The TQM JournalDeveloping and validating a total quality management model for healthcareorganisationsAli Mohammad Mosadeghrad

Article information:To cite this document:Ali Mohammad Mosadeghrad , (2015),"Developing and validating a total quality management modelfor healthcare organisations", The TQM Journal, Vol. 27 Iss 5 pp. 544 - 564Permanent link to this document:http://dx.doi.org/10.1108/TQM-04-2013-0051

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Developing and validating a totalquality management model for

healthcare organisationsAli Mohammad Mosadeghrad

School of Public Health,Tehran University of Medical Sciences, Tehran, Iran

AbstractPurpose – The purpose of this paper is to develop a total quality management (TQM) model forhealthcare organisations and validate it using a sample of Iranian healthcare organisations.Design/methodology/approach – A validated questionnaire was used to collect data from allhealthcare organisations that implemented TQM in Isfahan province, Iran.Findings – Using the proposed model, TQM implementation was measured in healthcareorganisations. The level of TQM success in Isfahan healthcare organisations was medium. The highestscore was achieved in the dimension of “customer management”, followed by “leadership” and“employee management”. Employee management, information management, customer management,process management and leadership had the most positive effect on TQM success. Using a series ofquality management techniques had “synergistic” effect on TQM success.Practical implications – Top management support, effective management of human resources, fullinvolvement of the entire workforce including physicians, education and training, team working,continuous improvement, a corporate quality culture, customer focus and using a combination ofmanagement techniques under a quality management system are necessary for TQM successfulimplementation.Originality/value – A healthcare context-specific model of TQM was developed and tested andsuggestions were provided for its successful implementation.Keywords Total quality management, Success, Healthcare organizationsPaper type Research paper

IntroductionIn the past two decades the acknowledgement of medical errors, leading to patient injuryand even death, has generated potential healthcare legislation and consumer awarenessabout considering and integrating quality in healthcare (Becher and Chassin, 2001; Ruiz andSimon, 2004). Concepts like clinical governance, clinical effectiveness, clinical audit, peerreviews, accreditation and continuous professional development are examples of attempts tomonitor and improve the quality of healthcare services. Many healthcare organisationsutilised various industrial quality management strategies such as quality assurance,continuous quality improvement, total quality management (TQM), business processreengineering, six sigma and quality function deployment to improve the quality of care.

TQM enables healthcare organisations to identify customer requirements, benchmarkfor best practices and improve processes to deliver appropriate care and reduce thefrequency and severity of medical errors. TQM implementation may lead to higherquality care, improved patient satisfaction, better employee morale and increasedproductivity and profitability (Alexander et al., 2006; Cauchick Miguel, 2006; Kunst and

The TQM JournalVol. 27 No. 5, 2015pp. 544-564©EmeraldGroup Publishing Limited1754-2731DOI 10.1108/TQM-04-2013-0051

Received 4 May 2013Revised 15 January 201420 July 2014Accepted 25 September 2014

The current issue and full text archive of this journal is available on Emerald Insight at:www.emeraldinsight.com/1754-2731.htm

The author would like to thank all those who kindly agreed to participate in the survey.The author is also grateful to the editor and anonymous reviewers of TQM journal for theirconstructive comments and guidance for improving this paper.

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Lemmink, 2000; Macinati, 2008). The TQM success in industry has encouragedhealthcare managers to examine whether it can work in the health sector. Accordingly,many healthcare organisations increasingly implemented TQM principles to improve thequality of outcomes and efficiency of healthcare service delivery (Boerstler et al., 1996;Kunst and Lemmink, 2000; Macinati, 2008).

Iran healthcare system faces serious challenges concerning efficiency and quality(Aghamollaei et al., 2007; Mohammadi and Shoghli, 2008; Tabibi et al., 2009). Reports ofthe successful TQM implementation in the world encouraged Iranian policy makers tointroduce this strategy to healthcare organisations there in the hope of improvingquality and efficiency. Consequently, TQM has been implemented in several healthcareorganisations in the country (Askarian et al., 2010; Hamidi and Tabibi, 2004;Mohammadi et al., 2007). Many managers began to apply the concept of TQM withinhealthcare organisations using the Deming quality improvement approach calledFOCUS-PDCA. Besides, ISO 9001:2000 quality management system was accepted as amodel for TQM implementation (Mosadeghrad, 2014).

Despite numerous attempts to incorporate TQM/CQI in Iranian healthcare organisations,relatively little is known about its effectiveness. In order to bridge this gap, an investigationinto the effects of TQM implementation in Iranian healthcare organisations is truly needed.Such a study helps in identifying problem areas and possible remedies.

