Discussion Post 2
Best Practices of Total Quality Management Implementation in Health Care Settings
FAISAL TALIB Mechanical Engineering Section, University Polytechnic, Faculty of Engineering and
Technology, Aligarh Muslim University, Aligarh, India
ZILLUR RAHMAN and MOHAMMED AZAM Department of Management Studies, Indian Institute of Technology Roorkee,
Roorkee, India
Due to the growing prominence of total quality management (TQM) in health care, the present study was conducted to identify the set of TQM practices for its successful implementation in healthcare institutions through a systematic review of literature. A research strategy was performed on the selected papers published between 1995 and 2009. An appropriate database was chosen and 15 peer-reviewed research papers were identified through a screening process and were finally reviewed for this study. Eight supporting TQM practices, such as top-management commitment, teamwork and participation, process management, customer focus and satisfaction, resource management, organization behavior and culture, continuous improvement, and training and educa- tion were identified as best practices for TQM implementation in any health care setting. The article concludes with a set of recom- mendations for the future researchers to discuss, develop, and work upon in order to achieve better precision and generalizations.
KEYWORDS health care institutions, total quality management, TQM implementation, TQM practices
Address correspondence to Faisal Talib, Assistant Professor, Mechanical Engineering Section, University Polytechnic, Faculty of Engineering and Technology, Aligarh Muslim University, Aligarh-202002, Uttar Pradesh, India. E-mail: ftalib77@yahoo.co.in
Health Marketing Quarterly, 28:232–252, 2011 Copyright # Taylor & Francis Group, LLC ISSN: 0735-9683 print=1545-0864 online DOI: 10.1080/07359683.2011.595643
232
INTRODUCTION
The health care and medical services are growing immensely due to a high influx of the private sector, changing disease patterns, medical tourism, and demographic variations. Development of new and advanced techniques, increased awareness on patient’s safety, intensity of competition in health care market, and new generation of purchasers and providers have forced the health care institutions to improve the efficiency and introduce a consumer culture in their institutions for effective cost and quality of care (Mosadegh Rad, 2005; Lee, Ng, & Zhang, 2002; Short, 1995). Quality of care is the vital issue for every health care institution and there is an immediate need for health care reforms in order to address and resolve the problems associated with quality of care, as well as patient preferences, safety, and choice (Koeck, 1997). Another critical issue is the consistently increasing operating costs of health care institutions. Rising health care expenditures have created serious financial burdens for the ex-chequer (government department in charge of national revenue or national treasury) in many coun- tries like Canada, the United States, the United Kingdom, and Taiwan (Yang, 2003), and are facing a serious fall in business and a debt crisis. In such a situation, health care institutions need to re-examine their ways of doing business in order to decrease their operating costs while increasing quality and value in their delivery process.
To address the aforementioned issues a plethora of literature in health care were reviewed which showed implementation of different quality man- agement practices and tools such as ISO9000, continuous quality improve- ment, health quality improvement circle, quality management systems, and others are important in this respect (Yang, 2003). However, one of the sug- gested approaches to resolve these issues more effectively and practically, and to bring better quality to health care institutions, is the adoption of total quality management (TQM) approach (Manjunath, 2007; Yang, 2003; Moody, Motwani, & Kumar, 1998; Short & Rahim, 1995; Kim & Johnson, 1994). TQM have now taken a central role in the health care quality management (McLaughlin & Simpson, 1999). By adapting the concepts of TQM, the health care institutions can transform their traditional quality improvement system to customer oriented system through a framework involving customer focus, pro- cess management, new tools and techniques, and teamwork (Klein, Motwani, & Cole, 1998). Within such an approach, health care institutions focus on cre- ating physical, psychological, and social environment that is conducive to their patients and staff. Externally, they also concentrate on promoting the health and well-being of communities and on reducing costs (Ovretveit, 2000).
While the TQM concept and practices have been widely accepted in health care institutions, its sincere and systematic adoption is a must for its success. It is evident from the studies that adoption of TQM practices tends
Best Practices of Total Quality Management 233
to improve the health care institutions if implemented properly; otherwise it may result in TQM failure (Short, 1995; Claver & Molina, 2003). A number of studies, empirical as well as exploratory, have been carried out to explain the factors influencing TQM implementation, and are well documented (Wali, Deshmukh, & Gupta, 2003; Wayhan & Balderson, 2007; Nair, 2006; Sila, 2007). However, the studies on TQM practices in health care settings are rare. Therefore, a systematic review of identifying the various practices underlying the success of TQM implementation is the need of the hour, which may help in developing a base for future researchers and help health care managers in adopting the same.
The aim of the present study is to identify a set of TQM practices that are helpful and are applicable in health care setting for resolving their problems effectively. These practices are therefore, termed as best TQM practices in this study.
Further, the scope of this study offers a good background in arguing that these identified best TQM practices, if implemented properly and systemati- cally, would provide a framework for quality improvement in health care institutions and thus, will result in delivering upgraded service quality and patient satisfaction with improved performance.
To achieve this objective, the article first addresses the literature on the development of TQM program in the health care environment. It then describes the methodology and lay down the objectives of the study. Next, the results of the study are presented in detail. The article concludes with providing of the brief discussion on the results of the study together with the direction for future research in this area.
