Tasks of Total Quality Management (TQM)                                                                                    

Medical care systems will only change, when there is a real fear from outside that the system is in real danger. Competitive structures could bring this necessary fear.

In the author's mind there are three major element hindering the needed change: the abuse of ethics, the status of physicians, and under age treatment of the patient. It seems contradictory, but the noble ethic to save and to help every person in need, means that health care is seen as a gift never to be questioned, rather than a right to receive the best health care available. Many physicians behave like gods themselves, although they are only the service men for health. The high status of a physician in countries like Germany, practically forbids critic and control, and so the needed feedback for continuous improvement does not exist. Patients are often treated as under age, although patient motivation is an essential task of any physician. Long waiting lists give a good impression but in reality they are only a poor sign of bad distribution. Why are famous surgeons not motivated to serve as multiplying factors in training other physicians? It seems to be that internal rivalry and formal structures of responsibility hinder flow of information, training and the continuous improvement process. Maybe, the fear of being judged causes physicians to cover any information which might otherwise lead to improvements in quality and help prevent risks in the future. That pressure due to absence of patients and that information exchange systems between institutions are missing, hinders even more, quality in health care.

Future medical care needs to be managed around the patient. Physicians and clinic managers need to consider the patient's view-point. Instead of merely satisfying the wishes of the bosses, it is the patient who needs to be satisfied. The process the patient from entering the institution until leaving it needs to be optimised: short and pleasant stays, procedures which guarantee minimised risk of false treatment and best possible results. Well managed motivation structures using everyone's wish for respect, and team structures are vital for reaching highest quality.

3.2.1.2 In Refractive Corneal Surgery

Refractive surgery is a fairly new field in medicine. Until a couple of years it was not taken very seriously due to missing tools and more important problems in other fields of ophthalmology. With recent developments and laser surgery, correcting ametropia might become as normal as getting rid of wisdom teeth and wearing brackets. Refractive surgery is somewhere settled between needed surgery and cosmetic medicine. In many cases Refractive Surgery is an elective alternative to glasses or contact lenses. Whereas in essential medicine total quality 'can be a luxury', in Refractive Surgery it will be a market must: patients will not risk their vision for rather minor benefits.

If the individual has sufficent money and the country's ophthalmologic infrastructure allow good practical correction, the patient will take his best corrected vision as reference. In highly developed countries it will therefore be more difficult to persuade anybody to undergo surgical intervention whereas in third world countries poor patients will be pleased for any correction of the uncorrected vision to make gains in actual vision, as there is no money for optimal glasses or contact lenses.

Refractive surgery in western countries, especially if the health insurance company does not pay for the surgery, will not harmonise with usual ophthalmologic practice. The elective nature of treating one's eye will not be possible within the five minute attendance of the patient. Information and education of the patient and the patient's selection process will be completely underestimated.