International Journal for Quality in Health Care 15:47-055 (2003)
© 2003 International Society for Quality in Health Care
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Evaluating implementation of quality management systems in a teaching hospital’s clinical departments
1Unité de Qualitique et Evaluation Médicales, CHU de Grenoble
2Laboratory CRISTO (Centre de Recherche: Innovation Socio-Technique et Organisations industrielles), Université Pierre Mendès-France, Grenoble, France
Objectives. This study evaluated a strategy for implementing continuous quality improvement based on a decentralized quality management system in the clinical departments of a hospital.
Setting. The institution is a 2000-bed teaching hospital of tertiary health care employing 8000 people.
Methods. The quality management intervention was tested in six volunteer departments. This intervention comprised an instructional seminar, methodological assistance, and the dissemination of guidelines. The program was evaluated 1 year after the intervention and included a quality audit, interviews with department staff, and analysis of the written documents produced by the departments.
Results. The quality management systems are functioning in all the departments. Quality teams meet regularly and multidisciplinary work groups are in place. The topics most often addressed are patient reception and communication between department staff members. The level of compliance with the guidelines has increased, from 39% before the seminar to 54% 1 year later (P < 0.05). All of the staff members interviewed judged the process useful for them and for the department, while waiting for the concrete results. Among the difficulties the staff members encountered were changing their work habits, lack of time, and the tedious aspect of writing procedures.
Conclusion. Implementing continuous quality improvement in hospital departments seems to be an interesting alternative to organization-wide implementation strategies. However, these results need to be confirmed by long-term evaluations and by deploying the program in other departments.
Keywords: continuous quality improvement, health care quality, hospital, implementation
Although the necessity of introducing quality and health care risk management procedures in health care institutions is no longer contested, it must be recognized that total quality control is coming to hospitals very slowly, particularly in European countries [1]. Indeed, quality management is a profound change in the hospital that leads to transformation of its organization [2]. This transformation concerns every actor within the organization: it implies a change in culture, habits, and behavior, and it disrupts the sociological hierarchy and power systems [3–6].
However, the hospital environment is not a particularly favorable terrain for such changes. It is an organization characterized by a high level of involvement on the part of health care professionals, particularly doctors, in the decision-making processes [7]. In this ‘professional bureaucracy’, the hierarchical authority has only Limited power, contrary to the ‘mechanical bureaucracies’ found in industry [7,8]. Moreover, health care institutions are structured in departments with significant autonomy of action, which enhances even more their ability to resist change.
Setting up quality management should take into account these obstacles, which implies leading the organization’s culture and management, as well as its actors, to evolve [9,10]. Whatever the quality management model retained, great importance must be placed upon the implementation strategies and modalities, a major research issue in the field of quality management [11].
Our team works within a public health medical structure responsible for implementing quality management and health risk management processes in a university hospital. We have set up organization-wide projects for improvement based on themes such as the quality of hospitalization reports and medication prescriptions [12,13]. These actions, founded on the quality assurance model, have turned out to be incapable of significantly mobilizing health care professionals and leading them to active participation in improvement actions [14].
This observation has led us to turn our attention to continuous quality improvement (CQI) based on the participation of staff members in multidisciplinary work groups using problem-solving tools [3,4,15]. We chose to implement CQI activities in the medical departments of the hospital. This mode of implementation is therefore not organization-wide but respects the heavily segmented organization of the institution. This approach is considered as a step whose objective is to train health care professionals and to involve them in quality management activities within the current structures of their jobs [16,17].
The work we present here is the short-term evaluation of the experimental application of this strategy to a group of six volunteer medical departments. The intervention involved implementing a quality management system in each department, which was made up of a quality team and two quality team leaders, training staff in the concepts and methods of quality management, and supplying them with methodological assistance.
Material and methods
The intervention
The intervention involved introducing quality management activities into each of the hospital departments participating in the study by setting up a specific organization—the department’s quality system. It included a training seminar, setting up structures internal to the department, methodological assistance, and written guidelines.
The training seminar lasted for 3 days and involved quality management concepts and methods centered around problem-solving methods. The participants were brought to identify the problems of the department, to define priorities, to analyze the causes of the priority problems, to build solutions, to plan how to implement them, and to evaluate the results. The topics of improvement were chosen by the members of the quality teams at the end of a process which included listing all the department’s problems, as perceived by the staff members or as identified through patient satisfaction surveys, and the analysis of patient complaints. The members of the quality teams chose the priority topics from this list, using a weighted vote technique where each member had the same number of votes. The 12 to 20 participants were volunteer staff members who represented the different professions and teams of the department. The presence of the head physician of the department was mandatory.
