TWO QUALITY EVOLUTIONS: INDUSTRY VS. HEALTH CARE

paper explains evolution of Global Quality Management Theory through changes of different quality management approaches in time and compares it to the evolution of Quality Management in Healthcare. Authors relied on already existing information and data sources published in scientific journals to define evolution paths and conduct their comparison to identify gaps and recommend improvements in Healthcare Quality Management. Additionally, four major activities that could improve healthcare quality management emerged from analysis, such as: mechanism for constant and systematic tracing errors, managing quality of supportive processes, control of outsource organizations and application of IT for quality assurance.


intrOdUCtiOn
Healthcare system is an integral part of every society and it is considered to be an important indicator for country's level of development.The development level of a health care system is in direct correlation with the development level of the belonging country.on the one side, the quality of the health care system and health care services depend on the financial resources invested in health care, as a percentage of country's GDp. on the other side, the life quality of every citizen depends on the quality of the health care system.Therefore, the first aim of this system is to improve the quality of services and health of people in their daily life 1 .
Quality management in health care organizations evolved relatively independently from the development of the quality management theory 2 .one of the reasons for independent quality evolution could be the perception that health care differs from other hazardous industries in important ways 3 .other reasons could be found in affiliation of those who contributed to healthcare quality management theory, while most of them were experts in medical sciences, but lacked in formal organizational and management knowledge, therefore neglecting similarities between healthcare and other industries, which resulted in neglecting existing achievements of the quality management theory.
Studies on the results of the implementation of quality management theory achievements testify that application of proposed models, principles and knowledge in industry, enables significant costs reduction 4 , performance improvement through productivity and effectiveness 5 , an increase in customer satisfaction 6 and elimination of noncon-formities or low quality of products and services 7 .At the other side, there are numerous discussions on quality results and effectiveness of applied measures and concepts in health care, whereas problems of high costs 8 poor service 9 and too frequent patients' disappointing outcomes 10 are constantly stressed in reports, studies and manuscripts.poor quality in other industries has no fatal impact on human's life, and in most of the cases it can be reparable, but poor quality of health care can make lethal consequences immediately or after a certain time.Therefore, it could be concluded that achieving quality in health care is one of the most important goals, and that all efforts and obtained scientific knowledge should be aimed at achieving total quality in health care.
However, today's results in certain area of scientific discipline represent a significant scientific heritage, which a scientific discipline has passed from the moment of its birth until today.The evolution path of a scientific discipline in some areas can be seen as a series of interdependent steps, while previous finding influences next research, and therefore the future findings as well.To understand whether there is a difference in the perception of health care quality and perception of quality in the industry, as well as if whether there were an actual difference, then in order to understand why such difference would exists, we would have to study evolution of quality management in both areas.

MetHOdOLOgY OF reSearCH
The aim of this manuscript is to explain evolution of Global Quality Management Theory through changes of different quality management approaches and to compare it to evolution of Quality Management in Health Care, both timely based.Additionally, comparison should result in enabling identification of the gaps and recommendations for future research and improvements in Health Care Quality Management.
In order to pursue the aim of this research the authors relied on already existing information and data sources published in scientific journals.The research was divided in three phases of research: research on evolution of Global Quality Management Theory, research on evolution of Quality Management in Health Care and comparative analyses of both obtained researches.
For the purpose of the first research phase, EBSCo scientific base was used to access scientific journals which contained useful data for the research.period in which reviewed and analysed scientific journals were published dated from 1900-2014, although the history of scientific management begins with the life and career of Frederick Winslow Taylor 11 .Key words "quality evolution" or "quality history" or "quality movement" in the title of manuscripts were used as a criterion of search, which resulted in 217 manuscripts.Abstracts of all manuscripts were analysed while only 37 of them were useful for research on Global Quality Management Theory evolution.According to the analyses of useful manuscripts, phases in Global Quality Management Theory evolution were identified, timely ordered and specified through their characteristics.
For the second phase of research EBSCo base together with Free Medical Journals base were used to obtained data referred to the evolution of quality management in health care.This time key words were "health care" in the text of manuscript and "quality" and "evolution" in the title of manuscript, which resulted in 334 manuscripts, but only 14 of them contained useful information.All useful manuscripts were analysed, stages in Health Care Quality Management evolution were identified and timely ordered, separately from the results of previous research phase and each stage of evolution was specified through their characteristics.
In the third phase of research, obtained results of the second research phase were compared to obtained results of the first research phase, gaps were identified and recommendations for future evolution path were defined.

