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468Total quality management and the Deming approach to
quality management
Peter B. Petersen
Professor of Management and Organization Theory,
Johns Hopkins University, Baltimore, Maryland, USA Keywords Deming, TQM
Abstract This article discusses the total quality management (TQM) movement and then elaborates about W. Edwards Deming’s experiences and views. Finally, there is a comparison of total quality management and the Deming approach to quality management. The TQM movement was attractive to many organizations during the 1980s and the first half of the 1990s. To succeed, total quality management had many long-term requirements. One of these was that top management must have a passion for the subject. Without this sustained passion top management’s attention and energy towards TQM would be diverted to other pressing needs. While Deming insisted that there was no “instant pudding”, many consultants in establishing themselves with a client suggested short-term gains. Because of this search for short-term gains, process improvement and reductions in cycle time became very popular and in some cases a final objective. Unfortunately, after they ran their short-term course, many efforts collapsed and TQM was often declared a failure.
While W. Edwards Deming (1900-1993) is often associated with total quality management (TQM), he did not use nor tolerate use of the term “total quality management”. When the term was included in comments from members of his audience or visitors, Deming would be quick to emphasize that he was unaware of the term or that he did not understand the question. Then, he would usually ask the speaker to define TQM. As might be expected, the person who referred to TQM would more than likely stumble through a hastily composed definition. Deming would pick apart the definition and reveal its limitations. There was no doubt that Deming had a low regard for both the term “total quality management” and the application of a quality management practice that differed substantially from his own.
In reviewing the TQM movement two major contributors deserve recognition. The first, Joseph M. Juran, like Deming, spent his life’s career in the field of quality management. Particularly popular in the field of health care, Juran is famous for the Juran trilogy, the tripol concept, and his overall approach titled, “Continuous quality improvement”. Another major contributor to the TQM movement is Philip B. Crosby. As founder of the Quality College, he
This article is part of a special symposium issue on an operational code approach to W. Edwards Deming: the man, the context, the savant and the legacy, guest edited by Ronald Stupak.
Journal of Management History, Vol. 5 No. 8, 1999, pp. 468-488.
? MCB University Press, 1355-252X
TQM and the Deming approach to quality 469is famous for conducting extensive training sessions both at his facility in Winter Park, Florida, and on-site for many corporations and other organizations. Known nationally for his work on zero defects, Crosby further developed his quality improvement process when the need and demand for it became evident at the beginning of the 1980s.
Beyond the acronyms and “buzz” words of the past two decades the theories of Deming have not only endured, but they are also as applicable today as they were years ago. In addressing current and future challenges Deming’s system of profound knowledge provides a solid theoretical framework that lends itself to practical application. Unlike the failed TQM efforts, Deming’s theory and practical approaches remain. Reasons for the life and death of TQM will be debated for many years. This article contributes to this debate by comparing TQM with the Deming approach to quality management.
Total quality management
Following the Second World War, US business and industry dominated many of the world’s markets because US industry was at its operational peak, while other major industrial nations were in disarray because of war damage or strains on their productive capacity. Wrongly attributing success in many cases to methods of managing and operating, some US firms attempted to enhance their profits by shifting their attention from productivity and quality to other roles such as marketing, finance and organizational restructuring. Initially, for some firms, this shift in attention was profitable; however, when many European nations and Japan recovered from the Second World War, US business and industry found itself facing a different level of competition. It became apparent in the 1970s that US automotive and electronic industries could no longer take for granted their dominance of world markets. Actually,both the Japanese and the Germans were gaining increasing market share throughout the world and in domestic US markets. “Foreign competition began to threaten US companies in the 1970s. The quality of Japanese products such as cars and TVs began to surpass US-made goods” (Gitlow et al ., 1995, p. 17).One attempt to remedy the situation was to increase the number of management seminars used to teach managers and potential managers how to manage more efficiently and effectively. At the time, this seemed to be the correct approach. As a result, management seminars became more popular and the number of management consultants increased. In an attempt to improve their presentations, consultants frequently offered additional approaches or remedies. In time, the number of management consultants increased even further and became a permanent component in the operation of business and industry in the USA. Many of these consultants specialized in specific skills such as marketing, finance and information systems. However, those who specialized in leadership and management were particularly popular because they focused their attention on how the running of the overall organization could be improved. For a while, the application of general systems theory seemed to be the solution to unify all of the functions in an organization.
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470Unfortunately, in the early 1970s many adherents lost interest in general systems theory because of its unclear academic sounding terms and theoretical complexity. Concurrent with other consulting efforts, applied behavioral science became popular in the 1970s. Further, the subjects of organizational behavior and organizational development were explored by numerous consultants and practitioners who, in many cases, lacked the time or perhaps the patience to fully understand and apply these concepts. It is also interesting to observe that during the late 1970s consultants who focused on leadership and management tended to fall into two camps: one had an emphasis on the human side of enterprise and the other had an emphasis on more traditional approaches. Those in the more traditional camp emphasized, for example, management by objectives (from years earlier) or a wide array of more pragmatic approaches such as “tough minded management”.
During the late 1970s and early 1980s the search for solutions on how to manage intensified. At the time, applied behavioral science continued to be popular and was presented in many forms. One, perhaps extreme example, was Werner Erhard’s est.Popular in the late 1970s, Erhard emphasized that: “You and I possess within ourselves, at every moment of our lives, under all circumstances, the power to transform the quality of our lives.” Indeed, many of Erhard’s clients believed that his program made a major change in their lives. William Ouchi’s book, Theory Z, published in 1981, urged Americans not to copy the Japanese. Arguing that you cannot superimpose one nation’s culture on another, Ouchi offered another solution. First, he presented what he described as theory A (the American approach in the workplace); then theory J (the Japanese approach in the workplace); and, finally theory Z (those portions of the Japanese approach that could work in the US workplace). In explaining Theory Z,Ouchi discussed the need to integrate the needs of the individual with the needs of the organization. In reflecting on the work of Argyris, Ouchi considered:
Argyris challenged managers to integrate individuals into organizations, not to create alienating, hostile, and impersonally bureaucratic places of work. In a real sense, the Type Z organization comes close to realizing that ideal. It is a consent culture, a community of equals who cooperate with one another to reach common goals. Rather than relying exclusively upon hierarchy and monitoring to direct behavior, it relies also upon commitment and trust (Ouchi, 1981, p. 83).
Even more significant in 1982 was the book In Search of Excellence, written by Tom Peters and Robert Waterman. It provided lessons from 42 of the best run companies in the USA. At a time when business and industry were being bombarded by stories about Japanese successes, this book was a welcome relief. Focusing on eight attributes of performance excellence, Peters and Waterman described what these 42 successful US companies had in common. The idea was that readers should learn these eight attributes and apply them to their organizations.
It was during this time and in this setting in the early 1980s that Deming’s approach for success in the workplace gained momentum. While he became
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famous, in June 1980, because of his message in the NBC News documentary,several years would pass before his approach was applied in a major US corporation: Ford, it turned out, was one of the first major US companies to “discover” Deming’s expertise in quality management. The association between Detroit’s second-largest automaker and America’s forgotten quality pioneer would change history for both of them. Less than a decade after their first encounter, Ford would be hailed as a model of American management, and Petersen would lay much of the credit at Deming’s feet (Gabor, 1990, pp. 3-4).Interestingly enough, managers wanted to improve their operations but did not understand Deming’s approach or what many consultants were now describing as TQM. Nevertheless, they were in favor of it. Years later, Joji Arai, a pioneer in Japanese quality improvement and a friend of Deming, would observe:
If you want to sponsor a seminar … and you put “Total Quality Management” as the title,you’ll be assured of very enthusiastic participation on the part of American managers. If you ask the sponsors of the program what the definition of total quality management is,essentially what they come up with is nothing more than excellence in management, which American businessmen and academicians have been saying for so many years (Dobyns and Crawford-Mason, 1991, p. 279).
This definition is wrong because there is so much more to TQM. Actually what is needed is an overall transformation. Unfortunately, many managers did not understand this point. Further, while there was a strong demand for TQM during the early 1980s, there were very few individuals who were well-versed on the subject. The major quality management gurus in the USA at the time were:W. Edwards Deming, Joseph M. Juran and Philip B. Crosby. Consequently,hundreds of consultants rushed into this void, and in many cases they attempted to learn about TQM while applying it for a client. While some TQM applications were successful, there were many failures due to misunderstandings and lack of a sustained effort. In some cases the approaches used by these consultants were a mixture of: the behavioral science efforts they used previously, the theories of Deming, and the application methodologies used by Juran and Crosby. Occasionally, popular management approaches, such as empowerment, were added to this eclectic mixture. Unfortunately, the resulting brew lacked cohesion and was often a poison rather than a cure. To understand the evolution of TQM, one also needs to understand the views of two other major contributors. Therefore, the following segment will discuss Juran and Crosby’s approaches. Then, the views of Deming will be presented.Finally, the overall TQM approach will be compared with Deming’s approach to quality management.
Two other major contributors
While Deming was clearly the paramount figure in the field of quality management, there is general agreement that Juran was also a major figure.Most observers place Juran second only to Deming, and after Juran many other figures follow, such as: Philip B. Crosby, Genichi Taguchi, Kaoru Ishikawa,Armand V. Feigenbaum, Myron Tribus, Joyce Orsini, Gipsie Ranney, Brian
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472Joiner and Peter Scholtes. Further, no list of major figures would be complete without naming Walter A. Shewhart, Deming’s mentor and the person responsible for many of Deming’s theoretical underpinnings.
Rather than report the accomplishments of all of these figures and many more, two individuals, Juran and Crosby, will be discussed. Juran was selected because his unique theoretically based approach is very popular in the health care field, and Crosby because his popular approach is similar to many other TQM consulting efforts conducted during the 1980s and first half of the 1990s. Joseph M. Juran
Juran and Deming are similar in many respects. Juran was born in 1904, Deming in 1900. Deming began his significant and extensive work with the Japanese in 1950, and Juran was invited in 1954 to deliver a series of lectures in Japan. While much was accomplished in Japan before Juran’s arrival, both men assisted the Japanese and in time Emperor Hirohito awarded each of them Japan’s highest award given to foreigners, the Order of Sacred Treasure.
Born in Romania, Juran immigrated to the USA in 1909 and, like Deming, he had a humble and Spartan upbringing. Finally, in 1920, after many years of hard work and frugal living, Juran enrolled at the University of Minnesota and graduated in 1924 with a BS in electrical engineering. After graduation he was employed by the Inspection Department of Western Electric’s Hawthorne Plant located near Chicago. During the Great Depression, when working at a reduced hourly schedule, Juran earned a law degree from Loyola University. In 1937, he moved to the east coast and headed industrial engineering at Western Electric’s corporate headquarters in New York. However, at the start of the Second World War, Juran took a leave of absence from Western Electric to serve in a series of positions with the federal government in Washington, DC. Following the Second World War, Juran was chairman of the Department of Administrative Engineering at New York University. While there he also spent considerable time and effort in developing a consulting practice and in researching, writing and publishing about quality management. In 1979, Juran founded the Juran Institute, an organization that teaches, consults and applies many of Juran’s ideas and approaches about quality management. After devoting much of his time and energy to the institute, Juran stepped down as its chairman in 1987 and then ceased his public appearances in 1994. The institute is now headed by his colleague and former assistant, A. Blanton Godfrey.