Theoretical frameworkMany researches were undertaken investigating TQM critical success factors during thelast two decades (Black and Porter, 1996; Dayton, 2001; Metri, 2005; Sila and Ebrahimpour,2002). All of these researchers developed their TQM frameworks based on their ownresearch purposes. TQM is a western management concept, which evolved out of Japanesemanagement practices. Hence, it may not integrate well into a different context (e.g. Iran)and industry (e.g. health). Each organisation may require different approaches for TQMimplementation (Mosadeghrad, 2013). Indeed, many of the theories developed in thewestern developed countries may need to be reassessed in developing countries such asIran. For instance, Iran according to Hofstede’s (2003) cross-cultural dimensions, highlyscored on “power distance” and “uncertainty avoidance”. Therefore, the country may needa different quality management model compared to Denmark which scored low on both.

Thus, an extensive review of literature on quality management models and frameworkswas performed to identify critical factors for successful TQM implementation in healthcare.A generic model of TQM has been proposed based on the literature review and informalinterviews with quality management experts (see Figure 1). From each study, a list ofconstructs of TQM was created. Quality management experts’ opinions were used incompleting this list. In total, 15 most common constructs of TQM were chosen for inclusionin the model, of which ten are enablers and five are results. Enablers direct and drive theresults. The model starts from the logical point of leadership and management and endswith overall performance results. The belief is that “excellent results with respect toorganisation, customer, employee, supplier and society are achieved through leadership andmanagement, strategic quality planning, quality culture, education and training, employeemanagement, customer management, supplier management, resource management,information management and process management”.

Leadership and managementThe success of TQM depends largely on managers’ ability to create a vision, planfor and lead the organisational change required for TQM success. The literature both

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in general industry and healthcare, addressed and emphasised the importance ofvisionary leadership, including philosophy, style and behaviour in the implementationprocess of TQM initiatives (e.g. Kunst and Lemmink, 2000; Mosadeghrad, 2005). Theleadership and management construct examines how senior managers as leaders arepersonally involved in developing and implementing a quality management system,inspire and drive the quality management change and support a culture of continuousimprovement. Accordingly, I postulate:

P1. Leadership and management are positively and significantly related toorganisational performance.

Strategic quality planningQuality improvement can only result from planned management action. The successfulimplementation of TQM requires careful strategic planning based on total quality.Including specific objectives for quality, as part of the strategic planning process, isassociated with the degree of TQM success (Dayton, 2001; Francois et al., 2003; Taylorand Wright, 2003). Healthcare managers should integrate quality as a strategic priorityin their organisations’ vision, policies and long-term strategies through a strategicquality planning process. The strategic quality planning construct examines howmanagers sets strategic directions, establishes a long-term vision, develops the valuesrequired for long-term success, sets strategic goals and objectives, incorporates qualityin the strategic goals and objectives and implements these via appropriate strategies,policies and action plans. Thus, I propose:

P2. Strategic quality planning is positively and significantly related toorganisational performance.

Quality cultureTQM requires changes in managers’ and employees’ believes, attitudes and behavioursto focus on continuous improvement. Successful implementation of TQM requires asignificant commitment to a culture emphasising trust, empowerment, entrepreneurship,teamwork, cooperation, risk taking and continuous improvement (Kaluarachchi, 2010;Mosadeghrad, 2006; Wardhani et al., 2009). TQM programmes are more likely to succeedif the prevailing organisational culture is compatible with the values and basic

Evaluation, improvement and organisational learning

Strategic quality planning

Education and training

Quality culture

Customer management

Employee management

Information management

Supplier management

Resource management

Pro

cess

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agem

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Customer results

Lead

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ResultsEnablers

Employee results

Supplier results

Society results

Organisation results

Figure 1.A conceptualframework of TQMfor healthcareorganisations

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assumptions proposed by the TQM discipline (Kujala and Lillrank, 2004). The qualityculture construct examines how managers develops a nurturing organisational culturethat supports quality. Hence, the following proposition is proposed:

P3. Quality culture is positively and significantly related to organisationalperformance.

Education and trainingContinuous and widespread education and training provide a good foundation forcultural change required for TQM implementation. Education and training help developemployees’ capabilities on a continuous basis. The review of literature corroborates theimportance of appropriate education and training in the process of TQM implementation(Goetsch and Davis, 2010; Palo and Padhi, 2003; Yusof and Aspinwall, 2000). Theeducation and training construct examines how managers recognises and nurturesthe development of employees’ abilities, skills and knowledge. Accordingly, I propose:

P4. Education and training are positively and significantly related to organisationalperformance.

