Implementation of the right Quality Improvement method(s) for Kingston Hospital, A&E Services

The fundamental principle of making healthcare safe, patient orientated effective and timely efficient is to focus on improving quality. This is an interesting field of study because the NHS has not entirely focused on improving the quality of healthcare. It means that the NHS needs to deal with these issues as they are under continuous tension not only by the patients but also by the government. The NHS should react as soon as possible before these issues develop into a ‘crisis’. The aim of this study is to satisfy the research objectives which include the investigation of patient quality issues in the Accident and Emergency Department in Kingston Hospital (NHS). This study is also concerned with the reason for these problems. Interviews, Questionnaires and Observation research techniques were used to investigate the complex causes of the issues. These results will help to understand the nature of each issue. These form the ultimate research objective which includes the possible solutions for these issues. This study also places a great value on a fundamental part of the quality agenda; focusing on improving quality. It will consider organizational or industrial approaches to improve quality. The final aim of this study is to choose the most suitable approach within healthcare setting for measurable quality improvement.

Introduction

The purpose of this study is to investigate and solve the patient quality issues which commonly occur in the Accident and Emergency Services in Kingston Hospital.  This study is going to explore the birth of National Health Services (NHS) for the purpose of understanding the patient quality issues through its development. As mentioned before, the purpose of this study is to investigate and solve the current patient quality problems; this could be achieved. The NHS uses several management systems which are still recent developments. I will therefore investigate and recommend which management technique could be implemented to solve the existing problems Kingston Hospital faces. For a successful implementation of the appropriate management technique to solve each issue, we need to get familiar with all concepts of techniques which will be discussed in the ‘Literature Review’.

Reliance on articles by media, interviews and surveys of patients about the NHS services is not always detailed enough. A large number of respondents do not guarantee representativeness. Even more reliable sources such as corporate documents which are by nature, cryptic and tedious, often try to blanket any possible faults (Jaffe, 2014). These sources do not always reflect the real issues behind the curtains. These facts this study reveals that relatively little is known about the patient quality issues in the NHS services. The aim of this project is to fill and investigate this research gap and demonstrate a deeper understanding of these problems and implement possible solutions for the A&E services in Kingston Hospital.

My aim will be achieved by satisfying the research objectives:

• In order to achieve this aim I am going to collect Secondary Data. Furthermore Interviews and Questionnaires which are Primary and Qualitative Research methods are going to assist this dissertation in this research field.
• For a deeper insight and for a better understanding of the patient quality issues in the A&E in Kingston Hospital, I am going to design an Empirical Framework, using Direct Observation.

 

• This dissertation will analyze, demonstrate and challenge the Quality Improvement methods in the A&E Department.
• Investigating and answering the research questions are the best representation of the objectives of the study. The research questions are:

1. What are the main patient quality issues in the A&E Department in Kingston Hospital?
2. Which Quality Improvement method(s) could solve the identified issue?

The motivation for this study was my personal experience at the A&E Department in Kingston Hospital. I had advanced tonsillitis and I decided to visit the A&E services in Kingston Hospital as my GP did not prescribe medication. My personal experience was negative so I decided to investigate and find out more about the patient quality issues in the NHS. It also motivated me to carry out further research of Quality Improvement methods which are usually used by the NHS.

 Literature Review

The struggles during the development of NHS

“Creating the National Health Service covers Britain’s greatest piece of twentieth-century social legislation, and is a fascinating account” (Rintala, 2004). After the Second World War, the idea that everybody should be entitled to good health care regardless of wealth created out the NHS. It was launched by Aneurin Bevan, the famous politician of the Labour Party and then the minister of health, on July 5, 1948. Everybody and everything in the existing health care systems were brought together, including hospitals, doctors, dentists, opticians, pharmacists and nurses under one organisation for the ultimate goal which was to create the NHS to provide free services for all (NHS, 2015).

In 1979 the Conservative Government wanted efficiency and effectiveness in the NHS (Nwabueze, 2004). The government needed a precise plan to reform the NHS as it lagged behind expectations (Adamou, Marios and Hale, 2004). Through the initiative of value for money, the fundamental challenge for the government was to improve on the current resources to maximize medical services for the taxpayers in the UK. To achieve this ultimate goal, the government needed “improvements in the re-structuring and management of the service, improved accountability of health authorities, and better utilisation of manpower and the execution of substantial and sustained cost improvement programmes” (Nwabueze, 2004). The NHS also began to contract external services from the private sector, for example cleaning and catering services. The government expected efficiency improvement from these contractors. Efficiency became the underlying rationale of competitive tendering which was the way of reducing costs for the NHS and the government (Nwabueze, 2004).

The government made the right steps and decisions improving the efficiency and effectiveness in the British health care, but the NHS was still struggling in the 1980s. The NHS was facing efficiency issues in the daily operations which became a political issue. A lot of different departments closed down and there were delays to treatments which later on captured the attention of the media as there were patient complaints. As a form of action the Secretary of State forced them to deal with the situation. As a result the current Prime Minister, Margaret Thatcher proceeded to look into the existing problem. The members of the team were working secretly and they remained anonymous. The findings of the investigation were released to the public in January 1989. The review contained various measures and agreements. The most radical proposal was to empower hospitals to manage their matters independently. It meant that each hospital was given a budget which was controlled by general practitioners, which they spent on the appropriate care for patients. The proposal also recommended that the NHS should remain free at the point of delivery for the public and be funded from general taxation just as Bevan’s original idea. (Nwabueze, 2004).

