business approaches to quality improvement: they are...

Quality in Health Care 1996;5: 104-1 10104

Business approaches to quality improvement: whythey are hard for the NHS to swallow

Christopher Pollitt

Business approaches to qualityimprovementDuring the past two decades private sectorbusiness seems to have developed a series ofpowerful, generic approaches to improving thequality of its goods and services. Companiessuch as Rank Xerox, Ford Motor, Kodak, TacoBell, Texas Instruments, Citibank, andSwedish Post have reported radical, quantumleaps in productivity and quality. During thepast decade these approaches have beenimported to the public sector on an in-creasingly large scale. The National HealthService (NHS) has certainly not been immuneto this trend; indeed, it is awash withapproaches to quality improvement which havetheir origins in private sector business practice.These include BS5750/ISO 9000 (see later),several varieties of total quality management,benchmarking and, most recently, businessprocess re-engineering. Progress has been andundoubtedly is being made at many NHS sitesand in many NHS contexts. Tangible qualityimprovements are being secured and often staffseem (in the jargon) to be "taking ownership."

Yet behind the facade of steady progress andthe progressive adoption ofmodem techniquesthere are several unsolved and sometimesunacknowledged problems. In this paper Iwant to argue that where such contemporaryapproaches have been tried in the NHS theirimpacts often have been considerably less thanthose promoting them had predicted or hopedfor. For example, a detailed study of attemptsto implement total quality management at 38NHS sites came to the conclusions that: "whenmeasured against rigorously stated objectives,total quality management was not implemen-ted successfully at more than two pilot sites inour sample."

Also, comparing NHS sites with two com-mercial controls: "The commercial companiesmade more progress than the NHS TQM[total quality management] sites on all TQMcriteria except customer empowerment."'

If this is correct (and I suggest that it is notonly correct but also applies to other businessapproaches as well as total quality manage-ment) then it raises an important questionabout why these allegedly powerful approachesseem to lose some of their steam in NHSenvironments. Is it because the approachesthemselves are flawed and oversold, or becausethere are some factors which are special to theNHS, or some combination of the two?Thus the main objective in the paper is to

analyse the "fit" between approaches to qualityimprovement which have come from the

private sector and the "host" conditions forthese approaches within the NHS. Homegrown or health specific approaches to qualityimprovement such as medical audit or thedevelopment of clinical protocols are thereforelargely excluded from the discussion.

Analysis will suggest that certain pre-requisites would need to be satisfied if totalquality management, benchmarking, re-engineering, and similar techniques were tohave a more profound impact than in practicethey have yet achieved. It should not beassumed, however, that the paper is arguingthat these prerequisites necessarily should bemet. Meeting them would be likely to generateother consequences, both positive and nega-tive. It is doubtful whether the effort to applybusiness techniques full bloodedly - in theways their originators or gurus recommend -

would prove worthwhile overall. Instead amore gradual mixed strategy is advocated.The focus here will be on quality improve-

ment efforts in acute hospital settings, althoughmuch of what follows probably applies in largemeasure to other healthcare contexts as well.However, the large modem hospital is auniquely complex organisation, both in termsof the number of different products it deliversand because of the range of differentoccupational groups and technological systemswhich need to work smoothly together ifoverall quality is to be achieved. Thus there isa sense in which the hospital is one of thehardest tests any approach which claims toimprove quality can face.

The nature of recent business approachesto service quality improvementIn the business world different approaches toquality have followed each other in rapidsuccession. In the following sections I willattempt to summarise the main characteristicsof the best known techniques. The variousapproaches will be described and analysed inthe same sequence as, chronologically, theyachieved prominence in private sectormanagement.

