Waddington, Michael E. (1995) Total Quality Management : the development, application and analysis of a Total Quality Management paradigm in healthcare. Doctoral thesis, University of Huddersfield.

The research programme focuses on Total Quality Management adoption and application.
TQM which is established in a number of businesses and industries has more recently been
introduced into healthcare. TQM definition and eclectic paradigm has been developed and
tested for establishing quality performance and distinguishing radical change and continuous
improvement approach. A number of critical elements and variables concerning
implementation and application are identified which pertain to organisations which through
size and bureaucracy operate with diverse missions, a wide range of systems and are
characterised by degrees of rigidity from an employee mix of multiple knowledge,
understanding competences skills and hence commitment.

Research was conducted in healthcare provider organisations, which involved eighty-three
NHS hospitals/Trusts, wherein two pilot, twelve TQM demonstration and sixty-nine sites
were involved. The main focus concerned a case study Trust, which although
demonstrating keen interest in quality management had not reached the formative stages of
developing TQM definition or paradigm.

The research framework is based on a number of approaches in that methods selected for
evaluation were appropriate both to the situation and the context of TQM strategies being
examined. Intention was to identify successes and failures of the TQM processes applied,
establish similarities and distinguishable differences and determine extent to which TOM
objectives were achieved and the impact of the processes on specific groups.

The investigation was undertaken using longitudinal analysis which involved in-depth
interviews with top managers and clinicians and a mix of employees, customers, potential
customers and purchasers in the form of managers, consultants, hospital doctors, nurses,
support services personnel, patients, members of the public and GPs. TOM Awareness and
Action Seminars and Workshops involving personnel from a variety of international
healthcare organisations provided an additional source of data. Self-completion
questionnaires were also used.

Data analysis compares and contrasts varying TQM models, processes, activities and results
from degree of emphasis placed on critical elements and variables. Stage predictions and
resulting outcomes are presented and quality of care improvements suggested from analysis
of customer perceptions of quality and value. The findings show significant variations in
approach between the hospitals/Trusts in matters which concern organisation, management
and culture issues, resulting in a high proportion viewing TOM process as evolution from
quality assurance to radical change, hospital process re-engineering and patient focused
care A minority only included such processes in their application of TQM.

Key conclusions result from attempt at establishing some measure of success and failure
from TQM implementation and application. Findings contribute to the extant literature
specifically in that beyond top management and clinician commitment to high level strategic
focus is a combination of facilitator-led culture change, motivation and shared values
directing attention to exceeding that of merely doing enough for reducing poor quality and
customer complaints. Patient involvement in TOM is more problematic than literature
suggests from both the patients and professionals perspectives of patient empowerment.

Bottom-up action focused TQM paradigm working simultaneously with top down support
and commitment requires barrier breaking, culture transformation and the establishment of
internal/external customer and supplier chains and seeking to establish opportunities for
continuous improvement and radical change in advance of attempts at in-depth
implementation and evaluation. It is not over-statement to conclude that the majority of
managers and clinicians were unaware of the costs of getting things wrong.

Despite TOM being acted upon as driving force for competition most had limited knowledge
of how much non-quality cost them, suggesting that they had not earlier thought it
necessary to measure the costs of none or low quality. Research results, irrespective of
applications definition or paradigm, question the views that TQM is long-term process.
Whether these may be concluded as desire to integrate TOM with other foci or vacuum
sucking in panaceas was unclear. It was clear however that although quality in healthcare
is sacred total quality management is not.

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