Quality Management in Health Care Services

Date First Published: September 24, 2019
Date Last Revised: July 12, 2020



Methods of ensuring quality have developed through the years from dependence on product inspection (often erroneously equated with quality control); followed by preoccupation with improvement through problem solving; and evolving now towards a more complete and comprehensive approach through the work of many quality experts in both manufacturing and service industries.

Juran’s Quality Trilogy® i.e. Quality Planning, Quality Control and Quality Improvement, comes closest to a comprehensive and integrated system that pays attention to quality at every stage of the “production” process. It looks at quality from a manager’s perspective.

Armand Feigenbaum advocated the same principle, when he wrote:

“… the underlying principle of this total quality view is that to provide genuine effectiveness, control must start with the design of the product and end only when the product has been placed in the hands of a customer who remains satisfied, … the first principle to recognize is that quality is everybody’s job”

Deming placed emphasis on culture, leadership, training and individual excellence. Notable principles advocated by Crosby include putting in the prerequisites for ensuring quality (quality is built in), the importance of teamwork and the concept of “cost of quality”.

Donabedian, a pioneer of the quality movement in health care applies the “Systems Theory” which emphasizes the dependence of output on structures (input, organization), processes and the cultural environment. His model of ‘the greater Q.A.” describes a comprehensive system of Quality Management.

The need for Quality Management has been pointed out by Oakland, “Quality has to be managed – it will not just happen”. ISO 9001 quality system standards and the Malcolm Baldrige Criteria both describe an integrated quality management system involving all aspects of the production process.

The invaluable contributions of the quality gurus can be blended into an effective framework for a quality management system. Yet the proliferation of literature on the subject of “quality” also causes considerable confusion. For example, ISO 9000 QM Standards are often misunderstood with too much emphasis placed on documentation rather than  understanding the quality principles and methods (as advocated by the gurus). Around the world there is still an ongoing debate on what approaches to take on the path to quality.


Quality of a product or service quality has at least three meanings i.e.

  1. Meeting customer needs (the customer wants to buy the product)
  2. Fit for use (the customer can and will use the product and benefit from it)
  3. Conforms to specifications (was actually the product that was intended to be produced)

There is a great debate among quality experts as to the meaning of quality. It is true that satisfying the needs of the customer is the guiding principle in defining product quality. However it is neither possible nor desirable to meet all the needs of customers. It is obvious that product features and production are subject to constraints and limitations. The laws of nature is certainly the first constrain. Next, technology and costs have limits. Finally, the society imposes certain norms, laws and regulations.
At the design stage, the definition of quality as that of meeting customer needs is sacrosanct. However even here, quality already means conforming to specifications e.g. technological requirements and regulations such as environmental laws. A limitless variety of features can be built into a product in response to customer requests or because technology is available but that does not guarantee that the product will function. Quality of a product defined as “fit for use” demands that the product be extensively tested for features such as functionality, user-friendliness, durability and “serviceability”.
At the stage of production, especially in manufacturing industries, the dominant meaning of quality must be “conformance to specifications”. It is important that the production operator knows what the external or internal customer needs. However the way that he or she will satisfy these needs, is to produce the product (intermediate or final) according to specifications set by the designer. In service delivery such as nursing or teaching or entertaining there is a need to vary product features according to the need of individual patient or pupil or patron. But the principal features must still conform to policies or the syllabus or house rules. Indeed in modern food outlets for example, most of customer needs is defined through market surveys. These needs are met, to a considerable extent, by providing variety in the menu and providing the customer the choice of additional flavouring such as ketchup, salt and pepper. Yet as far as food preparation is concerned the ingredients, method of cooking and serving are strictly defined as specifications. Even if the food is prepared according to specifications and bought by patrons, the manager still needs to observe whether the food are actually consumed.

Taguchi equates quality with the degree of loss to society when a product is made available to the public; thus emphasizing the effect of products not just on the user but on the community at large.

The Quality Management System being proposed here subscribes to the view that all the principal definitions of quality mentioned are relevant and applicable in achieving, maintaining and improving quality of products and services. In addition the systems approach to operations management, used extensively in this proposal, clarifies the meaning and purpose of each and every element, strategy and tool of quality management. Much emphasis and value has been placed recently on marketing strategies and techniques. Marketing and after sales services are important activities of any organisation and are important components of the quality of products and services but they should not dominate to the extent of putting aside attention to essential features such as functionality and effectiveness.
Perhaps the confusion in understanding quality evoked by current literature is the same quandary faced by the seven blind men when asked to describe the elephant.


Based on current understanding, it may be deduced that quality management must be:

  1. Guided by a philosophy and a set of principles
  2. Driven by an approach
  3. Realized through effective tools and techniques


Management of Quality is the aspect of management that is concerned with achieving, maintaining and improving quality of products or services. All activities of any organization affect quality in some way or another. Therefore Quality management must involve all aspects of management i.e. Planning, Leading, Organizing and Controlling.The Quality Function itself must be recognized as an integral part of the overall management function.

The following principles would be a natural derivation of the above conviction:

  1. Quality has to be integrated with all other functions.
  2. Quality initiatives need to be organized, coordinated and focused.
  3. There is organization-wide commitment to quality, based on shared values and culture and expressed as goals, objectives and policies.
  4. There is clear assignment and deployment of responsibilities for various aspects of quality management; quality being everybody’s job
  5. All policies, procedures and processes are aligned with quality goals
  6. Integration of all efforts at achieving, maintaining and improving quality


It is proposed here, that a quality management system should be guided by a set of principles that form the core elements and sustained by some supportive elements.

 The guiding principles are:

  1. Quality of products or services emanate from good design and planning
  2. Quality has to be measured and controlled
  3. Deficiencies need to be corrected and problems solved
  4. Quality of products or services should be continuously improved.

Successful implementation within this framework depends on a supportive base which include:

  1. Internalization of quality culture within the organization
  2. An effective organizational structure to facilitate the implementation
  3. Adequate resources
  4. Skills and expertise in using quality management methods and tools

The elements can be summarized below:

  1. Core Elements
    • Quality through Design, Planning and Implementation
    • Quality Measurement & Quality Control
    • Continuous Quality Improvement
  2. Supportive Elements
    • Quality Culture
    • Organization and Support.
    • Training in Quality

The relationships of the elements can be expressed in the chart below:

Relationships of The Elements of an Integrated Quality Management System

4 Core Elements
Core Elements of Quality Management

All the above elements are interrelated and interdependent. Each element is part of a continuum, contributing to common objectives i.e. achieving, maintaining and improving quality.
The quality of any product or service is dependent to a large extent on good design. Indeed, besides the product itself, the production system and the Quality management system too need to be properly designed. Two other essential requirements are: Measurement and Control. By ensuring conformance to specifications quality control maintains quality and at the same time provides feedback for improvement. Much of improvement is about improving design and ensuring better control. Quality can be improved by finding solutions to problems. The lessons learned can also be used for improving future design. There is also a need to develop and encourage a cultural environment that promotes quality. Proper organization and support is essential for all these initiatives are to succeed.
The various elements are discussed further in separate articles i.e.

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