Employee managementEmployee empowerment, commitment and involvement in quality management arekey factors in successful implementation of TQM and were indeed included in previousTQM studies (Lee and Quazi, 2001; Metri, 2005; Soltani et al., 2003). The employeemanagement construct examines how managers develop and manage the capabilitiesof people at individual, team-based and organisational levels, promote fairness andequality, involve, encourage and enable people to contribute to the achievement ofthe organisational goals and recognise their achievements. I propose then:

P5. Employees management is positively and significantly related to organisationalperformance.

Customer managementMany quality gurus and writers considered customer-driven quality a major successfactor of the TQM effort (Crosby, 1992; Deming, 1986; Oakland, 2003). Systems andprocesses must be in place to identify customer needs, translate these needs intoappropriate organisational requirements and satisfy them. The customer managementconstruct examines how the organisation builds relationships with customers,determines customers’ requirements and expectations and measures their satisfaction,and uses the feedback of customers in improving quality of services. Thus, thefollowing proposition is offered:

P6. Customer management has a positive influence on organisational performance.

Supplier managementOn an average, 40 per cent of production cost is due to purchased materials (Besterfield,1994). On the other hand, purchased materials are often a major source of qualityproblems (Zhang et al., 2000). Thus, supplier management is an important aspect ofTQM. An effective supplier management reduces procurement costs and enhances thequality of purchased products (Slaight, 1999). The supplier management constructexamines how the organisation manages suppliers effectively and efficiently to supportkey organisation processes, policies, strategies and action plans. Therefore, I expect:

P7. Suppliers management has a positive influence on organisational performance.

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Resource managementQuality improvement requires additional investments in time, capital and resources todevelop an appropriate infrastructure for quality. Allocation of resources (i.e. human,equipment and material) is necessary for delivering desired healthcare services to meetcustomer needs. Managers are responsible to provide appropriate resources to makethe implementation of TQM successful. An effective resource management systemenhances efficiencies, improves safety and reduces errors. The resources managementconstruct examines how the organisation manages its internal physical resourceseffectively and efficiently to support key organisation processes. The followingproposition is therefore proposed:

P8. Resource management has a positive influence on organisational performance.

Information managementFundamental to TQM is collecting accurate, timely, reliable and relevant data andinformation from both inside and outside the organisation for assessing, improvingand evaluating purposes ( Joss and Kogan, 1995; O’Brien et al., 1995). Such informationis necessary for the appropriate usage of resources, identification of customerrequirements, evaluating the effectiveness and efficiency of the operations anddetermining the cause of quality problems. Several studies reported that a lack of goodinformation system and information required for quality managemnet influenced thesuccess of quality improvement (Lee et al., 2002; Shortell et al., 1998). Thus, it ishypothesised that:

P9. Information management has a positive influence on organisational performance.

Process managementTQM focuses on studying, understanding and improving the processes. Processmanagement concerns the value adding system and involves the policies, proceduresand practices that are required to control the process. Many TQM writers have pointedout the importance of focusing on the effective management of processes (Beskese andCebeci, 2001; Flynn et al., 1994; Oakland, 2003). The process management constructexamines how key processes are designed, implemented, managed and improved tosupport the organisation’s strategy and action plans, fully satisfy customers and otherstakeholders and achieve better performance. Therefore, I propose:

P10. Process management has a positive influence on performance results.

MethodologyPurposeThe purpose of this study was to explore the impact of TQM in Iranian healthcareorganisations. In addition, this study sought to identify critical success factors of TQMimplementation.

MethodThe data for this research were drawn from a cross-sectional questionnaire surveycollected from healthcare organisations that implemented TQM initiatives.

Settings and participantsManagers or quality managers of healthcare organisations (e.g. hospitals and healthcentres) in both public and private sectors in Isfahan province, Iran were asked to

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participate in this survey. Healthcare organisations were categorised into threegroups: small (with less than 100 employees), medium (with 101-500 employees) andlarge sized (with more than 500 employees).

Questionnaire developmentThe survey questionnaire was divided into two sections. The first section sought generalinformation about the healthcare organisations and demographic information of therespondents. In the second section of the survey, the degree of TQM implementationin each organisation was measured. Three different types of validity were tested inthis study (i.e. content validity, construct validity and criterion-related validity). In thisresearch, 15 TQM constructs have content validity since they were derived from anextensive review of the literature, and detailed evaluations by academics andpractitioners who have worked in the area of TQM in Iran.

The construct validity of each TQM construct was evaluated separately by factoranalysing the items corresponding to the construct to ensure that items in eachconstruct reflected sufficiently the scope of each construct. Based on factor analysis,the initial 52 variables in TQM success questionnaire are factored on to 15 TQMelement constructs. All the constructs were uni-factorial; and the item loading range foreach extracted factor was high. Each factor accounted for more than 70 per cent of thevariance of the respective item sets. Results of the factor analysis indicate a high levelof construct validity of the measure. Table I lists the correlation matrix for the 15 scalesof the TQM implementation practices.

