The 12th Symposium on QFD/Gth International Symposium on QFD 2000 - Novi

International Symposium on QFD 2000 - Novi

A Study in Medical Quality:

Applying QFD in a Hospital Setting

Yoji Akao, Ph.D., Asahi University

Hiroshi Fujimoto, Ohtsuka Ltd.

Abst tact
For the Health Care TQM model used in our research, we propose a model that combines
the general industry model of (hospital-society) with a service industry model (hospital
physicians-nurse-patient). According to this model, from a medical quality point of view,
we could established a hypothesis of quality from a dual perspective, in which we could
separate the output of quality, Q, into Ql: the quality of the of the recovery of the patient
and rate of rehabilitation, an external evaluation like in general industry, and Q2: the
quality of the medical services provided by the hospital, the quality of the tasks
performed, q, which is an internal evaluation like in service industries. We divided the
matrices into demanded quality - quality elements, and operations functions - operations
quality elements, to validate this hypothesis, and were able to better clarify the substance
of medical quality.

1. Introduction
Quality Control has been introduced to the medical field, but when medical quality is
questioned, its substance is unclear. This paper presents research conducted to look at the
appropriateness of using Quality Function Deployment (QFD) to address questions
regarding medical quality.

Quality itself has been the subject of numerous discussions for a long time. Aka0 et a1
have established that the quality outputted can be evaluated by the subjective evaluations
directly from the customer (narrowly defined quality), and that the quality of the
activities necessary to assure this, that is process quality (operations quality), and that the
combination of these can be called broadly defined quality [I]. I have pointed out that
is Quality Function Deployment (QFD) [2, 31, in which the narrowly defined quality
or Quality Deployment (QD) and the narrowly defined quality function deployment or
operations quality are closely associated. An example of this for service industries was
presented by Aka0 and Inayoshi at the 5'h International Symposium on QFD [4],on their
research in a university library. The output quality for a service, Q, and the operations
quality, q, were generally classified such that the latter was further divided into quality of
operations visible to the user, q l , and the quality of the operations not visible to the user,
$2.

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In applying this approach to heath care, we can think of these as the activities to assure
that the societal evaluation of the entire hospital, and the activities to treat the patient.
The former is the output quality, Q, which corresponds to the societal evaluation of the
entire hospital, and the latter is the medical operations quality, q, which corresponds to
the recovery rate of the patient.

From a QFD perspective, the former is QD, and the latter is narrowly defined QFD.
Using a case study from Hospital “N,” we will show this application in a medical setting.
In medicine, the patient’s own judgment of his treatment and recovery is used weight
how well the associated medical procedures were controlled when they were performed.
In this study, medical characteristics were classified so that a new model could be
constructed that makes medical quality more concrete [SI.

2. QFD in a Hospit
2.1 Output Quality Deployment for a hospital
Based on the raw data of a free response survey conducted by Hospital N, a Scene
Deployment was defined and a Demanded Quality Deployment hierarchy was created.
From these, quality elements were extracted that would aid in measuring the evaluation
of the demands. These were formed into a Quality Elements Deployment hierarchy, and
the two hierarchies were combined in a matrix to form a medical quality table, a kind of
“Hospice of Quality” shown in Attachment 1. This allowed us to see the correlation
between customer needs and the output quality.

2.2 Operations Quality and Narrowly Defined Quality Function Deployment

To better grasp hospital operations, we created a Operations Function Deployment from
data provided by Hospital N of their nursing operations. The data was stratified according
to each duty, and the job contents of each duty were differentiated. Then, to
comprehensively evaluate the nursing operations of the entire hospital, we generated
expressions that would use standard operational terminology, to improve the level of
abstraction of professional operations, by each duty. (Attachment 2.) Grouping these into
an Affinity Diagram using the KJ Method consolidates all the nursing operations into an
Operations Function Hierarchy.