Juran has significantly added to the body of knowledge for quality management. In his post, prior to the Second World War, as head of industrial engineering at Western Electric’s corporate headquarters, he was an in-house consultant and often networked with other companies. On one such visit to General Motors, Juran conceptualized the Pareto principle. Today, the frequent application of the Pareto principle in TQM sessions can be attributed to Juran. In 1951, he published the Quality Control Handbook,which is now used extensively and is in its fourth edition. Juran is also the author of numerous articles, papers and 14 other books. In his latest book, A History of Managing
TQM and the Deming approach to quality 473
for Quality , Juran edits and brings together 17 chapters that are written by a diverse group of authors. This collection of writings focuses on the evolution,trends and future directions of managing for quality. In this book, about the history of managing for quality, Juran discusses TQM in terms of its origin and definition:
By the 1980s it was becoming clear to upper managers that quality leadership could not be achieved by pecking away – by bringing in this or that tool or technique. Instead, it was necessary to apply the entire array of quality know-how (the “quality disciplines”) throughout the entire company – to all functions and all levels – and to do so in a coordinated way. One shorthand expression for this comprehensive approach is the term total quality management,or TQM.
At the onset there was no agreed standard definition for TQM, so communication became confused. This confusion has since been reduced by the publication of the criteria used by the American National Institute for Standards and Technology (NIST) to judge the applications for the United States’ Malcolm Baldrige National Quality Award (Juran, 1995, p. 649).Juran’s notable contributions to the quality management field include: the Juran trilogy, the triprol concept, and company-wide quality management.
The Juran trilogy is used to explain the interrelationship of three processes used to manage quality;
(1)quality planning;
(2)quality control.
(3)quality improvement.
While the first two processes are important, the third process is most significant because improvements in the system substantially reduce chronic waste. Then,lessons learned for improving the system are incorporated as the Juran trilogy is repeated. Conversely, Juran’s triprol concept is depicted as a flow diagram.This simple diagram shows the three roles that people have in an organization:
(1)customer;
(2)processor; and
(3)supplier.
The idea is to consider systems rather than individual functions. Studying these interrelationships provides an understanding of the system and subsequently furnishes substantial increases in quality.
Company-wide quality management is also one of Juran’s major themes. The idea is that an all inclusive, systematic approach is needed to set and meet quality goals throughout the company. Juran also emphasizes the need to address and measure quality management with the same attention to detail that we use for financial management. Indeed, like Deming, Juran made a substantial contribution to the field.
Philip B. Crosby
Crosby was a popular figure in the TQM movement. His extensive corporate background, superb communications skills and keen ability as an entrepreneur
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474enabled him to be one of the major figures in the TQM movement during the 1980s. Indeed, Crosby had almost four decades experience as a quality management professional and corporate executive. At Martin Marietta (now Lockheed-Martin) he created the concept of zero defects, and then as a vice-president of the ITT Corporation, he was responsible for ITT’s world-wide quality operations. In 1979, when he retired from ITT, Crosby founded Philip Crosby Associates. As the demand for information about quality management intensified, he created the Quality College, which, during the 1980s, became the world’s largest TQM consulting firm.
His philosophy about quality can be best described in his four absolutes of quality management. They are:
(1)The definition of quality is conformance to requirements.
(2)The system of quality is prevention.
(3)The performance standard is zero defects.
(4)The measurement of quality is the price of nonconformance.
Finally, the absolutes came together as the four basic concepts of the quality improvement process. There is a fifth: “There is no such thing as a ’quality problem’.” But that is for the professional quality people, and very few of them understand that its purpose is to pinpoint problems more tightly than: “The quality department is a mess” (Crosby, 1984, p. 58).
Crosby’s presentations were highly professional and convincing. While Deming and Juran often focused their corporate discussions on concepts and theories, Crosby impressed his corporate audience with a variety of graphic aids, well-coordinated, rapid moving discussions, and crisp but precise responses to questions from corporate executives. Crosby’s advice was easy to understand. For example: “Why spend all this time finding and fixing and fighting when you could prevent the incident in the first place” (Crosby, 1979, p. 291). Crosby provided the style, format, and pace that chief executives expected in a briefing. As a result, corporate executives were impressed with Crosby and his proposals. Many organizations sent their executives to the Crosby College and frequently they would agree to have Crosby’s teams of consultants work on-site in their organization. After he was established on-site with his client’s organization, Crosby would follow his 14 steps of quality improvement.
They are:
(1)management commitment;
(2)quality improvement team;
(3)measurement;
(4)cost of quality;
(5)quality awareness;
(6)corrective action;
(7)ZD (zero defects) planning;
TQM and the Deming approach to quality 475(8)employee education;(9)ZD day;(10)goal setting;
(11)error-cause removal;
(12)recognition;(13)quality councils;
(14)do it over again (Crosby, 1984, p. 99).
Crosby enhanced his consulting efforts with a well-trained team of consultants,excellent sets of training literature (often custom-made for the needs of the client) and a complete line of services to help his clients become knowledgeable about his quality improvement approach and how to implement it. Emphasizing continuous improvement, some of Crosby’s associates almost became permanent figures in their clients’ organizations. In time, however, many of Crosby’s clients had a change of heart and their interests were directed elsewhere, or they wanted to try their own approach without any help from Crosby. In some other cases, a change in leadership or organizational structure would bring a new set of executives who had their own agendas. While there were successes, the efforts of Philip Crosby Associates have waned in recent years. A major loss to this energetic firm occurred in 1991 when the charismatic Philip Crosby retired. He is now chairman of Career IV, Inc. where he assists executives in further developing their careers.
Deming’s approach to quality management
As was mentioned earlier, Deming became famous in the USA during June 1980as a result of his appearance in the NBC documentary, “If Japan can, why can’t we?” The video described the Japanese industrial recovery following the Second World War and contrasted Japanese successes with the problems of US business and industry. These problems were known in 1980, and the video examined the specific ills that needed to be corrected. Unlike most of the other participants in the film, Deming offered positive solutions about how the US could improve itself. In addition, it became evident to the viewer that Deming was the person to whom the Japanese gave credit for their industrial renaissance during the 1950s. After Deming’s years of work with the Japanese,Halberstam had the following appraisal of Deming and his accomplishments in Japan:
Deming was an American expert on quality control, and by the late fifties he had become something of a god in Japan. With the possible exception of Douglas MacArthur he was the most famous and most revered American in Japan during the postwar years (Halberstam,1986, p. 311).
Tall and distinguished looking, he appeared to be in reasonably good health for a man of 79. He also gained credibility in this video because of his overall demeanor and a skillful presentation of his views.
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In the 1980 NBC White Paper, “If Japan can, why can’t we?” he was called the “founder of the third wave of the Industrial Revolution”. Today Deming is generally regarded as the top leader in quality management, and is still cited as the founder of the third wave of the Industrial Revolution (Brocka and Brocka, 1992, p. 64).
Consequently, since 1980, most articles about TQM have included a discussion about Deming’s experience and views. Unfortunately, many of these articles confuse Deming’s views with the views of TQM.
Deming’s experience
W. Edwards Deming was born on October 14, 1900, in Sioux City, Iowa. Raised under frugal conditions, he labored long hours; however, his life was filled with intellectual stimulation and the motivation to thrive in a Spartan environment. In time he substituted W. for William because his father’s given name was also William. His middle name, Edwards, was his mother’s maiden name. The major highlights of the first 22 years of his life included graduating with a BS in electrical engineering from the University of Wyoming in 1921 and marrying Agnes Bell in 1922. Agnes Deming died in 1930. From 1922 to 1924 he earned an MS in mathematics and mathematical physics from the University of Colorado. At the same time, he was employed as an assistant professor of physics at the Colorado School of Mines. Following graduation, he was an assistant professor of physics at the University of Colorado.
In 1925 Deming moved to the east coast and became an instructor in physics at Yale from 1925-1927. He was then employed as a mathematical physicist at the Department of Agriculture from 1927 to 1939. Concurrent with his work at the Department of Agriculture, Deming earned a PhD in mathematics and mathematical physics at Yale in 1928. In 1932 he married Lola Shupe who would be his wife for 54 years. Then in 1935, he became Head of the Department of Mathematics and Statistics in the Department of Agriculture’s Graduate School. In the following year, 1936, he had the opportunity to study with Sir Ronald A. Fisher and Jerzy Neyman at University College in London.
While he was employed, primarily from 1939 to 1945, as the head mathematician and sdvisor in sampling at the Census Bureau, he held other concurrent positions that started during the beginning of the Second World War. They included:
?1940-1950. Consultant to Secretary of War and Secretary of Defense.
?1942-1944.Taught statistical quality control courses to defense supply industries.
?1942-1953. Advisor for Sampling, Bureau of the Budget (Spangler and Sullivan, 1995, pp. 2-3).
Starting in 1946, Deming began a long teaching commitment at New York University. He held this position for most of the remainder of his life.
Deming’s long association with the Japanese started in 1947 when he was an advisor for sampling techniques on General MacArthur’s staff. Three years later when the Japanese were seeking methods to improve the quality of their
TQM and the Deming approach to quality 477manufactured products, they invited Deming to lecture the Union of Japanese Scientists and Engineers. Managing Director Kenichi Koyanagi of the JUSE thought that a lecture course by a famous statistician like Dr Deming could bring about epochal results. For he had been well aware that Dr Deming was one of the American pioneers in statistical quality control, making immense contributions to the education and dissemination of quality control methods (Kilian, 1992,p. 31).Thus, Koyanagi wrote to Deming on March 8, 1950, and asked that Deming give a course for several days to Japanese research workers, plant managers and engineers. Koyanagi also asked Deming if he would write a message for the inaugural issue of the Japanese journal, Statistical Quality Control . Deming was delighted to comply with both of these requests.
During the summer of 1950 Deming presented his courses to 230 engineers in Tokyo. Then he traveled throughout Japan and taught an additional 170engineers. Deming’s audiences were very enthusiastic and eager to learn how to improve the quality of their products. Indeed, at the time, Deming’s presentations filled an important need for the Japanese. As word about Deming’s courses spread throughout the engineering and management community, his Japanese audience continued to grow. Significant in all this was that his audience included many of the leaders of Japanese commerce and industry. During the first two years, 1950-1951, Deming’s audience exceeded 1,100 Japanese engineers and managers. Reflecting on his initial seminars in Japan during 1950, Deming provided the following comment concerning the reservations of the top Japanese managers:
The first hurdle to overcome with top management in Japan in 1950 was the general supposition that it would be impossible for them to compete with industry in America and Europe in view of the reputation for shoddy quality of consumer goods that Japan had earned.The year 1950 was the beginning of a new Japan in quality (Deming, 1986, pp. 489-90).
From 1950 until his death in 1993 Deming would continue his contacts with the Japanese. Initially, he focused his attention on statistics and then, when the Japanese asked, he gave advice on what to do to improve the actual results revealed by their statistical analysis. As his contacts with the Japanese continued during the 1950s, Deming’s views about good management practices began to shape and mature. However, it can be argued that Deming probably learned as much from the Japanese as they learned from him.
