First, we need to define what is Quality?

The basic definition in most dictionaries is that quality is “the standard of something as measured against other things of a similar kind; the degree of excellence of something.” While the business definition would be “a measure of excellence or a state of being free from defects, deficiencies and significant variations, it (quality) is brought about by strict and consistent commitment to certain standards that achieve uniformity of a product in order to satisfy specific customer or user requirements.” Also, from the point of view of an accrediting body such as the International Organization for Standardization (ISO), quality means “the totality of features and characteristics of a product or service that bears its ability to satisfy stated or implied needs.”

There are different names for a Quality Team, the most popular of which are Quality Assurance and Quality Circle Teams, but other organizations or hospitals use Quality Management, Quality Control and / or Quality Improvement Teams.

International accrediting bodies such as ISO and the Joint Commission International (JCI) encourage hospitals to have a Quality Management System (QMS) within their organizations.

By definition, Quality Management is the act of overseeing all activities and tasks needed to maintain a desired level of excellence. This includes the development of a quality policy, creating and implementing quality planning and assurance, quality control and quality improvement. Therefore, the team has four (4) major functions as follows:

  1. Development of Quality Policy – This is a document developed by the team and approved by top management to express the overall intentions, objectives and direction of the organization with respect to quality. The Quality Policy should express top management’s commitment to the QMS and should allow managers to set quality objectives. It should be based on the international accreditation standards on quality management principles and should be compatible with the organization’s other policies and be consistent with its vision and mission.
  2. Quality Assurance / Quality Monitoring – This consists of that “part of quality management focused on providing confidence that quality requirements will be fulfilled.” The confidence provided by quality assurance is two-fold — internally to management and externally to customers, government agencies, regulators, certifiers, and third parties. It relates to how a process is performed or how a product is made and is performed during the project to help make sure the product meets the quality standards. The results of the quality control process are used by the quality assurance process to determine if any changes are needed to the quality assurance process.
  3. Quality Control – Quality control is a procedure or set of procedures intended to ensure that a manufactured product or performed service adheres to a defined set of quality criteria or meets the requirements of the client or customer. It is more the inspection aspect of quality management and when activities are performed after a product has been created to determine if it meets the quality requirements.
  4. Quality Improvement The systematic approach to reduction or elimination of waste, rework, and losses in production or service process.

Depending on the hospital’s goal, the Quality Team may have any or all of the functions listed above.

What’s important is that there should be a full-time employee (FTE) who will take charge of the quality management functions or head the quality team. The number of FTEs will again vary with the organization’s goals. In the healthcare setting, this team would have to expand in cases when the hospital applies for JCI accreditation.

When I established the Quality Department in The Medical City back in 2003, there were only two FTEs: me (I assumed role of manager) and my supervisor. At that time, we worked on Quality Policy in coordination with The Medical City stakeholders.

The hospital’s quality team, comprised mostly of Industrial Engineers, grew to five people by the end of 2003. It was a gradual increase that took into consideration the number of hospital departments that needed the quality policy, as well as conducting quality improvement functions for all processes that required automation.

When the The Medical City decided to go for JCI accreditation in 2006, we had to expand the team. We grew to about 10 in 2006 and up to 40 in 2014, bringing together Industrial Engineers, Physicians, Nurses, and Safety Engineers. We eventually consolidated all of the quality units including quality improvement, infection control, and safety into one division inside TMC: Quality Improvement and Safety Division.

Please stay tuned for Part 2 of How to Build your Quality Team!


Written by Ma. Carla G. Naniong, MBAH