The pressure of the NHS Review, in 1991, lead to the introduction of the Health and Community Care act of 1990 (Healthcare Act, 1990) and the services improved to patients. The provision of services remained free at the point of delivery. In order to meet these objectives, the NHS went through some major organisation and structure changes. Health authorities and GPs began to buy health services for their residents and local hospitals begin to provide those services. From this point the NHS is shifting from major struggles towards a new management style and culture. Employees are more empowered, health authorities and GPs made their own decisions on purchases. Quality managers, quality officers, directors of nurses etc. became responsible for delivering vertically the new management approach to the rest of the staff in the NHS. Efficiency and quality became a real subject. The NHS became very customer orientated where they did not go quietly into the night. They had the right for quality care. This is the 1990’s, “Gone are the days of the quiet and compliant patient who dared not speak, much less challenge the care provider. Today’s better-informed patient can and is willing to make judgements and to discriminate about the quality of care” (Nwabueze, 2004).

 The 1990s is a new beginning of the NHS, the era of TQM. After careful study of Nwabueze’s work ‘The Rise and Decline of TQM in the NHS’ it is safe to say that the new management style which is considered a new management approach includes all the main principles of TQM which includes:

• Communication between Employers and Employees (Everyone is involved)
• Employee Empowerment
• Efficiency and Effectiveness
• Quality is first priority
• Continuous Quality Improvement
• Customer Orientation
• Listening to Customers

Even though the TQM approach was implemented for some hospitals in the early 1990s, according to an Evidence Summary from Homerton University Hospital NHS in 2016, “Quality improvement (QI) in healthcare is a relatively recent development and the use of QI methods and tools is growing” and “There are a wide range of initiatives aimed at improving quality in health care. Typically, they use models and tools first used in the industry. Foremost among these are: Total Quality Management (TQM), Continuous Quality Improvement (CQI); (aka the Model for Improvement, Plan-Do-Study-Act); Lean Thinking and Six Sigma” (Homerton, 2016). In layman’s term QI techniques are still a recent development and the NHS hospitals are still struggling with OM problems which come from implementing QI strategies with a wrong approach. According to the Telegraph “A Telegraph investigation discloses that the number of hospitals admitting to A&E delays of at least 20 hours has doubled in just one year” (Donelly, 2015). Dr Peter Carter, the chief executive of  the Royal College said that “staff shortages were contributing to the crisis, so that A&E units could quickly end up becoming “overwhelmed” by the number of patients in their care” (Donnelly, 2015).

In the section of ‘Results, Analysis and Discussions’, the chosen methods will investigate the situation in the A&E Department in Kingston Hospital and will reveal the real problems behind the scenes.

Total Quality Management

As Piratic ltd (2012) argues “If you agree with the argument that a company is much more likely to produce high quality if all departments are motivated to achieve high quality results then you already have a good understanding of the basic principles of Total Quality Management (TQM)” (Piratic Ltd, 2012). However, understanding the basic principles is not enough to implement TQM for an organisation successfully, nor does it solve problems straight away and it does not define the full concept of it either. We need a deeper exploration and understanding of TQM.

According to Ross and Perry (1999) who borrowed quality expert J.M Juran’s definition ‘Total Quality Management (TQM) is the set of management process and systems that create delighted customers through empowered employees, leading to higher revenue and lower cost’ (Ross and Perry, 1999). However, it comes from a quality expert; this concept is lacking some key features and concepts which are fundamentals of TQM. A dissertation must define these basics for the readers. Therefore, it brings up the question of: What is Total Quality Management exactly? When answering this question, it is important to establish a common understanding of these key features and concepts. Regarding this my explanation is not different from academic authors. According to Nigel Slack’s argument (1991), examining the three words in TQM delivers a simple but great definition:

1. Total: In TQM, Total means that everyone is involved individually and collectively through teamwork in the organisations work output and effort to understand and respond to the needs of the customer (Slack, 1991).
2. Quality: It has to be defined in a way that nobody could have any doubts what quality means. It should not be subjective and it has to be measurable. Radziwill (2017) defines quality as ‘The totality of features and characteristics of a product or service that bears on its ability to satisfy stated or implied needs’ (Radziwill, 2017).
3. Management: This part of the term TQM has two implications. The first is that an organisation needs to have set goals, a target along with its principles. The highest priority of management is to communicate with its colleagues. The second implication is that management is a continuous process. TQM is not a trial run; it is a highlighted source of one’s attitude to work, to be better than the rest in its field, to have a higher success rate. It needs a continuous flow in order for its expansion and growth (Slack 1991).

In conclusion these three words Total, Quality and Management in combination formulate an overall definition of mine: TQM is a process orientated management system or strategy where everyone is involved from top to bottom and it continuously improves the quality of products, services and the process of production in all areas.