The department had to set up structures: two quality leaders (a physician and a head nurse) and a quality team including the different staff members from the department. A member of our team provided the methodological assistance by attending the quality team meetings. He could intervene at the request of the quality leaders to conduct a work session or participate in an action.
The quality guidelines were developed by our team to assist in setting up the quality management system. Inspired by the ISO 2004-2 norm [18] and the French accreditation manual [19], it included 59 criteria on the structures and activities for managing quality in a clinical department (see Appendix). These guidelines were also used to evaluate the advancement of the program.
Setting
Our institution is a 2000-bed teaching hospital, employing 8000 people, which offers a complete range of health care services. The health care sector is structured in 56 departments, 18 of which are medical departments, 18 are surgical departments, 16 are medical technology departments (imagery, biology, functional exploration), and four are intensive care and anesthesiology departments.
A call for volunteer departments was launched among the clinical department chiefs. Of the 40 clinical departments of the hospital, 12 volunteered to participate, six of which were selected by the hospital’s quality committee for testing the intervention. The pilot departments were two medical departments (nephrology and gastroenterology), two surgery departments (vascular and maxillofacial), and two anesthesiology/intensive care departments (medical intensive care and anesthesiology). These departments include a total of 186 beds and employ 655 people, 99 of whom are physicians, with 450 paramedical personnel and 106 administrative or housekeeping and food service employees. A total of 98 people participated in the seminar, including 19 physicians, 14 head nurses, 33 nurses, 15 other paramedical staff members, nine secretaries, and eight ancillary employees.
Study design
The present study, conducted 1 year after the training seminar, had the following goals: to evaluate the operation of the quality system set up by each pilot department; to evaluate the level of compliance of the department in terms of the quality guidelines criteria; and to participate in identifying the restraints, the catalysts, and the changes brought about in the departments.
The study was based on three joint approaches: a quality audit, interviews with the staff members, and an analysis of written documents.
The quality audit was carried out with quality guidelines developed in-house. Two auditors completed the audit by interviewing the department head and the department’s two quality leaders. The department’s compliance was assessed for each criterion on a four-point scale: total, high, partial compliance or non-compliance. The department’s level of compliance was interpreted by comparing it with the results of an identical audit performed before the intervention, i.e. 1 year earlier.
Interviews with the department’s staff members were conducted face to face using an interview guide, by researchers in sociology independent of the hospital staff and of the team that conducted the intervention. The questions covered the perception of the quality process, the expectations and motivations of the staff members, their level of commitment to the process, the effect perceived in terms of their work and the department’s work, and the problems and obstacles encountered. The interviews were conducted with a sample of 12 staff members from the departments: two physicians (one of which was a department head); seven paramedical staff members (one head nurse, three nurses, two nurse’s aides, one physical therapist); two housekeeping or food service workers, and one secretary. Among these people, six had attended the training seminar provided for the intervention, and six were members of the same pilot departments but had not been directly involved in the training. The interviews were recorded and typed. Researchers in sociology, using a manual process of thematic analysis, studied the corpus of the interviews.
The study also examined all of the written documents generated by the pilot departments during their quality process, for example, meeting reports, procedures, and studies.
Results
Implementation of the department’s quality system
The structures of the quality system were in place in the six departments. Two quality leaders, a physician, and a head nurse were designated in each department. In three departments, the physician provided the leadership, in two departments it was the head nurse, and in one department this leadership role seems to have been shared by a physician and a head nurse. The quality teams met regularly; we counted 72 meetings for an average of 10 meetings per year per department (one department that was organized into two sectors set up two quality teams). These meetings produced a written report, most often indicating the staff present (Table 1). The different professional categories were represented in the quality teams with a predominance of nurses and head nurses who made up nearly half of the participants in these meetings. The number and the distribution of professional categories of those present at the meetings were stable over time (Table 2).