Whether a job is performed well or poorly really depends on the purpose of the job. Thus,
in order to have some measurement by which to evaluate an operation, we must develop
some type of metric, an Operations Quality Element [6] that is tied to the purpose of the
operation, We can systematically extract these one by one, order them, and create a
Operations Quality Element Hierarchy. This can then be joined in a matrix with the
Operations Function Hierarchy, which will then help clarify operations quality.

3. Output Quality and Operations Quality: An

Investigation
Aka0 and Nagai [7] conducted a study of service quality in their application to a
university library, which clarified the basics of operations quality by encompassing the
concepts of output quality found in manufactured products. As the trend towards service

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businesses continues, we must be able to concentrate resources according to some

evaluation of operations quality that includes this output quality. Thus, the translation of
demanded quality into quality elements, and the relationships between operational
functions and the operation quality elements that compose them were studied. The results
were that the service quality could be classified into output quality, Q, and operation
quality q, which could be further divided into the quality of operations that are visible to
the user, q l , and those that are invisible to the user, q2.

This study was made to determine whether the above concept is appropriate or not. Table
3.1 displays the results of this study in a matrix showing the relationships between the
Quality Elements Hierarchy and the Operations Quality Elements Hierarchy, based upon
the above classifications.

Table 3.1 Analysis of output quality and operations quality

Quality clcassificatianhierarchy levds are least detailed at the margins; relationships are shown in matrix.

*QualityElements: 82 items in 3
levels
Output Quality Q
0 : 13 items
Operations Quality q 1
@ : 14 items
Operations Quality q 2
@ : 47 items

47 items in 3 levels
Output Quality Q

Operations Quality q 1
@ : 24
Operations Quality q 2
0 : 15

The results were that there were not as many as expected Output Quality Q strongly
related to Quality Elements which reflect patient needs, and there were remarkably few
relationship symbols for Quality Elements such as “cure rate” and “recovery rate.” When

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the Operations Quality Elements from the operations which had relationship symbols for
“reliability of diagnostic tests” and “appropriateness of judgments” were compared to
Quality Elements Q, it was thought that they were related to the output of direct medical
personnel-patients. It is thought that the reason for this is due to Quality Elements are
judging the hospital from an external perspective, which did not include the judgment of
the medical processes of the internal medical personnel to the patients. From this, a new
model of medical TQM was proposed.

4. Dual Pers ective Hypothesis of ical TQM and Quality

In their study of TQM at universities, Aka0 et a1 [7] showed that there is both an external
evaluation of the university that can be done with a general industry model, and an
internal evaluation for which a service industry model is more fitting. This is illustrated
in Figure 4.1.

University

Places accepung
graduates
College Education
Socieiy

0 input
1- ouQul 0J IndustIy

Q input oupul Q

Figure 4.1 Internal and external perspectives of a college education

In medicine, as far as the patient’s judgment of his cure and recovery are concerned and
as far as the characteristics of the relationship of the medical staff to the patients are
concerned, the university model seems appropriate. (Figure 4.2)

7Hospital 1-
L a
input output
f-
+ O E
= a
&
!! .?=
M s s i on Discharge 22s
* E
I
‘
I
a1 -/
Figure 4.2 External evaluation model (general industry model)
Rza:et:

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For a medical TQM model, we are advocating a more complex model that encompasses
both the general industry model of hospital-society and the service model of hospital
personnel-patients. (Figure 4.3.)

Hospital side
MD Nurse

9
A
- input

Admission! Discharge
A
Patient side
Ql{ Cure rate
Recovery
rate, etc.

Reliability
.. Complaince with of tests
diagnostic information
ql
Visible operations

Invisible operations Reliability of Patient

teabnent

Accuracy of diagnosis, eb.

... Completeness of
emergency system
Appropriateness of
drug management

Figure 4.3 Internal evaluation model (service industry model)

From an external perspective, the goodness or badness of a hospital could be judged by

the rate at which patients were cured or recovered as a result of their medical treatment.
As figure 4.2 suggests, this is equivalent to the general industry model of output quality
Q1. In contrast, figure 4.3 shows that from the internal perspective of the hospital, one
model of service quality is thought to be better at expressing the medical worker-patient
relationship. The lower portion of figure 4.3 calls out on portion of the medical worker-
patient relationship, where reliability of treatment and accuracy of diagnosis, etc. are
evaluated as output quality Q2.

