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We used quality control circles (QCC) followed by the PDCA Deming cycle and analyzed the application of QCC to the sustained improvement of a medical institution in Zhejiang province. Analyses of the tangible and intangible achievements of QCC revealed that the achievement indices for reductions in internal errors, reductions in costs, improvements in the degree of patient satisfaction, improvements in work quality, and improvements in economic performance were 109.84% ± 16.47%, 135.04% ± 50.33%, 126.26% ± 53.69%, 100.58% ± 22.83%, and 104.07% ± 5.45%, respectively. The improvements in these areas were 61.12% ± 13.2%, 60.47% ± 28.91%, 34.41% ± 22.96%, 49.22% ± 25.39%, and 73.70% ± 5.24%, respectively. The intangible achievements were reflected as follows: 5% of QCC members showed an activity growth value of 1–2 points, 83% 1–2 points, 12% more than 2 points. As a result, QCC activity showed prominent results in fostering long-lasting improvement in the quality of medical institutions in terms of both tangible and intangible factors. In short, QCC can be used as an effective tool to improve medical quality. Keywords: Quality control circle (QCC), Medical quality Introduction and gradually pay attention to the construction of med- The content and goals of modern QCC have outgrown ical quality. their original range in business management. QCC has Quality circles were first established in Japan in 1962; been gradually applied in the domestic medical and Kaoru Ishikawa has been credited with their creation. healthcare fields. Its goal is to increase the morale of The movement in Japan was coordinated by the Japanese medical workers by improving their awareness of spot- Union of Scientists and Engineers (JUSE). The first cir- ting and solving medical problems, improving medical cles were established at the Nippon Wireless and Tele- working environments, and eventually increasing the graph Company but then spread to more than 35 other quality of medical care, reducing the costs of medical companies in the first year. By 1978 it was claimed that management, and increasing the efficiency of medical there were more than one million quality circles involv- services. ing some 10 million Japanese workers. They are now in During the past 30 years of China’s reform and opening most East Asian countries; it was recently claimed that up, the medical quality management system has been there were more than 20 million quality circles in China basically established. On one hand, the administrative Currently, QCC has been widely established in hospitals department of health has begun to give full attention in Taiwan (Chang et al. 2010; Lin et al. 2009), Japan to the medical continuous quality improvement and (Helmer & And Gunatilake 1988), Germany (Wensing medical safety management, and formed a good medical et al. 2009; Wensing et al. 2004), and Australia (Spiegel quality management philosophy. On the other hand, with et al. 2012) and has achieved prominent results. the development of the market economy system, the hos- QCC has been gradually introduced to medical institu- pitals formed the quality consciousness to some extent, tions in China since 2001. Activities included reducing the number of internal errors in outpatient prescription dispensation, improving the work quality of operating * Correspondence: firstname.lastname@example.org room nursing, reducing the rate of complications caused Department of Pharmacy, The First Affiliated hospital, College of Medicine, Zhejiang University, 79 QingChun Road, Hangzhou, Zhejiang 310000, by venous indwelling needles, and increasing the inspection People’s Republic of China © 2013 Wang et al.; licensee Springer. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Wang et al. SpringerPlus 2013, 2:141 Page 2 of 5 http://www.springerplus.com/content/2/1/141 rate of urine and stool samples of orthopedics patients. department (workplace). To condense the QQC centri- These achievements have involved the areas of nursing petal force, guarantee smooth execution of QCC activ- technique and management (Zhong et al. 2002), pharmacy ities, and achieve QCC goals, participating members management (Wang et al. 2010; Zhang et al. 2009; Zhang form a circle and announce with determination and will et al. 2010), operating room management (Wang 2009), that they will improve quality. Effective circling forma- and other types of quality management (Tong 2009). The tion typically starts with finding the right candidates. results were pronounced, and the quality and efficiency of The optimal number of QCC members should be about corresponding departments were noticeably improved. 