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Work groups were set up to deal with the different themes and problems encountered within the department. We counted 57 work groups, in which 165 people participated, i.e. 25.1% of the pilot departments’ staff members. This participation ranged from 8% to 58% of the staff members, depending on the department (Table 3). Note that a large percentage of those who had received the training participated in the work groups (82%). In addition, more than half of the work group participants (52%) had not received the training but had taken an interest in the process studied. The main themes for improvement were patient and family reception (five departments), telephone reception (two departments), trainee arrival in the department and supervision (two departments), practice of asepsis for medical procedures (two departments), nosocomial infections (four departments), and transmission of information (four departments) (Table 4). Improvement actions most often consisted of reviewing a process, writing one or several protocols, and doing surveys or developing informative documents. However, none of the departments undertook a formal evaluation or set up indicators to evaluate the effectiveness of the intended improvements. In addition, work groups were given the task of setting up a process for managing adverse events, for example of developing forms for reporting incidents and non-compliance, and writing up analysis and intervention procedures (five departments). Other groups were given the task of organizing the department’s quality documents by updating the department’s procedures and protocols, and by classifying this material and making it available to others (three departments). Two departments conducted training sessions on quality for those who had not attended the training seminar.
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The level of compliance with the criteria of the guidelines improved considerably (Figure 1). The number of criteria that were ‘totally complied with’ went from 39% before the training seminar to 54% 1 year later, and the number of criteria ‘not complied with’ decreased from 27% to 14% (P < 0.05). This progress was observed in all departments. The most important progress concerned the criteria involving management of quality and risk.
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Staff members’ view of the improvement process
All of the staff members interviewed perceived the quality process positively and judged it to be useful for them and their department. They saw it as a way to improve the quality of the health care provided and their working conditions. They felt that the quality process would increase their ability to take on responsibility, in particular due to writing-up protocols.
Acceptance of the concept of quality management seems to be activated, above all, by personal motivations. We noted a certain curiosity among staff members about this new approach to work. We also found a desire for satisfaction at work and that a high value was attached to professional identity. This motivation was especially clear for the professions that are traditionally considered less essential, such as the housekeeping or food service workers or the nurses’ aides. On a group level, the motivations stem from the need to make the department evolve and comply with accreditation requirements. Above all, the staff members expected the quality process to contribute to solving the problems and dysfunctions of the department that certain groups had experienced over a long period of time. The concrete results will be the judge; adhering to the process implies certain conditions, but the professionals preferred to give the process the benefit of the doubt until concrete results came in. The staff were ready to invest their energies, but they wished to be recognized for this effort, even if only symbolically.
Those who had attended the training seminar adopted the new work methods more than the theoretical concepts of quality management. However, although the problem-solving tools and methods taught during the training seminar were well known, they were not mastered well enough to be used routinely in the work groups. Only brainstorming and protocol writing were common practices. The staff members involved in the work groups were conscious of the lack of methods and asked to be able to obtain long-term methodological assistance. Certain staff members saw this outside assistance as an essential factor in the permanence of the quality process in their department.
Dissemination of concepts and methods to staff members who did not attend the training seminar varied greatly from one department to another. In one department, all the personnel were asked to attend informational meetings where the quality leaders explained the essential points of the process. Other departments organized communication within the department on the quality management activities: making meeting reports and documents produced by the quality team available to others, disseminating departmental notes and writing up an information exchange book that was accessible to everyone. But in most of the departments, the quality team engaged in little communication. The process then tended to be limited to a circle of initiates; the other staff members were only kept informed by informal conversation.
However, those questioned noted that the process had the effect of improving communication within the department, and in particular communication with the department heads. The staff members appreciated being able to report problems and to participate with management in finding solutions.
Among the obstacles and problems, the first problem raised was how difficult it was to change habits, particularly for the hospital workers who had been with the department the longest. They also brought up the necessity of freeing up work time for quality management activities such as meetings and document writing. Other obstacles were related to formalizing the method and to the necessity of writing documents, such as procedures, protocols, meeting reports, etc. This activity tended to reduce the motivation of certain staff members who did not see the value of such work and feared inflation of paperwork. Finally, several people interviewed thought that the policy of increased quality without an increase in resources was an unrealistic concept.
