Sağlık sektöründe toplam kalite yönetimi
Total quality management in healt-care industry
Yazar: METİN ŞENGÜL
Danışman: PROF. DR. ETHEM TOLGA
İstanbul Teknik Üniversitesi / Fen Bilimleri Enstitüsü / Endüstri Mühendisliği Ana Bilim Dalı
Derece: Yüksek Lisans, 1997
Konu: Endüstri ve Endüstri Mühendisliği = Industrial and Industrial Engineering
Dizin: ISO 9000 = ISO 9000 ; Sağlık kontrolü = Health control ; Toplam kalite yönetimi = Total quality management

Özet:
ÖZET Tezde Toplam Kalite Yönetimi'nin sağlık sektöründe nasıl, hangi teknikleri kullanarak ve hangi anlayışları temel alarak uygulanması gerektiği anlatılmaktadır. Tez beş bölümden oluşmaktadır. Giriş bölümünde kısaca günümüzde işletmelerin içinde bulunduğu ortam tanıtılmış ve bu işletmeleri yeni yönetim teknikleri uygulamaya zorlayan etmenler açıklanmıştır. ikinci bölümde toplam kalite yönetimi; kalite kavramı, Toplam Kalite felsefeleri, temelleri, engelleyen unsurlar ve İSO 9000 standartları konuları ile detaylı bir şekilde incelenmiştir. Üçüncü bölümde hizmet sektöründe genel olarak Toplam Kalite Yönetimi'nin hangi esaslara dayandığı açıklanmıştır. Bu açıklamalar hizmet sektörünün özgün yapısı, hizmet işletmeleri, hizmet kalitesi, Toplam Hizmet Kalitesi ve hizmet kalitesini iyileştirme yolları ana başlıkları altında verilmiştir. Dördüncü bölümde sağlık sektörü ana hatları ile tanıtılmaya çalışılmıştır. Bu bölümde sağlık kuruluşları, sağlık göstergeleri, hasta haklan ve çalışma için özel önemi olan hasta - müşteri ayrımı açıklanmıştır. Beşinci bölümde ise sağlık kuruluşlarında Toplam Kalite Yönetimi detaylı olarak ve birçok örnekle açıklanmıştır. Bölümün ana başlıkları şunlardır: Sağlık sektöründe kalite kavramı; sağlık sektöründe Toplam Kalite Yönetimi; sağlık sektöründe "sıfır hata" anlayışı; sağlık kuruluşlarında üst yönetimin organizasyonu; klasik kalite kontrol tekniklerinin sağlık sektöründe uygulanması; sağlık kuruluşlarında verimlilik; çalışma saatlerinin düzenlenmesi; pazarlama, halkla ilişkiler ve rekabet; sağlık sektöründe teknoloji kullanımı; sağlık sektöründe endüstri mühendisliği uygulamaları. Son olarak genel bir değerlendirme yapılmış ve sağlık sektöründe yapılacak TKY uygulamaları için öneriler getirilmiştir.