From 1946 to 1980 Deming was primarily employed as a consultant in statistical studies. In this role, he would often appear in court as an expert witness when the amount of a substantial award would hinge on the statistical sampling of a damaged product or the amount that should be paid in damages to compensate for a lost opportunity. In many legal arguments about sampling methodology Deming’s views would win the case for his client. In addition,Deming also spent considerable time in further refining and writing about the application of statistics. In 1980, after Deming gained fame as the world’s leading expert about quality, he focused his attention for the rest of his life
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478(1980-1993) on transforming the ways of western management. In his last year, at the age of 93, he continued to unselfishly give his time and energy. “Dr Deming is imbued with a missionary zeal in imparting the message in which he and a host of disciples so strongly believe” (Mann, 1985, p. 156). His message had been heard, his latest book revised, and finally US products and services were regaining their reputation for quality.
Emergence of Deming’s views
Unlike many of today’s management consultants, Deming’s views about management emerged from his work as a consultant in statistical studies. When he became famous in the USA as a management expert at the age of 79, he continued to view himself as a statistician, specializing as a consultant in the design and analysis of statistical surveys. In fact, for the rest of his life, his stationery continued to describe him as a consultant in statistical studies. However, “starting in 1980 (from a practical point of view) his name became synonymous with quality” (Walton, 1990, p. 13). He believed that an emphasis on the production of quality products would also yield a reduction in waste materials and the time required to produce these products. From a realistic point of view, Deming also understood the importance of meeting the customer’s needs:
The business process starts with the customer. In fact, if it is not started with the customer, it all too many times abruptly ends with the customer. Dr Deming has said for decades that the customer is the most important part of the production line (Scherkenbach, 1990, p. 9). While he stressed the importance of quality throughout his career, his work with the Japanese in June, July and August 1950 actually shifted his emphasis from being a statistician to being a management consultant. However, this need to consider corrective action as well as statistics can be traced back to Deming’s association with Walter Shewhart in the 1920s:
Deming’s views on statistical quality control and his philosophy of management are a direct result of this early influence by Shewhart. One should remember that Deming was in his fifties when he started working with the Japanese, but he was in his twenties when influenced by Shewhart (Petersen, 1987, p. 133).
During an interview in 1986, Deming discussed his work at the Hawthorne plant and how he learned about Shewhart:
In 1925 I went to work at the Hawthorne plant of Western Electric near Chicago. They told me about Dr Shewhart who was working at the Bell Laboratories … When I came to Washington after finishing my degree at Yale in June of 1927, I worked for the Department of Agriculture in the Fixed Nitrogen Research Laboratory … The Deputy Chief was Dr Charles R. Kunsman and as it happened, he knew Dr Shewhart very well … They were good friends and Dr Kunsman thought that my acquaintance with Dr Shewhart and his work would be interesting to me and might even help my work; he felt it would broaden my education … So he arranged that I worked with Dr Shewhart from time to time, which was a very great privilege (Petersen, 1986, pp. 7-8).
In March 1938, Shewhart presented four lectures at the Graduate School of the Department of Agriculture. Deming and Shewhart had a close relationship, and
TQM and the Deming approach to quality 479in 1939 Deming edited a book by Shewhart containing these four lectures. It is titled Statistical Method from the Viewpoint of Quality Control . In the foreword,as the editor, Deming revealed a significant point in 1939 relative to his later development as a management consultant:
Most of us have thought of the statistician’s work as that of measuring and predicting and planning, but few of us have thought it the statistician’s duty to try to bring about changes in the things that he measures (Shewhart and Deming, 1939, p. IV).Shewhart, who was a major contributor to the development of the field of statistics, also became known as the father of the quality movement. As Deming’s mentor in the 1920s and 1930s, he had a major impact on Deming’s theoretical underpinnings both as a statistician and as a quality expert. In a discussion of the practical application of statistics, Shewhart offered the following:
Statistical methods of research have been highly developed … Similarly, statistical methods of control have been developed by industry for the purpose of attaining economic control of quality of product in mass production. It is reasonable to expect that much is to be gained by correlating so far as possible the development of these two kinds of statistical techniques (Shewhart and Deming, 1939, p. V).
As might be expected, Deming’s views about management evolved over a considerable length of time. While his publications prior to the Second World War focused on the use of statistics, there is clear evidence that he was concerned about management’s responsibility to improve the system and to correct the errors he was identifying. A major point made by Deming was that variation is the enemy of quality. That is, variation from set standards causes errors in products or services. In his analysis of outcomes he isolated two causes of variation:
(1)Common causes of variation – caused by the system – a responsibility of
management to correct.
(2)Special causes of variation – caused by an individual worker.
Deming stressed that too much attention was being paid to correcting mistakes by individual workers, and not enough effort was devoted to improving the system. In discussing this concept he credited Shewhart with an earlier version:Shewhart used the term assignable cause of variation where I use the term special cause . I prefer the adjective special for a cause that is specific to some group of workers, or to a particular production worker, or to a specific machine, or to a specific local condition. The word to use is not important; the concept is, and this is one of the great contributions that Dr Shewhart gave to the world (Deming, 1986, p. 310).
Deming emphasized these views during his many training sessions during the Second World War. In 1942, he originated his red bead experiment and used this demonstration, in his many courses at 23 universities, to help the war effort.The red bead experiment requires 800 red beads and 3,200 white beads.Volunteers from the class are asked to use a paddle with 50 depressions to draw 50 beads from a mixture of the red and white beads. Before drawing the beads,
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480volunteers are instructed to draw only white beads when they dunk their paddle into the mixture. Unfortunately, when the volunteers drew out their paddles red beads were mixed with the white beads. The point to be made is that the system needs to be corrected; that is, red beads should not be included when the mixture is prepared. The essence of the lessons learned from the red bead experiment are summarized below:
?The system (mistakes and all) turned out to be stable.
?All of the variation was provided by the process itself.
?The result or output was not related to worker performance. Indeed, under no circumstances could any of the workers have done better.
?It is wrong to rank workers based on performance that is out of their control.
?Pay for performance in this case was futile.
?The experiment was a display of bad management practices. Procedures were rigid and workers had no chance to offer suggestions to improve output.
?Management should have worked with the supplier to eliminate red beads from the incoming material.
Further development of Deming’s views
In considering the evolution and development of Deming’s views, it is clear that one of the major pillars of his theoretical underpinnings is that planning requires prediction. In this regard, Deming believed:
The reason to study the results of a change is to try to learn how to improve tomorrow’s product, or next year’s crop. Planning requires prediction. The results of a change or test may enhance our degree of belief for prediction, for planning (Deming, 1986, p. 88).
A further understanding of these views can be gained by examining the evolution of what Deming would later call the “Shewhart cycle”. Shewhart’s 1939 book edited by Deming explained what Shewhart called “the three steps in a dynamic scientific process of acquiring knowledge” (Shewhart and Deming, 1939, p. 45).
?Step 1 … Specification.
?Step 2 … Production.
?Step 3 … Inspection.
This shift, from “old” knowledge to “new” knowledge, was portrayed by Shewhart in 1939 by arranging the above three words in a circle with clockwise arrows. In 1986, in referring to the Shewhart cycle, Deming related: “I called it in Japan in 1950 and onward the Shewhart cycle. It went into immediate use in Japan under the name of the Deming cycle, and so it has been called there ever since” (Deming, 1986, p. 88).
TQM and the
Deming approach
to quality 481
The 1986 version of this model contained the following six steps:(1)What could be the most important accomplishments of this team? What changes might be desirable? What data are available? Are new observations needed? If yes, plan a change or test. Decide how to use the observations.
(2)Carry out the change or test decided upon, preferably on a small scale.(3)Observe the effects of the change or test.
(4)Study the results. What did we learn? What can we predict?
(5)Repeat step 1, with knowledge accumulated.
(6)Repeat step 2, and onward.
Titled “the Shewhart cycle”, it appeared as a circle with four numbers superimposed in a clockwise fashion and listed steps five and six below the circle.
The 1986 version was developed at a time when Deming was emphasizing that the western style of management must change to halt the decline of western industry. Years later, in 1993, Deming would refine this cycle further in his book, The New Economics . This third version was titled, “The Shewhart cycle for learning and improvement … the PDSA cycle” (Deming, 1993, p. 135).Containing four steps, it was intended as a flow diagram for learning and improving a product or a process. In a circle, the functions plan, do, study, act (PDSA) are listed in a clockwise fashion.
In 1993 he provided a further insight about the origin of this cycle. “The PDSA cycle originated in my teaching in Japan in 1950. It appeared in the booklet Elementary Principles of the Statistical Control of Quality (JUSE, 1950,out of print)” (Deming, 1993, p. 134).
Another pillar in Deming’s overall theoretical framework is his flow diagram to illustrate how improvements in quality improve many other components and byproducts of the system. This chart is one of Deming’s favorites, and it appeared in most of his major publications from 1950 to 1993. “This chart was first used in August 1950 at a conference with top management at the Hotel de Yama on Mount Hakone in Japan” (Deming, 1986, p. 4). Titled “Production viewed as a system”, it illustrates how an improvement of quality impacts on the entire production line, from incoming material to the redesign of product or service for the future. For service organizations Deming pointed out that various sources could be sources of data or work from proceeding operations.Within the scope of this figure, Deming argued in many of his publications that improvements in quality will result in:
?increases in productivity;
?decreases in cycle time;
?increases in capacity;
?lower production costs;
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?improved profits;
?happier customers;
?greater market share;
?more jobs;
?fewer customer complaints;
?less litigation.
Western management’s deadly diseases
The Japanese were responsive to Deming’s advice, and it was heartening for him to see that his advice was partially responsible for the successes of Japanese business and industry. Concurrent with decades of traveling to and from Japan, Deming taught at New York University and Columbia University while also continuing his consulting efforts in statistical studies. It was during these decades (1950-1980) that Deming noticed the steady decline of western business and industry. Pondering the causes of this decline, Deming formulated what he would later call “management’s seven deadly diseases”. “To overcome these diseases will require, Deming says, no less than ‘a complete shakeup of Western style of management’ ” (Walton, 1986, p. 89). Earlier versions contained five “deadly diseases” while a final version contained seven “deadly diseases”. In 1985 he stated the reason for the decline of western management and listed management’s seven deadly diseases:
For years, price tag and not total cost of use governed the purchase of materials and equipment. Work standards, quotas, exhortations, numerical goals devoid of methods to achieve them, failure to invest in knowledge, failures of training and supervision, have added their contribution to the decline.
Other forces are still more effective:
?Lack of constancy of purpose to plan product and service that will have
a market, keep the company in business, and provide jobs.
?Emphasis on short-term profits: short-term thinking (just the opposite from constancy of purpose to stay in business), fed by fear of unfriendly takeover, and by push from bankers and owners for dividends.
?Personal review system, or evaluation of performance, merit rating, annual review, or annual appraisal, by whatever name, for people in management, the effects of which are devastating.
?Mobility of management; job-hopping from one company to another.
?Use of visible figures only for management, with little or no consideration of figures that are unknown or unknowable. Peculiar to industry in the USA.
?Excessive medical costs.
TQM and the Deming approach to quality 483?Excessive costs of warranty, fueled by lawyers that work on contingency fee (Deming, 1985, pp. 6-11).Deming was not reluctant to blame management. In fact, each of the seven deadly diseases are critical of how management operates. Deming’s strong criticisms about management are further illustrated in his comments during an interview in 1988.Management has grown up as a hoax. That is, without theory. Without any basic understanding of what the needs of the country are, who is the customer, what is our purpose in life. Each one perpetuates what he believes to be his job. He is not doing wrong. He just doesn’t know any better. How could he know? (Petersen, 1988, p. 11).