This dissertation focuses on the NHS (which is a service organisation) and its management system, one of the most appropriate TQM model to use to understand the basic principles of TQM in a public service organisation like NHS is from Tallinn and Rahman which consists of nine critical success factors. According to Tallinn and Rahman (2010) these nine factors were recognised from just over 30 empirical and exploratory studies. Tallinn and Rahman also argues that this model is the most appropriate for service organisations as these nine critical key success factors are frequently used by researchers in the service sectors. This model consists of nine critical factors which were specially designed for service areas:

“1. Customer Focus

2. Training and education
3. Continuous improvement and innovation
4. Supplier quality management
5. Employee involvement
6. Employee encouragement
7. Benchmarking
8. Quality information and performance measurement
9. Top management commitment” (Tallin and Rahman, 2010).

 

Figure 2 (Faisal Talib and Zillur Rahman, 2010) demonstrates the TQM model with these nine critical success factors.

Continuous Quality Improvement

Lean Thinking

Six Sigma

 

 

 

 

 

Methodology

In this section of this study, we are going to take a deeper look into the systematic, theoretical analysis of methods used for the field of study to achieve the stated objectives in the ‘Introduction’ section. There were different research methods applied for gathering the answers for the research questions. In the following sub-sections, we are going to answer the two questions regarding the methods which were used in this dissertation:

1. How was the research approached?
2. Why were the methods used which were used?

The research was approached by 4 main research methods which will be discussed in the following sub-sections.

Secondary Data

Secondary research is also known as Desk Research. It is a widely-used research technique for collecting data. Secondary research accessed data which has been already carried out by the originator of Primary Research; the researcher accesses data which has been already carried out by someone. In this dissertation, Secondary Research accessed academic text books, journals, company websites and online articles. This dissertation investigates three different major topics including the rise of NHS and its struggles and different quality improvement techniques and solutions for the patient quality issues. To be able to answer these major topics, secondary data was also collected as many of the information came from data which was already carried out by someone else. Furthermore, a lot of background information, which makes up the literature review, had to be researched and collected due to the complex nature of the topics. Without this, it would have been very difficult to answer the research questions.

Advantages

1. The Ease of Information Access – With the availability of internet access, large amount of information can be accessed electronically. Furthermore, all this information can be saved and reviewed again if needed.
2. Saves Time – Accessing large amount of data through internet saves a lot of time as the researcher is not required physically go and look for text books, reports and newspaper articles. Google allows us to make searches within seconds if not a fraction of second. Without the internet, secondary research would take a much longer time to complete for the researcher.
3. Low Costs – Most of the data that this dissertation needs, could be accessed with zero cost. Most of the educational websites could be accessed through institutional access which was free. Furthermore, many websites provide articles and e-books for very little or no costs.
4. Clarifying my research questions – Using secondary research technique helps to clarify each of the research questions this dissertation seeks to answer.

Disadvantages

1. Out of Date Information – Some data could be very valuable and useful for a study but when its ‘old’, there is a risk that the information becomes invalid due to a very quickly changing environment where companies evolve to compete.
2. Anything can be published on the internet – Unlike when the internet was first introduced, sources do not need to go through thorough editing and reviewing to be published. Therefore, time and effort is needed to evaluate each source to determine whether it is valid or not.

Qualitative Research: Interviews

To be more specific, the Interviews I carried out were Standardized, Open Ended Interviews. Each person who was interviewed was asked the same open ended questions, not a set of options of answers.

The 3 interview participants decided to remain anonymous in the dissertation. With respect to their wish to remain unknown, let us address them as Participant A, B and C. These interviews can confirm or refute my allegation from my Empirical Research. In addition, it is going to reflect the quality of healthcare in the A&E Department in Kingston Hospital.

Advantages

1. Freedom for Participants – This type of interview provides more freedom as questions were not a set of options of answers and interviewees could provide more detail, and answers that the interviewer may not have thought of.
2. Easy for Participants – As questions were pre-written and the same for each person, the process became easier and did not take place for a long time for the participants.
3. Efficient comparison – Due to each participant answering the same questions, the conclusion could easily be written as their responses could be directly compared, question by question.

Disadvantages

4. Time consuming – As most people had waited in the A&E for a long time and/or were uncomfortable due to illness, many of them did not wish to complete the survey which was very time consuming for the interviewer to find participants who were willing to participate. Designing my Interview also took a great amount of time.
5. Discomfort – As it was mentioned before, people had waited for a long time and most of them were not in a good state therefore I felt uncomfortable to bother them with interviews about their experience.

Qualitative Research: Questionnaires

Questionnaires are set of questions designed for a survey study. More specifically my Questionnaire combined Closed Ended Questions and Open Ended Questions. Closed Ended Questions means that there are not a set of options of answers whereas Open Ended Questions means that there are options the participant can choose from.

The questionnaires were designed to test the staff’s knowledge about quality healthcare. The results could help to confirm or refute my allegation which came from the empirical research. Furthermore, the outcomes in this method of research could also help to address the patient quality and other issues mentioned in the employees’ answers.

Advantages

1. Close Ended Questions – Close Ended Questions took less time as the Questionnaire also contained set of answers to be answered and the answers were easier to compare.
2. It provided accurate information

Disadvantages

1. Time Consuming – As the NHS staff seemed to be busy at the time when I went to get my Questionnaire complete, it took a while to get my answers. Designing the Questionnaire also took great amount of time.
2. Discomfort – As I mentioned above, the NHS staff seemed to be busy at the time when I was there, I felt uncomfortable to ask them to complete the Questionnaire.
3. Open Ended Questions – Open Ended Questions took more time as the Questionnaire also contained questions which were not a set of options of answers and the answers were more difficult to compare.

