3.1 Tasks of Total Quality Management (TQM)                                                                              

Instead of directly applying a rigid quality scheme the real tasks of quality are to be discussed. Three questions must be answered: What for? How to employ it ? Which tools are useful?

3.2.1 Purpose of Total Quality Management
The purpose of Total Quality Managment is outlined in medical service and in Refractive Surgery in particular.

3.2.1.1 In Medical Service
Surgery is an art,
which needs to be learned
science and technology
only gives the set up.

Cutting the cost explosion seems to be the major topic when western politicians are talking about the medical service sector. At first glance cutting costs seem to lower the quality of service. However, the academic medical community itself even abuses this argument to keep the status quo. For the average patient it seems logical that cutting cost will lower the service's quality. The result is that more and more awful, and often unneeded, diagnostic examination are given to patients, while time left for a personal diagnosis is minimised to a couple of minutes. Medical care is not only becoming less efficient, it is even becoming less effective as more patients cannot be cured by subscribing more drugs or pushing them from one machine's inversion to another.

The misleading myth is that costs can only be cut if quality is lowered. The opposite is true, but not wished for by the physician because it means significant change and induces a different attitude towards their patients. However, in the author's point of view it makes more sense to talk about improving the quality of health service, and the question of cost will be solved automatically.

Somehow, physicians are often seduced to believe that by buying the ultimate improvements in technology will make them significantly better physicians. It seems to be much easier to buy the latest technology than to be a really skilled doctor. It's true that technology is essential but training is even more important. Patients often seem to ask for the latest technology rather than asking the doctor to show his personal certified learning curve.

Quality can be measured on a macroeconomic scale by adding all the outcomes of people needing treatment. The best distribution and equal service for everyone is therefore of major importance and a must for macroeconomic quality approaches. Offering the best quality to only a few makes no sense. Although this will not be a topic of this work, it needs to be kept in mind, that any discrimination within medical services will reduce a country's medical quality.

Quality is strongly reflected by an individual patient's satisfaction and by the standards of results achieved. The developed quality approach in chapter six follows this double strategy of comparing outcome measurement with individual satisfaction measurement.

The major task of Total Quality Management is to assure that quality of conformance and quality of design are almost identical. Daily achieved quality must meet the possible quality.

However, its seems that the reality is far cry from this ideal. The KAP phenonemon describes this deficit. K stands for knowledge, A for attitude and P for practice. It seems to be very human, allowing for ease and laziness in confronting change to new achievements.

What are the reasons that knowledge is not implemented in daily practice?

Comparing the medical care situation with the western car industry, radical reorganisation in the car industry happened because significant outside pressure allowed knowledge implementation. If there is no essential need, nearly all reorganisation programmes have no effect. The built in importance for stability in organisations never gives a real chance for radical changes in 'good times'.