Abstract:
SUMMARY TOTAL QUALITY MANAGEMENT İN HEALTH-CARE INDUSTRY in this study, implementation of Total Ouality Management in health-care institutions, methods used to implement it and the main principals are explained and several examples are given. General belief that Total Ouality Management tools cannot be implemented completely in health-care institutions is rejected and several examples are used to prove that ali fundamental tools can be used. But implementers have to understand the service concept and health-care industry which is a kind of its own among other service industries. Health çare institutions are obliged to give a chance to professional managers in their institutions and let them implement Total Ouality Management to survive in competition and to fulfill the public expectations. it is not a choice, it is an obligation. There are three main factors vvhich drive companies into an environment vvhich they found "very thrilling": Customer, competition and change (Hammer and Champy, 1994). Surviving becomes more and more difficult each day and this fact forces companies to develop strategies to çöpe with it. Total Ouality Management (TQM) is öne of these prescriptions to survive. TOM is a well-known technique for the manager and industrial engineers (lE's) in manufacturing industries for many years. But in service industries it is comparatively very new and stili looks a bit strange. Because there are many difficulties in implementing a TOM program into a service company (Lovelock, 1991): 1.Nature of the product: As Leonard Berry describes a good as "an object, a device, a thing" in contrast to a service vvhich is "a deed, a performance, an effort". Although services often include tangible actions (such as sitting in an airiine seat, eating a meal, ör getting damaged equipment repaired) the service performance itself is basically an intangible. Like ali perfomnances, services are timebound and experiential, even though they may have lasting consequences. 2.Customer involvement in production: Often customers are actively involved in helping to create the service product, either by serving themselves (as in a fast-food restaurant ör Laundromat) ör by cooperating with service personnel in settings such as hair salons, hotels, colleges and hospitals. 3.People as part of the product: The difference betvveen two service businesses often lies in the quality of employees who deliver the service. As such, people become part of the product in many services. 4.Ouality control problems: When services are consumed as they are produced, final "assembly" must take place under real-time conditions. As a result, mistakes and shortcomings are harder to conceal. Further xivariability is introduced by the presence of service personnel and other customers. These factors make it hard for service organizations to control guality and offer a consistent product. 5.No inventories for services: Because a service is a deed ör performance rather than a tangible item that the customer keeps, it cannot be inventoried. 6.Importance of the time factor: Many services are delivered in real time. There are limits as to how long customers are vvilling to be kept waiting for the service to be provided. 7.Different distribution channels: Unlike manufacturing firms, which reguire physical distribution channels for moving goods from factory to customers, service businesses either use electronic channels (as in broadcasting ör electronic funds transfer) ör else combine the service factory, retail outlet and point of consumption into öne. Generally goods are much more easier to evaluate than services. Health- care services seem to be the most difficult öne to evaluate among ali of the goods and services. The evaluation of a health-care service is much more complex than any other service. Because (Bulut, 1996):.His/her expectation is to recover if he is ili. If not, his expectation will be not to lose his health. But mainly he expects not to be damaged..Even his expectation is just not to lose his health, it is not possible to measure it..He cannot evaluate the service he buys..Expectations will be different as people who buy it are different, although the service is completely same. it is really very difficult to describe "health-care quality". But some characteristics can be very useful to define it (Ak and Sargutan): 1.To be effective: The ability to achieve the best nursing çare and greatest improvements in today's health-care environment. 2.Productivity: The ability to reduce costs vvithout reducing improvements. 3.Optimality: Balancing costs and nursing-care served to achieve the optimum situation for the hospital. 4.Acceptability: Continuity for the expectations of patients and their families. 5.Legality: Obeying legal and moral rules of the society during the service. 6.To be judicial: Continuity of the principles determines rules of distribution of health-care series among society judicially. Due to evaluating medical-care itself is very difficult, patient (customers) usually make their judgments by evaluating the physical environment and the behavior of the personnel. Health-care is a hümanistle profession vvhose academic and professional preparation emphasize the need to provide the best quality çare based on human xiineed. Those who have been trained in the old school of thought fınd some of their professional values challenged in today's environment of cost containment. Like other businesses, the hospital must compete for land, labor, capital, and entrepreneurial ability. And, like manufacturing organizations it is also expected to pass the profitability test. TQM applications in health-care industry are special types of Total Service Ouality Management (TSQM). The fact that health-care has many different tasks, doesn't necessarily mean that classical tools of TQM cannot be used in TSOM applications in health-care industry. This thesis mainly defends that ali of the tools of TQM can be and must be used in TSQM applications in health-care. An second emphasis of the thesis is health-care institutions serves "customers", not "patients" and this vision can only be obtained by implementation of TQM with the strict participation of employees (including practitioners). There are several examples of TSQM in health-care. Applications such as Naval Hospital Ortando, Bumaby Hospital, The George Washington University Medical