5–10, and the members should come primarily from the Since 2008, there were successive QCC activities and same department or workplace. Each participating QCC activity symposiums initiated by hospitals in Shanghai, member should have a corresponding work responsibil- Zhejiang, Hainan, Jiangsu, and Jiangxi. The provincial ity. Running QCC in hospitals is the responsibility of all Hainan government used the opportunity to start third- members, but different members should take charge in party evaluations of hospitals, including QCC as part different specific areas. Generally speaking, duty assign- of quality control. QCC activities have been widely pro- ments can be based on whether the member is directly moted throughout Hainan. or indirectly related. Typical roles include project dir- The QCC activities carried out in Zhejiang met the ector, liaison, counselor, circle head, and circle member. era’s requirement for sustained improvement of medical Execution: QCC activity starts with the circle head quality. Under the direction of the administrative depart- and members using in situ data and materials to look ment of healthcare, a QCC activity promotion work for actual problems through brainstorming. Ideas are team was established in the hospital pharmacy manage- then analyzed and modified with quality management ment quality control center. With the combined efforts approaches. In QCC activities, circle meetings are the of the Zhejiang Medical Association, Zhejiang Hospital most important form. Good circle meetings promote the Association, Zhejiang Hospital Pharmacy Management smooth execution of the whole QCC process and Quality Control Center, and Zhejiang Nursing Associ- provide solid tangible and intangible achievements. Bad ation, the first and second QCC activity achievement circle meetings, i.e., meetings without discussion, discus- symposiums and the third provincial hospital QCC ac- sion without decision, decision without execution, tivity initiation meeting were successfully held. Until hinder QCC activity. The 10 steps of QCC activity are now, there have been over 200 circle activities. In the theme selection, activity planning, understanding status provincial rank hospital appraisal, QCC activity has quo, setting goals, analysis, formulating strategy, execution become a hard criterion for assessing the performance and evaluation, confirmation of results, standardization, of hospital management. Reductions in internal errors, review, and improvement. The circle meeting should be reductions in costs, improvements in the degree of held monthly and an activity log should be maintained. satisfaction, improvements in work quality, and improve- One cycle of QCC activity lasts 6 months. ments in economic performance are the main theme activ- ities that QCC carries out. These have greatly promoted Sources of materials hospitals’ active roles in quality management and control. The data were based on the first and second phases and They have also promoted the application and practice of parts of the third phase of the QCC activity that took advanced tools for quality control in our country. place in a Zhejiang medical institution between Jan 2009 and June 2011. Materials from the 92 QCCs uniformly Materials and methods trained and executed under the supervision of hospital Formation of QCC and the execution of QCC activity pharmacy management quality control center, mainly in- Training: The purpose, operational procedure, and cluding activities carried out by pharmaceutical and methods by which QCC activities were to be carried out nursing departments, were summarized and analyzed. were taught by trainers, who placed a focus on strength- ening ideas and reaching consensus in order to encour- Summarization and organization of the data age trainees establish a “hoping to do, wanting to do and Based on the characteristics of the QCC theme activities, able to do” attitude. The training took place through we summarized the data in the following respects: re- combinations of class training and individual training. ductions in internal errors, reductions in costs, improve- All employees were trained in classes; and heads and ments to the degree of patient satisfaction, improve- counselors were trained individually with mock practice. ments in work quality, and improvements in economic A combination of theoretical teaching before execution performance (Table 1). The basic steps of QCC activity and practical guidance during execution was adopted. generally followed the Deming cycle (PDCA cycle). The Forming the circle: The objective of QCC is to solve four stages, plan, do, check, and act, were realized problems by relying on the personnel of the same through 10 basic steps (Figure 1). The performance of Wang et al. SpringerPlus 2013, 2:141 Page 3 of 5 http://www.springerplus.com/content/2/1/141 Table 1 Basic data of QCC activities (n = 92) such aspects as the ability to solve problems, sense of re- Category index Number of Percentage sponsibility, communication and coordination, team cohe- cases (%) siveness, self-confidence, and approach to quality control. Department As previous described (Wensing et al. 2009; Spiegel et al. 2012), each aspect was marked by self-evaluation of Pharmacy 54 58.7 the QCC