Qualitative Research: Empirical Framework

Empirical Research is a research method which acquires information through direct or indirect observation or experience. The evidence gathered from such research called empirical evidence which could be analyzed qualitatively and quantitatively. 

The most important topic is of this dissertation s the current patient quality issues. The priority is that we need to identify the patient quality issues. As there is little literature known on the present situation, which is that patient reports and complaints cannot always be accurate enough as “Using a large number of respondents does not of itself guarantee representativeness” (McSweeny, 2002), therefore I decided to build an Empirical Framework.

I had advanced tonsillitis before carrying out my research. I decided to visit the E&A services in Kingston Hospital as my GP did not prescribe medication. The visit allowed me to gain a limited but still valid insight into the operations of NHS. It was a great opportunity to build my Empirical Research which was based on my observations and experiences. This type of research supported me with original first-hand information.

Advantages

1. Supportive – It helped to develop and test my hypothesis. It also gave good grounds for further investigation into the research field as it built upon what we know from the Secondary Research.
2. The information is first-hand – As the researcher must be physically in the research field, the information is acquired from a real-world environment.

Disadvantages

1. Limitations – Empirical Research is only based on the researcher’s observation and experiences which might not be enough to produce proof.
2. Time consuming – Empirical Research is time consuming as it requires conscious planned research designs. Furthermore, the researcher must dedicate time to be in the research field to be able to observe, perceive, and experience. It may take hours to acquire all the information that is needed.

 

The Ethical Approach behind my Methodology

This sub-section is very closely linked with the main section, the ’Methodology’. Before beginning academic studies at University of Roehampton in 2014, there were numerous lectures about plagiarism. It taught that “Ethics in this context has largely been associated with following ethical guidelines and / or gaining ethics approval from professional or academic bodies before commencing data collection (Mauthner,  2002)” but there is more into ethics than just being aware of plagiarism. For example, ethics should play a vital role in any research as other parties are being affected by the researcher while the research is being carried out. The following sub-sections will represent my ethical principles behind my methodological approach.

Respect to Intellectual Property

Plagiarism was taken as a very serious matter in this dissertation. Due to institutional policy as well as personal principles, a great value was placed on honoring copyrights, patents and any other types of intellectual property. Therefore, all the results from Secondary Research come from professional writers and authors. These results are referenced with appropriate referencing style; University of Roehampton Harvard Referencing Style in the ‘Bibliography’.

 

Truthfulness

My Methodology aimed for truthfulness in all aspects. All the methods, data and findings from Empirical Research, Interviews and Questionnaires were reported truthfully. None of these were manipulated or falsified. The Methodology of this study has no attempt to misrepresent the University’s assessment procedures or anybody who reads this study.

Integrity and Protection of Human Subjects

In respect to participants in the Interview and Questionnaires, they all remained anonymous and for the purpose of the dissertation only. The information from the results is not used for marketing or financial purposes.

Respect and Tolerance

Regarding to the Interviews and Questionnaires, all participants or potential candidates received the same level of respect and tolerance. All the questions which have been asked were not personal or inappropriate.

Analysis

 

Results

 

Discussion

 

Recommendations

There are 3 major factors which needs to be considered that influence the decision making, which could assist us making the decision on the recommendations:

1. What is the aim? – To improve the quality of health care in A&E in Kingston Hospital
2. What are the possible solutions? – Implementing new management strategies
3. What is the right thing to do? – Implementing TQM, Changing the Values and Believes of all employees and Demand Management Strategies

I am a big believer and admirer of Crosby’s work (1980) and I believe that implementing TQM with his 14 steps for quality improvement could solve these 4 internal Operational Management issues which were mentioned above.

The only one identified major external problem which the NHS is facing could be solved by Demand Management Strategies. Demand Management is the forecast, plan for and management of the demand. This involves 4 major components:

1. Planning Demand
2. Communicating Demand
3. Influencing Demand
4. Managing and Prioritizing Demand

However implementing these strategies would impact the NHS as a whole. According to Prosci.com (2017) “When you introduce a change to the organization, you are ultimately going to be impacting the one or more of the following:

• Process
• Systems
• Organization Culture
• Job roles” (Prosci, 2017).
• In other words we cannot avoid cultural change in an organization when implementing new management strategies. Therefore a careful and sophisticated strategy is needed to change the management and the culture, because if  “when workers aren’t clear about organizational change and what’s required of them, things can get chaotic rather quick. The scramble to adopt new tasks and processes can, consequently, take a detrimental toll on the organization’s culture, raising doubts, fears and paranoia” (Juarez, 2017). Therefore I recommend the implementation of a theory of management change.

My recommendation includes these 3 following steps:

Implementing TQM

Due to Crosby has an expertise in the topic as a TQM technician. His 14 steps for quality improvement are going to be used to recommend implementation of TQM in the NHS. This will be done by suggesting Crosby’s steps that are appropriate to identify problem areas of the A&E department. Further on in this section, scenarios specific to the NHS with the possible improvements using this method shall be discussed.