Transformation of western management
Having stated the causes of the decline of western business and industry,Deming did not have to search very long for a solution. His solution was the process he used years earlier in Japan. As would be expected, many leaders of US business and industry spoke with Deming after he gained fame in the USA in 1980. His main problem was to state his views in a way that would be understood by these American leaders. While most of his theories existed prior to these meetings and discussions, he now had a reason to consolidate his views and clearly articulate them. Consequently, Deming refined his theories and a clearer version was titled, “Principles for transformation of western management”. His book,Out of the Crisis , published in 1986, contained the clearest rendition to that time of Deming’s approach to quality management. A major feature of this book was the explanation of his principles for the transformation of western management. The general idea was that US industry was in nothing less than a crisis, and Deming offered a way out of this crisis. As always, he demanded a total transformation rather than incremental improvements in the way we do business. On some occasions, these principles were referred to as “Deming’s 14 points for management”. A condensed version is presented below:
(1)Create constancy of purpose toward improvement of product and
service, with the aim to become competitive and to stay in business, and to provide jobs.
(2)Adopt the new philosophy. We are in a new economic age. Western
management must awaken to the challenge, must learn their responsibilities, and take on leadership for change.
(3)Cease dependence on inspection to achieve quality. Eliminate the need
for inspection on a mass basis by building quality into the product in the first place.
(4)End the practice of awarding business on the basis of price tag. Instead,
minimize total cost. Move toward a single supplier for any one item, on a long-term relationship of loyalty and trust.
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(5)Improve constantly and forever the system of production and service,
to improve quality and productivity, and thus constantly decrease
costs.
(6)Institute training on the job.
(7)Institute leadership. The aim of supervision should be to help people
and machines and gadgets to do a better job. Supervision of
management is in need of overhaul, as well as supervision of
production workers.
(8)Drive out fear, so that everyone may work effectively for the company.
(9)Break down barriers between departments. People in research, design,
sales, and production must work as a team, to foresee problems of
production and in use that may be encountered with the product or
service.
(10)Eliminate slogans, exhortations, and targets for the work force asking
for zero defects and new levels of productivity. Such exhortations only
create adversarial relationships, as the bulk of the causes of low quality
and low productivity belong to the system and thus lie beyond the
power of the work force.
(11a)Eliminate work standards (quotas) on the factory floor. Substitute leadership.
(11b)Eliminate management by objective. Eliminate management by numbers, numerical goals. Substitute leadership.
(12a)Remove barriers that rob the hourly worker of his right to pride of workmanship. The responsibility of supervisors must be changed from
sheer numbers to quality.
(12b)Remove barriers that rob people in management and in engineering of their right to pride of workmanship. This means, inter alia,
abolishment of the annual or merit rating and of management by
objective.
(13)Institute a vigorous program of education and self-improvement.
(14)Put everybody in the company to work to accomplish the
transformation. The transformation is everybody’s job (Deming, 1986, pp. 23-24).
Deming insisted that his clients apply all of his philosophy rather than selected portions. In addition, he did not want to be part of quality efforts that included other consultants. Obviously, his view that organizations should have sole source suppliers pertained to consultants as well. Similarly, he had a passion for speaking to groups of managers and students, but would not welcome being part of a panel where his ideas might be diluted or critiqued.
Deming’s views matured even further from 1990-1993 when his theories continued to evolve and were expressed in what he called “profound
TQM and the Deming approach to quality 485
knowledge”. His last book, The New Economics , published months before his death in 1993, described “profound knowledge” and its relationship to his 14points for management.The route to transformation is what I call Profound Knowledge . The system of profound knowledge is composed of four parts, all related to each other:
Appreciation for a system.
Knowledge about variation.
Theory of knowledge.
Psychology.
My 14 Points for Management (Out of the Crisis , MIT/CAES, 1986) follow naturally as application of the system of profound knowledge (Deming, 1994, pp. XV-XVI).Comparison of TQM and the Deming approach
There is a wide range of opinions on how to conduct TQM. As would be expected, TQM is conducted differently by many consultants and organizations. With this in mind, it should also be recognized that there are some basic similarities that can be found in any successful TQM effort. For example: “For TQM to be successful, it must be adopted throughout the organization and it requires a long-term commitment from the top down” (Price and Chen, 1995, p. 116). Hearing this, advocates of both the TQM approach and the Deming approach would be quick to point out that you need to “walk the talk as well as talk the talk”. That is, the right action as well as a stated philosophy is needed.
In examining TQM, it is noticeable that there are major differences between TQM and the Deming approach. This is in spite of the fact that there is a range of differences within the theory and practice of TQM. The major differences between TQM and the Deming approach are:
(1)The Deming approach represents one philosophy that is used in its
entirety or not at all. In contrast, “TQM is a general philosophy of management. It can be tailored for a particular environment, and there are as many ways to implement TQM as there are companies adapting it” (Price and Chen, 1995, p. 116).
(2)Both the TQM and Deming approaches agree that a successful effort
requires long-term commitment by top management. However, while Deming would not hesitate to drop a client if top management’s commitment started to wane, many consultants in the TQM movement would not be so eager to depart an ongoing effort.
(3)The Deming approach insists on a constancy of purpose while TQM
adapts itself, in many cases, to the realities of its environment.Consequently, TQM’s pragmatic approach often lacks a constancy of purpose.
(4)The Deming approach adopts a new philosophy; that is, one that is
intended to transform the western style of management. This philosophy titled “Profound knowledge” has four components:
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?Appreciation for a system.
?Knowledge about variation.
?Theory of knowledge.
?Psychology.
The TQM approach lacks this unified and integrated philosophy:?While the TQM approach tends to emphasize process improvements and reductions in cycle time, the Deming approach emphasizes nothing less than an overall transformation.
?The Deming approach is intended to help top management initiate the transformation and then to depart when this effort is under control by top management. In contrast, many TQM consultants seek long-term consulting efforts with their clients.
?Deep-seated in Deming’s approach is his belief in the social responsibility of business. If the purpose of the organization is to make a profit, it is not to earn a huge profit at the expense of the community, but to make a reasonable profit and provide jobs and give stability to the community it serves. In addition, the Deming approach treats “workers throughout the organization with the respect naturally due every human being. There is a moral tone to the Deming approach that is absent in the others” (Hunt, 1992, p. 81).
Many TQM efforts failed because they lacked a well-developed philosophy. In addition, many of these efforts, especially those conducted on an ad hoc basis, were doomed to failure because of their temporary nature and a loss of their client’s interest as other events and other attractive management approaches diverted the attention of top management.
The views of W. Edwards Deming are worthy of detailed study. His views are complex and not prone to casual reading. Instead, his approach, if it is to be applied, must be studied in detail and applied only in its entirety. A good source of his views is his last book, The New Economics. Now in its second edition it is well worth reading.
Closing remarks
During the 1980s and the first part of the 1990s TQM was a popular subject for many people, especially leaders, managers, consultants, business writers, business school professors and students. The subject, represented by the acronym TQM, was contained in countless books, articles, papers, seminars, and consulting efforts. Often promoted as a solution for many of our organizational ills, it failed to materialize when it was applied superficially. Apart from these TQM efforts, Deming had his own approach for improving organizations. He argued that his approach was an economic necessity and spelled out his approach for transforming the ways of western management. Careful not to invent an acronym or even a phrase that could become a “buzz”
TQM and the Deming approach to quality 487word, he sometimes referred to his approach as “my way” or “the transformation into a new style of management”.Many people continue to view TQM as excellence in management, which Americans have been working on for many years. Unfortunately for them,TQM is so much more than this. In addition to being a transformation and a way of thinking, TQM should not be considered as a recipe that can be applied and forgotten. Further, instead of solving problems as they occur, an effective quality effort should improve the system to prevent these problems in the first place. The Deming approach accomplishes this and focuses on top management and the need for top management to change the system. That is, rather than dwell on special causes of variation and search for errors caused by individual workers, Deming emphasizes the removal of common causes of variation by improving the system. Deming’s approach emphasizes that top management must implement what he elaborated in his 14 points and his system of profound knowledge.
Beyond the acronyms and failed approaches of the past decade and a half,there is a need to focus on real-world quality issues that continue to challenge management. A first step in this direction would be to study the views of Deming. Then, a more difficult step would be to apply them. Finally, an even greater challenge would be to maintain a constancy of effort to continuously improve our products and services.
References
Brocka, B. and Brocka, M.S. (1992), Quality Management: Implementing the Best Ideas of the Masters , Business One Irwin, Homewood, IL.
Crosby, P .B. (1979), Quality Is Free: the Art of Making Quality Certain , McGraw-Hill, New York,NY.
Crosby, P.B. (1984), Quality without Tears , McGraw-Hill, New York, NY.
Deming, W.E. (1985), “Transformation of western style of management”, Interfaces ,Vol. 15 No. 3, May-June, pp. 6-11.
Deming, W.E. (1986), Out of the Crisis,MIT Center for Advanced Engineering Study, Cambridge,MA.
Deming, W .E. (1993), The New Economics: For Industry, Government, Education , MIT Center for Advanced Engineering Study, Cambridge, MA.
Deming, W .E. (1994), The New Economics: For Industry, Government, Education, 2nd ed., MIT Center for Advanced Engineering Study, Cambridge, MA.
Dobyns, L. and Crawford-Mason, C. (1991), Quality or Else: The Revolution in World Business ,Houghton Mifflin, Boston, MA.
Gabor, A. (1990), The Man Who Discovered Quality: How W. Edwards Deming Brought the Quality Revolution to America – The stories of Ford, Xerox, and GM , Times Books, New York,NY.
Gitlow, H., Oppenheim, A. and Oppenheim, R. (1995), Quality Management: Tools and Methods for Improvement, 2nd ed., Irwin, Burr Ridge, IL.
Halberstam, D. (1986), The Reckoning , William Morrow, New York, NY.
Hunt, V.D. (1992), Quality in America: How to Implement a Competitive Quality Program ,Business One Irwin, Homewood, IL.