evOLUtiOn OF gLOBaL QUaLitY ManageMent tHeOrY
Some authors argue that there were four main stages in Global Quality Management Theory evolution in the last century 12 .Some other authors insist on five stages in quality movement 13 also in the last century, arguing that last phase begun in late 90s and is still on-going.The authors of this manuscript have opted to the evolution of the Global Quality Management Theory based on five phases in the last century, aiming to better comprehend the difference in approaches and methodologies for quality achievement.Therefore, the most suitable manuscript for tracing changes in evolution of the Global Quality Management Theory was written by Raho and Mears and was published in 1997.Research and analysis of happenings in Global Management Theory pointed to the adoption of new concepts and methods in 21st century.Therefore, the authors argue that evolution of the quality management theory has developed through six main phases, constantly using experience of industry.Each phase of quality management theory evolution characterise application of methods or approaches which were motivated by an efforts for assuring quality of particular entity, i.e. a part of an organization or its output.Also, in each phase the quality was understood in different ways, and attention was directed to different entities of an organization to be managed for quality achievement, as well as the different parts of an organization were considered as responsible for the quality of stressed entity.phase characteristics of the Global Quality Management Theory evolution are explained in Table 1.
The switch from previous phase to the next one was not characterized by reengineering, which assumes abandoning everything that has marked the previous phase.The evolution of quality management theory is rather proposing a growth of knowledge in the field of the quality management, based on adding new concepts to the concepts that showed results in previous phases.It means that inspection of products and detection of nonconformities were never abandoned, as methods for quality achievement 14 .Moreover, nonconformities are not looked at only as defective products, but also as mistakes and errors in all processes of a business system.Analyses of causes that led to nonconformities enable system's corrective actions that are important part of continuous quality improvement.until the early 1980s the manufacturing sector was centre stage in the quality debate 15 .However, from the mid-1980s quality management theory started to pay a greater interest to issues of customer services while nature of service organizations raised methodological and conceptual issues in relation to the transfer of quality management practices developed in manufacturing 16 .
Through time, quality management theory developed concepts and models that are applicable on any type of industry.All concepts and models are based on standards, regulations or recommendations that can be used as guidelines for designing a specific model for a specific organization 17 .However, the major breakthrough was made in 21st century by the appreciation of other scientific disciplines achievements and the development of the Global Quality Management Theory through the synergy of IT technology, cybernetics, theory of organization and management in all disciplines.

evOLUtiOn OF QUaLitY ManageMent in HeaLtH Care
Evolution of quality management in health care was caused by efforts to reduce high mortality rate of wounded soldiers in the Crimean War 18 which led to establishing standards for nursing care and efforts to manage conditions which would enable desired results of care.until than up to nowadays, quality in health care has gone a long way during which the theory of management and theory of organization were slowly creating an impact on contemporary understanding of quality in health care.
The beginnings were based on the attempts to control the isolated parts of the health care business system, which was not seen at that time as a system at all, until Donabedian proposed his model.Although achievements in maintenance of human health have been the main goal of the health care system always, the quality has been understood in different manner in the different periods of evolution.The change in perception of quality of health care was heavily influenced by the development of medical science.In fact, in the beginnings of evolution of quality management in health care, the medical knowledge was modest compared to today's knowledge opus; the medical equipment was rather primitive compared to today's modern medical devices and the pharmaceutical industry was still in its infancy.Therefore, the desired results could not be achieved anyway; however, the question of whether results would be better in past if   than knowledge of the Global Quality Management Theory was applied in health care quality attempts is arising.
Authors of manuscript recognized five stages of the quality management evolution in health care.Those stages along with their characteristics are given in Table 2.
Every next stage in evolution did not bring radical redesign destroying all the previous approaches.The evolution of quality management in health care was also contributing to the upgrade of knowledge base, where in certain periods of time some of the approaches and methods dominated the stage by incorporating previous accomplishments.Influence of the Governments and role of the World Health organization in quality management of each health care institution should not be neglected, while health care is being, in contrast to industry, the area of importance for each country and an integral part of social and political programs of every Government's policy.