TQM constructs can have criterion-relation validity if the collective measure of theTQM practices is highly and positively correlated with a measure of qualityperformance. In this study, the ten TQM practices (enablers) are the predictors and thefive performance measures are the relevant criteria. The correlation coefficient obtainedwas more than 70 per cent. These correlations were statistically significant at po0.001,indicating strong criterion-related validity. In addition, the questionnaire wasadministered to three ISO certified hospitals. It was found that on all the questionsin the final draft of the questionnaire, a high total score was obtained by the ISOcertified hospitals. This was indicative of the criterion validity of the instrument.

Item numbersScales 1 2 3 4 5

Leadership and management 0.717 0.777 0.764 0.703 –Strategic quality planning 0.743 0.851 0.872 – –Quality culture 0.798 0.707 0.712 – –Education and training 0.786 0.703 0.772 – –Employee management 0.781 0.716 0.812 0.798 0.816Customer management 0.764 0.710 0.727 0.754 0.791Supplier management 0.716 0.722 0.733 – –Resource management 0.872 0.848 0.798 – –Information management 0.771 0.737 0.785 – –Process management 0.733 0.796 0.800 0.824 0.712Employee results 0.841 0.734 0.711 – –Customer results 0.830 0.733 0.715 – –Supplier results 0.820 0.809 0.771 – –Society results 0.817 0.764 0.753 – –Organisation results 0.760 0.720 0.780 – –

Table I.Item to scale

correlation matrix(Pearson correlation)

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Cronbach’s α was computed separately for the items of each scale. As shown inTable II, Cronbach’s α values of the 15 TQM constructs all exceed the 0.70 standard ofreliability for survey instrument. Accordingly, the instrument has been proven to be anacceptable and reliable instrument through this test.

A five-point response scale was used for these items (from 1¼ very little extentto 5¼ very large extent). The possible justified scores for TQM success werevaried between 1 and 5. Scores of 2 or lower on the total scale indicate very low,scores between 2 and 2.75 indicate low, scores between 2.76 and 3.50 indicate moderate,scores between 3.51 and 4.25 indicate high and scores of 4.26 or higher indicate veryhigh TQM success.

Data analysisThe data were analysed using the Statistical Package for the Social Sciences (SPSS 11).Descriptive statistics such as means and standard deviations were computed for each ofthe questionnaire items. Independent-samples t-test and analysis of variance wereperformed to determine the significance of the difference among means of the consideredgroups. Regression analysis was used to identify the most important predictor domainsin overall TQM success. A confirmatory factor analysis using AMOS software was usedto test the TQM model.

Hypothesis developmentA test value of 3.50 was decided based on the Likert scale coding method of thequestionnaire. Hypothesis can be written in a statistical equation as follows:

H1. µ⩾3.50 (TQM is successful)

ResultsOut of 90 questionnaires sent to the healthcare organisations, 55 questionnaires werereturned and were analysed (61 per cent). In total, 33 organisations were hospitals andthe rest were health centres. In total, 41 (74.5 per cent) of healthcare organisations were

TQM constructs Item numbers Number of items Cronbach’s α

Leadership and management 1-4 4 0.82Strategic quality planning 5-7 3 0.87Quality culture 8-10 3 0.83Education and training 11-13 3 0.89Employee management 14-18 5 0.83Customer management 19-23 5 0.83Supplier management 24-26 3 0.75Resource management 27-29 3 0.89Information management 30-32 3 0.82Process management 33-37 5 0.88Employee results 38-40 3 0.73Customer results 41-43 3 0.78Supplier results 44-46 3 0.85Society results 47-49 3 0.82Organisation results 50-52 3 0.81Overall TQM success 1-52 52 0.96

Table II.Internal consistencyanalysis

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public organisations. Of the total, 7.3, 78.2 and 14.5 per cent of healthcare organisationswere small-, medium- and large-sized organisations. Three hospitals were successful inobtaining ISO 9001:2000 certificates.

The majority of respondents were in their 30s and held either a bachelor or a masterdegree. Totally, 67.3 per cent of respondents had taken part in TQM, 40 per cent in ISO9000 series, 38.2 per cent in productivity management, 25.5 per cent in human resourcemanagement, 18.1 per cent in statistical quality control tools, 14.5 per cent in qualitycosting, 9.1 per cent in six sigma and 7.2 per cent in EFQM-training programmes.

The mean score of TQM success in healthcare organisations was 3.41 (medium) fromfive credits compared with the possible range of 2.06-4.17 (Table III). It can be seen that thesample mean of 3.41 is lower than the hypothesised value of 3.50. A p-value of 0.180 wasdetermined which suggests that the null hypothesis is accepted (one-sample t-test). Hence,it can be concluded that TQM was not successful in Iranian healthcare organisations.

