Quality management in the NHS: the doctor's role--II.
Authors: D. M. Berwick, A. Enthoven, J. P. Bunker
Journal: BMJ (1992)

In last week's issue (p 235) we argued that the of which can act without the participation of all the introduction of market conditions into the NHS, others.designed to achieve greater accountability and createThe doctors of the NHS, specialists and generalists incentives for efficiency and improved quality of care, alike, are key parts of that potential system, and its will not alone be sufficient to achieve improvement.'success may rise or fall depending on the willingness of Also needed is a sound and effective method by which British doctors to learn, accept, and adapt to the new medical leaders, managers, and practitioners can circumstances of work in an integrated system of care.implement strategies for improvement.In the absence We believe that TQM offers a set of general principles of such a method efforts to reform the financing of with which the British medical profession can build an medical care and increases in accountability may result NHS of the future that is proud, capable, supported by in more waste and fear than progress.its constituents, and, indeed, as satisfying to work in as We propose that total quality management (TQM), it has been in the past.a collection of approaches to quality, efficiency, andTo achieve this transformation will require that leadership that has matured over the past few decades doctors accept a body of new skills to learn and in industries other than health care, can be used practise.Though not taught in medical school, these effectively within the health care system as a powerful skills are essential for proper work in an interdependent force for improvement.Last week we reviewed system of care.Indeed, so crucial are these skills to the basic principles of TQM and suggested how, with successful conduct of medicine in the future that we appropriate modifications, these principles can apply suggest they be classified as the "new clinical skills" of to the work of medicine; how market forces can modern, integrated medical care.They belong in the increase the motivation for improvements in quality repertoire of the doctor just as much as the "classical and efficiency; and how TQM can provide a method clinical skills" that the new system must preserve and for acting on that motivation.support.In this article we explore the special opportunities that TQM offers to NHS doctors as leaders of a American medical economy.Put boldly, the NHS, involved in a common process-such as ordering Correspondence to:.*Dr D M Berwick, 131 Lake unlike much of American health care, is, or at least can and reporting laboratory test results, or controlling Avenue, Newton, be, a system, and because of that it has great potential postoperative pain, or the registration of patients for Massachusetts 02159, USA.for rational planned action to meet the needs of those it hospital admission-would take the time to meet, to serves.But that systemic property also creates strong make their processes or work explicit through suchBMJf 1992;304:304-8 and ineluctable bonds among its components, no one techniques as flow diagrams, and to plan specific steps 304