anaLYSiS and diSCUSSiOn
According to comparative analysis shown in Table 3, it is obvious that the differences between evolution paths of health care quality management and global quality management theory actually exist.As authors claimed in introduction part, that quality management accomplished better results in industry than in health care, first question that arises is why there is a difference between those two evolution paths?If the cause for these differences between these two evolution paths does not lay in substantial differences between industry and health care, which would disable implementation of industry methods in health care, than the second question is what health care can learn from quality management theory to avoid unwanted outcomes?
As it is proven that health care institutions can be seen as a business system 19 than no obstacle to the use of industry achievements in improving the quality of health care institutions could be identified.However, the cause of differences in evolution paths could be found in formal education of their contributors while doyens to health care quality management evolutions were not familiar with the science of organization or management science.Edwin Chadwick was a lawyer by training 20 , Florence Nightingale was a nurse 21 , Abraham Flexner was an educator 22 , Avedis Donabedian was a physician 23 .Therefore, the basis for analysing and conclusions about the ways for improvements in health care institutions in that time could not be the same as the conclusions of their contemporaries who have shaped the evolution of global quality management theory through researches and studies in the industry.Comparative analyse showed that health care quality management failed to apply: • Mechanism for constant systematic identification of errors and its analysis in order to eliminate its cause (concluded from last row in table 3: identifying errors; identifying critical activities in processes; setting control points; using recorded data on errors to prevent them in future)

•
Applying system and process approach on whole health care institution, not only on clinical parts (concluded from last row in table 3: control of supportive processes in certification and accreditation; controlling all elements of system; not just stuff, clinical processes and equipment; applying TQM principles on whole organization, not just clinical stuff and processes; using quality tools, methods for process and costs optimization and Six sigma for any improvement; monitoring and measuring quality parameters of key and critical processes, not only of medical methods, departments or facility.) • Controlling outsource organization.
• using IT for quality achievement and for service delivery

Systematic identification of errors
Identification of nonconformities was the base to the first phase of evolution in industry and that method is still present in practice and theory, nowadays.However, it has spread from production process on whole business system by monitoring and measuring key processes, conducting internal audits and analysing customer complains.All nonconformities are analysed to identify their causes and to eliminate them by corrective actions.It is common mechanism for quality improvement in industry, which cannot be applied in health care if errors are not traced.
Serious errors in health care are reported, but methods that would allow detection of minor errors in the whole system of health care facility and which would enable health care facility to react before something serious happens are not implemented.Authors believe that major reasons for absenteeism of systematic tracing errors could be: • Tracking errors in health care institutions is not an easy process and requires additional engagement of employees and their conscientiousness, honesty and self-criticism.
• Errors which are caused by lack of medical knowledge can initiate serious consequences for employee's career, while those errors caused by malicious intentions can open judicial processes in which the doctor can face a jail and exclusion from society • patient complain only when they have suffered serious consequences of errors but they usually do not recognize errors if there were no serious consequences • Internal audits are conducted in clinical processes while supportive processes are neglected even if it is known that supportive processes influence results of health care institution 24 • Internal audits are conducted by experts in medicine who are usually not familiar in audit methodology 25 .

System and process approach
Quality management theory recognized service or product quality dependence on process and system performance.Therefore, most models for quality management are based on process and system approach, which respect all of the important processes, which are supportive processes and production processes, in quality achievement.In health care institutions, supportive processes are less present in percentage compared to clinical processes and in the development of health care institution are often neglected, i.e. considered as not important although their quality significantly affects the quality of clinical processes.An example of the supportive process impact on clinical process can be found in the process of procurement which, if not optimized, can give bad or insufficient inputs or resources to clinical processes: bad or insufficient medical supplies, defective or insufficient medical devices and under competent or insufficient medical personnel, and thus it would jeopardize the quality of clinical processes and the quality of their outcomes.At the first glance supportive processes seem less important for achieving the quality of health services, but they need to be improved and controlled together with clinical processes.As one of the methods of achieving quality of clinical processes is protocol or procedure, the same method should be applied in quality management of supportive processes.If measuring and monitoring quality parameters of clinical processes or conducting internal audits on them, why not doing the same in the case of important supportive processes?While there is no shortage of written protocols in healthcare, they are not as effective as they could be in helping healthcare workers to avoid errors 26 .Reasons of poor quality in health care could be found in barriers for implementation 27 , as well as in understanding and transforming guidelines into the specific model, which does not cover all elements of healthcare organization systems in most of the cases 28 .

Controlling outsource organization
often, more than one healthcare institution participates in the process of delivering healthcare services 29 and all of them influence final outcome.Therefore, it is important that all of those manage their quality constantly and systematically.Much like a military control of outsource by conducting audits, in the case of health care institution it would require stuff trained in audit methodology, or a partnership with specialized companies tailored for auditing process.However, such effort would decrease possibilities of misdiagnosis or bad treatment and the initial additional financial investments in additional activities of audits would lead to a reduction of costs in the future period.