members, with the highest possible score being Nursing 37 40.2 5 points and the lowest 1. The Activity Growth Value = Drug company branch 1 1.1 mean mark after activity – mean mark before activity. Theme activities Activity Growth Value was used to assess the intangible Reductions in internal error 55 59.8 achievement: positive values indicated improvement and Reductions in costs 4 4.3 negative values indicated deterioration. All data were repre- sented as x±SD. Improvements in degree of satisfaction 14 15.2 Improvements in work quality 16 17.4 Improvements in economic performance 3 3.3 Results The results of QCC activity were mainly reflected in tan- gible and intangible achievements. QCC activity was evaluated in terms of tangible and in- tangible achievements. Statistical analysis of the data Tangible achievements The evaluation indices for tangible achievements included For tangible achievements, data were recorded based on the following: Achievement Index = [(data value after im- the QCC theme activity such as reductions in internal provement – data value before improvement)/(goal value - errors, reductions in costs, improvements in the degree data value before improvement)] × 100%; Improvement of patient satisfaction, improvements in work quality of Index = [(data value after improvement – data value before work, and improvements in economic performance. improvement)/data value before improvement] × 100%. For Scores were recorded (before improvement vs. after intangible achievements, evaluations were made regarding improvement) in the following way: 1.Select theme 2.Plan activity 3. Assess status quo Plan 4.Set goal 5.Analyze 6.Formulate strategy 7.Execute and evaluate Do 8.Verify results Check 9.Standardize Act 10.Review and improve Figure 1 Basic steps of QCC activities. Wang et al. SpringerPlus 2013, 2:141 Page 4 of 5 http://www.springerplus.com/content/2/1/141 Table 2 Tangible achievements of QCC theme activities (%, x± SD) Theme activity Reductions in Reductions in Increases in degree of Increases in Improvements internal errors costs patient satisfaction work quality in economic Index performance Achievement index 109.8 ± 16.5 135.0 ± 50.3 126.3 ± 53.7 100.6 ± 22.8 104.1 ± 5.5 Improvement index 61.1 ± 13.2 60.5 ± 28.9 34.4 ± 23.0 49.2 ± 25.4 73.7 ± 5.2 self-evaluation by each QCC member, with the highest Achievement Index ¼½ðdata value after improvement mark being 5 points and lowest 1 point. Activity Growth –data value before improvementÞ =ðgoal value data value before Value = mean mark after activity – mean mark before improvementÞ 100%; activity. The results show that after QCC activity, the medical workers showed improvement in ability to solve problems, sense of responsibility, communication and Improvement Index ¼½ðdata value after improvement coordination, self-confidence, team cohesiveness, initia- –data value before improvementÞ tive, approach to quality control, harmoniousness, lan- =data value before improvement guage skills, sense of honor, and personal qualifications. 100%: Five percent of QCC members showed an activity As shown in Table 2, after each goal value was set, the growth value of 0–1 points, 83% 1–2 points, and 12% achievement indices were 109.84% ± 16.47% for reduc- above 2 points. The intangible achievements of QCC tions in internal errors, 135.04% ± 50.33% for reductions theme activities are shown in detail in Table 3. in costs, 126.26% ± 53.69% for improvements in the de- gree of patient satisfaction, 100.58% ± 22.83% for im- Discussion provements in work quality, and 104.07% ± 5.45% for The term tangible achievements here refers to achieve- improvements in economic performance. The improve- ments that can be quantified, such as defect rate, error rate, ment indices were 61.12% ± 13.2%, 60.47% ± 28.91%, delay rate, number of complaints,or absentee rate. The 34.41% ± 22.96%, 49.22% ± 25.39% and 73.70% ± 5.24%, quantities before and after the execution of measures meant respectively. to improve quality can be determined concretely. Usually, they can be represented in materialized format and their Intangible achievements economic implications can be calculated. Examples include Evaluations of intangible achievements were made with reductions in the number of internal errors in outpatient respect to ability to solve problems, sense of responsibil- prescription dispensations, reductions in the density of ity, communication and coordination, self-confidence, baumanii infections in the ICU, decreases in the duration team cohesiveness, initiative, approach to quality con- of equipment malfunction, increases in productivity, and trol, harmoniousness, language skills, sense of honor, decreases in error items in electronic nursing reports. Tan- and personal qualifications. Each aspect was assessed by gible achievements are more prone to attracting people’s Table 3 Intangible achievements of QCC theme activities ( x± SD) Theme activity Reductions Reductions Increases Increases Improvements