One of the more remarkable social transformations of this century was the emergence of a powerful Japanese economy from the debris of the Second World War. Fundamental to this climb to global competitiveness were a commitment to quality and a determination to prove false the then-common belief that Japanese goods were shoddy and worthless. Guided by the innovative teachings of Deming (1993), Juran (1988) and others, Japanese managers and engineers adopted practices that have ultimately evolved into a comprehensive management system rooted in the basic concept of quality. Fundamentally, this system represents a shift in thinking. The traditional view was that quality had to be balanced against the cost of attaining it. The view that Deming and Juran urged was that higher quality led to lower total cost and that a systems approach to improving work processes would help in attaining both of these objectives. Japanese managers adopted this management philosophy, engineers learned and practised statistical quality control, workers were trained and involved in process improvement, and the outcome was dramatic (Ishikawa 1985; Imai 1986).
By 1980, alarmed at the erosion of their markets and seeking to broaden their reach in the global economy, European and American managers began to search for ways to regain a competitive position. In the ensuing 15 years, more and more companies came to understand the principles underlying quality management and to apply them, initially in industrial production and later in the service sector as well. While there are a variety of names for this management system, the most commonly used is total quality management or TQM; an exception is the health care sector, which more frequently uses the term continuous quality improvement, or CQI. Recently, the term business process reengineering (BPR) has also come into use, but this tends to mean an emphasis on specific techniques for process improvement rather than on the adoption of a comprehensive management system or philosophy.
TQM is available in many “flavours,” but it is important to understand it as a system that includes both a management philosophy and a powerful set of tools for improving the efficiency of work processes. Some of the common elements of TQM include the following (Feigenbaum 1991; Mann 1989; Senge 1991):
- primary emphasis on quality
- focus on meeting customer expectations (“customer satisfaction”)
- commitment to employee participation and involvement (“empowerment”)
- viewing the organization as a system (“optimization”)
- monitoring statistical outputs of processes (“management by fact”)
- leadership (“vision”)
- strong commitment to training (“becoming a learning organization”).
Typically, organizations successfully adopting TQM find they must make changes on three fronts.
One is transformation. This involves such actions as defining and communicating a vision of the organization’s future, changing the management culture from top-down oversight to one of employee involvement, fostering collaboration instead of competition and refocusing the purpose of all work on meeting customer requirements. Seeing the organization as a system of interrelated processes is at the core of TQM, and is an essential means of securing a totally integrated effort towards improving performance at all levels. All employees must know the vision and the aim of the organization (the system) and understand where their work fits in it, or no amount of training in applying TQM process improvement tools can do much good. However, lack of genuine change of organizational culture, particularly among lower echelons of managers, is frequently the downfall of many nascent TQM efforts; Heilpern (1989) observes, “We have come to the conclusion that the major barriers to quality superiority are not technical, they are behavioural.” Unlike earlier, flawed “quality circle” programmes, in which improvement was expected to “convect” upward, TQM demands top management leadership and the firm expectation that middle management will facilitate employee participation (Hill 1991).
A second basis for successful TQM is strategic planning. The achievement of an organization’s vision and goals is tied to the development and deployment of a strategic quality plan. One corporation defined this as “a customer-driven plan for the application of quality principles to key business objectives and the continuous improvement of work processes” (Yarborough 1994). It is senior management’s responsibility—indeed, its obligation to workers, stockholders and beneficiaries alike—to link its quality philosophy to sound and feasible goals that can reasonably be attained. Deming (1993) called this “constancy of purpose” and saw its absence as a source of insecurity for the workforce of the organization. The fundamental intent of strategic planning is to align the activities of all of the people throughout the company or organization so that it can achieve its core goals and can react with agility to a changing environment. It is evident that it both requires and reinforces the need for widespread participation of supervisors and workers at all levels in shaping the goal-directed work of the company (Shiba, Graham and Walden 1994).
Only when these two changes are adequately carried out can one hope for success in the third: the implementation of continuous quality improvement. Quality outcomes, and with them customer satisfaction and improved competitive position, ultimately rest on widespread deployment of process improvement skills. Often, TQM programmes accomplish this through increased investments in training and through assignment of workers (frequently volunteers) to teams charged with addressing a problem. A basic concept of TQM is that the person most likely to know how a job can be done better is the person who is doing it at a given moment. Empowering these workers to make useful changes in their work processes is a part of the cultural transformation underlying TQM; equipping them with knowledge, skills and tools to do so is part of continuous quality improvement.
