the client (although one should point
out that industry still uses consumer feedback in its operations e.g. market research).
Di Primio further adds the following differences between products and services:
.
Services are intangible hence their outcomes are also difcult to measure.
.
Services are extremely perisheable (Mene, 1999) and no inventory can be held of
them. That is services cannot be stored for future use.
.
Services require a process of delivery that is user-friendly and time sensitive.
.
Client satisfaction measures are a more important feature of performance than in
product oriented industries (although those industries still rely on consumer
satisfaction most notably in terms of numbers who buy a particular product).
With this understanding, it is argued that even if there exists a clear distinction between
products and services, there cannot always be such clear cut distinction between the
operations of product oriented industries (manufacturing) and service oriented
industries (healthcare). This is evident in the statement that every industry has some
amount of service provision (Ellis and Whittington (1993)). This is represented by the
hypothetical model of the product-service spectrum shown in Figure 2. The model
Figure 2.
The product-service
spectrum
Products
Services
Manufacturing Healthcare
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claims that the output of everyindustry or organisation will be a mixture of products and
services depending on where it may be considered to be located within the two extremes
of the spectrum.
One common denominator however is that the provision of both products and
services involve processes. Some researchers (Cox and Wyndrum, 1994; Yeung et al.,
2004) have emphasised that focusing on the process is important because quality
improvement is process improvement and this could be applied in healthcare. In as much
as there are several examples and efforts of using industrial techniques in healthcare
(Mohammed, 2004; Benneyan et al., 2003; Lane et al., 2007), such as Statistical Process
Control (SPC), the full potential of these tools are yet to be appreciated. Mohammed
(2004), describes the specic case of SPC in healthcare as notable exceptions and not the
rule. Further, change management approaches, such as total quality management
(TQM) and business process reengineering (BPR) have been popular among some
healthcare managers, but these have so far resulted in only limited outcomes and a
somewhat complex picture (Iles and Sutherland, 2001; McNulty and Ferlie, 2002).
Hence, it is not just a matter of taking tools that work in manufacturing and using
them in healthcare, but vital to rst understand the product-service spectrum. Given
that all industries have some level of service provision, it may be appropriate to ask
how the techniques that are working in industry are being applied to the service
components of its operations.
Part of the challenge for the future will be how to appropriately apply the
techniques that have proved successful at the left end of the spectrum to a healthcare
system at the other end. A key problem will be resistance to change, as observed by
commentators such as Okes (2006). It is important to stimulate discussion on the
appropriate customisation of industrial techniques to t another industry depending
on its location on the spectrum.
Some current research in healthcare quality
While some literature around the use of industrial techniques for improving healthcare
quality has already been cited, this section seeks to take a snapshot of current research
in the area. This is intended to give a broad idea of the methods of assessment that are
still being used by researchers and not meant to be an exhaustive review.
One method that remains prominent in healthcare quality research is the review
of literature to determine factors or indicators that will improve or measure quality of
care. Some recent reviews are Berenholtz et al. (2002), Campbell et al. (2000), Campbell
et al. (2002) and Mainz (2003). These studies all had different objectives. For example,
Berenholtz et al. (2002) were looking at quality indicators in intensive care units whilst
Campbell et al. (2002) focused on primary care. Other methods identied are interviews
(structured or unstructured) as conducted by Che Rose et al. (2004) and Baltussen and
Ye (2006), surveys by Wisniewski and Wisniewski (2005) and the use of the analytic
hierarchy process (AHP) together with the Delphi method by Tavana et al. (2003).
These all had different objectives and show how researchers may look at the same
concept of quality differently. The problem with relying on these methods alone is that
though they are effective for measuring the state of affairs, they do not wholly provide
the necessary control and exibility that will ensure continuous quality improvement.
According to some authors in the eld, such as Hutchins (1990), what is needed is a
localisation of quality that:
QM in healthcare
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365
. . . encourages a feeling of ownership and greater likelihood of pride in personal and group
achievement akin to the internalised values of the medieval craft groups. Without such
internalisation, a climate of quality cannot be said to exist (Jessee, 1981).
Also noted is that:
. . . the most accurate diagnosis of a healthcare problem and the most valid assessment of the
factors contributing to it will not produce the desired improvement unless effective
techniques for changing individual and organisational behaviour can be applied when
necessary.