Thus, we see these two perspectives of quality: output quality Q1 derived from an
external evaluator of quality Q, and output quality 42 derived from an internal hospital

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evaluator. This gives us our two perspectives of quality, depending on whether we are
external or internal, the evaluator or the evaluated.

5. Validating the Hypothesis of the Two Perspectives of Quality

To validate the above hypothesis, table 5.1 shows the study upon which was based the
new hypothesis of different types of quality proposed in the preceding section, which
indicates their hierarchies and relationships in a matrix.

Table 5.1 Validating the hypothesis of the two perspectives of quality

This show the hospital case where the we can differentiate between the output which is external quality Ql, and internal quality
Q2 of the medical professional-patient.

The results were that from the Quality Elements Hierarchy extracted from the Demanded
Quality, outside of the items extracted during the study shown in table 3.1, we were able
to call out new evaluations of medical care from the patients, Q2, such as “quality of
patient contact,” “receptivity,” etc. Also, from the Operations Quality Elements, we were
able to call out new Q2 such as “attention to quality of life,” etc. Thus, our hypothesis is
adequately validated for hospitals, that we can differentiate the output Q1 which is
external and the Q2 which is between the internal medical professional and patient.

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6. Conclusion
We considered what problems might arise if we were to apply the standard service
quality model developed for universities to medical care, and we advocated an new
medical TQM model. For the external evaluator, the general industry model is a good
analogy, but for internal evaluators, there is a more complex model incorporating the
service industry model. We hypothesized a model of quality from two perspectives, and
validated it with the above Quality Function Deployment.

Thus, we can separate externally evaluating the output quality Q1 of patient cure and
recovery rate and internally evaluating the output quality 4 2 of medical service quality.
Consequently, invisible operations quality q2 can be determined both after the design
phase q21 and during the design phase q22.

This clarifies the structure of medical quality.

We wish to express our extreme gratitude for the invaluable data and support provided to
us by Dr. S. Iida, Director, and Kiyoshi Ohishi, General Manager of Nerima General
Hospital in Tokyo.

References
1. JSQC Education and TQM Research Committee (1994). “Research Report on
Industrial Education and Quality Management: Education and TQM.” p. 58
2 . Mizuno, Shigeru and Yoji Akao, ed. (1978). Quality Function Deployment: Approach
to Company Wide Quality Management. JUSE
--- (1994). QFD: The Customer-Driven Approach to Quality Planning and
Deployment. Asian Productivity Organization.
3 . Akao, Yoji ed. (1988) Applications of Quality Function Deployment for New
Prodcuct Development. Japan Standards Association.
--- (1990) Quality Function Dep1oyment:Integrating Customer Requirement into
Product Design. Productivity Press.
4 . Akao,Y..,Inayoshi,K. (1999) “A Study of Service and Operational Quality-An
Application of QFD in Library Services, Proceedings of the 5‘hInternational
”

Symposium on Quality Function Deployment. August 24-25 ’99, Belo Horizonte,

Brazil, p.200-2 11.
5 . Fujimoto, H. (2000). “A Study of Medical Quality: The Appropriateness of Quality
Function Deployment.” Asahi University Masters Thesis.
6 . Akao,Y.,Hattori,Y. (1998) “Quality System based on IS0 9000 combined with
QFD.” Proceedings of the 4’hInternational Symposium on Quality Function
Deployment, August 2-5, Sydney Australia, pp. 1-8
7 . Akao, Y., Nagai, K., Maki, N. (1996) “QFD Concept for Improving Higher
Education.” Proceedings of the ASQC 50th Annual Quality Conference. Chicago.
May 13-15. pp. 12-20.
8 . Maki,N., Nagai,K., Akao,Y. (1996) “QFD Analysis of Customer Satisfaction in
University Education,’’ Proceedings of the International Conference on Quality-
Yokohama’96. October 15-18, p.387-390.

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