1.是保障人民健康的重要方式.它是卫生部门使用卫生资源向居民提供医疗、预 防和康复的过程.卫生服务的功能包括预防、诊断、治疗、康复、保健和健康促进. 2.卫生系统：WHO定义为所有以促进、恢复和维护健康为基本目标的活动总体。 3.初级卫生保健：是指最基本的、人人都能得到的、体现社会平等权利的、人民群众和政 府都能负担得起的卫生保健服务。 4.社区卫生服务：是社区建设的重要组成部分，是在政府领导、社区参与、上级卫生机构 指导下，以基层卫生机构为主体，全科医师为主骨干，合理使用社区资源和适宜技术，以人的健康为中心、家庭为单位、社区为范围、需求为导向，以妇女、儿童、老年人、慢性病人、残疾人、低收入人群等为重点，以解决社区主要卫生问题、满足基本卫生服务需求为目标，融预防、医疗、保健、康复、健康教育、计划生育技术等为一体的，有效、经济、方便、综合、连续提供的基层卫生服务。 5.社区护理：是综合公共卫生与专业护理学的理论，为个人、家庭、社区提供促进与维持 健康的一门完整的实务工作。 6.社区卫生服务管理：是指综合运用管理学的理论、方法和技术，通过组织、计划协调和 控制等功能，充分地运用社区卫生中心所拥有的资源，使之发挥最大的效率，产生最大的效益，达到社区卫生服务的目标。 7.知情同意：也称知情许诺或承诺，是指患者有权知晓自己的病情，并对医务人员采取的 防治措施有决定取舍的自治权。 8.医学伦理：是指存在于医疗实践领域中的关系和秩序。 9.医德规范：是医务人员在各种医学活动中应遵守的行为准则。其内容主要是：公正与平 等地对待患者；诚实与慎言守密；信任、尊重与爱护同行；热爱医学事业，不断进取，钻研与发展医学科学技术；廉洁奉公与文明行医等。 10.社区卫生服务伦理：是一般伦理学原理在社区卫生服务中的具体运用，即运用一般伦理 学的原则来解决社区卫生服务过程中的医学道德问题。 11.伦理：是指调整人与人之间相互关系的道理和准则。 12.道德：是指由一定的社会经济关系决定的，以善恶为评价形式，依靠社会舆论、传统习 俗和内心信念，用以调节人际关系的心理意识、原则规范、行为活动的总和。 13.诊疗最优化：是指在社区卫生服务实践中，诊疗方案的选择和实施追求以最小的代价获 取最大效果的决策。 14.保守医密：是指医务人员在医疗中不向他人泄露能造成医疗不良后果的有关患者疾病的
一. 单选（共61题,共61分） 1. 社区卫生服务发展计划的特点是（） A.以“六位一体”的卫生服务为基础 B.以教育培训为龙头 C.以中心管理的实践为支撑 D.以科学研究为发展源泉 E.以上都是 ★标准答案：E 2. 问卷设计中问题的排序要遵守的规则不包括（） A.先普遍性问题后针对性问题 B.先易后难 C.按一定的逻辑顺序排列 D.敏感问题排在后面 E.自由回答的问题放在后面 ★标准答案：A 3. 社区卫生服务网络建设的说法正确的是（） A.网络是以一级医院为基础的 B.网络是以基层组织为主体 C.网络的建设需要计算机专门人才 D.涉及面很广的社会系统工程 E.以上都不对 ★标准答案：D 4. 形势分析的范围不包括（） A.社会经济形势 B.国际卫生事业发展形势 C.社区卫生工作形势 D.社区人口形势和健康问题 E.社区卫生资源状况 ★标准答案：B 5. 定性研究的意义（） A.可获得较深层反应的信息 B.可对定量研究的结果进行补充 C.可以帮助解决定量研究不能解决的问题 D.是收集原始资料的一种方法 E.以上都是 ★标准答案：E 6. 关于社区服务站设置说正确的是（） A.服务人口一般为1000-1500人 B.业务用房面积不低于60平方米 C.每1000-2000人口配备一名全科医师 D.护士在上岗前需有全科护士执业资格 E.全科医师无需医师执业资格证 ★标准答案：B 7. 社区卫生服务的组织结构设计的基本出发点是（） A.确定组织目标 B.确定业务内容 C.确定组织结构 D.规定职责权限 E.配备职务人员 ★标准答案：A 8. 卫生服务需求评价目的是（） A.发现社区存在哪些问题 B.发现社区内居民有什么需要和需求 C.发现社区存在的优先解决的问题 D.为将要实施的社区卫生服务项目 E.以上都是 ★标准答案：E 9. 问卷调查技术的优点是（） A.调查范围广.花费时间长.适用性小 B.适用于面对面的交谈的问题的调查 C.受样本大小限制 D.便于调查者统计调查资料 E.以上都是 ★标准答案：D 10. 问题类型按其内容可分为：（） A.客观的与主观的问题 B.理论性与实践性的问题 C.态度的或情感的问题 D.特异性与非特异性的问题 E.以上都不是 ★标准答案：C 11. 关于社区服务对象说明正确的是（） A.健康人群不属于社区服务对象 B.只有重点保健人群才属于社区服务对象 C.只有病人才是社区服务对象 D.社区服务对象应该是亚健康人群 E.高危人群是社区服务对象之一 ★标准答案：E 12. 适合大规模调查，方便统计分析的是（） A.开放型问卷 B.封闭型问卷 C.图画型问卷 D.半开放型问卷 E.以上都不是 ★标准答案：B 13. 组织文化的特征不包括（） A.特异性与非特异性的统一 B.无形性与有形性的统一 C.稳定性与变革性的统一 D.观念性与实践性的统一 E.个异性与共同性的统一 ★标准答案：A 14. 组织文化的功能不包括（） A.导向功能 B.激励功能 C.约束功能 D.创新功能 E.经济功能 ★标准答案：E 15. 运用其他管理方法时都要与之相配合的管理方法是（） A.法律的方法 B.行政的方法 C.经济的方法 D.思想教育的方法 E.咨询顾问的方法 ★标准答案：D 16. 下列哪项不影响问卷调查结果（） A.回答者对所进行的研究的认识与态度 B.回答者对调查者的印象与态度 C.回答者对所调查内容的兴趣 D.回答者的智力.学识水平 E.回答者的年龄.性别 ★标准答案：E 17. 下列哪项不是社区服务管理的职能作用（） A.预测和计划 B.规范和提高 C.挖潜和创新 D.监督和控制 E.组织和指挥 ★标准答案：B 18. 卫生服务需求的特点不包括：（） A.需求的不确定性。 B.需求的主动性。 C.需求的层次性与发展性。 D.需求和利用的外部关联性。 E.费用支付的多源性。 ★标准答案：B 19. 社区卫生服务网络与二、三级医院之间应建立固定的（） A.双向转诊 B.单向转诊 C.多向转诊 D.偶然转诊 E.以上者不是 ★标准答案：A
全面质量管理基础知识 -、概论 1、质量管理的发展分为五个阶段： 操作者质量管理、工长质量管理、检验员质量管理、统计质量管理、全面质量管理。 2、质量管理随看生产的发展已成为一门具有完整理论体系 的边缘学科。 全面质量管理的发展和深化将成为人类生产活动的永恒主题。 3、全面质量管理的深化和发展的主要标志是建立一个包含 IS09000和IS014000标准的全面质量一体化管理体系（TQIMS）,把全面质量管理推向更加科学化、规范化和标准化的新阶段。 4、ISO8402术语标准对全面质量管理的定义： 一个组织以质量为中心，以全员参与为基础，目的在于通过让顾客满意和本组织所有成员及社会受益而达到长期成功的管理途径。 5、全面质量管理的原理：是基于对质量形成的全过程，即 质量环的控制，并通过有效的质量体系或系统工程为基础来实施和体现。质量环和系统工程可以用过程来体现，过
程的不稳定性，正是全面质量管理的控制目标。 6、不同的行业和产品都有各自的特点，因此质量环的划分 应该随行业和产品不同而有一定的差异，但是，无论质量环如何不同，其产品质量形成的全过程都应包括在内并进行有效控制。 7、全面质量管理的特点：全员、全过程、全范围及多方法 的质量管理。 8、全面质量管理与传统质量管理的差异：强调系统管理、 强调预防为主、强调不断改进、强调满足顾客需要。 二、全面质量管理体系的建立与运行 1、全面质量管理的构成要素包括：质量方针、质量目标、 质量体系、质量策划、质量 成本、质量改进和质量文化及质量审核。 2、质量方针：由组织的最高管理者正式发布的该组织总的质量宗旨和质量方向。 3、质量体系：为实施质量管理所需的组织结构、程序、过程和资源。 三、过程控制和质量控制点 1、过程控制是质量管理的核心和基础，质量控制点是过程 控制的重要措施和方法。 2、过程是将输入转化为输出的一组相关联的资源和活 动。资源可包括人员、资金、装置、设备，以及技术和方
**汽车全面质量管理推行方案 一、目的： 通过推行全面质量管理，提高公司各部门关于产品、服务、安全等质量管理水平，以满足公司各项工作实现又快又好及构建和谐企业文化的需求，实现企业增收、品牌度提升、巩固和提高公司在行业中的地位，做顾客最满意的企业，打造享誉国际的知名品牌企业。二、范围： 本方案适应于**汽车制造有限公司 三、目标： 1、实施全面质量管理从基础现场5S、看板管理、产品“三检制”（自检、互检、专检）推行，再到全面质量改进小组活动（简称QC活动）实现工作和服务效率提升、人员组织结构优化、职责和权限明确化 2、通过全面质量活动推行，增强员工自主改善意识，实现快速提升工厂的过程控制能力 四、职责 1、**汽车制造有限公司厂长为全面质量推进组组长负责整个活动推进中的资源协调支持。 2、质量部负责整体方案的策划、跟踪。负责全面质量推进各项活动的组织、跟进、协调及管控工作。 3、技术部负责制定、修改完善公司的生产技术文件（如作业指导书、检验标准等） 4、生产管理部、物流及各车间负责整改内部非标准作业及推近“三不原则”，各工序坚持自检、互检。 5、其他部门部门负责人向所在部门宣贯TQM知识、负责TQM具体推行及指导落实等管理工作 五、具体实施内容 立即实施项目： 1、重点质量问题管理：通过梳理生产过程、市场反馈、整车功能设计等存在的急需解 决的关键问题，成立QC小组，快速功关。**汽车2月起实施QC小组活动，各部门提
交部门内的重点质量问题至质量部文控处，进行立项攻关解决，QC小组负责进行统一并形成公司跟进项目进行监督实施进度及结果。 2、分段质量改进，建立惩罚机制： ①零部件质量通过对供应商能力、零件到货质量进行统计，制定供应商提升计划及现场辅助计划，形成《整改报告》，明确零部件的质量标准，并组织供应商签订明确的《质量保证协议》，并逐步组织联合评价组完成对供应商的审核评价工作，实现供应商的科学管理，优化一批，淘汰一批。 ②检验及过程质量在发生问题时由QC小组成员或车间负责人采取现场实物会的模式将操作者、检验员及下序操作者集中到问题的面前，让其了解问题的状态及发生的原因及过程，切身感受自身的失误造成的问题结果，让下序对上序的工作内容及标准熟知且能有效截留，并对重点问题制作成《质量警示卡》置于操作现场、检验关口进行时刻提醒来促进过程及检验的问题意识的提升及技能水平进步。 六持续循环推进项目： 1、意识建立： 对全员进行《全面质量管理基础知识》理论培训，从知识、思想上使全员认知并了解全面质量管理的内涵及推行的积极意义 质量部负责课件制作，各车间部门负责培训工作组织，综合办公室协助配合。 2、现场5s活动推进：建立5s是一切工作的基础理念，将现场所有物品按照定品、定量、定位的原则进行标识目视管理，防止错送、拿、装等失误的发生，提升现场工作效率及准确率，并结合5s的具体内容（见下图）进行循环式持续提升。