British Standard 5750 ISO 90002BS5750 is now something of a veteran in thequality improvement stables. In 1987 it ac-quired an international equivalent - IS09000.BS 5750 had its origins in attempts to setstandards for the supply of military equipmentto the Ministry of Defence. The essential ideais that the processes by which goods or servicesare produced and delivered should be veryclearly specified and documented and that

Centre for theEvaluation ofPublicPolicy and Practice,Faculty of SocialSciences, BrunelUniversity, Uxbridge,Middlesex UB8 3PHChristopher Pollitt,professor and codirector

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Business approaches to quality improvement: why they are hardfor the NHS to swallow

everyone who needs to know should be familarwith the relevant specification and docu-mentation. An organisation which seeks regis-tration for a particular process or system underBS5750/ISO 9000 pays a fee and sub-sequently, after a period of preparation, under-goes external assessment. If the assessordecides that the process concerned meets therequirements of the standard then the organ-isation can display its accreditation in itsliterature and on its products.Although originally written with manu-

facturing industry in mind BS5750 was cast insuch general terms that it proved possible toadapt and interpret it for application to almostany organisation that produces goods orservices. However, in 1991 an additional partto the standard (ISO 9004-2) was introducedfor services. Also, the ISO 9000 series ofstandards was adopted by the European Unionas EN29000 and parts of BS5750 were revisedand renumbered as BS EN ISO 9001: 1994.The requirements for BS5750/ISO 9000

registration are complex, and lay heavyemphasis on documentation. The proceduresfor designing the product or service, con-trolling documents, purchasing key inputs,rendering the product identifiable and trace-able, inspecting and taking corrective action allhave to be set down in considerable detail. Forexample, in relation to document control thestandard requires the organisation to be ableto:* Identify which documents need to be

"control documents" (for example, manuals,handbooks)

* Only issue control documents which havebeen checked by designated staff

* Ensure availability of control documents toeveryone who needs them

* Ensure removal or updating of out of datecontrol documents

* Maintain a master list of those who are toreceive control documents.

BS5750 does not itself set numerical qualitystandards. It does require a system foraccurately identifying customer requirements,although it does not specify how this should bedone. It has therefore been criticised for failingto accord a more salient role to user satis-faction.3 ' It has also been said to be rather anexpensive and essentially bureaucratic processwhich, of itself, does little to motivate orinvolve rank and file staff.5-7 Nevertheless, itdoes offer the customers of an organisation aguarantee that the organisation will have beenthrough a strenuous process of focusing on thefine detail of its systems for assuring aconsistent, well controlled product.BS5750 has been adopted in several NHS

settings. An early attempt to adapt the stan-dard for NHS purposes was that of Rooney8who proposed criteria in 20 distinct aspects ofservice provision. Some general practices andbiomedical engineering departments areamong the NHS units which have achievedaccreditation. It has also been quite widelyadopted by local government, especially intrading standards and highway departments.9

Total quality managementTotal quality management is probably the bestknown contemporary approach to qualityimprovement. Conceptually it is far moreambitious than BS5750/ISO 9000. However, itis not easy to provide a definitive summary oftotal quality management because there areactually several major varieties, each with itsown guru.'102 Nevertheless, a recent survey ofthe (vast) literature suggested that total qualitymanagement usually includes at least thefollowing elements:* A corporate perspective, frequently entailingthe production of an organisation-wide planembodying specific quality goals

* The generation of real commitment andenthusiasm for quality all the way down theline from top management to the "shopfloor"

* A transcendence of departmental and disci-plinary boundaries (many quality problemstypically arise within such boundaries)

* A willingness to make a substantial invest-ment in training

* A commitment to continuous improvement:total quality management emphasises anongoing process rather than a once and forall setting of quality standards

* An emphasis on avoiding mistakes or defectsbefore they occur rather than correctingthem retrospectively (and often expensively):this is encapsulated in the catch phrase "rightfirst time."'13Thus total quality management covers a

much broader front than BS5750/IS09000,although there is no reason why a total qualitymanagement system should not incorporatethe use ofBS5750 as a way of guaranteeing theintegrity of subsidiary processes within thelarger whole.The European quality award is explicitly

founded on total quality management prin-ciples. From 1996 this award will invite publicsector applicants.'4 It is administered by theEuropean Foundation for Quality Manage-ment which was set up by several large privatesector corporations in 1988. Applications arebuilt on the European Model for BusinessExcellence. This model accords specific pointscores or weightings to different elements, asfollows:Management variables (total weighting, 50%),leadership (10%); people management (9%);policy and strategy (8%); resources (9%);processes (14%).Results (total weighting, 50%), people satis-faction (9%) (in this case people means princi-pally the organisation's workforce); customersatisfaction (20%); impact on society (6%);business results (1 5%).