The overall mean is below 4.0 on all of the TQM constructs, indicating that theseaspects of implementation are not well executed in any of these healthcare organisations.TQM practices (enablers) and results (performance) received mean ratings of 3.44 and3.34, respectively. Of the 15 TQM constructs in Table II, customer management receivedthe highest mean score of 3.69 and 70.9 per cent of the organisations achieved a highscore for this construct. Supplier management was rated lowest.

Private healthcare organisations were more successful in their TQM programmethan their public counterparts (3.53 compared to 3.38). However, the difference wasnot statistically significant ( p¼ 0.292). Although statistically insignificant ( p¼ 0.257),it was observed that the TQM implementation score was lower as the size of theorganisation increases, indicating that smaller organisations tend to implement TQMmore successfully than larger ones.

The mean score of TQM success in healthcare organisations, in which their topmanagers were strongly committed to quality management, was higher than otherorganisations with lower top management commitment (3.47±0.39 in comparison with3.09±0.76). The differences between the values were statistically significant ( p¼ 0.04).

% distribution of mean scoresTQM constructs Mean score SD Low (o2.75) Medium (2.75-3.50) High (3.51-5)

Leadership and management 3.59 0.53 12.7 27.3 60.0Strategic quality planning 3.24 0.68 20.0 38.2 41.8Quality culture 3.46 0.49 9.1 36.4 54.5Education and training 3.43 0.59 18.2 30.9 50.9Employee management 3.56 0.58 9.1 27.3 63.6Customer management 3.69 0.56 5.5 23.6 70.9Supplier management 3.12 0.64 27.3 41.8 30.9Resource management 3.18 0.72 25.5 32.7 41.8Information management 3.38 0.54 18.2 32.7 49.1Process management 3.45 0.59 10.9 43.6 45.5Employee results 3.35 0.56 18.2 34.5 47.3Customer results 3.39 0.54 16.4 32.7 50.9Supplier results 3.20 0.66 23.6 38.2 38.2Society results 3.41 0.58 10.9 43.6 45.5Organisation results 3.37 0.57 16.4 32.7 50.9Overall TQM success 3.41 0.47 12.7 30.9 56.4

Table III.The mean score

of TQM principles’success in Isfahan

healthcareorganisations

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The Pearson correlation matrix shows that top management support is significantlycorrelated with both TQM practices (r¼ 0.714, po0.0001) and organisational performance(r¼ 0.626, po0.0001). Top management commitment has been significantly correlatedwith other TQM constructs such as strategic quality planning (r¼ 0.727), employeemanagement (r¼ 0.664), education and training (r¼ 0.570) and quality culture (r¼ 0.537).This shows that top management plays a critical role in promoting TQM implementationin the organisation.

There are associations between TQM success and the manager’s education inquality management techniques. The more knowledge managers had about TQM, thegreater was their commitment to quality (r¼ 0.303, p¼ 0.041). Employee involvementand commitment was also related to management commitment (r¼ 0.369, p¼ 0.006).Organisations with the greatest emphasis on employee empowerment achieved ahigher implementation score (3.62) than those with medium (3.26) and low degrees ofempowerment (2.42). The differences between values of TQM implementation werestatistically significant ( po0.001).

The mean score of TQM success in ISO 9000 certified organisations was 3.95±0.24while in non-ISO 9000 certified organisations was 3.38±0.47. Significant differenceswere observed between values ( p¼ 0.04). The ISO certified organisations meanscores are higher on all TQM constructs, and significantly higher on five constructs(Table IV).

A majority of the respondents (80 per cent) were found to have adopted participativemanagement techniques in their organisations. The second highest degree of practicewas business process reengineering (27.3 per cent). Total productive maintenance(TPM) was the least preferred and implemented technique in the healthcare organisations(10.9 per cent). Quality management systems (e.g. ISO 9001:2000) was found to be themost useful activity in TQM success. Managers who incorporated and used a number oftechniques and tools achieved more success from their TQM programme. For example,the success of TQM in organisations that used one, two, three, four, five, six and eightdifferent managerial techniques was 3.13, 3.29, 3.44, 3.60, 3.71, 3.80 and 4.17 on a fivescale, respectively.