LITERATURE REVIEW
TQM in Health Care Environment
The concept of TQM was first implemented in the manufacturing sector in early 1980s followed by the service sector and other sectors. In the recent years, many health care institutions have applied the principles and practices of TQM in order to solve most of the problems that they are currently facing (Chesanov, 1997; Counte, Glandon, Oleske, & Hill, 1995; Kim & Johnson, 1994). The reasons behind the wide acceptability of TQM in health care insti- tutions are many, but before highlighting these reasons it is necessary to understand what TQM is in context to health care environment.
It is defined as:
The satisfaction of patients, doctors, nurses, and suppliers (i.e., social shareholders) and other interested groups, achieved by implementing effective planning, programs, policies and strategies (i.e., hard issues),
234 F. Talib et al.
and human and all other assets (i.e., soft issues) efficiently and continu- ally within a hospital context. (Arasli, 2002, p. 347)
Further, the TQM focuses on: customer (patient) satisfaction, continuous improvement, teamwork, process management, systemization, organization culture and structure, and lastly commitment from management and support- ive leadership. Several studies have also emphasized that successful imple- mentation of TQM can result in significantly superior outcomes in health care institutions (Short & Rahim, 1995; Yang, 2003; Counte et al., 1995), some of these outcomes are:
. Upgraded quality of service
. Improved health care quality and performance
. Patient satisfaction
. Reduced operating cost of health care institutions
. Employee satisfaction, and
. Patient safety
Therefore, health care institutions have started to implement it rigorously, even some of the hospitals associations and organizations have directed all its health care institutions to adopt TQM as early as possible. Some of the stu- dies show the positive aspects of TQM movement for hospitals such as qual- ity improvement, financial performance, competitive advantage, and employee commitment in various hospitals and nursing homes (Alexander, Weiner, & Griffith, 2006; Chesteen, Heigheim, Randall, & Wardell, 2005; Douglas & Judge. 2001).
A study conducted by Lee et al. (2007) concluded that for the successful implementation of TQM system in hospitals requires hospital control, devel- oping an incorporated performance measurement system, and a broad approach for quality progress.
Horng and Huarng (2002), in their study based on survey of 76 hospitals in Taiwan, tested a multilevel model addressing the issue of TQM adoption. Results of the analyses indicated that the nature of the network relationship and prospector strategy, the two constructs out of five identified constructs, are positively and significantly related to the extent of TQM adoption. Further analysis shows that prospector strategy is related to TQM adoption for profit earning hospitals while network relationship is related to TQM adoption for nonprofit hospitals.
The study by Yasin and Alavi (1999) illustrated the use of market share model for achieving competitive advantage of TQM in health care and con- cluded that TQM contributes to increase in market share and organizational effectiveness.
Komashie, Mousavi, and Gore (2007) argued that though the theory of quality has a long history, but the supervision of quality and its control in
Best Practices of Total Quality Management 235
health care industry is not as highly developed as in manufacturing industry. They mentioned several reasons, such as kind of procedures and production involved, and dissimilarities between the two industries in terms of concerns for quality.
Chow-Chua and Goh (2000) concluded that continuous improvement and innovative approaches such as TQM have generated cost and time sav- ings and helped to streamline work processes. They further concluded that large hospitals and public hospitals are more inclined to implement TQM approach while medium sized hospitals tend to use continuous improvement as a medium for quality improvement.
Other similar studies of interest based on TQM in the health care environment are those of Ovretveit (2000); Satia and Dohlie (1999); Brennan (1998); Nwabueze and Kanji (1997); and Aggarwal and Zairi (1997).
Moreover, implementing TQM principle and practices will not only miti- gate the financial crisis of the health care institutions but will also help to overcome many critical problems which they are facing. It is also pertinent to understand that the pressure the health care institutions are facing might push them to implement TQM program to resolve the critical issues involved. Thus, TQM can become an alternative option for policy makers as well as for managers of health care institutions.
RESEARCH OBJECTIVE AND METHODOLOGY
The purpose of the study is to identify a set of best practices of TQM in health care setting that could be used by the researchers and practitioners of the health care institutions for its successful implementation. The methodology selected for this study was literature review of the published research papers on the current subject and area. To identify the appropriate published research papers for this study, a search strategy using the following expres- sions and phrases was conducted: ‘‘TQM strategy,’’ ‘‘quality management,’’ ‘‘Hospital guidelines and administration,’’ ‘‘Health care organizations= institutions,’’ ‘‘TQM framework and implementation,’’ ‘‘TQM practices and problems,’’ and ‘‘quality management system and practices.’’ A comprehen- sive computer-aided search of papers in the ProQuest Advanced Search Database published from 1995 to 2009 was performed using these expres- sions and phrases. The results were further narrowed down with the keywords like ‘‘health care,’’ ‘‘hospitals,’’ ‘‘TQM,’’ ‘‘QM,’’ and ‘‘TQM prac- tices.’’ Not included were terms including ‘‘strategy,’’ ‘‘guidelines,’’ ‘‘adminis- tration,’’ ‘‘problems,’’ or ‘‘clinical methods.’’ With a limitation on English language, full text, and scholarly peer-reviewed papers, the search resulted in 836 hits.