Crosby’s steps shall formulate a basic principle that every single penny that the NHS spends on quality improvements has to be well spent. In this theory there are also four compulsory elements of TQM:

1. The NHS should define quality as something that is beneficial for the company and every stakeholder in the organization.
2. The NHS should realize that quality begins with prevention. All defects should be prevented rather than acting on the defect. The following example will help to clarify what is exactly meant by prevention. Participant B in the interview said that “They did not give any medication. They just said that ‘Come back in two weeks if it does not get better. (Participant B, 2017)”. This is what is meant by presentation. In this two weeks period Participant B might have developed more severe symptoms which would have required more serious medicine that what he should have received in the first place. It would have prevented that Participant B returning to A&E. According to the whole interview, Participant C’s quality experience was very negative with the A&E services.
3. “Zero defects” should be the standard for performance in the NHS which they should seek continuously.
4. The NHS should focus on the cost of quality rather than on other quality measurement techniques. The cost should be associated with the quality of the service.

Keeping Crosby’s theory with these four compulsory elements in mind, now the NHS should implement the 14 steps to achieve TQM in the public sector organization:

1. Management commitment – The NHS must focus on this fundamental step for achieving successful TQM in the A&E Department in Kingston Hospital. Everything starts with leadership. The management must be 100 per cent committed as they are the most influential layer of the company. Talib and Rahman (2010) argue that TQM should not even be considered if the top management is not committed and involved. The foundation for implementing TQM is set by the top management. The management’s commitment and involvement sets the right example vertically down to the bottom of the company and inspires the whole organization (Talib and Rahman, 2010). As these steps involve leadership, and the department already has a problem with leadership, therefore this step needs to be implemented with a lot of care.
2. Quality improvement team – The NHS should form a team which is concerned with improvement of quality of health care in the A&E department. The team should include members with multiple skills who are responsible for modeling quality improvement commitment.  The members also should not be involved with other projects therefore they can over commit themselves effectively towards improvement of quality healthcare. One person should be appointed as a chair of the team.
3. Quality measurement – We already know where the room is for quality improvement in healthcare. The previous research showed that there are problems with leadership, communication, teamwork, ethics, integrity and trust which affects healthcare negatively. Furthermore we also know that there is a problem with increasing demand. This part of the steps needs a lot of attention as the A&E department is already struggling with these problems.
4. Cost of quality evaluation – Cost of quality should not be used as an exact performance measurement for the NHS. It should be used as an indication where corrective action will be beneficial for the organization. Where higher the cost, the more corrective action is needed. In the perspective of A&E, the costs are not monetary. The cost is employee satisfaction. If customer needs are not met then the quality will be compromised. As we know by now that increasing demand for service is one of the major concerns for A&E (and also the NHS), they need to direct most of their resources to this area.
5. Quality awareness – The quality improvement effort has to be realized. It is time that the management of A&E Department to communicate effectively to the bottom and raise employee awareness about the importance of quality and TQM.
6. Corrective action – By now, we know the problems of A&E Department. It is time to take corrective actions. The solution for leadership, communication and teamwork problems lie in the first step of Crosby’s 14 steps. If the leadership which is the most influential layer of the NHS sets the right example of communication and teamwork, then all the employees will follow this example. The management needs to make sure that doctors, nurses and receptionists communicate and work effectively with each other. Regarding to ethics and integrity problems, the leadership and all employees should be aware and listen to customers to solve the issue. Ethics and integrity implies discipline about good and bad and also implies morals, values and fairness. The staff should reappraise these concepts. If all these are taken into account and if changes are made, then it will build trust to patients.
7. Ad hoc committee for zero defects – A group of people should be appointed for ensuring the quality and that there are ‘zero defects’ in the services that the NHS provides. The concept ‘zero defects’ does not mean minimizing defects. The NHS has to take this concept literally and seek for it.
8. Supervisor training – The NHS staff should be trained on a regular basis with quality in mind and also with the 4 compulsory elements from Crosby’s theory of TQM.
9. Zero defects day – The A&E Department should organize a quality event called “Zero Defect Day”. The purpose of this event is to inform the staff of the changes in management strategy and it would also raise the awareness of NHS staff of quality when implementing TQM.
10. Goal setting – In TQM, ‘total’ has to be understood literally. The NHS management needs to involve everybody in the organization. Everyone needs to participate in goal setting which is ‘zero defects’ in good quality of health care.
11. Error cause removal – The management should ask each employee to express their problems and feelings which affects them negatively and stops them working effectively. Any problems identified should be acknowledged within 24 hours period. This process would build trust between employees and managers which would make sure that this system can carry on forever.
12. Recognition – The management should recognize and award all employees who participated in quality improvement efforts and met their goals. It would encourage them to continue in participation of quality improvement efforts.
13. Quality Councils – The NHS quality professionals and chair of teams should get together on a regular basis to communicate with each other about upgrades and further improvement plans.
14. Do it over again – Quality improvement should not stop here. In order to succeed in improving the quality, Crosby’s program should be repeated continuously (Crosby, 2005).

