The Textbook of Total Quality in Healthcare

Rating:
Summary: A reasonably ample introduction to TQM in health care.
Review: The Textbook of Total Quality in Health Care attempts to summarize in an introductory didactic format the state of the "total quality" (TQ) movement in today's health care industry. The target audience is "TQ and health care professionals and students in management, clinical, and support services." Although the editors present their work as a "textbook," it is actually a reader, comprising articles--some original and some published previously -- on the various dimensions of the TQ movement in health care and written by clinicians, academicians, health care administrators, and health law experts, mostly from the Oklahoma area. The result is a collection of articles characterized by the pluses and minuses typical of such synthetic attempts: the inclusion of number of different perspectives (even if somewhat localized) and an interesting combination of different types of articles.

The perspectives of organized medicine and health care accrediting agencies proffered in this book are a welcome addition. The editors have done satisfactory job of bridging the sections with introductory transitional pieces. However, the book reflects the challenge involved in compiling a cohesive, well-integrated set of articles and presenting them in a "seamless" format. The book also suffers from some of the repetition that results when several authors are writing on the same subject. For example, W. Edwards Deming, probably the best-known TQM guru, is discussed in no less than eight articles. The book is divided into five parts and contains an annotated bibliography.

The articles in Part I provide a useful introduction, to the concept of total quality, especially as it relates to health care. The short, but surprisingly enlightening history of U.S. health care and its obsession with "quality" is worthwhile.

In Part II, the concepts of "structure", "process" and "outcome" as they relate to total quality are introduced, and the importance of these concepts is constantly reconfirmed throughout the work. Part II also introduces the reader to the leading thinkers in the history of total quality--an important section for TQM neophytes. Perhaps the most useful section of Part II is the distinction that is made between traditional quality assurance (QA) activities in health care and the more contemporary concept of TQ and TQM. While this section clarifies what TQ is, the reader has to wait until a later section to find out how TQ is distinguished from some of the other "quality" disciplines. The efforts to translate experiences with TQ in other industries to health care are not very convincing, given the unique character of the health care field. Some of the earlier experiments with TQ in health care are described, however, and these are helpful. The importance of process in health care is clearly brought home here. Chapter 5 in this section is devoted to data management for TQ. The material, however, does not appear to be specific to either total quality initiatives or health care. It is actually a compendium of data collection, analysis, and presentation techniques that have been utilized in total quality initiatives. The chapter does introduce some of the organizational development techniques that have been popularized through TQ efforts, such as run charts, control charts, and force field diagrams. This chapter almost represents a standalone reference document.

Part III, which is devoted to the TQ environment, opens with an insightful chapter on the "cost" of quality. It breaks down cost factors into prevention costs, appraisal costs, and failure costs, and then outlines techniques for measuring these costs and determining their implications for the process. Chapter 7 in this section examines the TQ issue from a legal perspective. Although this chapter is not a very comfortable fit in this section, it does introduce key issues, players, etc. from a legal perspective. Chapter 8 describes the types of organizations that exist in U.S. society and briefly discusses the implications of each from a TQ perspective. The increasingly important concept of "corporate culture" is introduced in this chapter.

Part IV, on TQ strategies, opens with a chapter on the integration of TQ and QA within health care. This is followed by a chapter on outcome analysis. Clearly, if this anthology were being compiled today, this issue would be given much more attention. Outcomes analysis twill no doubt be one of the major issues in health care for the rest of the decade. The final chapter presents research aspects of TQ, and reminds us that timely and accurate data provide the foundation for any meaningful analysis in health care today. This chapter also presents a long-overdue review of terms often used in TQ discussions. This chapter suffers, however, from the same deficiency as the outcomes chapter (i.e., too little too late in an environment that is deteriorating in the face of inadequate data). The final section includes a case study on the application of total quality methods at a particular Veterans Administration medical center. There is probably some benefit to be derived here but, standing as the sole case study, its usefulness is limited. In conclusion,

The Textbook of Total Quality in Health Care represents a reasonable attempt to pull together articles dealing with disparate aspects of TQ. Most of the articles are well written and include enough technical material to be informative but not enough to confuse the readers targeted by this work. The contributors incorporate most of the buzzwords and acronyms being used in the field today. On the negative side, the work is essentially about where total quality in health care has been and not where it is going. Critical considerations in today and tomorrow's health care system are not adequately covered. Managed care is mentioned only once in passing and capitation is not mentioned at all, to give two examples. Because of this, the reader is left with the need to follow up this work with more future-oriented materials. The book offers a reasonable introduction, but more will be required by any serious student of TQ.