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Founded in 1968, the Falls Church General Hospital (FCGH) is a privately-owned, 6l5-patient bed facility in the incorporated township of Falls Church, Virginia. Falls Church is four miles from downtown Washington, D.C., and is surrounded by the counties of Arlington, Fairfax, and Alexandria, Virginia, all affluent urban/suburban communities with a highly-educated population composed largely of employees of the U.S. government and high-tech engineering firms.

Falls Church General Hospital, with 895 employees, provides a broad range of health care services, including drug/alcohol abuse wards, emergency rooms, x-ray and laboratory facilities, maternity wards, intensive- and cardiac-care units, and outpatient facilities. In January 1990, the hospital began a series of ads in The Washington Post highlighting its concerned doctors and nurses, its friendly support staff, and its overall philosophy that its employees care about their work and their patients.

The Issue of Assessing Quality Healthcare

Quality healthcare is a goal all hospitals profess, but few have developed comprehensive and scientific means of asking customers to judge the quality of care they receive. A tremendous amount of effort has been devoted to assessing the clinical quality of hospital care; books, journals, and papers on the topic abound. The problem, however, is that past efforts to measure hospital quality have largely ignored the perceptions of customers--the patients, physicians, and payers. Instead of formally considering customer judgments of quality, the healthcare industry has focused almost entirely on internal quality assessments made by the health professionals who operate the system. In effect, a system for improving healthcare has been created that all but ignores the voice of the customer.

The board of FCGH believes that all hospitals need to make the transformation from the current practice of attempting to ensure quality to measuring and improving the quality of care from both the external, customer perspective and the internal, provider perspective. Fueled by concerns in recent years about costs and medical practice variation and by the demand for greater social accountability, there is an emerging demand by patients and payers that quality healthcare be provided at best value.

As board president Dr. Irwin Greenberg recently stated at the annual FCGH meeting:

"As the prices people pay in the future for given levels of service become more similar, hospitals will be distinguished largely on the basis of their quality and value as assessed by customers. We must have accurate information about how our customers, not just the healthcare professionals who work here, judge the quality of care in this institution. Many hospitals already have some methods for measuring patient satisfaction. A recent survey of more than two hundred hospitals showed that two-thirds routinely conduct patient satisfaction surveys. Typically, the surveys are distributed at discharge to patients who are free to respond or not. The main value of such surveys is to gain quick knowledge of problems experienced by patients, many of whom often fill out questionnaires because they are disgruntled about some specific aspect of the care they received."

In response to Dr. Greenberg's statement, and in light of the advertising campaign, hospital administrator Carla Kimball called a meeting of her department heads to discuss the issue of quality. "Can we really deliver on our promises? Or are we in danger of failing to live up to the level of healthcare our patients expect, and do we risk losing them?" Ms. Kimball asked.

Annie Kerr, head of nursing, continued the debate

"I agree that surveys, such as the one Dr. Greenberg mentioned in his speech, are valuable. But how do we measure the quality of our doctor? Some patients who leave FCGH happy may have actually received poor treatment here. If we are serious about improving the quality of care, we need more valid and reliable data on which to act. We need answers to specific, quality-related questions about activities in areas that affect patients--admission, nursing, medical staff, daily care, and ancillary staff."

"I have an idea," said Merrill Warkentin, Kimball's staff director. "I just finished reading a book by John Groocock. He's the Vice-President for Quality at TRW, a big manufacturer. He says there are 14 steps in TRW's internal quality audits. I made a photocopy of those steps (see Table 1). Why don't we consider his approach?"

When the meeting ended, Ms. Kimball read Groocock's list again and began to think about the whole issue of quality control in U.S. firms. It had worked in many manufacturing companies, but could the concepts of quality control really be used in a hospital?

TABLE 1
Steps in TRW's Quality Audit

1. Quality to the customer. Is conformance of the product to established quality standards measured? Is quality of the organization's product compared with that of competitors' products?
2. Quality costs. Have the costs of quality been measured and have areas for possible cost savings been identified?
3. Design review. Do procedures exist to review designs for quality? Are these procedures being carried out?
4. Product qualification. Have procedures been established and followed to qualify new products before any deliveries to customers?
5. Product liability. Has each product been scrutinized regarding safety and are appropriate records kept? Does a written plan exist for dealing with a major product liability problem?
6. Process capability. Has the capability of all processes been measured and is that information used in product design and development?
7. Incoming inspection. Are incoming lots inspected in an efficient manner and are appropriate records kept?
8. Supplier quality. Are suppliers made aware of their quality responsibilities? Are records kept on nonconformance?
9. Process control. Has the company developed policies for controlling processes? Have employees been trained to follow those policies?
10. Inspection and test planning. Do inspection and test plans exist for all products and are records maintained on the results? Is all test equipment calibrated regularly?
11. Quality performance indicators. Are quality performance indicators regularly published throughout the organization and made available to employees?
12. Employee involvement program. Are employees involved in quality improvement through some process such as quality circles?
13. Multifunctional quality improvement team. Has a quality improvement team covering all functional areas been established to monitor quality and work to improve it?
14. Quality business plan. Has quality been integrated into the organization's business plan--and from there into the overall strategic plan?

1. Why is it important to get the patient's assessment of healthcare quality? Does a patient have the expertise to judge the healthcare he or she receives?
   