第十二章社区卫生服务管理 一、名词解释 1．社区卫生服务 2．社区卫生服务质量 3．居民健康档案 二、填空题 1．根据社区人群的基本情况，可将社区卫生服务对象分为、、、和五大类。 2．社区卫生服务以中心、为单位、为范围、为导向的基本医疗卫生服务。 3．社区卫生服务内容应该 融、、、、、为一体。 4．居民个人健康档案主要包括、、和四个部分。 5．社区卫生服务管理信息的内容，主要包 括、、。
三、选择题 1．社区卫生服务是以人的（）为中心的基层卫生服务。 A 需求 B 健康 C 家庭 D 经济 2．社区卫生服务的特点是（） A 以专家为基础的服务 B 以保健为基础的服务 C 以医疗为基础的服务 D 以社区为基础的服务 3．社区卫生服务对象是（） A 病人 B 老年人 C 社区内的全体人群
D 重点保健人群 4．社区卫生服务是以（）为导向的基层卫生服务。 A 健康 B 病人 C 需求 D 利用 5．老年人是属于（） A 慢性病人群 B 亚健康人群 C 高危人群 D 重点保护人群 四、简答题 1．简述社区卫生服务主要内容。 2．简述社区卫生服务的特点。 3．简述个人健康档案中问题描述“S-O-A-P”的具体内容。
1．论述社区卫生服务质量评价要点。 参考答案 一、名词解释 1．社区卫生服务是社区发展建设的重要组成部分，是在政府领导、社区参与、上级卫生机构指导下，以基层卫生机构为主体、全科医师为骨干，合理使用社区资源和适宜技术；以人的健康为中心、家庭为单位、社区为范围、需求为导向；以妇女、儿童、老年人、慢性病人、残疾人等为重点；以解决社区主要卫生问题，满足基本医疗卫生服务需求为目的；融预防、医疗、保健、康复、健康教育、计划生育技术服务等为一体的、有效的、经济的、方便的、综合的、连续的基层卫生服务。 2．社区卫生服务质量是指向全社区人群提供最佳可能的医疗、预防、保健、康复等服务，使全体人群满意。良好的社区卫生服务质量应该包括对社区卫生服务需求者提供可及的、适宜的、有效的、高质量的又能充分利用社区资源，鼓励居民和社区积极参与，以达到增进社区全体人群健康、延长期望寿命和提高生活质量。 3．居民健康档案是记录有关居民健康信息的系统化文件，它是社区卫生服务工作中收集、记录社区居民健康信息的重要工具。
名词解释名词解释： .卫生服务:是保障人民健康的重要方式.它是卫生部门使用卫生资源向居民提供医疗、预防和康复的过程.卫生服务的功能包括预防、诊断、治疗、康复、保健和健康促进. .卫生系统：定义为所有以促进、恢复和维护健康为基本目标的活动总体。 .初级卫生保健：是指最基本的、人人都能得到的、体现社会平等权利的、人民群众和政府都能负担得起的卫生保健服务。 .社区卫生服务：是社区建设的重要组成部分，是在政府领导、社区参与、上级卫生机构指导下，以基层卫生机构为主体，全科医师为主骨干，合理使用社区资源和适宜技术，以人的健康为中心、家庭为单位、社区为范围、需求为导向，以妇女、儿童、老年人、慢性病人、残疾人、低收入人群等为重点，以解决社区主要卫生问题、满足基本卫生服务需求为目标，融预防、医疗、保健、康复、健康教育、计划生育技术等为一体的，有效、经济、方便、综合、连续提供的基层卫生服务。.社区护理：是综合公共卫生与专业护理学的理论，为个人、家庭、社区提供促进与维持健康的一门完整的实务工作。 .社区卫生服务管理：是指综合运用管理学的理论、方法和技术，通过组织、计划协调和控制等功能，充分地运用社区卫生中心所拥有的资源，使之发挥最大的效 率，产生最大的效益，达到 社区卫生服务的目标。 .医学伦理：是指存在于医疗 实践领域中的关系和秩序。 .医德规范：是医务人员在各 种医学活动中应遵守的行 为准则。其内容主要是：公 正与平等地对待患者；诚实 与慎言守密；信任、尊重与 爱护同行；热爱医学事业， 不断进取，钻研与发展医学 科学技术；廉洁奉公与文明 行医等。 .社区卫生服务伦理：是一般 伦理学原理在社区卫生服 务中的具体运用，即运用一 般伦理学的原则来解决社 区卫生服务过程中的医学 道德问题。 .伦理：是指调整人与人之间 相互关系的道理和准则。 .道德：是指由一定的社会经 济关系决定的，以善恶为评 价形式，依靠社会舆论、传 统习俗和内心信念，用以调 节人际关系的心理意识、原 则规范、行为活动的总和。 .诊疗最优化：是指在社区卫 生服务实践中，诊疗方案的 选择和实施追求以最小的 代价获取最大效果的决策。 .保守医密：是指医务人员在 医疗中不向他人泄露能造 成医疗不良后果的有关患 者疾病的隐私。 .合理用药：是指以当代药物 和疾病的系统知识和理论 为基础，安全、有效、经济、 适当地使用药品。 .政策：是指国家和政党为了 实现一定的目标而确定的 行动准则，它表现为对人们 的利益进行分配和调节的 政治措施和复杂过程。 .卫生政策：是指社会为了满 足人们医疗卫生需要而采 取的行动方案和行动依据， 其目的是研究配置有限卫 生资源的合理方法。 .法：是指由一定社会物质生 活条件决定的统治阶级意 志的体现，是以国家制定或 认可，并以国家强制力来保 证实施的行为规范的总和。 .卫生法：是指由国家制定或 认可，并由国家强制力保证 实施的旨在调整保护人体 健康活动中形成的各种社 会关系的法律规范的总称。 .卫生法律关系：是指由卫生 法所调整的国家机关、企事 业单位和其他社会团体之 间，它们的内部机构以及它 们与公民之间在卫生管理 和医药卫生预防保健服务 过程中所形成的权利和义 务关系。 .医疗事故：是指医疗机构及 其医务人员在医疗活动中， 违反医疗卫生管理法律、行 政法规、部门规章和诊疗护 理规范、常规，过失造成患 者人身损害的事故。 .社区卫生服务组织管理：是 通过社区卫生服务机构内 部管理和社区卫生服务的 民主管理来达到实现高效 率完成社区基本公共卫生 服务和社区基本医疗服务 任务的过程。 .社区卫生服务管理理念强 调：以人群健康为中心，社 区为范围，家庭为单位，需 求为导向，便利低价快捷为 手段，提供健康教育、预防、 保健、康复、计划生育技术 服务和一般常见病、多发病
全面质量管理思想集中体现在PDCA循环上： 1、计划(plan)阶段：包括四个步骤，即找出存在的问题，分析产生问题的原因，找出主要原因、制定对策。 2、执行（do）阶段：按照制定的对策实施，并收集相应的数据。 3、检查（check）阶段：检查取得的效果，对改进的效果进行评价，看实际结果与原定目标是否吻合。 4、处理（Aact）阶段：包括两个步骤：即制定巩固措施，防止问题发生；提出遗留问题和下一步打算。 全面质量管理 一、TQM的来源 全面质量管理（Total Quality Management，简称TQM）是以质量管理为中心，以全员参与为基础，旨在通过让顾客和所有相关方受益而到达长期成功的一种管理途径。菲根堡姆于1961年提出全面质量管理的概念。发达国家组织运用全面质量管理使产品或服务质量获得迅速提高，引起了世界各国的广泛关注。全面质量管理的观点逐渐在全球范围内获得广泛传播，各国都结合自己的实践有所创新发展。目前举世瞩目的ISO9000族质量管理标准、美国波多里奇奖、欧洲质量奖、日本戴明奖等各种质量奖及卓越经营模式、六西格玛管理模式等，都是以全面质量管理的理论和方法为基础的。 二、TQM的定义 为了能够在最经济的水平上并考虑到充分满足顾客要求的条件下进行市场研究、设计、制造和售后服务，把企业内各部门的研制质量、维持质量和提高质量的活动构成为一体的一种有效的体系。 TQM的管理理念是已客户为导向的，所有全员质量管理组织的人员通过全员参与的，通过跨功能、跨等级的管理，利用所有的解决问题的方法来系统地管理组织的改进与进步。 TQM 结合了产品质量，过程控制，质量保证，和质量改进，从而成为一个经过变革后的组织中的过程的控制，能通过更经济有效的方式来满足客户要求。受控的生产过程在产品和服务未能满足客户需求时仍不能帮助公司增长市场份额。 三、实施TQM的作用： 1. 提高产品质量 2. 改善产品设计 3. 加速生产流程 4. 鼓舞员工的士气和增强质量意识 5. 改进产品售后服务 6. 提高市场的接受程度 7. 降低经营质量成本
白峰镇社区卫生服务中心慢性病管理制度 发布时间：2007-11-16 14:52:29 阅读：1786次 白峰镇社区卫生服务中心慢性病管理制度 慢性非传染性疾病是目前严重危害人民健康的主要疾病，为预防和控制肿瘤、冠心病、脑卒中、高血压和糖尿病等非传染性疾病的发生和流行，为了加强我镇慢性病登记报告管理工作，结合我镇实际情况，制定本制度。 一、管理组织：成立由中心主任、预防保健部和医疗服务部人员组成的慢性病管理小组，负责全中心慢性病管理工作。 组长：童世杰 副组长：张国安胡磊 组员：陆勇毅乐明伟史旭东虞锋华郑康军周科位张金伦 二、报告对象 辖区内有常住户口的居民 三、报告单位 辖区内社区卫生服务中心、社区卫生服务站。 四、报告内容： 1、糖尿病确诊为糖尿病的病例； 2、高血压病例（单指原发性高血压）； 3、冠心病急性发作病例（非致死性）； 4、脑卒中发作指非致死性脑卒中（蛛网膜下腔出血、脑出血、脑血栓形成、脑栓塞及未分类脑卒中），不包括一过性脑缺血发作及慢性脑动脉硬化。 5、肿瘤确诊为恶性肿瘤和中枢神经系统的良性肿瘤病例。 五、病例个案收集方法 1、医疗机构报告 ①本辖区社区卫生服务中心、社区卫生服务站发现的冠心病急性发作、脑卒中发作病例、确诊新发糖尿病病例、高血压病例。 ②在区外医疗保健机构已经确诊，但在我区医疗机构为初次就诊的五种慢性病病例。 2、漏报调查