in internal in costs in degree in work in economic Growth value errors of patient quality performance Item evaluated satisfaction Ability to solve problems 1.4 ± 0.6 0.9 ± 0.1 1.3 ± 0.6 1.5 ± 0.7 Sense of responsibility 1.3 ± 0.8 0.9 ± 0.5 1.4 ± 0.8 1.2 ± 0.7 1.4 ± 0.9 Communication and coordination 1.2 ± 0.5 1.4 ± 0.5 1.4 ± 0.7 1.3 ± 0.9 Confidence 1.5 ± 0.6 1.3 ± 0.6 1.3 ± 0.8 1.1 ± 0.8 1.2 ± 0.4 Cohesion 1.3 ± 0.6 1.1 ± 0.8 1.5 ± 0.7 1.3 ± 0.7 Initiative 1.3 ± 0.7 1.1 ± 0.9 1.5 ± 0.6 1.5 ± 0.8 Approach of QC 2.1 ± 0.9 2.8 ± 1.1 2.6 ± 0.9 2.1 ± 0.9 1.3 ± 0.3 Harmonious degree 1.3 ± 0.7 1.1 ± 0.4 1.1 ± 0.7 1.5 ± 0.8 1.0 ± 1.4 Language skills 2.0 ± 0.9 Sense of honor 1.2 ± 0.5 1.3 ± 0.7 Personal qualification 1.4 ± 0.8 1.3 ± 0.5 *Growth values were self-marked by members of QCC; for each item the highest mark was 5 points, lowest 1 point. Wang et al. SpringerPlus 2013, 2:141 Page 5 of 5 http://www.springerplus.com/content/2/1/141 attention and to become the focuses of organized achieve- realized. This can also help administrative managers work ment more scientifically and rationally. Overall, medical quality reports, publications, and rewards. After each goal value can be broadly improved. was set, in the theme activities, reductions in internal The standardization of QCC activity is to break down errors, reductions in costs, improvements in the degree of the current work procedure to every step and every satisfaction, improvements in work quality, and improve- actbased on the analysis and diagnosis of work flowchart. ments in economic performance, the achieve- ment indi- Then, according to scientific techniques, regulations, and ces were 109.84% ± 16.47%, 135.04% ± 50.33%, 126.26% ± practical experience, the work flowchart is improved with 53.69%, 100.58% ± 22.83%, and 104.07% ± 5.45%, respect- the goal of achieving better safety, quality, and economic ively. The improvement indices were 61.12% ± 13.2%, performance. This promotes the formation of an optimal 60.47% ± 28.91%, 34.41% ± 22.96%, 49.22% ± 25.39%, and operating procedure. Standardization is the summariza- 73.70% ± 5.24%, respectively. If the achievement index is tion of the practical experiences in QCC, an important step too high (>150%), it indicates that the confidence level is in improving QCC and one of the goals of QCC activity. low when the goal value is set. If the achievement index is Competing interests too low (<80%), the improvability of the circle may have The authors declare that they have no competing interests. been overestimated. Authors’ contributions The term intangible achievements refers to achievements LW and XZ gave the basic idea of this project, YW and YL collected and analyzed that are hard to quantify, such as the personal growth of the data. YL drafted the manuscript. All authors read and approved the final the circle head or members. Promoting QCC activity can manuscript. stimulate work morale, improve the knowledge and skill of Acknowledgement the staff, encourage active work attitudes, cultivate leader- This work was supported by the Medical Scientific Research Foundation of ship, improve institutional image, reduce institutional Zhejiang Province (No. 2010KYA065). costs, and increase degree of satisfaction. Intangible Received: 29 November 2012 Accepted: 18 March 2013 achievements can be represented with relative plots scored Published: 2 April 2013 by the members themselves or by the chief director. The References total number of evaluation items is best to even, in the Chang YN, Lin LH, Chen WH, Liao HY, Hu PH, Chen SF, Fu SH, Chang J, Peng YC range of 5–8. Balanced improvement is optimal. 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It has been successfully carried out in Zhang XG, Zhao QW, Li Y (2009) The exploration and practive of QCC in the overseas business circles for several decades and has been hospital pharmacy management. Prac Pharm Clin Rem 12:233–235 gradually extended to hospital management in recent years. Zhang Y, Li Y, Xu LF (2010) Improving management quality of outpatient dispensary. Chinese Health Qual Manag 17:14–16 The participants can learn about scientific quality manage- Zhong RH, Ming YF, Xiong ML (2002) Improving work quality of operating room ment knowledge and tools. Training workers at the grass- nursing through QCC activity. Acta Academiae Medicinae Zunyi 25:582–583 roots level can increase the awareness of amending doi:10.1186/2193-1801-2-141 problems and increase work efficiency. In this way, a har- Cite this article as: Wang et al.: The role of quality control circles in monious work team can be built; the quality of medical sustained improvement of medical quality. SpringerPlus 2013 2:141. service can be improved; and the hospital’s costs can be lowered. Through the bottom-up execution procedure of QCC, self-management of department personnel can be
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Published: Apr 2, 2013
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