Total quality management has been quitewidely adopted within the NHS - at least inname. In 1989 17 pilot projects were launchedwith the aid of pump priming finance from theDepartment of Health. In 1991 HewlettPackard sponsored a new healthcare qualityaward for a "workgroup which is judged tohave made the best use of these (quality)techniques - in particular the technique of total

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quality management. 'I The term total qualitymanagement was subsequently applied tomany other quality improvement projectsacross many health authorities and trusts. TheDepartment of Health financed an inde-pendent academic evaluation of the earlyprojects, which identified key success factorsand pointed to ways in which most of the NHSinitiatives had fallen short of parallel efforts inthe commercial sector.1 6An introduction toone of the more successful NHS total qualitymanagement projects can be found in the NHSManagement Executive's booklet Quality inlaction: the St Helieir NIHS Trust: a case studyl.A particularly interesting variant of total

quality management is SERVQUAL, sometimesreferred to as "gap analysis.""' Those who havedeveloped the SERVQUAL approach claim tohave identified five generic dimensions ofservice quality- tangibles (the physical appear-ance of facilities, staff, etc), reliability, respon-siveness, competence, and empathy. An instru-ment is applied which measures, for each of thefive dimensions, the gap between what the userof the service expects and what they perceivethemselves as actually getting. This is known asthe perception-expectation (or P-E) gap. Usersare also invited to weight each dimension, byallocating 100 points across them. Pilotschemes with the SERVQUAL method havebeen carried out in outpatient clinics inLeicestershire, and the results compared withfindings from the use of SERVQUAL in othersectors."' Compared with the users of a sampleof American banks, insurance companies, anda telephone company it would seem thatLeicestershire outpatients have lower expec-tations of service but higher perceptions of theservices that they actually receive.

BenchmarkingBenchmarking - another American import -

followed hard on the heels of total qualitymanagement. The idea behind it is deceptivelysimple. Find an organisation that is good(preferably the best) at some particular processthat your organisation also performs (bookingpeople into spaces; conducting pharma-cological tests; managing large buildings),study carefully how it does it so well, makeplans to raise your own performance to thatlevel (or beyond), implement the plans, andmonitor the results.Benchmarking rapidly became famous when

a best selling book was produced whichexplained how the technique had assisted theXerox Corporation to regain the initiative upondiscovering that their global dominance of thephotocopying market had begun to disappearunder challenge from competitors) BritishTelecom, Eastman Kodak, LL Bean, TrusteeSavings Bank, and ICL were among the otherhousehold names which enthusiasticallyembraced the approach.Most texts on benchmarking stress the

importance of several features. Firstly, theprocess to be benchmarked should be one thatis important to the users of the goods orservices which the organisation concernedproduces. Secondly, it is essential to achieve a

deep understanding of the nature of theselected process as it currently operates withinboth the organisation wishing to improve itsperformance and the best practice organisationthat is being used for comparison. Bench-marking therefore requires detailed research: itis not a "quick fix.""' Thirdly, in a competitiveenvironment there must be something of valuein the benchmarking comparison for the bestpractice organisation as well as the aspirant.Attempts to benchmark a key function in adirect competitor may well encounter accessproblems. This is one reason why "functionalbenchmarking" is often recommended as agood way to begin. In functional benchmarkinga comparator may be chosen who is unlikely tofear direct competition from the organisationwishing to benchmark- for example, a hospitalconcerned about outpatient bookings may seekto study the seat bookings process operated bya successful airline. Large organizations withmany different delivery units may also conductinternal benchmarking to see whv oneparticular unit seems capable of higher qualityor higher productivity than most of the others.