From these selected research papers, this study further searched for those papers which focused on factors and practices influencing TQM or
236 F. Talib et al.
QM in health care organization and which were either empirical or review studies. The QM=TQM studies which are limited on describing one specific quality improvement action or using service quality approach=case based approach=articles=commentaries=projects were excluded. The titles and abstracts based on these criteria were reviewed and excluded 585 publica- tions. A total of 251 abstract were further reviewed for the second criteria, which concerns the identification of TQM practices in the health care institu- tions. This resulted in the exclusion of 173 publications and the search now was left with 78 publications specifically describing the TQM or QM practices and their implementation process. These 78 selected publications were then retrieved for the full text documents to evaluate their methodology of study, approaches, and findings. The 78 fully retrieved papers were then further examined for their empirical and review studies thus, excluding 41 single case study papers, five projects papers and 17 papers on short articles and commentary. Only 11 empirical and four review studies were included for further review. Finally, a total of 15 research publications were reviewed. The systematic approach of present literature review is depicted in Figure 1. Data from these 15 studies were also extracted into a structured summary as shown in Table 1 where the objectives, methodology, approach, and main findings have been explained. All the TQM practices identified
FIGURE 1 Systematic literature review. Process.
Best Practices of Total Quality Management 237
T A B L E 1
D e sc ri p ti o n o f O b je c ti v e s, M e th o d o lo g y , a n d M a in
F in d in g s o f th e S e le c te d S tu d ie s
A u th o r( s)
O b je c ti v e
M e th o d o lo g y a n d a p p ro a c h
N u m b e r o f
T Q M
p ra c ti c e s
M a in
fi n d in g s
L in
a n d C lo u si n g
(1 9 9 5 )
A ss e ss in g T Q M
p ro g ra m
st a tu s a n d e x e c u ti v e s
a tt it u d e in
th e h o sp it a ls
C o n st ru c t: T Q M
M e th o d : C ro ss -s e c ti o n a l
A p p ro a c h : C o rr e la ti o n
S a m p le
ty p e : N o rt h e rn
L o u is ia n a
h o sp it a ls , U n it e d S ta te s
S a m p le
si z e : 3 1 h o sp it a ls
7 L im
it e d im
p le m e n ta ti o n o f T Q M
L a c k
o f to p -m
a n a g e m e n t in v o lv e m e n t
a n d c o m m it m e n t, e m p lo y e e
in v o lv e m e n t, w e a k n e ss
o f li n k a g e
w it h p a ti e n t sa ti sf a c ti o n
R a ja
e t a l. (2 0 0 7 )
C o m p a ri n g q u a li ty
a w a rd s
a n d th e se le c ti o n c ri te ri a
fo r a ss e ss in g h e a lt h c a re
p ro c e ss e s q u a li ty
st a tu s in
p ri v a te
se c to r h e a lt h c a re
in st it u ti o n s
C o n st ru c t: Q u a li ty
m a n a g e m e n t
(Q M ) a n d se rv ic e q u a li ty
M e th o d : C ro ss -s e c ti o n a l
A p p ro a c h : P ri n c ip a l c o m p o n e n t
a n a ly si s
S a m p le
ty p e : H e a lt h c a re
st a k e -
h o ld e rs , In d ia
S a m p le
si z e : 6 2 p ri v a te
h o sp it a ls
5 P ro v id e in si g h ts in to
th e re la ti o n sh ip s
a m o n g th e d im
e n si o n s li k e :
re la ti o n sh ip
b e tw
e e n le a d e rs h ip ,
re so u rc e m e a su re m e n t, p e o p le
m a n a g e m e n t, p ro c e ss
m a n a g e m e n t, a n d c u st o m e r
sa ti sf a c ti o n .
H a z il a h (2 0 0 9 )
C o m p a ra ti v e a n a ly si s o n
Q M
p ra c ti c e s a m o n g th e
th re e le v e ls o f p u b li c
h o sp it a ls
C o n st ru c t: Q M
M e th o d : C ro ss -s e c ti o n a l
A p p ro a c h : T -t e st , o n e -w
a y
A N O V A
S a m p le
ty p e : P u b li c h o sp it a ls
(D is tr ic t, st a te
a n d n a ti o n a l
le v e l) o f M a la y si a
S a m p le
si z e : 2 3 h o sp it a ls
9 Q M
p ra c ti c e s si g n if ic a n tl y h ig h in
d is tr ic t h o sp it a ls , b u t n o si g n if ic a n t
d if fe re n c e in
p e rc e p ti o n o n
im p le m e n ta ti o n o u tc o m e b e tw
e e n
th e th re e le v e ls o f h o sp it a ls .
