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Hands on Management

Total Quality Management in Healthcare

Tools to measure TQM in health practice


I once attended a short course in Total Quality Management (TQM) in a one-day seminar in Eldoret, which targeted hospital workers at Moi Teaching and Referral Hospital and other managers. The seminar brought together medical doctors, other professional medics, professional managers and chemical engineers. Most notable was Dr Meshack Kitui, a Chemical Engineer teaching Nano-Chemistry at Maasai Mara University and Doctor Elim, an eye specialist at Turkana Level Five Hospital. The key presenters, trainers and speakers included the then Moi University Quality Assurance dean, Professor Laban Ayiro, David Simiyu the then Branch Manager of Kenya Institute of Management (KIM) Eldoret branch, Dr Caleb Akuku, an Expert on management of Quality in Engineering systems and Francis Prachisikombe Nyaraombe an expert on Financial Management Quality systems. Both Nyaraombe and Akuku are also Lecturers at KIM in Eldoret. The day’s agenda was to decipher what ‘Quality’ is, what ‘Total Quality Management’ is, and establish to which extent TQM can be applied in customer funded public health systems.

Understanding TQM

At the inception of the seminar, Professor Ayiro, explained how the business world sees TQM as an addition to the traditional way of measuring quality. He defined TQM as; ‘Total’ as in made up of the whole ‘Quality’ as pertaining to the degree of excellence, product or service and ‘Management’ as an act, art, or manner of handling, controlling or directing the process. 

Ayiro encouraged the audience to appreciate the observations by Dean and Bowen (2015) who argued that all organisations, whether in the public or private sector, need to analyse their managerial effectiveness within their specific contexts and cultures in order to obtain information about their comparative performance with competitors, and hence take steps to become more productive. He said this with hope that it would help illuminate the way to understand the terms ‘Total’, ‘Quality’, and ‘Management.’  

During the training, Dr Akuku alluded to Aristotelian philosophy that ‘Quality is a habit of excellence in whatever you do in your capacity as a public servant,’ a position he defended by pointing out that, “if a public health service provider can embrace the main tools of Quality Management that include TQM, Kempa Kaizen, Six Sigma, Statistical Quality Control, Capability Index, Leadership, Documentation and communication, then excellence in public health service would be achieved at individual and at National level.”

Of concern was the universality of Six Sigma as a quality management tool. Professor Ayiro had praised the six-sigma principal for its effectiveness in managing the quality process of the health care system. He argued that Six Sigma predicts possibility of error and prevents probability of failure of expected quality level not to deviate from the expected standard by only allowing the standard deviation with a magnitude of positive or negative three.

Is six-sigma in public health plausible? 

The intellectual back-drop readily attests that Professor Ayiro was right. It is evident in scholarly writings on quality economics that management scholars such as Mitzberg, Dean Kontz, Crossby, Juran and Oakland have praised Six Sigma to be the magic behind industrial achievements in quality management in the USA and Japan. The main logic behind the glorified six-sigma in the industrial world is that it enables the quality system to suffer minimal deviation to an extent of negative or positive magnitude of the standard deviation. 

However, the technical undoing of Six Sigma is that the size three of its standard deviation in the industrial world can be tolerated, but it is not the case in management of healthcare systems. The standard deviation with a magnitude of three in a hospital system can sometimes mean deaths of a hundred patients in a day or hundred surgical failures in a week.  Dr Elim alluded to the sociological values of clinical practice like clinical governance, clinical effectiveness, and quality of patient care to fault the Managerial Six Sigma by arguing out that the standard deviation with the Magnitude of three in some public health-care facilities like Kenyatta National hospital can be equivalent to clinical officer letting over a thousand people to die because on that day, the same clinical officer had succeeded to save 96,000 lives.

Primary essence of nursing

Generally, an intellectual back-up for faulting of the Managerial-economics Six-Sigma borrows some strength from the book Clinical Effectiveness in Nursing by Kenworthy, Snowley and Gilling (2015) who jointly argue that the primary essence of nursing is to provide corrective care with one primary focus on beyond zero death. It is under such light-shedding contexts that one can realise that the philosophy of ‘beyond zero death’ as enticed by Margaret Kenyatta is ethically important and valuable way of out-look in the medical world.

In a nutshell 

In the workshop, the celebrated tools of TQM were not accepted as strategically effective in health quality management systems. It was also deliberated that the Supply chain management tools as used in the commercial world need to be refine-tuned to fit the expectations of users of a healthcare system. However, it was agreed that there is need for a strong Total Quality Culture (TQC) in all healthcare organisations.

Alexander Opicho is an essayist and freelance writer based in Lodwar, Kenya. Email:

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