CHAPTER ONE
1. PUBLIC SECTOR HEALTH POLICY IN BOTSWANA: OVERVIEW
1.10 Performance Improvement Initiatives in Botswana
1.10.1 Total Quality Management
Schlenker (1988:2) defines Total Quality Management (TQM) as „the control of all transformation processes of an organisation to better satisfy customer needs in the most economical way.‟ Customers, it is noted, are clients both within and external to the organisation. Zablocki (1993) noted that no American industry could benefit more from the utilisation of Total Quality Management (TQM) techniques than health care considering that a huge amount of the country‟s annual expenditure on health care goes to waste through inefficiency. The value of TQM, she noted, was that it would help in the delivery of quality service as well as the cutting of costs. The challenge for the public health sector was that in spite of the reported benefits of TQM, only a few hospitals in this sector practised TQM, most probably due to resistance to change amongst the leadership. TQM was seen to function well in institutions where there was effective communication that allowed the views of employees, patients and visitors to be accommodated. According to Zablocki (1993), the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) revised its standards, due to the success of TQM practices in hospitals, to include
quality-improvement methods with the shift being towards addressing issues of systems and processes rather than merely apportioning blame to individuals identified as being responsible for problems.
Banham (1993) wrote that during the 1980s, the Harvard Community Health Plan, a Health Maintenance Organisation (HMO) in Brooklyn, Massachusetts, introduced TQM principles and successfully managed health delivery costs and improved health care processes. The HMO benefited from courses offered by W. Edwards Deming, an expert in the field of quality management. Specifically, improvements in health services delivery were recorded through projects that ranged from improving billing procedures to communication networks that facilitated the handling of referrals of patients from one hospital to another.
The organisational efforts at performance improvement yielded positive results due to the adoption of innovative ways to analyse and change processes to improve quality.
Participants at an NFKL auditor quality workshop for candidates from the Botswana Ministry of Health and the Norwegian Board of Health held in Botswana in 1998 defined Total Quality Management as a
„management approach of an organisation, centred on quality, based on the participation of all its members and aiming at long term success through customer satisfaction ...‟ The workshop was part of the Health Sector Agreement of 1996 between the Botswana Ministry of Health and the Norwegian Board of Health in which the former was to be assisted to implement quality management systems. The introduction of TQM in Botswana required that health institutions put in place measures to determine whether quality activities complied with planned arrangements for effective implementation. The management of quality involves all members in an organisation engaging in activities to continuously improve the quality of its goods and services. TQM is meant to facilitate the process of preventing errors and attaining continued improvement in performance and quality. Teamwork and collaboration amongst the employees is paramount for success in improving the quality of services. Key problem areas in the quality management process have to be identified and remedial action taken.
Bashe (2007) defined quality as the degree of excellence of a commodity, whether a product or a service.
A service or product is said to meet the appropriate quality criteria if it meets the set standards and customer expectations. An excellent service or product does not only meet customer expectations but exceeds them. Processes to ensure quality products need to be planned for with the appropriate tools and techniques provide for the implementation of processes. Planning necessarily requires the involvement of all staff whose efforts are essential for the maintenance of quality systems. Such a systemic approach to planning and implementation is important since quality is an aspect that has to be prioritised throughout the organisation and not restricted to some of its parts. Continual quality improvement requires that
monitoring systems be put in place to detect deviations from planned activities so that corrective measures can be taken timeously. Monitoring of activities helps to identify flawed processes and contributes to the efficiency of organizational processes. The attainment of continual improvement is dependent on strategies that include keeping employees motivated to perform their duties through provision of conducive conditions of work. An organisation that motivates its workforce is likely to achieve high productivity levels and be successful at retaining its staff. Empowerment of employees is an integral part of motivation efforts as employees have to be allowed to participate in decisions that affect their well-being.
Rampey and Roberts (1992) described Total Quality Management as not being a separate programme but a total system approach that is an integral part of the organisational strategy, extending horizontally and vertically across departments. The major goal of quality interventions is customer satisfaction which is achievable through a minimisation of errors in the process of producing goods and services and ensuring the competency of organisational members through measures that include training. The external customers are the main focus for Total Quality Management processes because they have to get value for money for the products or services that they purchase. Kurtus (2001) observed that in a company there could be a chain of employees who can be referred to as internal customers since each plays a role in improving a product and then passes it along until it finally reaches the external customer. Each worker seeks not only to satisfy the internal customers but the external ones as well. Practitioners in organisations that aim to apply Total Quality Management processes also have to satisfy the agencies from which they themselves purchase goods and services if they are to continue in business. Such suppliers have to be paid timeously for their contribution to the business.
Repenning and Sterman (2001:65) wrote that there is little doubt that when applied appropriately, „TQM produces significant value to both organisations and their customers.‟ They also observed that a number of studies have demonstrated that companies that strictly adhere to the principles of TQM have often performed better than their competitors. A paradox that they noted, however, is that TQM is rarely ever used by companies, with TQM falling from the top three mostly used business tools in 1993 to 14th in 1999. A significant point made by Repenning and Sterman (2001) is that the number of performance improvement initiatives available for managers to use is ever increasing yet there has been little improvement in the capacity of organisations to incorporate the initiatives in their day to day activities.
Total Quality Management aims to improve organisational performance by pooling the efforts of organisational members for the achievement of a common goal. Through teamwork, the different organisational elements are expected to be productive by working smarter rather than harder since the
work that they do is complementary. The biggest challenge, it is noted, is having to implement the innovations successfully largely because they cannot simply be transplanted from elsewhere but have to be developed from within the implementing organizations, taking local conditions into consideration.