M e y e r a n d C o ll ie r
(2 0 0 1 )
E m p ir ic a l te st in g o f th e
B a ld ri g e M o d e l o f Q M
fo r
th e h e a lt h c a re
in d u st ry
a n d d e te rm
in in g th e
c a u sa l re la ti o n sh ip s
a m o n g th e B a ld ri g e
H e a lt h C a re
p il o t c ri te ri a
C o n st ru c t: Q M
M e th o d : C ro ss -s e c ti o n a l
A p p ro a c h : S tr u c tu ra l e q u a ti o n
m o d e li n g
S a m p le
ty p e : C o m m u n it y h o sp i-
ta ls (n
> 6 0 ), U n it e d S ta te s
S a m p le
si z e : 2 2 0 h o sp it a ls
7 M a n y o f th e h y p o th e si z e d c a u sa l
re la ti o n sh ip s in
th e B a ld ri g e m o d e l
a re
st a ti st ic a ll y si g n if ic a n t S tu d y
a ls o c la ri fi e s a n d im
p ro v e s
u n d e rs ta n d in g o f w it h in -s y st e m
p e rf o rm
a n c e re la ti o n sh ip s
238
C a rm
a n e t a l. (1 9 9 6 )
Id e n ti fy in g th e k e y su c c e ss
fa c to rs
fo r T Q M
im p le m e n ta ti o n a n d th e
im p a c t o f T Q M
o n
o rg a n iz a ti o n p e rf o rm
a n c e
C o n st ru c t: T Q M
M e th o d : C ro ss -s e c ti o n a l
A p p ro a c h : L o g is ti c re g re ss io n
S a m p le
ty p e : H e a lt h sy st e m s in
th e U n it e d S ta te s
S a m p le
si z e : 1 0 h o sp it a ls
7 S e v e n k e y su c c e ss
fa c to rs w e re
fo u n d
T h e d e g re e o f T Q M
im p le m e n ta ti o n d o e s n o t a ff e c t
o rg a n iz a ti o n p e rf o rm
a n c e .
K u n st
a n d L e m m in k
(2 0 0 0 )
Id e n ti fy in g a n d e x p lo ri n g
su c c e ss
p a ra m e te rs
o f
h ig h q u a li ty
p e rf o rm
a n c e
a n d th e ir
in te rr e la ti o n sh ip s
C o n st ru c t: T Q M
M e th o d : C ro ss -s e c ti o n a l
A p p ro a c h : F a c to r a n a ly si s u si n g
p ri n c ip a l c o m p o n e n t a n a ly si s
S a m p le
ty p e : G e n e ra l a n d u n iv e r-
si ty
h o sp it a ls in
S p a in , U n it e d
K in g d o m , a n d N e th e rl a n d s
S a m p le
si z e : 8 5 0 h o sp it a ls
8 D if fe re n t v a ri a b le s o r p a ra m e te rs
a re
li n k e d to
p ro g re ss
in T Q M
a n d
b u si n e ss
p e rf o rm
a n c e P o si ti v e li n k
b e tw
e e n p ro g re ss
in T Q M
a n d
p e rc e iv e d se rv ic e q u a li ty
b y
c u st o m e rs
M il le r e t a l. (2 0 0 9 )
A ss e ss in g th e c ri ti c a l fa c to rs
in fl u e n c in g th e Q M
p ra c ti c e s in
h e a lt h c a re
C o n st ru c t: Q M
M e th o d : C ro ss -s e c ti o n a l
A p p ro a c h : F a c to r a n a ly si s u si n g
p ri n c ip a l c o m p o n e n t a n a ly si s
S a m p le
ty p e : S ta te
h o sp it a l
a ss o c ia ti o n m e m b e r h o sp it a ls ,
U .S . so u th e a st e rn
st a te
S a m p le
si z e : 1 8 9 h o sp it a ls
1 0
E ig h t fa c to rs
sh o w e d st a ti st ic a ll y
si g n if ic a n t e ff e c t o n Q M
p ra c ti c e s.
A v a li d a n d re li a b le
in st ru m e n t w a s
d e v e lo p e d a n d u se d to
a ss e ss
Q M
p ra c ti c e s in
h o sp it a ls th ro u g h o u t a
la rg e U .S . st a te
M o sa d e g h R a d (2 0 0 5 )
In v e st ig a te
th e su c c e ss
o f
T Q M
a n d b a rr ie rs
to it s
su c c e ss fu l
im p le m e n ta ti o n
C o n st ru c t: T Q M
M e th o d : C ro ss -s e c ti o n a l
A p p ro a c h : C o rr e la ti o n
S a m p le
ty p e : H e a lt h c a re
o rg a n i-
z a ti o n s in
Is fa h a n p ro v in c e , Ir a n
S a m p le
si z e : 9 0 h e a lt h c a re
o rg a n iz a ti o n s
8 T o p -m
a n a g e m e n t’ s c o m m it m e n t
in c re a se d th e su c c e ss fu l
im p le m e n ta ti o n B a rr ie rs
re la te d to
im p le m e n ta ti o n : h u m a n re so u rc e s,
st ra te g ic , a n d st ru c tu ra l p ro b le m s
S a la h e ld in
a n d
M u k h a la la ti (2 0 0 9 )
E x a m in in g th e
im p le m e n ta ti o n o f T Q M
in th e h e a lt h c a re
se c to r in
Q a ta r a n d d e te rm
in in g
th e m o st
im p le m e n te d
C o n st ru c t: T Q M
M e th o d : C ro ss -s e c ti o n a l
A p p ro a c h : M a n n -W
h it n e y te st
S a m p le
ty p e : P ri v a te
a n d p u b li c
h o sp it a ls , Q a ta r
9 C o m m o n u n d e rs ta n d in g e x is ts
b e tw
e e n m a n a g e rs
a b o u t th e
si g n if ic a n c e o f to p -m
a n a g e m e n t
su p p o rt , e m p lo y e e tr a in in g , a n d
in v o lv e m e n t in
th e T Q M (C o n ti n u ed
)
239
T A B L E 1
C o n ti n u e d
A u th o r( s)
O b je c ti v e
M e th o d o lo g y a n d a p p ro a c h
N u m b e r o f
T Q M
p ra c ti c e s
M a in
fi n d in g s
T Q M
in it ia ti v e s, th e le v e l
o f u n d e rs ta n d in g a n d
k n o w le d g e o f T Q M , a n d
th e c ri ti c a l su c c e ss
fa c to rs
o f T Q M
im p le m e n ta ti o n
S a m p le
si z e : 2 0 0 h o sp it a ls
im p le m e n ta ti o n . V it a l ro le
o f
su p p li e r in
su p p o rt in g q u a li ty
im p ro v e m e n t
D u g g ir a la
e t a l.
