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 September 1997 Article

Applying TQM
to an Academic
Cheryl A. Maurana, Ph.D.,Albert E. Langley,
Ph.D., Kim Goldenberg, M.D., Judith A. Engle, M.A

A unique community-academic partnership utilizes
TQM to improve education and community health.

The Center for Healthy Communities, established in 1994, began in 1991 as a partnership among the Dayton, Ohio, community and the health professions schools at Wright State University and Sinclair Community College. The partnership seeks to change how we educate health professions students, how we deliver health care to the community and how the community is involved in its own health. The center has grown steadily to achieve state and national visibility for its successful programs and activities.

In the development stages, center staff searched for ways to build teams between the community and academia. The staff was concerned that different educational and cultural backgrounds might interfere with team development. Would, for example, a community resident be intimidated by academics, or vice-versa? Would faculty and government leaders welcome a dialogue with neighborhood representatives?

During initial discussions with community residents, providers and faculty, center staff needed to ensure that each individual and group was afforded equal opportunity to participate and be involved in decision making, regardless of affiliation. The staff used concepts and techniques based on total quality management to achieve team development and build consensus. They chose TQM because it is based upon principles of partnership, empowerment, teamwork, a person-centered approach and continuous improvement in quality.

In early 1992, experts from Wright Patterson Air Force Medical Center and the Dayton Veteran Affairs Medical Center, local institutions that had already adopted TQM, helped train center personnel. To learn more about TQM concepts, center staff, faculty and selected community members developed and participated in a series of workshops. These classes introduced concepts, such as continuous improvement and customer focus, and tools, such as brainstorming and rank ordering of ideas.

Later workshops allowed the group to practice more complex activities, such as flowcharting and the Ishikawa diagram, a graphical tool that lists the causes and effects of variation. Brainstorming, used to generate a large number of creative ideas, enabled each member to offer an idea without criticism. They also learned about multiple voting and rank ordering, tools that are used to set priorities. They undertook extensive literature searches to identify practical ways to apply TQM methods to a nonprofit organization focused on health and education issues.


The technique of structured meetings was incorporated into the center's advisory council, governing board and all of its working committees. In TQM-structured meetings, members are assigned roles, such as leader, recorder, facilitator and timekeeper. Roles rotate with each meeting so that everyone has equal participation and opportunities for shared leadership. Rules of appropriate conduct are distributed to each group so that members understand appropriate meeting behavior. Center staff believe that these rules enhance open communication and raise participants' comfort level. Team members are addressed by first names, and titles and degrees are omitted from written materials. The rules are:

 Respect each person.

 Share responsibility.

 Criticize ideas, not people.

 Keep an open mind.

 Question and participate.

 Attend all sessions.

 Listen constructively.

 Have no side conversations.

 Raise hand for recognition by the leader.

Structured agendas were also incorporated into all center meetings. The agendas follow several well-defined steps: introductions (as necessary), review of last meeting's summary, assignment of meeting roles, review of agenda items, work through agenda items, verbal summary of meeting by the recorder, plan next agenda and evaluate meeting. Each step is allocated a time limit that is monitored by the timekeeper. If an agenda item requires more time, the group must vote to reallocate the time limits, or the item is tabled and put on the next agenda.

Each agenda step is given an action that indicates the desired outcome. These outcomes are frequently listed as update, decision, discussion, brainstorm or vote. After working through the agenda items, the recorder gives a quick summary of the meeting, emphasizing action items that need follow-up before the next meeting. The members then evaluate what was effective about the meeting, what could be improved for the next session and plan the next meeting.

Given the level of cooperation required for the success of a community-academic partnership, center staff expressed reservations about incorporating these concepts into center functions. Some concerns were that the structure would become restrictive rather than provide open communication. Others feared meetings would lose creativity or become a boring new "Robert's Rules of Order."

TQM concepts were unfamiliar to most of the partners, and center staff had to educate participants in the process and at the same time incorporate the concepts while setting and meeting goals. However, the lack of experience of most participants with TQM might also have served as a leveler, allowing team building to occur during the learning process. Some center staff felt overwhelmed, others anticipatory, but all agreed to move forward.

The working committees and governing board implemented the TQM concepts and techniques in a short period of time. Some working committees focused on developing programs, such as a community health advocacy outreach program; others concentrated on developing service delivery and client flow models. They also used the techniques to develop grant proposals, form policy and operationally define terms for community and academic partners. The structured meeting format allowed for open communication, yet kept working groups focused on specific tasks. Center staff observed that community and academic partners had equal opportunity to participate and make decisions.


The use of TQM in the center's development was carefully evaluated over the past three years as the center worked toward its goals. The Evaluation Task Force sent questionnaires to center participants as part of annual center evaluations. In 1993, the questionnaires were sent to 161 participants, with a 46-percent response rate; for the 1994 evaluation, the questionnaires were sent to 114 participants, with 32 percent responding.