In 1992 an NHS benchmarking referencecentre was set up and various attempts weremade to benchmark across the service.-` Theapplication of benchmarking is by no meansconfined to business processes such as stock-holding or record keeping. Clinical bench-marking has been used in obstetrics,pediatrics, and other specialties. Reportedsuccesses include reduced duration of stay,decreased requirements for blood transfusions,and improved pain management. 2 1 '1 In theautumn of 1995 the NHS Trust Federationand Newchurch and Company Ltd jointlylaunched a clinical benchmarking companythat will offer NHS trusts comparative per-formance datasets." There does not yet seemto have been any independent and systematicevaluation of NHS benchmarking activity.Unsurprisingly, however, the experience ofearlv practitioners shows that success cannotbe guaranteed. Typical problems includechoosing an inappropriate process to bench-mark (for example, an unimportant one);failing to implement change when monitoringdata shows that improvement is possible;failures by senior management to investsufficient time, resources, and support in thebenchmarking process; attempts to benchmarktoo many measures or processes all at once,and inaccurate or meaningless data.>

Business process re-engineeringBusiness process re-engineering is also asso-ciated with a best selling book. Americanmanagement consultants Michael Hammer andJames Champy subtitled their text A mianijfestofor a business revolutioni and they did notunderstate the power of their approach: "Re-engineering, we are convinced, can't be carriedout in small and cautious steps. It is an all-or-nothing proposition that produces dramaticallyimpressive results. Most companies have nochoice but to muster the courage to do it."

Definitions of business process re-engineering are quite elusive, or at least they

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are couched in such general terms that it canbe hard to visualise. Johansson et al28 offer atypical example: "Business Process Re-engineering is, by definition, the means bywhich an organisation can achieve radicalchange in performance as measured by cost,cycle time, service and quality, by theapplication of a variety of tools and techniquesthat focus on the business as a set of relatedcustomer-oriented core business processesrather than a set of organizational functions."

Like benchmarking, therefore, businessprocess re-engineering entails a tight focus onthe detail of key organizational processes. Ittracks these across the vertical, functionaldivisions that characterise most large bureau-cratic organisations (for example, in hospitalterms, pathology, surgery, imaging, supplies,finance). In some respects it seems to be a kindof reborn operations research, although with amuch more strategic and challenging manifestothan traditional operations research usuallyhad. However, in most of its manifestationsbusiness process re-engineering seems topossess a more dramatic quality than bench-marking. In this respect it is perhaps closer tototal quality management, in that it is oftenportrayed as not just a technique, more aphilosophy.

Like total quality management, businessprocess re-engineering has entered the NHSthrough pilot projects (at two teachinghospitals) supported by central NHS Executivefinance.29 Also several other providers andpurchasers have applied the fashionable labelto current improvement projects. For example,Leicester Royal Infirmary has made a name foritself by creating a "one stop" neurology clinicwhere previously an outpatient might have hadto make up to five visits.30 It is now going onto try to apply re-engineering principles tomuch more extensive tracts of the hospital'sactivities.3'

It is too early for an extensive criticalliterature to have developed around appli-cations of business process re-engineering inthe NHS. In the business world, however, ithas already attracted strong criticism as well aspraise. In particular it seems (in its original,Hammer and Champy form) to say very littleabout the human relations part of change.32This may not be unconnected with the fact thatin its early commercial applications it was oftenassociated with a radical decrease in the work-force.33 Various commentaries also expressedconcerns about the way in which businessprocess re-engineering can become a techno-cratic, top down exercise which focuses onorganizational processes without sufficientassurance that changes in that area will affectthose outcomes which matter most to the finalcustomers.To conclude this section it is worth noting

that the more "apocalyptic" of the businessapproaches - total quality management andbusiness process re-engineering - are high riskstrategies, even in the private sector corporateenvironment from which they originate. Theyseem to have performed best when corpor-ations face an immediate and visible crisis and