TQM constructs ISO 9000 certified Non-ISO 9000 certified p-value Results

Leadership and management 3.67 3.58 0.79 Not sig.Strategic quality planning 3.25 3.23 0.97 Not sig.Corporate quality culture 3.56 3.46 0.73 Not sig.Education and training 4.44 3.37 0.002 Sig.Employees management 4.13 3.52 0.08 Not sig.Customer management 3.80 3.68 0.74 Not sig.Supplier management 3.67 3.08 0.13 Not sig.Resource management 3.89 3.13 0.08 Not sig.Information management 4.11 3.34 0.015 Sig.Process management 4.73 3.38 0.001 Sig.Employee results 3.67 3.33 0.32 Not sig.Customer results 3.89 3.37 0.10 Not sig.Supplier results 3.78 3.17 0.12 Not sig.Society results 4.11 3.37 0.030 Sig.Organisation results 4.11 3.33 0.020 Sig.Overall TQM success 3.95 3.38 0.04 Sig.Note: Comparison between ISO 9000 certified against non-ISO 9000 certified healthcare organisation

Table IV.Results of qualitymanagementpractices

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In this study, 15 constructs of TQM were investigated, of which ten were enablersand five were results. Table V shows the correlation coefficients for TQM constructs.All the correlations among the TQM constructs were found to be positive andstatistically significant at po0.01. The correlations among the TQM constructsprovide an indication of the extent to which they reinforce one another in the TQMeffort. Therefore, an integrated approach should be taken to improve theTQM constructs.

Leadership has shown to have a direct impact on strategic planning and significantindirect effects on process management and organisation results. The impact ofstrategic quality planning on process management and overall performance has beenvalidated through indirect effects. Quality culture has demonstrated to have a stronginfluence on employee, customer and supplier management and indirect effects onprocess management. Teamwork and a participatory culture were positively related toemployee empowerment and involvement in quality improvement activities (r¼ 0.446,p¼ 0.001). Process management was observed to be related to customer satisfaction(r¼ 0.310, p¼ 0.02). The TQM implementation had a strong impact on qualityimprovement (r¼ 0.739, po0.001).

All quality management practices (enablers) were positively associated with TQMsuccess. The results of the stepwise regression analysis indicate that employeemanagement has the largest amount of variance in TQM success (81 per cent), followedby information management, customer management, process management, leadership,resource management, training, strategic quality planning and supplier management.

The most important contributing factors to successful TQM implementation inhealthcare organisations were considering customer needs in process improvementactivities, improving relationships between employees and managers, encouraginginnovation and creativity, developing a participatory culture, customer relationshipmanagement, pursuing long-term organisational goals and policies, identifying anddefining processes, management involvement in quality improvement activitiesand having an information management system.

Higher levels of TQM practices implementation were found to be associated withhigher organisational performance (r¼ 0.914, po0.001). TQM enablers werecategorised into primary (initial) enablers (i.e. employee, customer, supplier, resource,information and process management) and secondary (supportive) enablers(i.e. leadership, strategic quality planning, quality culture and education and training).Both initial and supportive enablers of TQM were inter-correlated and both jointlyenhanced performance. There was significant correlation between organisationalperformance and initial enablers (r¼ 0.811) and supportive enablers (r¼ 0.609).

The results of the stepwise regression model indicate that 83 per cent of the variancein overall organisational performance is explained by employee management,information management, customer management and process management. Thevariables – considering customer needs in process improvement activities, developingmission and vision according to customer needs, having an information managementsystem, continuous quality improvement and human resource development – are themost influential TQM dimensions for improving organisational performance.

Figure 2 shows the relationships among TQM practices and overall organisationalperformance. The results of the stepwise regression model indicate that 53 per cent ofthe variance in employee results is explained by Employee management and Leadership.Customer results are related to Process management, Education and training andCustomer management and the corresponding value of R2 is 55 per cent.