通过医院漏报调查发现的漏报病例应及时填写发病报告卡补报。 3、主动搜索与体检发现 结合我区三年为一周期的参保农民健康体检，发现病例及可疑病例，应做好报告登记或劝其及时诊治。 六、报告程序及报告要求 1、门诊医生发现糖尿病病例、冠心病急性事件、脑卒中发作、肿瘤（恶性肿瘤和中枢神经系统的良性肿瘤）四种病例，由接诊医生填写相应的发病报告卡，并在门诊病卡上签上相应的慢性病已报印章，在24小时内向疾病防制科报告。 疾病防制科收集报告卡，检查填写质量，于7个工作日内输入到相应的慢性病电子管理录入表。发病报告卡输入后10天内报送区疾控中心。将不在本辖区的病例从慢性病电子管理录入表中筛选出来，每周用Email发送到患者现住地的社区卫生服务中心防保科。各社区卫生服务中心每周对收到的Email内的有关慢性病信息及时整合到慢性病电子管理录入表。每月末5日前将当月的电子表分辖区打印装订成册。 高血压病例由接诊医生在24小时内登记到高血压发病登记册，由疾病防制科收集发病登记册，检查填写质量，每月5日前输入到高血压电子管理录入表。 2、医院漏报病例由医院防保人员负责查漏，由接诊医生补填发病报告卡和高血压发病登记册。补卡后及时输入到相应的慢性病电子管理录入表，报告卡及时报送区疾控中心。 3、疾病防制科于每月、季、年末5天前向区疾控中心上报本辖区内上述慢性病的发病报告统计表，并将当月电子表发送至中心gfkingdom@https://www.doczj.com/doc/9a17302261.html,备份 七、发病报告有关注意要点 1、急性心肌梗死（非致死性）、脑卒中 急性心肌梗死及脑卒中发病期限均定为急性发病后28天，28天内如有新发展或第二次急性发作均不作登记；如28天后有新发展或急性发作则按另一病例登记一次。（急性心肌梗死发病28天后无新的发作即算作慢性冠心病，脑卒中急性发作28天后无新的发作，但留有后遗症者均算作慢性脑血管病）。 2、恶性肿瘤 2.1填报对象 ①经病理组织学、细胞学检查、手术及其他专门检查诊断，或临床诊断（排除其他疾病）确诊的； ②对原发恶性肿瘤漏报的复发和转移病例； 填报时，复发和转移病例应注明原发部位及首次诊断日期；对同一患者先后出现的原发
社区卫生服务机构管理办法（试行） 服务功能与执业范围 社区卫生服务机构服务对象为辖区内的常住居民、暂住居民及其他有关人员。 社区卫生服务机构提供以下公共卫生服务： （一）卫生信息管理。根据国家规定收集、报告辖区有关卫生信息，开展社区卫生诊断，建立和管理居民健康档案，向辖区街道办事处及有关单位和部门提出改进社区公共卫生状况的建议。 （二）健康教育。普及卫生保健常识，实施重点人群及重点场所健康教育，帮助居民逐步形成利于维护和增进健康的行为方式。 （三）传染病、地方病、寄生虫病预防控制。负责疫情报告和监测，协助开展结核病、性病、艾滋病、其他常见传染病以及地方病、寄生虫病的预防控制，实施预防接种，配合开展爱国卫生工作。 （四）慢性病预防控制。开展高危人群和重点慢性病筛查，实施高危人群和重点慢性病病例管理。 （五）精神卫生服务。实施精神病社区管理，为社区居民提供心理健康指导。 （六）妇女保健。提供婚前保健、孕前保健、孕产期保健、更年期保健，开展妇女常见病预防和筛查。 （七）儿童保健。开展新生儿保健、婴幼儿及学龄前儿童保健，协助对辖区内托幼机构进行卫生保健指导。 （八）老年保健。指导老年人进行疾病预防和自我保健，进行家庭访视，提供针对性的健康指导。 （九）残疾康复指导和康复训练。 （十）计划生育技术咨询指导，发放避孕药具。 （十一）协助处置辖区内的突发公共卫生事件。 （十二）政府卫生行政部门规定的其他公共卫生服务。 社区卫生服务机构提供以下基本医疗服务： （一）一般常见病、多发病诊疗、护理和诊断明确的慢性病治疗。 （二）社区现场应急救护。 （三）家庭出诊、家庭护理、家庭病床等家庭医疗服务。 （四）转诊服务。 （五）康复医疗服务。 （六）政府卫生行政部门批准的其他适宜医疗服务。 社区卫生服务机构应根据中医药的特色和优势，提供与上述公共卫生和基本医疗服务内容相关的中医药服务。
《全面质量管理》学习心得 我单位组织学习了《全面质量管理》，学习了关于质量管理、质量文化，质量管理系统的重要内容。 朱兰的“质量管理三部曲”是我们今后学习和应用的最好内容。她提出要获得质量，最好从建立组织的“愿景”以及方针和目标开始。目标向成果的转化（使质量得以实现）使通过管理过程来进行的，而过程是生产预期成果的一系列活动。质量策划、质量控制和质量改进这三个阶段是相辅相成的。质量策划明确了质量管理所要达到的目标以及实现这些目标的途径，是质量管理的前提和基础。质量控制确保组织的活动按照计划的方式进行，是实现质量目标的保障。质量改进则意味着质量水准的飞跃，标志着质量活动是以一种螺旋式上升的方式不断提高。 随着质量概念的普及，人们越来越发现，质量与文化密不可分，质量管理需要良好的文化氛围，质量文化是组织文化的重要组成部分。组织文化有可见的不可见的两部分组成，规定了组织成员的行为模式。组织文化的可见部分是指通过对组织及其成员的观察而得到、听到和注意到的全部东西，如着装、标志、组织的仪式等。组织文化不可见部分是组织的价值观。其中有些价值观是组织员工有意识持有的，可以从组织中流传的故事、使用的语言等说明其存在；有些价值观深深根植于组织文化中，以至
于意识不到他们的存在，并无意识地引导着组织成员的行为和决策。这些无意识地价值观成为真正隐含的假设和信念，构成组织文化的精髓。在当今竞争激烈的环境中，全面质量管理作为企业战略竞争武器，是希望保持长期成功的企业必须选择的管理模式。也就是说，必须把全面质量管理的思想和观点融入到组织文化中，形成以质量为主导的组织文化，组织才能取得长期成功。从这个意义上讲，当组织正真开展全面质量管理活动，当组织取得长期成功时，质量文化已经成为组织文化的核心部分了。可见，质量文化是组织全体员工在质量方面所共有的价值观、信念、共识及规范的组合，在开展全面质量管理活动的组织中，质量文化是组织文化的核心内容。组织的领导者在质量文化创建和质量文化的氛围营造方面发挥着关键作用。 在激烈的市场竞争环境下，组织的质量管理涉及的问题很多，包含的范围也越来越广，为了实现组织的目标，就需要建立一个协调一致的系统，对所有关键活动进行持续的管理、控制和改进。所谓系统就是组织内一系列通过合作来达成组织的目的德功能或活动。系统的活动都可以作为过程来理解，因此每一个系统也就是一个诸多过程构成的过程的网络。在一个组织内，存在各种各样的系统，既有整体的经营管理，也有各职能活动系统，例如生产管理系统、质量管理系统等。每一个组织都有自己的使命、愿景，每一个系统也都要完成特定的任务，达到一定的目标，因此必须把所有的活动整合起来，使系统中的各过程相互协调，
全面质量管理的常用方法一 【本讲重点】 排列图 因果分析法 对策表方法 分层法 相关图法 排列图法 什么是排列图 排列图又叫巴雷特图，或主次分析图，它首先是由意大利经济学家巴雷特（Pareto）用于经济分析，后来由美国质量管理专家朱兰（J.M.Juran）将它应用于全面质量管理之中，成为全面质量管理常用的质量分析方法之一。 排列图中有两个纵坐标，一个横坐标，若干个柱状图和一条自左向右逐步上升的折线。左边的纵坐标为频数，右边的纵坐标为频率或称累积占有率。一般说来，横坐标为影响产品质量的各种问题或项目，纵坐标表示影响程度，折线为累计曲线。 排列图法的应用实际上是建立在ABC分析法基础之上的，它将现场中作为问题的废品、缺陷、毛病、事故等，按其现象或者原因进行分类，选取数据，根据废品数量和损失金额多少排列顺序，然后用柱形图表示其大小。因此，排列图法的核心目标是帮助我们找到影响生产质量问题的主要因素。例如，可以将积累出现的频率百分比累加达到70%的因素成为A类因素，它是影响质量的主要因素。 排列图的绘制步骤 排列图能够从任何众多的项目中找出最重要的问题，能清楚地看到问题的大小顺序，能了解该项目在全
体中所占的重要程度，具有较强的说服力，被广泛应用于确定改革的主要目标和效果、调查产生缺陷及故障的原因。因此，企业管理人员必须掌握排列图的绘制，并将其应用到质量过程中去。 一般说来，绘制排列图的步骤如图7-1所示，即：确定调查事项，收集数据，按内容或原因对数据分类，然后进行合计、整理数据，计算累积数，计算累积占有率，作出柱形图，画出累积曲线，填写有关事项。 图7-1 排列图的绘制步骤 排列图的应用实例 某化工机械厂为从事尿素合成的公司生产尿素合成塔，尿素合成塔在生产过程中需要承受一定的压力，上面共有成千上万个焊缝和焊点。由于该厂所生产的十五台尿素合成塔均不同程度地出现了焊缝缺陷，由此对返修所需工时的数据统计如表7-1所示。 表7-1 焊缝缺陷返修工时统计表 序号项目返修工时fi 频率 pi/% 累计频率 fi/% 类别 1焊缝气孔14860.460.4A 2夹渣5120.881.2A 3焊缝成型差208.289.4B 4焊道凹陷15 6.195.5B 5其他11 4.5100C 合计245100 缝成型差、焊道凹陷及其他缺陷，前三个要素累加起来达到了89.4%。根据这些统计数据绘制出如图7-2所示的排列图：横坐标是所列举问题的分类，纵坐标是各类缺陷百分率的频数。
论社区卫生服务管理及常用方法 摘要：社区是我们生活中不可缺少的一个综合基础的群众基础机构。他为我们居住在一个固定区域的居民群体范围内的居民，起着一种媒介桥梁作用。社区卫生服务是社区建设的重要组成部分，是在政府领导、社区参与、上级卫生机构指导下，以基层卫生机构为主体，全科医师为骨干，合理使用社区资源和适宜技术，以人的健康为中心、家庭为单位、社区为范围、需求为导向，以妇女、儿童、老年人、慢性病人、残疾人等为重点，以解决社区主要卫生问题、满足基本卫生服务需求为目的，融预防、医疗、保健、康复、健康教育、计划生育技术服务等为一体的，有效，经济、方便、综合、连续的基层卫生服务。 关键词：社区卫生服务管理方法 社区卫生服务从生物医学模式转变为生物一心理一社 会医学模式，是全球医学发展的大趋势，我国转变较慢，究其原因主要是医院医生从观念、制度到方法等方面，缺乏一整套促进医学模式转变的机制[1]。社区卫生服务在我国的实践仅仅10年左右，属于一个新生事物，经过近年在为我们广大居民群众做着一些日常生活中所需与社会团体旋节沟
通连贯的作用。是我们信任的一个基础机构，与居民群众生活有着息息相关的关联基层组织，随着医疗卫生走向市场化，社会公益性质的淡化，“看病难、看病贵”成为社会关注的热点问题。在构建社会主义和谐社会的今天，群众的看病就医问题不能看作是一个单纯的医疗卫生闯题，实际上是当前和谐社会建设的一个重要课题.特别是随着我国经济体制改革的深入，社会成员从属于就业单位的管理体制正在被打破，昔日的“单位人”逐步转变成为“社会人”。在这种情况下，大力加强社区建设，努力改善社区居民生活的服务功能，增强居民对社区的归属感和认同感，对于做好新形势下的社会管理和社会服务工作十分重要。 1.服务对象：社区卫生服务的主要对象包括老年人、妇女，儿童、慢性病人、残疾人以及贫困家庭、流动人口等。社区卫生服务为这部分弱势群体排忧解难，弘扬了中华民族的传统美德，丰富了社区建设的内涵。因此，积极发展社区卫生服务，不仅有助于建设新型的基层卫生服务体系，满足群众的基本医疗和公共卫生服务需求。做好社会弱势群体的医疗保障工作。促进卫生服务的公平性、可及性。缓解进而解决群众“看病难、看病贵”问题，更重要的是体现了构建和谐社会的重要思想和我国政府“以人为本”的执政理念，这对于维护社会稳定，巩固基层政权，促进国家长治久安具有深远的意义。