(2 0 0 8 )
Id e n ti fy in g th e d im
e n si o n s
o f p a ti e n t- p e rc e iv e d to ta l
q u a li ty
se rv ic e (T Q S ) in
th e h e a lt h c a re
se c to r a n d
th e re
im p a c t o n p a ti e n t’ s
sa ti sf a c ti o n
C o n st ru c t: T Q S
M e th o d : C ro ss -s e c ti o n a l
A p p ro a c h : M u lt ip le
re g re ss io n
a n a ly si s
S a m p le
ty p e : P a ti e n ts
d is c h a rg e d
fr o m
h o sp it a ls , In d ia
S a m p le
si z e : 3 0 0 p a ti e n ts o f m a n y
h o sp it a ls
6 S e v e n d is ti n c t d im
e n si o n s o f
p a ti e n t- p e rc e iv e d T Q S h ig h li g h te d .
P o si ti v e a n d si g n if ic a n t
re la ti o n sh ip s a m o n g th e
d im
e n si o n s a n d p a ti e n t sa ti sf a c ti o n
h a v e b e e n fo u n d
Is o u a rd
(1 9 9 9 )
Im p ro v in g a v a ri e ty
o f
p ro b le m
a re a s th a t a ff e c t
th e to ta l p a th o lo g y
se rv ic e o f th e h o sp it a l
P o te n ti a l b a rr ie rs
to a c h ie v e th e re q u ir e d
o rg a n iz a ti o n a l
e n v ir o n m e n t a re
a ls o
e x p lo re d
C o n st ru c t: T Q M
M e th o d : E x p lo ra to ry
st u d y
A p p ro a c h : D e sc ri p ti v e
S a m p le
ty p e : P a th o lo g y se rv ic e s,
A u st ra li a
S a m p le
si z e : N = A
4 F o u r e le m e n ts fo u n d to
b e im
p o rt a n t
to th e c re a ti o n o f th e T Q M
e n v ir o n m e n t: C h a n g e in
m a n a g e m e n t c u lt u re , d e v e lo p m e n t
o f te a m w o rk , fo c u s o n c u st o m e rs ,
a n d c o n ti n u o u s fe e d b a c k to
st a ff
K o z a k e t a l. (2 0 0 7 )
Id e n ti fy in g e m p lo y e e s’
p e rc e p ti o n s o f th e e x te n t
to w h ic h T Q M
p ro g ra m s
a re
im p le m e n te d in to
th e ir h o sp it a l
o rg a n iz a ti o n s a n d
C o n st ru c t: T Q M
M e th o d : E x p lo ra to ry
st u d y
A p p ro a c h : N = A
S a m p le
ty p e : H o sp it a l o rg a n iz a -
ti o n s, T u rk e y
S a m p le
si z e : N = A
5 T Q M
p e rc e p ti o n s a re
a ss o c ia te d in
th e m in d s o f h o sp it a l e m p lo y e e s.
T h e re sp o n si b il it y o f b o th
u p p e r- le v e l m a n a g e m e n t a n d
e m p lo y e e s h a s b e e n fo u n d a s th e
m o st
si g n if ic a n t e ff e c t o n
240
e x p lo ri n g th e p ro b le m s
th e y p e rc e iv e d u ri n g th e
su c c e ss fu l
im p le m e n ta ti o n o f T Q M
p ro g ra m s
e m p lo y e e s’ p e rc e p ti o n s a b o u t th e
n e c e ss it y o f T Q M
p ro g ra m s a t
h o sp it a l se tt in g s.
S h o rt a n d R a h im
(1 9 9 5 )
R e v ie w
a n d u n d e rs ta n d in g
th e p o te n ti a l a re a s o f
c o n fl ic t b e tw
e e n
h o sp it a ls ’ m a n a g e m e n t
a n d T Q M
C o n st ru c t: T Q M
M e th o d : L it e ra tu re
re v ie w
A p p ro a c h : D e sc ri p ti v e
S a m p le
ty p e : H e a lt h c a re
in d u st ry
o f C a n a d a a n d U S A
S a m p le
si z e : N A
6 H o sp it a l a d m in is tr a to rs
sh o u ld
a ss e ss
a n d m a k e n e c e ss a ry
c h a n g e s to
th e
st ru c tu re , p h il o so p h y , p o li c ie s,
to ta l c o m m it m e n t, a n d
m a n a g e m e n t st y le
b e fo re
in tr o d u c in g T Q M
T Q M
ta k e s ti m e
a n d e n e rg y
W a rd h a n i e t a l. (2 0 0 9 )
Id e n ti fi c a ti o n o f q u a li ty
m a n a g e m e n t sy st e m s’
(Q M S ) d e te rm
in a n ts
in h o sp it a ls
C o n st ru c t: Q M S
M e th o d : S e a rc h st ra te g y (l it e ra tu re
re v ie w )
A p p ro a c h : D e sc ri p ti v e (e m p ir ic a l
a rt ic le s)
S a m p le : M e d li n e d a ta b a se s (1 9 9 2 –
2 0 0 6 )
S a m p le
si z e : 1 4 e m p ir ic a l p u b li -
c a ti o n s o n h e a lt h c a re , h o sp it a ls
e tc .