This, together with the need to apply an approach that accounts for the uidity of the
product-service continuum, are key factors in moving quality improvement to the next
level.
A proposal for a new approach
Researchers and quality professionals continue to make a strong case for the
application of industrial techniques in healthcare. Some examples are Reid (2006),
Young et al. (2004) and Laffel and Blumenthal (1989). The possibility of this being the
norm in the near future is not far-fetched but the problems that need to be addressed
are appropriateness and practicalities. Several possibilities exist but one technology
that is possibly proving to be an effective decision support tool in healthcare is discrete
event simulation (Eldabi et al., 2007). This is the basis of a new approach proposed
below, that may have the advantage of ensuring management involvement and staff
ownership, as well as the exibility for ongoing quality assessment and improvement.
Most of the quality gurus have focused on the importance of management
involvement (Deming, Juran, Crosby, etc.). They have stressed that an effective quality
management programme must start from the top. Unfortunately, this does not always
mean that it reaches to the ground level where it matters most. This is proved in a
survey by Dahlgaard et al. (1998) where it was observed that though 83 per cent of
Japanese companies had management participation, only 25 per cent continuously
communicated the contents of their quality documents to all employees. Donabedian
(1966) in his seminal work on evaluating the quality of care rightly stressed that his
aim was almost exclusively to deal with the evaluation of care at the level of
physician-patient interaction. This level of operational quality is the focus of the new
approach. It is aimed at continuously monitoring what the patient (or customer)
actually feels at various points in time (e.g. different stages in the patient journey).
Previous research has mainly sought to assess what is currently going on, without
devising a means to also assess ongoing performance and inuence the culture of staff.
The current proposal seeks to develop a method for:
.
Assessing the quality of care being delivered in real-time providing ongoing
feedback to healthcare staff.
.
Raising the awareness of staff about quality in a non-invasive way.
.
Forecasting the impact of future demand on quality of care.
The proposed new approach, which forms part of a PhD being undertaken by one of
the authors, uses a real-time computer model of the healthcare environment that
displays a healthcare quality index (HQI) and other key performance factors. The
benets of this are that healthcare managers and staff on the ground can access a
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user-friendly approach to understanding current activity (e.g. hospital throughput,
waiting times) by viewing simulation models (in the form of a cartoon version of the
organisational workplace). Changes can be made to the current model (i.e. current
picture of what is happening) in order to test for different outcomes and assess which
would represent the best quality (e.g. reduced hospital length of stay, while minimising
re-admittance rates). This would represent one of the most sophisticated advancements
in healthcare quality as it would allow clinicians to be directly involved in decision
making on an ongoing basis, thereby improving the feeling of ownership and
enhanced efciency at the organisational and local levels. Both patient and staff
satisfaction (at the heart of the patient-professional interaction) can be measured at
various points along the care process and inputted into the model. Such an approach
is under development and evaluations are required in healthcare settings to assess its
full potential and applicability.
Conclusion
It has been highlighted that the concept of quality has a long history, but the
management of quality and its control in healthcare is not as advanced as in industry.
There are various reasons for this, such as differences between the two sectors in terms
of concerns for quality and the type of processes and outputs involved (e.g. product
versus service). The paper has also pointed out that with the growing interest in
applying industrial techniques in healthcare, issues of appropriateness and practicality
must be robustly examined. A key emerging theme from this analysis is the need to
develop quality systems that give staff ongoing ownership and pride in a way that is
akin to the era of the craftsmen. A computer-simulation based approach was proposed
as one possibility in this endeavour.
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About the authors
Alexander Komashie is a PhD Research Student in the School of Engineering and Design at
Brunel University. He recieved a BSc in Mechanical Engineering from the University of Science
QM in healthcare
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and Technology in Ghana and an MSc in Advanced Manufacturing Systems from Brunel
University. His current research interests include application of queuing theory and real-time
discrete event simulation for improving the quality of healthcare, patient satisfaction and
decision making. Alexander Komashie is the corresponding author and can be contacted at:
Alexander.Komashie@brunel.ac.uk
Ali Mousavi, is a Lecturer in the School of Engineering and Design at Brunel University. His
research interests include simulation modelling and analysis, especially techniques to improve
simulation analysis in practical applications.
Justin Gore, BA(Hons), MSc is Health Services Researcher and Evaluation Lead at North West
London Hospitals NHS Trust, UK. His interests include evaluation methodology, service
redesign and change management.
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