第一章绪论 一、社区的概念：社区是若干社会群体(家庭、氏族)或社会组织(机关、团体)聚集在某一地域里所形成的一个生活上相互关联的大集体。(费孝通) 二、构成社区的五要素： 1、以一定社会关系为基础组织起来共同生活的人口 2、一定的地域条件 3、有一定的生活服务设施 4、具有特定的文化背景、认同意识和生活方式 5、一定的制度和管理结构 三、社区卫生服务： 1、是城市卫生工作的重要组成部分，是实现人人享有初级卫生保健目标的基础环节； 2、是在政府领导、社区参与、上级卫生机构指导下，以基层卫生机构为主体，全科医师为骨干，合理使用社区资源和适宜技术，以人的健康为中心、家庭为单位、社区为范围、需求为导向； 3、以妇女、儿童、老年人、慢性病人、残疾人为重点，以解决社区主要卫生问题、满足基本卫生服务需求为目的； 4、融预防、医疗、保健、康复、健康教育、计划生育技术指导为一体的； 5、有效、经济、方便、综合、连续的基层卫生服务。 四、社区卫生服务的核心观念转变： 以医院为基础?以社区为基础 以疾病为中心?以人为本，以健康为中心 供方导向?需方导向 五、社区卫生服务管理学概念： 社区卫生服务管理学是应用管理理论和方法，研究社区卫生管理的基本特点和发展规律，完善社区卫生服务管理体制和运行机制，提高社区卫生服务的整体功效，更好地为社区居民提供良好的卫生服务，有效地保障人群健康的一门科学。 社区卫生服务管理学既与医学科学相联系，又与其他自然科学和社会科学相联系，是管理科学的一个分支学科，其应用性很强。 六、社区卫生服务的提供者： 下列人员构成社区卫生服务基本服务团队： 1、全科医师、社区专科医师、社区助理医师、社区中医师。 2、社区公共卫生人员与防保人员。 3、社区护理人员。 4、药剂师、检验师、康复治疗师及其他卫技人员。 5、管理者、医学社会工作者、志愿者。 七、服务对象： 1、健康人群 2、高危人群：高危人群是存在明显的对健康有害因素的人群，其发生疾病的概率明显高于其他人群。包括： (1)高危家庭的成员：凡具有以下一个或多个标志的家庭即为高危家庭：①单亲家庭；②吸毒、酗酒者家庭；③精神病患者、残疾者、长期重病者家庭；④功能失调濒于崩溃的家庭； ⑤受社会歧视的家庭。 (2)具有明显的危险因素的人群：如肥胖、吸烟、酗酒、吸毒、运动不足、睡眠缺乏规律等。
城市社区卫生服务机构管理办法（试行） (卫妇社发〔2006〕239号) 各省、自治区、直辖市及计划单列市卫生厅（局）、中医药管理局，新疆生产建设兵团卫生局，卫生部各直属单位： 为贯彻落实《国务院关于发展城市社区卫生服务的指导意见》（国发〔2006〕10号），加强对城市社区卫生服务机构的管理，根据有关法律、法规，卫生部和国家中医药管理局制订了《城市社区卫生服务机构管理办法（试行）》，现印发给你们，请遵照执行。 二〇〇九年三月十六日
城市社区卫生服务机构管理办法（试行） 第一章总则 第一条为贯彻落实《国务院关于发展城市社区卫生服务的指导意见》（国发〔2006〕10号），加强对城市社区卫生服务机构设置与运行的管理，保障居民公平享有安全、有效、便捷、经济的社区卫生服务，根据《中华人民共和国执业医师法》、《中华人民共和国传染病防治法》、《中华人民共和国母婴保健法》、《医疗机构管理条例》等相关法律法规制定本办法。 第二条本办法所称社区卫生服务机构是指在城市范围内设置的、经区（市、县）级政府卫生行政部门登记注册并取得《医疗机构执业许可证》的社区卫生服务中心和社区卫生服务站。 第三条社区卫生服务机构以社区、家庭和居民为服务对象，以妇女、儿童、老年人、慢性病人、残疾人、贫困居民等为服务重点，开展健康教育、预防、保健、康复、计划生育技术服务和一般常见病、多发病的诊疗服务，具有社会公益性质，属于非营利性医疗机构。 第四条卫生部负责全国社区卫生服务机构的监督管理。区（市、县）级以上地方政府卫生行政部门负责本行政区域内社区卫生服务机构的监督管理。 第二章服务功能与执业范围 第五条社区卫生服务机构服务对象为辖区内的常住居民、暂住居民及其他有关人员。 第六条社区卫生服务机构提供以下公共卫生服务： （一）卫生信息管理。根据国家规定收集、报告辖区有关卫生信息，开展
全面质量管理基础知识 一、概论 1、质量治理的进展分为五个时期： 操作者质量治理、工长质量治理、检验员质量治理、统计质量治理、全面质量治理。 2、质量治理随着生产的进展已成为一门具有完整理论体系的边缘学科。 全面质量治理的进展和深化将成为人类生产活动的永恒主题。 3、全面质量治理的深化和进展的要紧标志是建立一个包含ISO9000和ISO14000标准的 全面质量一体化治理体系（TQIMS），把全面质量治理推向更加科学化、规范化和标准化的新时期。 4、ISO8402术语标准对全面质量治理的定义： 一个组织以质量为中心，以全员参与为基础，目的在于通过让顾客中意和本组织所有成员及社会受益而达到长期成功的治理途径。 5、全面质量治理的原理：是基于对质量形成的全过程，即质量环的操纵，并通过有效的 质量体系或系统工程为基础来实施和体现。质量环和系统工程能够用过程来体现，过程的不稳固性，正是全面质量治理的操纵目标。 6、不同的行业和产品都有各自的特点，因此质量环的划分应该随行业和产品不同而有一 定的差异，然而，不管质量环如何不同，其产品质量形成的全过程都应包括在内并进行有效操纵。 7、全面质量治理的特点：全员、全过程、全范畴及多方法的质量治理。 8、全面质量治理与传统质量治理的差异：强调系统治理、强调预防为主、强调持续改进、 强调满足顾客需要。 二、全面质量治理体系的建立与运行 1、全面质量治理的构成要素包括：质量方针、质量目标、质量体系、质量策划、质量 成本、质量改进和质量文化及质量审核。 2、质量方针：由组织的最高治理者正式公布的该组织总的质量宗旨和质量方向。 3、质量体系：为实施质量治理所需的组织结构、程序、过程和资源。 三、过程操纵和质量操纵点 1、过程操纵是质量治理的核心和基础，质量操纵点是过程操纵的重要措施和方法。 2、过程是将输入转化为输出的一组有关联的资源和活动。资源可包括人员、资金、装置、 设备，以及技术和方法等。 3、工序是制造操纵的要紧环节。工序操纵的目的是为实现产品设计质量，通过制造最终 达到预期目标及满足用户要求。 4、工序能力确实是操作者、设备、工装、使用的原材料、操作方法、检验方法以及环境 等都在标准的条件下，操作呈稳固状态时所具有的加工精度，也确实是工序处于稳固状态下的实际加工能力。 5、在服务质量环中，较为重要的是服务设计过程和服务提供过程，他们是服务质量形成 的要紧环节。 6、质量操纵点：是指在质量活动过程中需要重点进行操纵的对象或实体。
全面质量管理的基本工作方法——PDCA循环 （一）PDCA工作循环的含义 美国质量管理专家戴明博士在20世纪50年代提出一种质量管理的工作程序：全面质量管理体系的运动就是周而复始地通过计划（Plan）、执行（Do）、检查（Check）、处理（Action）四个阶段的科学管理工作程序，即简称PDCA工作循环。PDCA工作循环可分为四个阶段、八个工作步骤。 第一阶段：P（计划）。确定企业总的质量目标和质量计划，把总目标落实到各部门和各环节，提出改进目标和改进措施。这一阶段分为四个步骤实现：（1）分析现状，寻找存在的质量问题。 （2）分析产生问题的各种原因。 （3）找出主要矛盾和主要原因。 （4）制定计划，拟订措施，并且具体落实到执行者。 第二阶段：D（实施）。根据计划要求具体实施措施质量，实现计划。 第三阶段：C（检查）。把实施结果与预定目标、计划对比，检查计划执行情况是否达到预期目的。 第四阶段：A（处理）。根据检查结果，总结经验教训，处理问题。这一阶段分为二个步骤实现： （1）把有效措施纳入质量管理标准，进行标准化，总结经验，巩固成绩。 （2）将遗留问题转入下一个循环，作为下一个循环的计划目标。 （二）PDCA工作循环的特点 1. 大环套小环和相互促进，不断运动 企业的方针目标和措施的计划、执行、检查、处理可视为大循环；各车间、科室按大环的要求进行本部门的小循环；班组的PDCA循环保证车间计划的完成，最终实现大循环。通过循环把企业各部门、各环节的工作有机结合起来，互相促进。 2. 不断循环，不断提高质量 循环每进行一次，就解决一些问题，使产品质量提高如同爬楼梯一样，推动PDCA循环前进。
社区卫生服务机构内部运行管理制度 行政管理制度 1.在地方政府和卫生行政部门领导下，为社区家庭和居民提供公共卫生和基本医疗服务，认真落实各项卫生工作指标。 2.接受卫生行政部门的监督管理及各专业防治、保健机构的业务指导。 3. 每年第四季度完成本年度工作总结及制定下一年度工作计划，并报上级卫生行政部门。 4. 建立和完善规章制度，每年至少检查一次执行情况，并提出可持续改进措施。 5. 建立请示报告制度。遇各类重大事项及突发事件，及时向主管领导、上级卫生行政部门请示报告。 6.建立例会制度。每月至少召开一次主任办公会、科主任会；每半年至少召开一次辖区街道办事处(社区居委会)协调会，及时传达上级有关部门的政策和精神，解决工作中存在的问题，部署具体工作。 7. 建立总值班制度。机构每日设专人负责处理医疗、行政事宜，并及时传达上级指令、处理紧急情况等。 8.实行院务公开制度。向社会公开服务信息、服务规范、服务流程、服务价格；向职代会公开发展规划、年度工作计划、规章制度、岗位职责、人事任免、财务预、决算、领导干部廉洁自律情况等。 人力资源管理制度 1.按服务人口合理配置全科医生、社区护士、预防保健人员及一定比例的中医药人员，制定任职条件、岗位职责、工作任务及工作标准。 2.建立全员聘用聘任制度。通过公开招聘、竞聘上岗，实行择优聘用、合同管理，签定聘用聘任合同。有法定执业资格要求的岗位，受聘人员应具有相应的执业资格、岗位合格证书和职称证书。 3.建立健全岗位考核制度。岗位考核以专业水平、工作业绩和居民满意度为主要标准，实行月绩效考核和年终绩效考核相结合。考核结果作为续聘、解聘的依据。 4.对于考核不合格的聘用人员调整其岗位；对不同意调整岗位，或者虽然同意调整工作岗位，但到新岗位后考核仍不合格，与之解除聘用关系。 5. 根据社区卫生服务发展、居民需求及机构内人员状况，制定5年人才培养、梯队建设规划及年度计划，并做好总结。 6.有计划地安排各级各类专业技术人员参加继续教育、岗位培训、全科医学规范化培训及到上级医院进修提高，每年底对实施情况进行自查。 社区卫生服务健康管理团队制度 1.由全科医生、社区护士、预防保健人员组成社区卫生服务健康管理团队，按照所辖区域、常住人口、服务功能与任务等情况，分片包干，落实管理责任制。