   
   
   
2. How might a hospital measure quality?
   
   
   
   
3. Using the steps in Table 1, discuss how each might apply to FCGH.
   
   
   
   
4. How can the value of a human life be included in the cost of quality control?
   
   
   
   
5. There are certain parallels between the evaluation of healthcare quality and educational quality. How are customer surveys used to evaluate the quality of teaching at your institution? How are the results used? Are any other measures available to assess educational quality? What improvements would you suggest to the current system?
   
   
   
   

Westover Electrical, Inc., is a medium-sized Houston manufacturer of wire windings used in making electric motors. Joe Wilson, Operations Manager, has experienced an increasing problem with rejected product found during the manufacturing operation. "I'm not sure where to begin," said Joe at the weekly staff meeting with his boss. "Rejects in the winding department have been killing us the past two months. Nobody in operations has any idea why. I have just brought in a consultant, Roger Gagnon, to take a look at the situation and make recommendations about how we can find out what is going on. I don't expect Roger to make technical recommendations -- just see if he can point us in the right direction."

Gagnon's first stop later that day was the production floor. His discussions with the production supervisors in the winding department indicated they had no real grasp of what the problem was or what to do to correct it. A tour of the winding operation indicated that there were three machines that wound wire onto plastic cores to produce the primary and secondary electric motor windings. After inspection by quality control (QC), these windings then went to the packaging department. Packaging personnel, Gagnon found, inspect their own work and make corrections on the spot. The problem is that too many windings are found to be defective and require reworking before they can be packaged.

Gagnon's next stop was the quality control department where he obtained the records for the past month's winding department rejects (Table 1).

No. Of Reject Units By Cause
Date	No. Inspected	Winder	Bad Wind	Twisted Wire	Broken Leads	Abraded Wire	Wrong Core	Wrong Wire	Failed Electrical Test
1	100	1	1	0	4	1	0	0	1
	100	2	2	1	0	0	1	5	0
	100	3	0	0	0	5	0	0	3
2	100	1	0	1	3	0	0	0	0
	100	2	3	1	0	0	2	3	0
	100	3	0	0	1	6	0	0	0
3	100	1	1	0	0	2	0	0	0
	100	2	0	0	0	0	0	3	0
	100	3	0	0	1	4	0	0	3
4	100	1	0	0	3	0	0	0	0
	100	2	0	0	0	0	0	2	0
	100	3	0	0	0	3	1	0	3
5	100	1	0	1	5	0	0	0	0
	100	2	0	0	0	0	0	2	1
	100	3	0	0	0	3	0	0	2
8	100	1	0	0	2	0	0	0	0
	100	2	0	0	0	0	0	1	0
	100	3	0	0	0	3	0	0	3
9	100	1	0	1	2	0	0	0	0
	100	2	0	0	0	0	0	1	0
	100	3	0	0	0	3	0	0	4
10	100	1	0	0	5	0	0	0	0
	100	2	1	0	0	0	1	0	0
	100	3	0	0	0	5	0	0	4
11	100	1	0	0	4	0	0	0	0
	100	2	0	0	0	0	0	0	0
	100	3	0	0	0	4	0	0	4
12	100	1	0	0	3	0	1	0	0
	100	2	1	0	1	0	0	0	0
	100	3	0	0	0	5	0	0	4
15	100	1	0	0	2	0	0	1	0
	100	2	0	0	0	0	0	1	0
	100	3	0	0	0	3	0	0	3
16	100	1	0	0	6	0	0	0	0
	100	2	0	0	0	0	0	0	0
	100	3	0	0	0	3	0	0	3
17	100	1	0	1	1	0	0	0	0
	100	2	0	0	0	0	0	0	1
	100	3	0	0	0	3	0	0	3
18	100	1	1	0	2	0	0	0	0
	100	2	0	0	0	0	0	1	0
	100	3	0	0	0	4	0	0	1
19	100	1	0	0	2	0	0	0	0
	100	2	0	0	0	0	0	0	0
	100	3	0	0	0	3	0	0	1
22	100	1	0	1	4	0	0	0	0
	100	2	0	0	0	0	0	0	0
	100	3	0	0	0	3	0	1	2
23	100	1	0	0	4	0	0	0	0
	100	2	0	0	0	0	0	0	1
	100	3	0	0	0	4	0	0	3
24	100	1	0	0	2	0	0	1	0
	100	2	0	1	0	0	0	0	0
	100	3	0	0	0	4	0	0	3
25	100	1	0	0	3	0	0	0	0
	100	2	0	0	0	1	0	0	0
	100	3	0	0	0	2	0	0	4
26	100	1	0	0	1	0	0	0	0
	100	2	0	1	0	1	0	0	0
	100	3	0	0	0	2	0	0	3
29	100	1	0	0	2	0	0	0	0
	100	2	0	0	1	0	0	0	0
	100	3	0	0	0	2	0	0	3
30	100	1	0	0	2	0	0	0	0
	100	2	0	0	0	0	1	0	0
	100	3	0	0	0	2	0	0	3

DISCUSSION QUESTIONS

1. Prepare an outline for Roger Gagnon's report.
   
   
   
   

2. What charts, graphs, computer printouts, and so forth might be included in the report?
   
   
   
   

3. Prepare Gagnon's recommendation, with justification, on one page.
   
   
   
   

4. Prepare the detail necessary to supplement Gagnon's recommendation and justification so Joe Wilson will understand how he arrived at the recommendations.
   
   
   
   

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