The collection of statistical data is a typical and basic step taken by workers and teams to understand how to improve work processes. Deming and others adapted their techniques from the seminal work of Shewhart in the 1920s (Schmidt and Finnigan 1992). Among the most useful TQM tools are: (a) the Pareto Chart, a graphical device for identifying the more frequently occurring problems, and hence the ones to be addressed first; (b) the statistical control chart, an analytic tool for ascertaining the degree of variability in the unimproved process; and (c) flow charting, a means to document exactly how the process is carried out at present. Possibly the most ubiquitous and important tool is the Ishikawa Diagram (or “fishbone” diagram), whose invention is credited to Kaoru Ishikawa (1985). This instrument is a simple but effective way by which team members can collaborate on identifying the root causes of the process problem under study, and thus point the path to process improvement.
TQM, effectively implemented, may be important to workers and worker health in many ways. For example, the adoption of TQM can have an indirect influence. In a very basic sense, an organization that makes a quality transformation has arguably improved its chances of economic survival and success, and hence those of its employees. Moreover, it is likely to be one where respect for people is a basic tenet. Indeed, TQM experts often speak of “shared values”, those things that must be exemplified in the behaviour of both management and workers. These are often publicized throughout the organization as formal values statements or aspiration statements, and typically include such emotive language as “trust”, “respecting each other”, “open communications”, and “valuing our diversity” (Howard 1990).
Thus, it is tempting to suppose that quality workplaces will be “worker-friendly”—where worker-improved processes become less hazardous and where the climate is less stressful. The logic of quality is to build quality into a product or service, not to detect failures after the fact. It can be summed up in a word—prevention (Widfeldt and Widfeldt 1992). Such a logic is clearly compatible with the public health logic of emphasizing prevention in occupational health. As Williams (1993) points out in a hypothetical example, “If the quality and design of castings in the foundry industry were improved there would be reduced exposure ... to vibration as less finishing of castings would be needed.” Some anecdotal support for this supposition comes from satisfied employers who cite trend data on job health measures, climate surveys that show better employee satisfaction, and more numerous safety and health awards in facilities using TQM. Williams further presents two case studies in UK settings that exemplify such employer reports (Williams 1993).
Unfortunately, virtually no published studies offer firm evidence on the matter. What is lacking is a research base of controlled studies that document health outcomes, consider the possibility of detrimental as well as positive health influences, and link all of this causally to measurable factors of business philosophy and TQM practice. Given the significant prevalence of TQM enterprises in the global economy of the 1990s, this is a research agenda with genuine potential to define whether TQM is in fact a supportive tool in the prevention armamentarium of occupational safety and health.
We are on somewhat firmer ground to suggest that TQM can have a direct influence on worker health when it explicitly focuses quality improvement efforts on safety and health. Obviously, like all other work in an enterprise, occupational and environmental health activity is made up of interrelated processes, and the tools of process improvement are readily applied to them. One of the criteria against which candidates are examined for the Baldridge Award, the most important competitive honour granted to US organizations, is the competitor’s improvements in occupational health and safety. Yarborough has described how the occupational and environmental health (OEH) employees of a major corporation were instructed by senior management to adopt TQM with the rest of the company and how OEH was integrated into the company’s strategic quality plan (Yarborough 1994). The chief executive of a US utility that was the first non-Japanese company ever to win Japan’s coveted Deming Prize notes that safety was accorded a high priority in the TQM effort: “Of all the company’s major quality indicators, the only one that addresses the internal customer is employee safety.” By defining safety as a process, subjecting it to continuous improvement, and tracking lost-time injuries per 100 employees as a quality indicator, the utility reduced its injury rate by half, reaching the lowest point in the history of the company (Hudiberg 1991).
In summary, TQM is a comprehensive management system grounded in a management philosophy that emphasizes the human dimensions of work. It is supported by a powerful set of technologies that use data derived from work processes to document, analyse and continuously improve these processes.