Implementing Kurt Lewin’s Theory of Change

As mentioned before, when changes are being introduced, the organization and its employees are going to be impacted. As the outcome results from the Questionnaires showed that many members of the staff has been working for the NHS for X years, they might not accept changes easily. Therefore I believe that Kurt Lewin’s Theory of Change should be implemented alongside TQM. It involves 3 steps:

1. Unfreezing – As some of the employees work there for a long time, they are very used to the current way of operation and they might not be open for changes. They are ‘frozen fossils’ therefore the management should ‘unfreeze’ them by making them aware of the existing problems in the A&E and the management should also make them understand why the existing way of operation cannot continue. The first step should start to ‘unfreeze’ the core of the organization which is the beliefs, values, attitudes and behaviors of employees which defines the organizational culture.
2. Moving (Change) – Once the staff is open for change and begin to believe in the new direction of the NHS then the change can be implemented. However accepting changes does take a long time. People working for the NHS should be continuously being reminded how it benefits them and the NHS as a whole. In this case NHS employees could be reminded if they perform well and achieve the set targets, then they will be recognized and rewarded.
3. Refreezing – The NHS managers need to make sure that the employees are ‘refrozen’ and changes are used all the time. The management needs to make sure none of the employees get back to the ‘old-fashioned way’ of doing things (Dries Faems, Igor Filatotchev, Don Siegel, Penny Dick, Daniel Muzio, Gerardo Patriotta, Corinne Post, Andrea Prencipe, John Prescott, Riikka Sarala, Li-Qun Wei, Bill Harley and Maddy Janssens, 2004).

Implementing Demand Management Strategies

The management of NHS needs to have a better customer insight. They should use a method which includes asking them about the reason of visiting the A&E, their experiences and other related topics. It would help the NHS to see a clearer picture and identify why people use A&E.  Furthermore it would also help to identify key concerns, problems and areas for improvement (Bristow, 2017).

After implementing the method mentioned above for a better understanding of why people engage with A&E services and having a better understanding of increasing demand for services, the NHS should reallocate people who actually do not need urgent medical attention. Furthermore the NHS should introduce pricing strategies and begin to charge people who have been re-allocated. It can work as a very powerful incentive to make people go to their GPs instead of A&E. However this technique could cause a lot of tension between customers and the NHS as it is funded from taxpayers’ money which means that everyone should be entitled for free healthcare.  

Furthermore, it would worth considering Crosby’s theory in more depth. In his theory there are four compulsory elements of TQM and the second bit is about prevention. If the NHS was able to prevent rather than treat symptoms they could manage the demand at some degree. They could prevent people going back to the A&E services. Presentation should starts at the local GPs. If they give the right medication at the right time, patients might not use the A&E services.

Conclusion

In conclusion, the evidence of the research shows that various changes are needed in the NHS. Implementing TQM, using the framework of Kurt Lewins and introducing demand managements strategies, will not only impact the NHS, but also the society which is made up of patients who are in need of high quality healthcare. By following the recommendations, these techniques should be incorporated in the correct order to maximise the benefits. For example, Crosby’s TQM and Lewins’ framework work hand in hand as TQM requires change in beliefs and values of every member of the organisation and the framework helps to do this. And only after this step, the NHS should focus on the demand management strategies. If it is not carried out in the right order, it will result in disorder within the organisation.

This would bring about a great reformation as the NHS would not just have organisational and employee focus, but would become more customer orientated as well. These strategies would ensure patients are directed to the appropriate departments, customers receive the correct treatments, the expected satisfactory quality is carried out, and the people’s trust in the NHS is gained.  Raising the bar higher for everyone would result in this very positive impact just as Bevan dreamt about when forming the NHS.

 

 

 

 

 

 

Appendices

Interviews

The Interviews consisted of 10 questions:

What was the reason of your visit to A&E Department?

A: “I had a bladder infection. I had severe pain and I wanted to get antibiotics immediately”

B: “I had a very aggravated cough. My chest was hurting for a week already. One day, I just could not fall asleep from the pain and continuous cough so I decided to come in.”

C: “I had severe pain in my back. I could not wake up from the floor.”

2. Was your visit during the day or during the night?

A: “During the night.”

B: “Night.”

C: “Day time”

3. How many people were working when you visited A&E?

A: “1 receptionist, 5 nurses and 2 or 3 doctors. So, 8-9 people.”

B: “I saw 3 or 4 receptionists, a nurse and a doctor.”

C: “I am not sure, 5 or 6.”

4. Approximately, how many other people were waiting for to be seen?

A: “About 8 people.”

B: “5 people.”

C: “I don’t know, maybe 8”

5. How long did you have to wait to be seen by a medical professional?

A: “I was waiting for 45 minutes.”

B: “I had to wait about for 2 hours.”

C: “1 hour”

6. Did you get any assistance before you were seen?

A: “Yes, I got paracetamol.”

B: “No,”

C: “No, I did not get any assistance. I was on the floor as I could not stand. They could have prioritize me.”

7. What did the medical professional do while you were being examined?

A: “I was given a dip and they did all the essential checkups but they didn’t take me seriously. When my results came back from my urine test, he was saying that I had ‘a very little infection’, despite me saying how much pain I was in. Plus, I had to repeat my problem three times.”

B: “The receptionist took my details and I reported my issue. Then I told the nurse what my problem was and then checked me out. After I went to see the doctor who asked the same question ‘What is the problem?’ It seemed like they did not do anything because I told them my problem 3 times in a row and then I left without medication.