Using IT for quality achievement and for service delivery
There are special softwares designed to manage quality in industry.Some of them control production process enabling people-less activity conduction, some of them advise employees in their working process (for example hotel's database on previous customers' needs), while some of them are designed to facilitate monitoring and measuring of quality parameters.Information technology is used predominantly for patient's electronic charts, and for data transfer from one health care unit to another.However, IT can replace people in routine clinical activities, this reducing human-error possibilities and accelerating activities.Also, indicators of possible errors occurrence, such as: diagnose change, too long treatments, complications in treatments, unusual symptoms developed during treatment could be monitored by contemporary and widely available IT. 29   Živaljević, A., Mitrović, Ž., petković, M., 516-541.

COnCLUSiOn
In recent years, the increasing importance of quality management has promoted the implementation and diffusion of tools finalized to measure and to monitor the healthcare outcomes 30 .However, for essential quality improvements it is necessary to trace nonconformities, analyse them to find their root cause and to implement corrective actions.Quality is defined as a customer satisfaction 31 , while the first step for its accomplishment is to eliminate errors and it cannot be done without tracing them.As tracing errors requires additional time, efforts and financial investments IT could be used to minimize all of those.
Researches on TQM implementation in health care facilities suggests that the gains made in health care (as in other organisations) have not been as great as predicted 32 .A particular problem has been its aggressive rhetoric and its failure to engage the staff on whom the organisation relies 33 .Nowadays, it is common to educate employees in industry's quality management practice in order to incorporate them in quality improvement efforts by their participation, team work and self-assessment.However, providers in health care often lacked basic Qi knowledge or experience in instituting Qi programs 34 .There are clear messages from conducted studies that, where some progress has been made, the engagement of clinicians has been essential, as well as senior management commitment and persistence 35 .Therefore, health care employees' knowledge on global quality management theory accomplishments has to be improved.Also, it is needed to incorporate quality control of supportive processes and of outsource organizations in quality management efforts in health care.
policy makers seek new ways to address continuing problems of variation in the quality of health care and dissatisfaction among patients, the public, and professionals 36 .Minimizing gaps between industry practices and health care practice, by adopting methods that gave desirable results in quality improvement, can improve quality in health care.Awareness of the sanitary problems associated with community dwellings 11 .Organizing hospital medical staffs 12 .Limiting staff membership to well-educated, competent, and licensed physicians and surgeons 13 .Framing rules and regulations to ensure regular staff meetings and clinical review 14 .Keeping medical records that included the history, physical examination, and laboratory results of a patient 15 Establishing supervised diagnostic and treatment facilities such as clinical laboratories and radiology departments 16 .

Concepts of accreditation and certification entered
the quality equation 17 .
Continued to focus on human and physical resources 18 .
Introduction in the clinical process-related standards and guidelines.Providers of health care were then "judged" on their compliance to certain explicit standards of care and practice parameters by their peers 19 .

Phase was caused by
Dr Edwin Chadwick, published a report in 1842 which vividly described the unacceptable sanitary conditions associated with urban and rural communities in Britain at that time 29

Back to outcomes
Performance which enhance and extend the life Standardizing care will decrease chance of error and improve control of patient care outcome 9 .
Enhancing life expectancy, quality of life, diagnostic and treatment options, as well as the efficiency and cost effectiveness of the healthcare system 10

Improving outcomes
Excellence of performance Shifting from an emphasis on process-related standards back to outcomes through assuring quality of clinical processes, equipment, clinical stuff and conditions 20 .Effectiveness and efficiency top the list, stressing that quality can be achieved only if processes are performed appropriately and in a cost conscious environment 21 .Quality must be associated with high technical capabilities 22 .Care provided by professionals and teams 23 .
Institution measures its performance against a number of well-known and agreed-on measures (or indicators), and the results are published so that the consumer can compare this institution with ones similar to it 24 .Engaging highly educated and well informed consumer 25 .Certification, accreditation and licensure measurement and public reporting of the adoption and spread of effective Qi strategies to improve care 26 .
Ensuring the equitable receipt of healthcare; and integration of alliance activities with payment reform initiatives 27 .Accreditation has spread across the world to become an established part of healthcare systems in over 70 countries and there is an associated international body 28 .
Strong movement of the industrial sectors towards a new theory of total quality management 37 .JCAHO first entered the field of clinical ethics in 1991, with the introduction of Patient Rights Standards 38 Synergy of medical and other science resulted in advanced, modern medical devices and medical technology for diagnosis and treatment.New quality dimensions have recently been introduced in the US by the prestigious Institute of Medicine in their 2001 report 39 .These are: safety, timeliness, equity, effectiveness, efficiency, and patient centeredness 40 .
In 2006, Af4Q program works to improve healthcare by engaging patients in their care, publicly reporting the performance of physicians and hospitals, and improving the quality of care delivered in each community 41

table 1 .
Evolution of the Global Quality Management Theory

table 2 .
Evolution of the Health Care Quality Management