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TQM

constructs

12

34

56

78

910

1112

1314

1516

17

1.OverallTQM

success

–2.Leadership

andmanagem

ent

0.827

–3.Strategicqu

ality

planning

0.813

0.785

–4.Qualitycultu

re0.763

0.740

0.760

–5.Edu

catio

nandtraining

0.799

0.600

0.644

0.624

–6.Employeesmanagem

ent

0.902

0.722

0.782

0.712

0.720

–7.Cu

stom

ermanagem

ent

0.810

0.692

0.656

0.653

0.518

0.707

–8.Su

ppliermanagem

ent

0.712

0.616

0.546

0.578

0.591

0.640

0.668

–9.Resourcemanagem

ent

0.634

0.450

0.434

0.526

0.546

0.608

0.516

0.629

–10.Informationmanagem

ent

0.766

0.625

0.580

0.471

0.660

0.611

0.535

0.515

0.506

–11.P

rocess

managem

ent

0.837

0.606

0.572

0.527

0.736

0.498

0.750

0.683

0.614

0.710

–12.E

mployee

results

0.730

0.548

0.591

0.571

0.513

0.701

0.617

0.681

0.464

0.414

0.558

–13.C

ustomer

results

0.797

0.713

0.684

0.479

0.621

0.652

0.646

0.589

0.499

0.624

0.651

0.512

–14.S

upplierresults

0.666

0.683

0.627

0.557

0.688

0.632

0.675

0.642

0.578

0.714

0.624

0.576

0.761

–15.S

ociety

results

0.689

0.491

0.423

0.384

0.523

0.560

0.630

0.567

0.446

0.548

0.527

0.440

0.575

0.624

–16.O

rganisationresults

0.626

0.645

0.551

0.591

0.622

0.679

0.618

0.611

0.603

0.737

0.772

0.558

0.626

0.645

0.559

–17.T

QM

practices

0.993

0.841

0.827

0.796

0.809

0.916

0.803

0.820

0.719

0.755

0.836

0.704

0.757

0.835

0.636

0.807

–18.O

verallperformance

0.89

40.645

0.554

0.409

0.613

0.734

0.674

0.572

0.591

0.602

0.738

0.669

0.818

0.681

0.658

0.793

0.914

Table V.Bivariate correlationmatrix ofindependentand dependentvariable constructfactor scores

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The dependent variable of supplier results is related to Supplier management, Processmanagement and Strategic planning, with an R2 of 71 per cent. Society results arerelated to Customer management and Information management with an R2 of 44 per cent.Organisation results are related to Process management, Resource management andInformation management with an R2 of 0.718 which indicates that 71 per cent of thevariance of organisation results is explained by these three enablers. All dependentvariables are predicted by a significant regression ( po0.001).

DiscussionThe findings suggest that TQM has not been fully successful in the healthcareorganisations of Iran. This seems to be in agreement with other research findings onthe application of TQM/CQI in healthcare (Huq and Martin, 2000; Lee et al., 2002;Theodorakioglou and Tsiotras, 2000). Implementing TQM in healthcare organisationsrequires an understanding of the particular nature of the sector, which influences theapplicability of TQM practices. Due to the distinctive nature of healthcare services,there are incompatibilities between the TQM philosophy and the practices on whichthe management of healthcare organisations is currently based. The very complexityof the healthcare system and its bureaucratic, and highly departmentalised andhierarchical structure can pose a significant obstacle to the implementation of TQMand decrease its effectiveness (Adinolfi, 2003; Lim and Tang, 2000; Mosadeghrad,2012a; Naveh and Stern, 2005).

The TQM constructs were also found to be highly interrelated. The interdependentnature of TQM constructs explains why TQM has not produced maximum benefits forIranian healthcare organisations. Both primary and supportive TQM enablers(constructs) jointly enhance results (organisational performance). Therefore, it isnecessary for all the TQM constructs to be present to ensure its success in anorganisation. Higher levels of organisational performance were significantly correlatedwith great utilisation of TQM practices in Iranian healthcare organisations. Thesefindings are consistent with those of Douglas and Judge (2001), who found thathealthcare organisations with a greater degree of implementation of TQM practiceshave a greater probability of improving their organisational performance.

Leadership and management

Employee management

Supplier management

Resource management

Customer management

Employee results

Organisationresults

Strategic qualityplanning

Education and training

Quality culture

Supplier results

Information management

Society results

Customer results

Process management Figure 2.

Path analysis of thelinks between the

TQM practices andthe results

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The finding showed that “primary” TQM elements have a more significant andpositive impact on organisational performance, when compared to “secondary” TQMelements. This is not suggesting that “secondary” TQM constructs are not useful, buttheir direct contribution is less than that of “initial” TQM constructs. Secondary’ TQMelements are significant to support the “primary” TQM elements. Employee management,information management, customer management, process management and leadershipwere the strongest significant predictors of organisational performance. Therefore, theeffective implementation of these practices is likely to result in improved performance. Thisfinding is supported by Samson and Terziovski (1999), who argue that categories ofleadership, people management and customer focus are the strongest significant predictorsof organisational performance. Sila and Ebrahimpour (2005) also found that leadership, andinformation and analysis carry strong implications in terms of a company’s business results.

A strong relationship between leadership and the success of TQM has been reportedin this study. The findings also revealed that leadership has positive effects onorganisational performance by influencing other TQM practices. The high correlationbetween leadership and management and each of the other constructs suggests that theformer played an important role in driving the latter. Leadership and management hadthe most effect on strategic quality planning, quality culture, employee managementand customer management. Sustainable top management involvement in TQM isvital for the success of TQM initiatives. The results have shown that for healthcareorganisations in which managers were committed more to TQM, its success wasgreater than in other organisations with a less management commitment. This findingis consistent with the TQM literature (Balding, 2005; Mosadeghrad, 2005). Topmanagement must be totally committed to TQM in both words and actions to sustain along-term effort to improve performance.