C: “They checked me and I received some painkiller which made me sleep. I was in a private room.”

8. How long did you wait for your medication?

A: “I had to wait quite a long time whilst the dip was in. I had to have another health check and then my antibiotics had to be ordered and given to me which took about 50 minutes. Overall, I was in a private room for around 3 hours.”

B: “Nothing! They did not give any medication. They just said that ‘Come back in two weeks if it does not get better.’”

C: “I don’t know because I fell asleep. It was quite a long time though.”

9. What medicine did you receive?

A: “Antibiotics”

B: N/A

C: “Some medicine for back ache and painkillers.”

10. Can you tell me how do you feel about the quality of the service from the A&E Department?

A: “I felt the service was unnecessarily long and longwinded especially because the doctor conceded the same thing, I had told the receptionist when I first came in 3 hours before. Furthermore, the receptionist was not tolerant when I was struggling to understand some of the things she was saying due to not being able to concentrate because of the pain”.

B: “Well, I had to tell my problem to the receptionist, then I said the same thing to the nurse and then to the doctor again. I expected the doctor to examine me in a greater depth than the nurse, and as I said, I left without any medication. My overall experience with the Accident and Emergency was very negative. 3 hours waste of my life!”

C: “I think they did a very good job as I got in terrible state and now after few hours I am on my own foot. I am pretty satisfied.”

Please note that not all the interviews have been recorded due to the wish of participants to remain anonymous. However, I could record participant C. For the audio evidence of the interview, please contact me on:

Questionnaires

This questionnaire has been designed to find out more about the management system of the NHS. It takes place in Kingston Hospital, Accident and Emergency Department. In respect to my participants, they all remain anonymous and only for use in my dissertation. The success of this research depends entirely on your voluntary collaboration and your truthful and valid response. I do hope you will be able to participate. Please circle or write your answers!

1.         How long have you been working for the NHS?

 

 

1. Less than a year

 

1. Between 1-5 years
2. Between 6-10 years

 

1. More than 10 years

 

2.         Could you please describe your current position / status in this department?

 

___________________________________________________________________________

 

3. In your opinion, what are the main Operational Management issues in the A&E?

 

________________________________________________________________

 

4. What are the main patient complaints?

 

________________________________________________________________

 

5. Do you feel like you could voice your opinion to the management? If ‘Yes’, do you think your opinion would be acted upon by the management?

 

 

1. Yes

 

1. No

 

6.         How regularly do you receive training based on service quality and what is expected by patients / customers?

 

 

1. Never
2. On one occasion
3. Once a year
4. More than once a year
5. Other_______________________

 

 

 

Thank you for your time!

 

 

For the physical evidence of the answers of the questionnaires, please contact me on:

 

 

 