6 S ix
fa c to rs
d e te rm
in in g Q M S
im p le m e n ta ti o n w e re
id e n ti fi e d in
th e re v ie w
T h e y a re : O rg a n iz a ti o n c u lt u re ,
d e si g n , le a d e rs h ip , fo r q u a li ty ,
p h y si c ia n in v o lv e m e n t, q u a li ty
st ru c tu re , a n d te c h n ic a l
c o m p e te n c e
A ra sl i a n d
A h m a d e v a (2 0 0 4 )
P ro p o si n g a q u a li ty
im p ro v e m e n t m o d e l fo r
h e a lt h p ro m o ti o n in
h o sp it a ls in
N o rt h e rn
C y p ru s a s w e ll a s
c o m p a ri n g a n d
u n d e rs ta n d in g th e th e ir
e x is ti n g p ro b le m s a n d
c h a ll e n g e s
C o n st ru c t: T Q M
M e th o d : C ro ss -s e c ti o n a l
A p p ro a c h : A N O V A te st
S a m p le
ty p e : P u b li c a n d p ri v a te
h o sp it a ls o f N o rt h e rn
C y p ru s
S a m p le
si z e : 7 h o sp it a ls c o v e ri n g
7 5 0 fa m il ie s
7 P u b li c se c to r is in
a m u c h w o rs e
p o si ti o n th a n th e p ri v a te
se c to r in
te rm
s o f to ta l q u a li ty
T h e p ro p o se d
m o d e l c o u ld
c o n tr ib u te
to to ta l
q u a li ty
p ra c ti c e s o f h o sp it a ls in
d e v e lo p in g c o u n tr ie s
241
from these 15 papers were recorded, and based on their frequency of occur- rence; the results were obtained as shown in Table 2.
RESULTS
Different findings and practical implications could be discerned from in-depth study of the 15 selected research publications with varying terms of their specific study approach, objectives, methodology, sampling type and size, setting, and respondents as shown in Table 1.
Overall, there are eight best practices in TQM implementation identified from the review of literature, namely, top-management commitment (or leadership; 11; teamwork (8); process management (8); customer focus and satisfaction (8); resource management (7); organization behavior and culture (6); continuous improvement (5); and training and education (5). These practices were identified on the basis of their frequency of occurrence in the literature review as shown in curly parentheses. The following part of this article will further explain each TQM practice.
Top-Management Commitment (Leadership)
Top-management commitment and support (or leadership) is found to be the most important enabling practice for implementing TQM in the health care institutions. Other elements of top-management commitment
TABLE 2 Major TQM Practices in Health Care Setting Investigated From Literature Review
TQM practice
Author(s) TMC TWP PM CFS RM OBC CI TE
Lin and Clousing (1995) p p p p
Raja et al. (2007) p p p p p
Hazilah (2009) p p p p p
Meyer and Collier (2001) p p p p p p
Carman et al. (1996) p p p
Kunst and Lemmink (2000) p p p p
Miller et al. (2009) p p p p p
Mosadegh Rad (2005) p p p p
Salaheldin and Mukhalalati (2009) p p p p p
Duggirala et al. (2008) p p
Isouard (1999) p p p
Kozak, Asunakutlu, and Safran (2007) p p p
Short and Rahim (1995) p p
Wardhani et al. (2009) p p p
Arasli and Ahmadeva (2004) p p p p
Total 11 8 8 8 7 6 5 5
TMC ¼ top-management commitment; TWP ¼ teamwork and participation; PM ¼ process management; CFS ¼ customer focus and satisfaction; RM ¼ resource management; OBC ¼ organization behavior and culture; CI ¼ continuous improvement; and TE ¼ training and education.
242 F. Talib et al.
include: leadership style, administrative support, upper-management involve- ment, support of upper-level management, and leadership for quality. Studies showed that quality of care has been connected to leadership in hospitals (Eubanks, 1992) and is an overall hospital systems driver (Meyer & Collier, 2001). The top-management acts as a coach to teach and to influ- ence the subordinate (Yang, 2003). It is generally accepted that any bottom-up quality action might fail without support from the hospital top management (Mosadegh Rad, 2005). Sometimes committed physicians also play an important role for successful implementation of TQM program in hospitals (Wakefield et al. 2001). Further, top-management allows and encourages everyone to contribute in the organization by encouraging them, and emphasize on process improvement rather than individual account- ability (Raja, Deshmukh, & Wadhwa, 2007). It can be concluded that top-management commitment is a prerequisite for effective and successful TQM implementation. This practice was well supported by 11 published studies during the present literature survey (Table 2).