are fighting to survive.34 3' Even in these highlycompetitive circumstances disappointmentsand failures have not been at all rare.36 In asurvey of 311 United States companies usingtotal quality management 63% said that theyhad reduced product defects by less than10%.37 Certainly several knowledgeable com-mentators have raised doubts about the useful-ness of total quality management in the publicservices sector.38 In fact the gurus of totalquality management and business process re-engineering are themselves candid aboutsuccess rates: "As far as measuring the TQM[total quality management] results that havebeen achieved, there's a big informationvacuum out there"39 and "Our unscientificestimate is that as many as 50% to 70% of theorganizations that undertake a re-engineeringeffort do not achieve the dramatic resultsintended. "40

Difficulties experienced by businessapproaches in NHS environmentsThat business approaches pose challenges forthe NHS is immediately apparent. In essencethis is because they assume ways of runningorganisations which have not hitherto been theway in which most of the NHS - and certainlynot the average large acute hospital - has beenrun. For example:(a) Business approaches place considerablestress on the importance of following processes(chains of activity) right across the organ-isation, from beginning to end.(b) They make no mention of professions or ofany particular or distinctive authority thatmight be accorded to standards, rules, or guide-lines emanating from professional bodies.(c) They demand a holistic, corporate ap-proach, driven by management.(d) They also require the investment of con-siderable time and resource in specialisedquality training.(e) With the partial exception of BS5750/IS0900 they emphasise the importance ofshaping quality strategies around customerperceptions of quality.(f) They claim both the possibility of and theneed for radical rather than incremental change(especially business process re-engineering).Such characteristics make business ap-

proaches something of a "foreign body" inmost NHS acute units. Take the first element- the "whole process" approach. Typically, inlarge hospitals, complex, elongated, un-standardised processes involve many differentdepartments and groupings at different stages.Patients with several problems may interactwith dozens of different hospital staff (porters,nurses, paramedics, doctors, etc) as theycomplete an episode of treatment. Many delaysand disjunctures can arise between differentstaff performing different activities (making aninitial assessment; finding a bed; taking an x rayfilm; getting results from pathology tests;scheduling theatre time; arranging discharge).In the past it would have been unusual for thewhole of this long sequence to be managed as

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a single process, or for staff concerned with oneactivity to know much about the requirementsof their colleagues in other parts of the hospitalwho were responsible for other activities. Yetthis is the intended direction of business tech-niques such as total quality management andbusiness process re-engineering.Or again, the almost complete silence of

business approaches with respect to the specialstatus of professional knowledge (note (b)) mayseem alien to the hospital setting. In the NHSprofessional groupings are both numerous andstrong. Partly because of this managers oftenexperience great difficulty in articulating orenforcing a "corporate approach" (note (c)).Resources and time (note (d)) are usually invery short supply.What is more, business approaches enter an

organizational landscape in which "standards"are already flowering in considerable pro-fusion, although not quite in a manner ofwhich advocates of total quality managementand business process re-engineering wouldnecessarily approve. The contemporary hospi-tal is likely to be deeply entangled with medicalaudit, nursing audit, clinical audit, organ-isational audit and protocols, and proceduralguidelines of various types.41 However, it isunlikely that these will be well integrated, onewith another, or that they will be firmlyfounded on market research into customers'wants, or that any one of these devices willcover the entire process that a patient goesthrough, from beginning to end.

In short, most hospitals exhibit a range ofquality oriented activities, but of a type which failto match many of the key elements identified atthe beginning of this section (corporatelyconceived, customer driven, based on a holisticdefinition of key organisational processes).Unsurprisingly, existing quality improvementactivities at NHS hospitals reflect the frag-mented occupational structures and principalpower relationships of those institutions.