Bibliography

1. Adamou, Marios and Hale, Anthony S. (2004) Total Quality Management in the NHS in England and Wales: a story untold? Journal of Quality Health Care [Online]. 3 (1). pp.1. Available from: http://eprints.hud.ac.uk/11324/1/Manuscript_03MS0083.pdf [Accessed: 3rd March 2017].
2. Aimee C. Juarez (2017) Organizational Culture and Strategic Network Planning [Online]. Available from: http://smallbusiness.chron.com/organizational-culture-strategic-network-planning-15313.html [Accessed: 27th March 2017].
3. Brendan McSweeny (2002) Hofstede’s Model of National Cultural Differences and their Consequences: A Triumph of Faith – a Failure of Analysis [Online]. 55(1) 33-55. Available from:
   http://hum.sagepub.com/content/55/1/89.full.pdf [Accesse 26th March 2017].
4. Chuck Jaffe (2014) 4 things smart investors look for in annual reports [Online]. Available from: http://www.marketwatch.com/story/4-things-to-look-for-in-annual-reports-2014-04-04 [Accessed: 30th Jan 2017].
5. Dan Bristow (2017) Meeting the challenge of increased demand on healthcare services [Online]. Available from: http://www.prudenthealthcare.org.uk/demandmanagement/ [Accessed: 27th March 2017].
6. David A. Garvin (1988) Managing Quality: The Strategic and Competitive Edge 1st Edition. New York: The Free Press.
7. Dries Faems, Igor Filatotchev, Don Siegel, Penny Dick, Daniel Muzio, Gerardo Patriotta, Corinne Post, Andrea Prencipe, John Prescott, Riikka Sarala, Li-Qun Wei, Bill Harley and Maddy Janssens (2004) Journal of Management Studies – Kurt Lewin and the Planned Approach to Change: A Re-appraisal [Online]. 41 (6) 977-1002. Available from: http://onlinelibrary.wiley.com/doi/10.1111/j.1467-6486.2004.00463.x/full [Accessed: 29th March 2017].
8. Erkan Bayraktar, M.C. Jothishankar, Ekrem Tatoglu, Teresa Wu (2007) ‘Management Research News’ in Evolution of operations management: past, present and future [Online]. 30 (11) pp.843-871. Available from: emeraldinsight.com/0140-9174.htm [Accessed: 15th Feb 2017].
9. Joel E. Ross and Susan Perry (1999) Total Quality Management [Online]. 3rd Edition. London: St. Lucie Press. Available from: https://books.google.co.uk/books?id=NUrTWuZy_3YC&printsec=frontcover&source=gbs_ge_summary_r&cad=0#v=onepage&q&f=false [Accessed: 19th Feb 2017].
10. Laura Donnelly (2015) Patients stuck in A&E for up to 46 hours [Online]. Available from: http://www.telegraph.co.uk/news/health/news/11561484/Patients-wait-in-AandE-for-up-to-46-hours.html [Accessed: 20th March 2017].
11. Lawrence L. Martin (1993) Total Quality Management in Human Service Organisations [Online]. 1st Edition. London: Sage. Available from: https://books.google.co.uk/books?id=I691AwAAQBAJ&printsec=frontcover&dq=Total+Quality+Management+in+Human+Service+Organisations+Martin&hl=en&sa=X&ved=0ahUKEwi4v_H8irPSAhVEKcAKHasvD8IQ6AEIHTAA#v=onepage&q=Total%20Quality%20Management%20in%20Human%20Service%20Organisations%20Martin&f=false [Accessed: 28th Feb 2017].
12. Lee Minh Cuong (2012). Armand V. Feigenbaum [Online]. Available from: http://qualityandproductivityforum.blogspot.co.uk/2012/09/armand-v-feigenbaum.html [Accessed: 14th March 2017].
13. Melanie Mauthner, Maxine Birch, Julie Jessop and Tina Miller (2002) Ethics in Qualitative Research [Online]. 1^st London: SAGE Publications. Available from: https://books.google.co.uk/books?id=MHUf66ibqOQC&printsec=frontcover&dq=ethics+in+qualitative+research+2002&hl=en&sa=X&ved=0ahUKEwjZtdurv_TSAhWFOBQKHQMNCBcQ6AEIHzAB#v=onepage&q=ethics%20in%20qualitative%20research%202002&f=false [ Accessed: 26^th March 2017].
14. Michael Rothlin (2010) Management of Data Quality in Enterprise Resource Planning Systems [Online]. 1st Edition. Koln: BoD – Books on Demand. Available from: https://books.google.co.uk/books?id=wyheQllcyh0C&pg=PA268&dq=crosby+1980&hl=en&sa=X&ved=0ahUKEwiCv5bZ8bLSAhXEJsAKHUYnAREQ6AEIHTAA#v=onepage&q&f=false [Accessed: 28th Feb 2017].
15. Nicole Radziwill (2017) How ISO 8402 (9000 para 3.1.5) Relates Quality to innovation [Online]. Available from: https://qualityandinnovation.com/2008/10/22/how-iso-8402-relates-quality-to-innovation/ [Accessed: 19th Feb 2017].
16. Nigel Slack (1991) The manufacturing Advantage: Achieving Competitive Manufacturing Operations 1st Edition. Michigan: Management Books 2000.
17. Philip B. Crosby (2005) Crosby’s 14 Steps To Improvement [Online]. Available from: http://www.agiledevelopment.org/download/qp1205crosby.pdf [Accessed: 28th March 2017].
18. Philip B. Crosby (1980) Quality is Free: The Art of Making Quality Certain 2nd Edition. New York: Penguin.
19. Piratic Ltd (Chris Hakes) (2012) Total Quality Management: The key to business improvement 2nd Edition. Kent: Springer Science & Business Media.
20. M. Deane (1979) The First Industrial Revolution [Online]. 2nd Edition. Cambridge: Cambridge University Press. Available from: https://books.google.co.uk/books?id=eMBG_soDdNoC&printsec=frontcover&dq=industrial+revolution&hl=en&sa=X&ved=0ahUKEwiM8tXKtPzRAhUEC8AKHWRZBU0Q6AEIGjAA#v=onepage&q&f=false [Accessed: 7th Feb 2017].
21. com (2017) DEFINITION OF CHANGE MANAGEMENT IN CONTEXT [Online]. Available from: https://www.prosci.com/change-management/thought-leadership-library/change-management-definition [Accessed: 29th March 2017].
22. Ray Wild (2002) Operations Management [Online] 6th London: Thomson. Available from: https://books.google.co.uk/books?id=MuPszLJ5aSsC&printsec=frontcover&source=gbs_ge_summary_r&cad=0#v=onepage&q&f=false [Accessed: 7th Feb 2017].
23. Talib and Zillur Rahman (2010) Success Factors of TQM in Service Organizations: A Proposed Model – Scientific Figure on ResearchGate [Online]. Available from: https://www.researchgate.net/232917892_fig1_FIGURE-1-A-proposed-model-for-TQM-critical-success-factors-in-service-organization [Accessed: 20th Feb 2017].
24. Tim Dhoul (2014) What is Operations Management [Online]. Available from: http://www.topmba.com/mba-programs/what-operations-management [Accessed: 7th Feb 2017].
25. Tim Stevens (2014) Armand Feigenbaum on Managing Quality (Part 1) [Online]. Available from: http://www.industryweek.com/quality/dr-armand-feigenbaum-managing-quality-part-1 [Accessed: 15th March 2017].
26. Upendra Kachru (2009) Production & Operations Management [Online]. 1st Edition. New Delhi: Excel Books. Available from: https://books.google.co.uk/books?id=zCNKRy2NF9YC&printsec=frontcover&source=gbs_ge_summary_r&cad=0#v=onepage&q&f=false [Accessed: 7th Feb 2017].