Discussion
This first report shows that the quality management structures are in place in all of the pilot departments and that they are working concretely toward analyzing and solving the problems of the department. The staff members are involved and collaborate in multidisciplinary work groups. They are attracted by the problem-solving approach and accept personal investment because they perceive the usefulness of improving the processes of their daily work. But this acceptance of the approach is conditional on obtaining concrete results in terms of improving the quality of health care and working conditions. Among the difficulties encountered by the staff members, lack of time requires particular attention, which calls for limiting the number of meetings and organizing group work to make it more efficient [18]. In addition, our study brings out a possible defect in the dissemination of quality management concepts, methods, and activities to those who have not participated in the training. This phenomenon deserves closer investigation because limiting the process to only those who have been trained runs the risk of locking the process away, out of the reach of many of the staff members.
The objectives of the intervention seem to have been reached; however, the limitations of this experience need to be delineated. This evaluation is relatively early in relation to the intervention and we will need to repeat the evaluations over time to judge the permanence of the process. In addition, the pilot departments volunteered to participate in the program, which assume that they are a setting for experimentation that is particularly favorable to the quality management intervention. This selection bias limits our ability to generalize the results to other departments and other institutions. Since the experimental phase that we are reporting here, 16 other departments have volunteered and have become involved in the quality process. Most of these departments have behaved like the pilot departments, but in a few cases we have encountered more difficult situations.
Where the program takes place in a relatively unfavorable context, it will be even more important to evaluate the program and its permanence over the long term. A study conducted by Shortell et al. on 61 American hospitals showed that CQI/TQM systems were implemented more easily in institutions that had adopted a participative, flexible organizational culture that accepted taking risks [11]. Our program takes place in a large institution whose organization is very hierarchical and profoundly bureaucratic, which is recognized as an obstacle to implementing CQI/TQM [11]. However, our experiment shows that implementing CQI can encourage staff members to adopt behaviors of participation and taking responsibility. In several departments, the quality management seminar led to creating a place for discussion between the staff members that had not existed before. This change, even partial, of the style of management has often gone beyond the programs of quality improvement projects and has been experienced in a very positive way by the staff members who found in it the opportunity to discuss their problems directly with the department’s managers.
Our intervention responds well to the principles and the theory of CQI in the following ways: (1) it emphasizes organizational processes as causes of weaknesses rather than blaming individuals; (2) it uses structured problem-solving methods; (3) multidisciplinary work groups are set up; (4) staff members are given responsibility; and (5) it addresses both internal and external clients (hospital employees and patients) explicitly [11]. Therefore we suggest that departments create multidisciplinary work groups, involve the people in charge of the improvement processes, and use problem-solving tools. Through the themes dealt with by the different departments, we can see a desire among the staff to turn their attention toward the clients, to work on how patients and student trainees are received (external clients), and to work on the processes of information transfer with explicit reference to internal client–supplier relations.
However, our procedure does not have the characteristics of total quality management, which assumes a systemic approach involving the entire organization and all of its actors, crossing the boundaries defining the professions and the internal structures of the hospital [6,19,20]. Quality management is said to be total when it becomes an absolute priority of the organization, outweighing other elements of management such as financial or budget management or management of human resources [1]. Our program, even if it is developing in other departments, remains an internal process within each department; it crosses the barriers existing between the various professions within the department, but not the barriers inherent to the institutional structures. A few experiments using this strategy of implementing CQI in university tertiary care hospitals have been reported in the literature [16,17,21]. The evaluation of these programs, examining a small number of departments (between one and six), demonstrated their ability to involve staff members and to obtain concrete results in terms of improving results and reducing costs.
Conclusion
The organizational changes related to implementing CQI in a hospital require prior transformation of the culture and behavior of health care professionals. Our experiment suggests that an implementation strategy founded on setting up a quality management system in current medical departments allows one to introduce CQI and to involve staff members in multidisciplinary work groups. By creating more and more isolated ‘CQI pockets’, we hope to ensure the culture of health care professionals evolves in order to progress over the long term to the necessary organizational transformations [2,9].
Appendix
criteria for assessment of the medical department’s quality process
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This study has been supported by INSERM (Institut National de la Santé et de la Recherche Médicale), the CNRS (Centre National de la Recherche Scientifique) and the MIRE (Mission Recherche du Ministère de l’Emploi et de la Solidarité) program ‘Decisional processes and changes in health care systems’.
Address reprint requests to P. François, Unité d’évaluation, Pavillon D Villars, CHU BP 217, 38043 Grenoble Cedex, France. E-mail: pfrancois{at}chu-grenoble.fr 
Accepted for publication September 30, 2002.
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