Teamwork and Participation
A second key practice of TQM is the development of teamwork and partici- pation. To overcome sectionalism, the entire organization should cooperate in improving quality and embark on quality improvement activities (Yang, 2003) by forming teams with full participation. The proper formation of qual- ity improvement teams is vital to an organization’s TQM success. It is essential that each issue and organizational problem is analyzed by all the team mem- bers who are responsible for its improvement (Brashier, Sower, Motwani, & Savoie, 1996). In hospitals, a team should be composed of personnel from each department and should be capable to improve a process. One of the important objectives of teamwork and participation is that they should solve the quality related issues in quick time who are sometimes called as quality action teams (Mayer, 1992). Hence, teamwork and participation is essential in health care institutions, as it requires cooperation among all related depart- ments. This practice is well supported by eight published studies (Table 2). The other elements of teamwork and participation are: people management, staff focus, work system, employee relations, and teamwork development.
Process Management
Process management is a critical practice of health care quality which empha- sizes conformance to patient (customer) requirements by means of error-free services in the most efficient way or in other words the experience of the patient with different processes that are a part of their stay in hospital (Duggirala, Rajendran, & Anantharaman, 2008). The key aspects of this practice covers: maintenance, setting standards, sincerity, effectiveness,
Best Practices of Total Quality Management 243
management by fact, giving priority to patient’s need, emergency of service system, admission procedure, registration procedure, security system, and process of clinical care. These elements ensure error free quality output. It emphasizes the way staff strengthen the processes through quality improvement and operational performance (Raja et al., 2007). Zeithaml, Parasuraman, and Berry (1990) described process management as the actual procedures, mechanism, and flow of activities by which the service (health care service) is delivered. Finally, it concludes that process management examines the patient’s perception with regard to the treatment process and the outcome of the treatment process. This practice was highlighted by eight published studies of the current literature survey (Table 2).
Customer Focus and Satisfaction
Customer focus and satisfaction is another important practice of the TQM movement because health care institutions can outsource their competitors by effectively addressing patients’ (customers’) needs and demands, and by anticipating and responding to their evolving interests and wants (Sureshchandar, Rajendran, and Anantharaman, 2001). Their primary duty is to provide the patients (customers) with the best possible services. These services begin with arrival of patient into hospital premises and at the regis- tration counter by delivering online registration and taking immediate action as per the condition of the patient without loss of time. Hence, first impression is formed at the very first service rendered to the patient and this activity plays a key role in the patient’s perception towards the hospital and may act as motivating force in his recovery. Effective food management and availability of hygienic food in the hospitals is also important in providing patients with high quality services. The amount of food offered to patients should be sufficient to satisfy their needs and suitable to all groups of patient (Arasali & Ahmadeva, 2004). Beside this, other items include: emergency ser- vices, customer expectations, confidence, treatment cost, patient focus, and complaint resolution. However, customer satisfaction is a short-term concept, which may or may not lead to commitment. The management’s responsibility is to ensure that satisfaction is converted into commitment in the long run. Every patient needs proficient and skilled medical personnel for sound diag- nosis, treatment and care (Raja et al., 2007). Hence, the ultimate aim is to satisfy customer. This practice was considered by eight published studies during the present literature survey (Table 2).
Resource Management
This practice of TQM assesses the patient’s perception of quality with regard to physical facilities in the health care institutions. Resource management is basically concerned with management of available resources which are
244 F. Talib et al.
needed right from patients’ entry in the hospital to their discharge and therefore, is a critical factor for any health care institution. This practice includes: resource measurement, infrastructure, cleanliness, maintenance, and availability of service such as ambulance, laboratory, operation theaters, wards, materials, information system, ATM, banks, and drug stores. Good service cannot be provided if there is insufficient provision of the aforemen- tioned items, no matter how professional doctors, physicians, and supporting staff are (Arasali & Ahmadeva, 2004). The provision of these facilities and materials has a direct impact on patient satisfaction (Hancock, 1999). Use of resource management as TQM practice was supported by seven studies in this literature survey (Table 2).
Organizational Behavior and Culture
The role of organizational behavior and culture plays an important role in successful implementation of TQM in health care institutions. The atmos- phere of the hospital should be friendly and respectful, both among staff and between staff and patients, and it has a great impact on the physical con- dition of patients (Arasali & Ahmadeva, 2004). A total quality culture creates an atmosphere where people freely help each other to achieve goals and have fun during the process. In a positive culture, people feel appreciated, their opinions are prioritized, and actions follow suggestions (Short & Rahim, 1995). Further, the hospitals should be free of organisms and clean, develop an environment to work as a team in improving the quality, and the objective should be problem solving and shared accountability. For TQM to be adopted successfully, the organizational culture and behavior must be able to sustain and nurture it (Atchison, 1992). Six empirical studies tested and supported this practice (Table 2).
Continuous Improvement
Continuous improvement is also an influencing practice in the implemen- tation of TQM. Five empirical studies found to support this quality manage- ment practice (Table 2). Institutionalizing continuous quality improvement in every department of health care institution will result in elimination of bar- riers, patient’s dissatisfaction, and complaints. The aim of customer improve- ment is to fulfill patient’s (customer) needs (Yang, 2003). Continuous quality improvement needs training and education of all staff and physicians together with the use of different quality improvement approaches, tools, and techniques. This practice ensures that organizations and staff do not settle for minimum standards but strive to do their best they can with avail- able resources (Satia & Dohlie, 1999). The items for this practice also includes: measurement of quality care, performance measurement, innova- tiveness, and performance analysis. Furthermore, the quest for quality
Best Practices of Total Quality Management 245
improvement is not a definable task, but a continuous journey that throws up more and more opportunities for improvement. It has no definable objective other than the desire to strive for continuous improvement (Sureshchandar et al., 2001) and to achieve patient’s satisfaction as a goal.