In both surveys, five questions were asked in reference to TQM's effectiveness. Participants were asked if the Center for Healthy Communities was effective in several key TQM areas: respect for individuals, customer focus, teamwork, continuous program improvement and meeting management. A high percentage of participants agreed that TQM methods were successful in center activities. Upon investigation, the drop in the percentage viewing TQM as effective for meetings stemmed from the participants' sense that the formal process had become such a part of the culture that less formal approaches worked equally well.

In the spring of 1995, the center again surveyed key participants specifically about their perspectives on using TQM in the center's program design and development. Twenty-one of 51 faculty and community representatives replied to the survey -- for a 42-percent return rate. Participants were first asked about their familiarity with TQM terms used by the Center for Healthy Communities.

Although center staff focused on the technique rather than specific terms when incorporating TQM, participants responded that they were very familiar with terms such as assigned meeting roles (80%), brainstorming (85%) and meeting steps (76%). High percentages of the respondents also were very familiar with the terms continuous improvement, meeting rules of conduct, multiple voting, patient-focused and rank ordering. The term flowcharting (55%) was the least familiar of all the terms because some groups, particularly the service delivery committees, used the technique frequently, and others used it rarely.


When asked about how frequently the participants had used TQM tools in center working groups and activities, the respondents indicated that they had used brainstorming (76%) most often and multiple voting and rank ordering (33% each) least often.

Respondents also indicated that the most useful tools were brainstorming (76%) and assigned meeting roles (66%). They indicated that multiple voting and rank ordering, the tools that were used the least, were also the least useful. When asked to give an example of how the techniques improved or enhanced center activities, respondents cited that the tools "allow everyone the opportunity to participate" and that "meetings were more focused, on track, productive and on time."

Respondents were also asked if they encountered problems using any of these tools and, if so, to briefly explain what these were. Assigned meeting roles (57%) and brainstorming (60%) indicated they had encountered no problems at all. Twenty-one and 30 percent, respectively, indicated that they had experienced some problems using both tools. Respondents indicated that they had encountered problems most frequently using flowcharting, with only 39 percent indicating no problems, 22 percent some problems, and 5 percent frequent problems. Flowcharting was described by two respondents as "somewhat difficult for some participants to understand." Others criticized rotating roles for meetings as a "lack of continuity" and the process as "rather artificial and rigid at times." Another suggested that problems occurred when "we drift away from the process."



For the past three years, TQM methods have guided the development of a community-academic partnership focused upon the health of the community and the education of its health care professionals. These methods have been successfully incorporated into the center's working and governing committees. Both community and academic participants have indicated high levels of knowledge and acceptance for the methods used.

Although originally developed and implemented in industry, the TQM methods practiced by the Center for Healthy Communities helped in the design and implementation of programs, aided consensus and team building for community and academic partners, and gave staff a structure on which to build a shared vision.



Berwick, D.M.; A.B. Godfrey; and J. Roessner. 1990. Curing Health Care: New Strategies for Quality Improvement. San Francisco: Jossey-Bass Publishers.

Collier, J.C. August 1992. "Becoming Empowered Through TQM." Quality Digest, 2934.

Collins, A. May/June 1990. "Quality Control as a Model for Education: It Would Improve Our Output." Engineering Education, 470471.

Fenwick, A.C. December 1996. "Five Easy Lessons." Quality Progress, 6366.

Joint Commission on Accreditation of Healthcare Organizations. 1992. Striving Toward Improvement. Oakbrook Terrace, Illinois.

Kaufman, R. December 1991. "Toward Total Quality 'Plus.' " Training, 5054.

Kramer, C.E. May 1993. "Improving Team Meetings." Quality Digest, 7480.

Namie, G. and R.P. Neuman. August 1992. "Quality in Health Care?" Quality Digest, 2027.

White, J.A. 1990. "TQM: It's Time, Academia." First National Symposium on the Role of Academia in National Competitiveness and TQM.


About the authors

Cheryl A. Maurana, Ph.D., is associate professor of family and community medicine and vice chairwoman and chief of the Division of Community Health, Medical College of Wisconsin. Previously, she was associate dean for community health development, Wright State University School of Medicine, and founding director of the Center for Healthy Communities. Telephone (414) 456-8291, fax (414) 266-8537.

Albert E. Langley, Ph.D., is associate dean for academic affairs and professor of pharmacology and toxicology at Wright State University School of Medicine. Telephone (513) 873-2161, fax (513) 873-3672.

Kim Goldenberg, M.D., is dean and professor of medicine at Wright State University School of Medicine. Telephone (513) 873-2933, fax (513) 873-3672.

Judith A. Engle, M.A., is director of the office of public relations at Wright State University School of Medicine. Telephone (513) 873-2038, fax (513) 873-3672.


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