Tasks of Total Quality Management (TQM)                                                                                    

teamwork versus internal competition
TQM relies strongly on teamwork structures and takes advantage of group pressure. Individual competition or privileges not of beneficial outcome to the group, will be sanctioned by group pressure. However, good working teams rely on good communication between all members and the communication abilities of physicians are often rather poor. In addition, the lack of rationality and emotional gambling are to overcome when changing from competition to teamwork inside the institution.

progress is not linear, nor is it smooth
The organisational friction caused through the change will probably lower quality and raise costs in the beginning. It might take time the until real profits of the change to TQMcan be seen. For every three steps forward, there may be one or two back. For almost any change and certainly for radical change, the learning process results in negative progress toward the goals before turnaround occurs and positive progress is made [AS94p.33]. Opposition can easily abuse this situation forcing a return to the former status quo.

3.2.2.3 Facilitators
Facilitators of implementing TQM in institutions make the usual obstacles look smaller and help to overcome them without getting caught by some of the risks mentioned above. These basically handle the human aspects of an organisation. The facilitators give a first set for developing a strategy of actual implementation and a realistic vision.

outside pressure: change or die
A crisis due to growing outside pressure will certainly help to overcome internal friction when implementing TQM. Groups of opposition will be easily unified to stand the threat from outside. Sometimes the outside pressure is not realised or seen by the members. Confronting its members with the outside pressure will then be the first thing to do to facilitate the needed change. However, sometimes, as in medical care, there seems to be no urgent threat. Simulation of outside pressure can then help. Often its even enough to point out a successful competitor. Members than compare themselves to the competitor.

leadership
Intention of change, introducing TQM, must be promoted by the highest leaders of the institution. Staff members must be shown that TQM is of major importance. Identifying a charismatic leader of the institution with TQM will help to motivate all staff members.

teaching and workshops
Informing all members what the purpose of TQM's is, will be essential. Once staff have understood the concept and need of TQM, typical situations confronting change should be outlined. Small supervised workshops can than be a good solution to finding the best local process.

motivation
Involving staff in decision making will help making friends with TQM. Moreover, localised knowledge will bring better results than giving orders from above which do not suit the situation. Local staff know their own situation best. Applauding early progress will close the circle for further motivation and improvement.

the right step at the best time
Handling the different obstacles to change, and the different classes of staff opposition needs a well planed and flexible strategy. All steps from the introduction to final the implementation need to be well thought out. The order and timing of each is of upper most importance. Many obstacles can be surpassed intelligently or even changed into 'supporting friends', but it can also easily happen that obstacles are provoked to join together to form walls which are difficult to overcome.