Other features contribute to the difficultiesexperienced by "immigrant" business ap-proaches. The NHS management, accounting,and control procedures may make it hard fora new quality improvement process to putdown roots. Such initiatives can easily end upas "bolt on extras," run through specialmanagement structures which are only looselyrelated to normal operational management.Reliable baseline data about costs andprocesses - meat and drink to most businessattempts to improve quality - can be very hardto come by within the NHS.

Is there a way forward?If my analysis is broadly correct, is there a wayforward? One easy, comfortable way is todismiss business approaches out of hand. Theycan be stereotyped as "foreign" or "American."It can be pointed out that they sometimes faileven in the private sector. It can be claimedthat the NHS is so special that it has little ornothing to learn from the world of profitoriented commercial companies. This generalline of thought (not one that I invented) leadsto the neglect or sabotage of business ap-

proaches, and is used to justify the cynicismwhich NHS staff sometimes show when profitoriented ideals are introduced. This cynicismsits comfortably with the notion that, by andlarge, "the professionals know best" andshould be left in peace progressively to raisetheir own standards through the reversed pro-cesses of improved training and peer review.The argument advanced here, however, is that

wholesale rejection of business approaches toservice quality improvement is unwarranted and,indeed, an intellectually and even ethicallyuntenable position to assume. The weaknessesof an exclusively profession based approach toquality improvement are clear to any student ofNHS history. Medical audit, for example,remained an unusual and exceptional activity foralmost 20 years after it became commonplace inthe United States, and was eventually taken onboard only when the government insisted on itin the 1989 white paper Working for patiel'Its.IEven with earmarked financial support it thendeveloped in such a way that most audit wasnon-comparative, weak on follow up,inaccessible to patients, and uncoordinated withother forms of quality assurance.43More broadly, until at least the mid-1980s

the NHS could be said to be the paradigm caseof professional paternalism, a system in whichthe consumers of the service were only rareRvpermitted to advance their own preferencesand concepts of quality.4' The tide of culturaldeference that permitted this stage of affairs tocontinue is running out fast. What is more theadvent of the NHS internal market createdpurchasing authorities which, as they mature,are less likely to be willing to accept assufficient the fragmented and purely profes-sional approaches to quality improvement. Ina market or quasimarket relation indepen-dently accredited, patient oriented approachesto quality assurance may well be the kinds oftokens of good faith that purchasers come todemand from providers. ("There remains, therefore, the search for

some sort of middle way. The aim would be tocombine the strengths of professionalism withthe insights and dynamism of commercialconsumerism, while discarding the character-istic weaknesses of both. In my view such anapproach would be unlikely to come in theform of a particular package of specific,universally applicable activities or techniques,complete with logo or acronym. More probablyit would consist of a set of design criteria whichany local quality improvement scheme wouldbe expected to meet (if a logo is necessary onecan be inverted locally). The criteria wouldembody some of the key insights (and vastexperience) gained in the commercial sector,but the substantive arrangements for meetingthese criteria would be a matter for theparticular trust (in partnership with otherstakeholders such as purchasers andCommunity Health Councils to decide.Each researcher would no doubt produce a

slightly different list of design criteria, or atleast different emphases within the list.However, certain themes recur so often thatthev would seem to be universally supported,

