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Total quality management (TQM) is a unifying business strategy for achieving and sustaining growth. TQM proceeds, step by step, project by project, to transform the organization into one smoothly working, quality-focused team. For successful implementation of TQM, the small projects are every bit as important as the large ones. The simple, accessible successes validate the skills that employees are acquiring and encourage them to try more complex, long-term endeavors. This article discusses several TQM projects conducted at Baptist Medical Center in Columbia, SC: streamlining medical records processing (a large project that freed up millions of dollars in cash flow); improving the reliability of all hospital equipment; and ongoing small successes in the recovery room. Although the dollar value of the projects varied considerably, all were critical to creating a culture of total quality management at Baptist Medical Center.

The difficulty of delivering respiratory therapy according to currently accepted standards is an important problem in many hospitals. As a result of this problem in our hospital, we developed a new therapy delivery system--the Respiratory Care Protocol. In response to an order for Respiratory Care Protocol from an attending physician, a senior respiratory therapist evaluates the patient, prescribes specific respiratory therapy according to a protocol, and then daily re-evaluates the patient and makes appropriate therapeutic changes, including discontinuing respiratory therapy when appropriate. The Respiratory Care Protocol has been well-accepted by patients, physicians, and respiratory therapists, and by Joint Commission on Accreditation of Hospitals evaluation teams. We believe that our use of the Respiratory Care Protocol has led to improved quality and to the reduced cost of our in-hospital respiratory care.

Although our operational audit involved evaluating the cost effectiveness and efficiency with which procedures or functions are performed, our focus remained on the actual operational problem as defined in our criteria. The pre-determined standards, on which our criteria statements were based, provided the yardstick for measurement. Our assessment and Treatment Plan for patient care was audited, followed by a review of our policy and procedure compliance and the application of managerial systems and controls. Although the total impact of this audit tool on astute clinical care, management, judgement, and educational needs is yet to be addressed, we believe we have taken an important step in the direction of quality control through the initiation of an evaluation system in the Respiratory Department.

Acquired immunodeficiency syndrome (AIDS) has recently received considerable media attention. Health care workers, including respiratory care practitioners, are concerned about the many medical and psychosocial implications of the disease. This article reviews the epidemiology and clinical features of AIDS. Health care workers do not have a demonstrably higher incidence of AIDS infection than does the general population; risks to the respiratory care practitioner may be minimized by adherence to the suggested guidelines for infection control. Respiratory care practitioners are ethically bound to treat all patients, regardless of the nature of their disease; the guidelines given in this article will help practitioners do this.

Measurement of the effect of therapy is a principle in the provision of all care, including respiratory therapy of newborns. Crucial to such measurement are guidelines of respiratory therapy services. The author offers a method for establishment of these guidelines, as well as a literature review of the outcomes of infants who required respiratory care.

Unlabelled: Because our Respiratory Care Department resources were overburdened and many orders for medicated aerosol therapy (MAT) and lung hyperinflation therapy (LHT) seemed inappropriate, we developed ordering guidelines for MAT and LHT. We then studied the effects on numbers of inappropriate treatments when therapist-evaluators discussed questionable orders with physicians., Methods: For 6 weeks, the physicians were divided into two groups, one interactive with therapists, the other serving as controls. The physicians then switched groups for a second 6-week period. Therapist-evaluators examined all orders for MAT and LHT and suggested therapy changes to interactive-group physicians who wrote questionable orders; they did not discuss inappropriate orders with control-group physicians. The percentages of inappropriate treatments ordered by both physician groups were recorded, and the costs of inappropriate therapy were calculated. After the 12-week study, the program continued, with evaluators interacting with all physicians when treatment was inappropriate., Results: Of treatments ordered by control-group physicians, 48% were inappropriate. Of treatments ordered by physicians in the interactive groups, 35% were inappropriate. Inappropriate treatments cost $15,960 in labor and supplies and required 3.6 full-time technicians. The cost of evaluation was $1,193. By 6 months following the study, therapist-physician interaction had reduced inappropriate treatments to 11% of treatments given., Conclusions: The use of ordering guidelines and therapist-evaluators who interact with physicians can significantly reduce the number of inappropriate respiratory care treatments and reduce costs.

The quality of services provided by respiratory therapists must be measured as part of a hospital's overall evaluation of patient care, as mandated by the Joint Commission on the Accreditation of Hospitals. An internal audit helps both the respiratory therapists and the attending physicians to know what kind of specific documentation is needed in the medical records to meet the desired standards. It also serves as a useful tool in identifying staff educational needs.

The equipment used in respiratory therapy can be the source of serious nosocomial infections unless close attention is given to appropriate sterilization, disinfection, and general measures that come under the heading of good housekeeping. And even the best of these measures will fail if therapists do not observe the cardinal rule of regular hand washing.

A respiratory therapy department determined that it could achieve substantial savings by producing rather than purchasing its own sterile water.

In 1981-1982, a Massachusetts Hospital Association and Massachusetts Blue Cross-Blue Shield task force reviewing ancillary services found that the use of respiratory therapy at New England Deaconess Hospital far exceeded the statewide average. These findings led to a hospital-wide effort to reduce ancillary services. As part of this effort, we studied the effect of the reductions in respiratory therapy on patient outcome. At the beginning of the study, senior respiratory therapists advised physicians about the optimal use of various respiratory-therapy services, including their discontinuation when no longer necessary. One year after the intervention began, we analyzed the use of respiratory therapy by employing data-collection techniques that were identical to those used by the task force. Marked reductions in all categories of respiratory therapy had occurred, but morbidity and mortality from pulmonary disorders had not increased. In the largest group studied--patients undergoing coronary-artery bypass surgery--the charges for respiratory therapy, the length of hospital stay, and pulmonary complications had all decreased. We conclude that consistent application of prescribed guidelines for respiratory therapy results in marked decreases in its use and that such decreases can be achieved without a reduction in the quality of care.

Half the task of setting up a quality assurance program is selling the idea to departments and enlisting committee members with positive attitudes to seek out and help solve problems.