Training and Education
Training and education was also noted as supporting practice for implement- ing TQM approach. This practice was cited by atleast five research studies in the present review (Table 2). This practice reflects the organization’s capability to use the quality management tools and techniques (Wardhani, Utarini, van Dijk, & Post, 2009). It includes: technical support, management training, statistical process control, employee training, scientific problem- solving approach, and information system. It is generally accepted that success in TQM relies on continuing education and training of all levels of personnel (Brashier et al., 1996). Technical training also intends to meet the needs of high performance at the workplace, as it effects employee and staff efficiency and safety. Further, the employees and staff need to be trained in statistical techniques for better quality management (Mahadevappa & Kotreshwar, 2004). Therefore, employee and staff training and education are the fundamental engineering during the implementation of TQM.
DISCUSSION AND CONCLUSIONS
From the present review of literature, eight important TQM practices were identified: top-management commitment (or leadership), teamwork and par- ticipation, process management, customer focus and satisfaction, resource management, organizational behavior and culture, continuous improvement, and training and education. It was found that these eight TQM practices are critical for the successful implementation of TQM in the health care institutions and will result in improved performance, patient satisfaction, improved quality of care, and reduced operating cost of health care institu- tions (Figure 2). Therefore, these practices are termed best practices of TQM in present study.
However, the findings of this study are, to some extent, different from previous studies related to the identification of TQM practices. Other studies have identified different number of practices as well as some other practices which are not found in the present study outcome. This inconsistency in find- ings may be due to several reasons. Some of them are due to:
. Limitations of the research methodology adopted in the study
. Some external environmental factors at each research site, and
. Outcome measures
246 F. Talib et al.
Analyzing briefly these reasons, it was found that all empirical studies con- sidered in this study were based on cross-sectional analysis except for few exploratory studies that have utilized literature review (descriptive) as method- ology. Besides this, sampling type and size was also found to be varying in each study. This may affect the outcome of the present study. Further going through all the 15 research studies, it was found that four studies were conducted in United States, two in India, and one each in Cyprus, Australia, Canada, United Kingdom, Malaysia, Turkey, Iran, and Qatar. Two studies were also undertaken based on cross-country data. This supports that a set of TQM practices are not identical across the globe=world but they may vary from country to country depending upon the structure, size, and ownership of health care institutions. In the present study, hospitals of different sizes, structures, and ownership were considered for literature review. This may be another factor for the incon- sistency in the result. Lastly, another reason for the inconsistency is related to the outcome measures. Most of the selected research studies utilized different standard models, such as the Malcolm Baldrige National Quality Award, the European Foundation for Quality Management, and Kanji’s Business Excel- lence Model as a measure of the degree of TQM implementation and hence, this approach also affects the results of the present study.
Further, it is concluded from the results of this study that top- management commitment is considered as the first requirement for
FIGURE 2 Conceptual model of TQM practices influencing its implementation in health care institutions.
Best Practices of Total Quality Management 247
implementing TQM as many research findings supported this practice. Hence, top-management should lead the effort in improving the quality of the health care institutions. While teamwork and participation, process man- agement, and customer focus and satisfaction are considered as other impor- tant practices for successful TQM implementation. These practices are also well supported by many research studies and play a dominating role in health care institutions. Similarly, other practices like resource management, organizational behavior and culture, continuous improvement, and training and education also play an important role as explained in earlier section. Thus, it is concluded that all these eight identified TQM practices are very effective and are considered critical to the successful TQM implementation in health care institutions. Therefore, they may be treated as best TQM prac- tices for health care institutions.
Managerial Implications
For the successful implementation of TQM philosophy in the health care institution some of the managerial implications of the current study are:
. Managers can use TQM philosophy as a strategic competitive weapon for achieving desirable outcome such as patient satisfaction, improved quality of care, and improved performance.
. Managers as well as quality policy makers in health care institutions should pay more attention to the vital role of top-management and employees and staff in the TQM initiation, implementation, and success stages.
. Managers can draw attention in enhancing the organization culture and developing teamwork and participation at all levels as well as the impor- tance of giving training and education to their employees for the successful implementation of TQM philosophy.
. Finally, managers can understand the importance of satisfying all internal and external stakeholders upon the introduction of TQM strategy.
Recommendation for Future Research
The scope and suggested direction for further research work in this area are:
. Further study can be undertaken to understand the barriers in the imple- mentation of TQM program and to broaden this study to other developing countries.
. A comparative study with other less developed countries may be carried out to observe the similarities and dissimilarities concerning TQM imple- mentation in health care institutions.
. Further studies need to be undertaken concerning the detailed impact of identified eight best practices of this study on TQM implementation.
248 F. Talib et al.
. Empirical research should be conducted to evaluate the understanding and the TQM practices based on customer’s point of view.
Finally, the results of the present study will help the managers and prac- titioners to adopt TQM program successfully in their organizations and will open new dimensions for other researchers in this area, contributing to the knowledge in enhancing the implementation of TQM philosophy.
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