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at least among those academics who haveattempted to interpret business approaches forpublic service contexts. In the following para-graphs these themes are briefly enumerated.(1)The main focus for quality improvementefforts should be the whole process asexperienced by the patient, not just fragmentedpieces of that process. In an NHS context thismakes notions such as "integrated care path-ways" a promising place to start, alwaysprovided that the patients themselves are givenan active and continuing voice in serviceredesign47 and that the pathways do not stopat the door of the ward, or even the hospital.Monoprofessional audits and other forms ofpeer review can significantly contribute toimprovement of such broad pathways orprocesses, but only if they are selected andplanned to fit in with the bigger picture.(2) Inside the organisation, there needs to beboth a team or multidisciplinary forum at theworking level and explicit and well informedleadership from the top. Processes cross thefrontiers between different departments andwards and the staff in each unit need a betterunderstanding of each other's problems.48 Forhospitals the level of involvement of con-sultants is almost always a crucial factor.Looking back, the leader of one of the NHS'smost successful total quality managementschemes said that if he were starting again hewould go for much more medical involvementin the design.49 This sentiment is echoed atmany other hospitals. It may be that it is moreimportant to persuade consultants to spendtheir valuable time in multidisciplinary teamsthan in monoprofessional audits.(3) For the team approach to succeed atworking level real decentralisation of bothauthority and budgets is usually required.50There may also be a case for re-examiningincentives (not merely salaries) so as to be ableto recognise quality improvements.(4) Quality should be everyone's responsibilityrather than something which is hived off to aseparate unit or directorate.5' The approachthat was common in the NHS in the mid-1980s - appointing a nurse as "director ofquality" but leaving all else unchanged - isunlikely to make any fundamental impact.(5) Intensive training is likely to be needed. Itshould mirror the multidisciplinary teamapproach advocated above. The team thattrains together works together.(6) The trade off between quality and costshould not be avoided but rather confronted atan early stage. Many quality improvementsmay be available at low or no cost, but thisshould be shown by careful analysis, notassumed. One useful way of beginning this canbe to attempt to estimate the cost of existingquality failures.52 If medical and clinical auditprocesses could be linked to cost data (moreoften and more closely than they have usuallybeen in the recent past) that would itself be aconsiderable step forward.(7) Top management needs to be firm andclear with the message that quality improve-

ment is likely to involve changes in job content(not just doing the same things faster or moreaccurately). Some of these changes maytrespass across what had hitherto been seen asoccupational or departmental demarcationlines. This needs to be on the agenda from thestart (it will be in staff's minds anyway). It maybe possible to reduce anxiety by coupling itwith some form of employment guarantee, orby strong commitments to retraining and jobenrichment through more generic forms ofworking. Ultimately the boundaries of medicalpractice itself will have to come under scrutiny(for example, through consideration of thewider use of nurses - see Richardson andMaynard53). There is no logical reason whydoctors should be the only occupational groupwhose contribution to processes and care pathsremain immune to reanalysis.(8) Another sensitive issue for urgentdiscussion is measurement. Attempts at qualityimprovement benefit enormously fromcomparisons with measured baselines (bench-marks) and from continuous monitoring toassess the extent to which planned improve-ments have actually been achieved. Going"softly softly" on the measurement issue isseldom appropriate.54(9) Most fundamental of all, most con-temporary business approaches stress theindispensability of research into customerwants and expectations. There is little point injust measuring achieved patient satisfactionunless there is also systematic enquiry into whypatients want what they want, and what factorsmost influence their expectations (seeEdvardsson et al55). The message from thebusiness world is that such research willprobably yield some surprises for even the mostexperienced provider of services.Time after time, analyses of business organ-

isations have shown that there is a need forbetter understanding of what the customerwants and expects. This research also indicatesthat most quality failures are due to faulty,complicated, or inappropriate systems ratherthan to individual people simply makingmistakes. What is more, most of these failurescan be traced to problems which occur acrossinternal organisational boundaries betweendifferent departments or occupational groups.There is every indication that these broadfindings hold true for hospitals too. Yet untilrecently a high proportion ofNHS training hasbeen devoted to improving the professionalskills of the individual person. There is muchfor healthcare staff of all kinds to learn from thebusiness literature, but no need to swallow itwholesale.

Part of the work on which this paper is based was financed bya grant from the British Council and the Flemish ResearchCouncil. Intellectually I am in particular debt to Professor GeertBouckaert of the Catholic University ofLeuven and to my Brunelcolleagues Richard Joss, Justin Keen, and Tim Packwood. Theresponsibility for the views expressed is mine alone.

1 Centre for the Evaluation of Public Policy and Practice.Total quality management in the National Health Service:final report of an evaluation. Uxbridge: CEPPP/BrunelUniversity, 1994:3-4.

2 British Standards Institute. Quality Systems Standard.London; BSI, 1987.

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