Center and İntermed Medical Center are given as examples. The thesis already shaped with the experiments of the writer in İntermed Medical Center during TSQM studies in last two years. Also a wide range of literatüre is searched. Especially Omachonu's ideas generally accepted. Seven classical quality control techniques (checksheets, graphs, Pareto analysis, cause and erfect diagrams, histograms, scatter diagrams, control charts) are handled and examples are given for each of them. Control charts is especially explained and three unique examples are given (Billing errors, Demos System and application of economic control charts in Henry Ford Hospital). Additionally the Ouality Function Deployment (QFD) method is discussed and an example is given. Productivity is the biggest concem of researchers in health-care. Although there isn't any widely-accepted method, there are several approaches. Especially lack of productivity measurement method for policlinics is a big problem. Because ali of the methods used now concem with bed capacities ör such physical inputs. But about 80-90% of patients need only policlinic services and do not "consume" any beds. Ouality should be defined in terms of conformance to standards as well as the needs and vvants of the customers. Productivity should be driven by the total resources consumed in the delivery of çare. in order to fully understand productivity, we must first understand ali cost components. Although outcome is important, it is even more important to understand that the process generates the outcome. A recent application of Data Envelopment Analysis (DEA) is included. This application has been done by Muzaffer Çağlayan in 1995. A few health-care institutions and departments in öne of them (İntermed Medical Center) compared with each other to calculate comparative efficiencies. Work scheduling is also very important in two ways. First almost ali of the institutions have to serve 365 days and 24 hours and so they have to keep necessary number of employees to keep departments öpen and service possible. Secondly health-care is öne of the most stressful job in the vvorld. Because the xiiiconcern is human life. We already know that night shift is an important stress factor. So working schedule must be prepared very carefully and education of coping strategies with stress must be given. The word "competition" seems very "unmoral" for many people, especially for practitioners. They say that health-care is an humanitarian act and a health institution shouldn't compete. But it is not logical. Competition cannot be understood just as a "deadly match", it indeed forces companies to serve in a better way and invent in new technologies. Damaging part of the competition, if there is, must be controlled by the government. It is not a reason to stop competition and discourage companies from developing themselves. The best approach to competition is the Michael Porter's "Competitive Strategy". His five-factor model is widely accepted and several implementations have been done. A five-factor model for health-care is developed by Bourke in 1994. This model is also given and factors affecting competition in health-care is discussed. If quality improvement is pursued only through technology, then increased quality may decrease productivity. According to Dr. Deming's (1986) chain reaction, improved quality leads to decreased costs, and increased productivity, both of which enhance an organization's ability to capture the market, stay in business, and have satisfied customers. Consequently, it is imperative to fully understand the concept of costs, productivity, and technology, as vital components of quality. Finally the roles of lE's in health-care studies is widely discussed. A few decades ago, the description of lE's in health care was "the engineer observes the radiology department, goes off and works on some formulas, does some calculations and comes back and says how to make some staff disappear". But description is different today. The mystery and black cape of industrial engineering is gone, at least in USA and other developed countries. Today, in those countries, lE's are parts of the organization and work with other employees for making improvements. Main areas of concern for lE's in health-care in recent years are as follows: Benchmarking, process simulation, comparative data analysis, quality management, system analysis, customer focus. In Turkey this concepts are very new and TSQM applications are very limited. Only a few institution are trying to implement such a program. There are very big problems in national health policy. As a result private sector has great opportunities and this brings competition to the market. IE departments in universities still only concern with manufacturing industries and this causes lack of information in service industries. Post-graduate studies in health-care have to be encouraged. Health care is primarily a growth industry and some evidence of this can be found in the increasing emphasis on technological development, clinical capability and greater reliance on the pure sciences. Accomplishments in all of these areas have been accompanied by rising costs. As the gap widens between consumer expectations and the services hospitals can deliver, health-care administrators are searching for ways to close this gap through more efficient resource management and quality improvement. The need is greater today for efficient management of human and non-human resources at all levels of a constrained hospital environment. xivIndustrial engineers, or management engineers as they have been commonly called, have been responding to this challenge by using basic techniques such as time study, activity sampling, and operations research tools for problem solving. Although these problem solving-tools can be effective in the process of continuous improvement, management engineers have generally used them to achieve the goals of cost containment rather than quality improvement. The role of today's management engineers needs to be redefined. Its definition must be based on a new paradigm of health-care practice, one that emphasizes quality improvement rather than arbitrary cost reductions. Without the adoption of a new operating philosophy, it will be difficult to realize the full benefits of the involvement of management engineers in the quality transformation. xv