Achieving and sustaining quality requires a long-term commitment to qualitymanagement. Quality should be recognised as an organisation’s strategic goal andshould be reflected in the organisation’s corporate vision and mission. The current studyshows that strategic quality planning had the most effect on quality culture, employeemanagement and customer satisfaction. However, Iranian healthcare organisations usestrategic quality planning to a lower extent. Managers should develop plans toimplement quality management changes and control their effects. A strategic qualityplan ensures the availability of resources for TQM implementation. It helps identifycustomers’ and other stakeholders’ requirements and then design strategies and actionplans to achieve the goals and objectives. Without the integration of quality managementwith strategic and operational plans, it becomes yet another initiative.

Organisational culture influences the thoughts, feelings and interaction amongpeople in an organisation (Boon et al., 2007). It acts as a force for cohesion in anorganisation and therefore can support or inhibit the process of change towards theapplication of TQM (Sinclair and Collins, 1994; Tata and Prasad, 1998). Organisationalculture must be congruent with TQM or TQM initiatives need to be modified to fit theIranian (or other) culture and healthcare systems. Although quality culture had themost effect on organisation, employee and customer results, TQM implementation hadthe least effect on organisational culture of Iranian healthcare organisations.Organisational culture is difficult to change due to its deep-rooted nature. Therefore,some managers may invest less on developing a quality culture before implementingtheir TQM initiatives to avoid the employees’ resistance.

Insufficient training on quality was found to impede successful TQM implementationin Iranian healthcare organisations. The results have shown that education and training

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were directly related to quality culture, employee management, process management,customer management and supplier management. A positive relationship betweenquality-related knowledge and managers’ involvement in and commitment to TQM wasalso found in this study. Therefore, it is necessary to ensure employees actuallyunderstand the values and principles of TQM, and are equipped with skills andknowledge required to improve the quality of their work. Education and training canresult in a more satisfied workforce and an environment for innovation and creativity.

The findings of this study indicate that employee management is arguably the mostimportant factor affecting the TQM programme. This finding is consistent with otherstudies claiming that employees have an important role in quality management success inservice organisations (Agus, 2005; Dilber et al., 2005). Employees are the driving force ofTQM success. Their active involvement in quality improvement activities plays critical rolein TQM success. Findings of this study indicated that Employee management had the mosteffect on customer management, process management, resource management, employeeresults, society results, customer results and organisation results. The findings also suggestthat those healthcare organisations emphasising employee empowerment are more likely tobe successful in their implementation efforts. Financial incentives and non-monetary rewardsystems increase the effectiveness of TQM programmes. Employees should be rewardedfor their efforts and successes at quality improvement. Managers should implement policiesand programmes that link performance to the accomplishment of quality objectives at theorganisational, group and individual levels (Allen and Kilmann, 2001).

TQM cannot exist without a strong customer focus. Customer focus is the foundationof the TQM philosophy. In fact, quality management cannot exist without a strongcustomer focus. The finding revealed that Customer management had the most effect onprocess management, customer results, and organisation results. These findingsconcurred with the assertions of other studies that concluded that effective customermanagement activities and focus on customers’ requirements could contribute towardsthe level of customer satisfaction (Mosadeghrad, 2012b; Terziovski, 2006).

Top management should establish effective information systems and encourageemployees to use objective data in their decision processes. Information managementhad the most effect on process management, employee results, organisation results,customer results and supplier results in this study. The results also confirmed theempirical findings of several previous studies that suggest a positive link betweeninformation and analysis and customer satisfaction (Min et al. 2002; Ooi et al., 2011).

Allocating necessary resources are essential for TQM programmes to be continuedeffectively. Resource management had the most effect on process management,organisation results, supplier results and customer results. Supplier managementemerged as an important construct of TQM, positively affecting process management,resource management, supplier results, organisation results and customer results.However, it was ranked as the least practiced by healthcare organisations. Thisindicates that a much greater emphasis must be given on supplier management infuture quality improvement programmes. If organisations do not manage theirsuppliers properly, the chances of getting high quality materials and services will belower and can result in lower quality healthcare services and higher total quality costs.

In TQM, the emphasis is on studying processes and improving them to providecustomers with desired products and services. Process management, was found to havea positive significant impact on organisation results, customer results, employee resultsand supplier results in this study. Similarly, Kumar et al. (2008) found that processmanagement is a critical driving force of customer satisfaction.

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Another point worth mentioning here is that ISO certified hospitals have better qualitymanagement practices and enjoy better quality results. A quality management system suchas ISO 9001:2000 could be a good first step towards TQM implementation, mainly becauseof raising awareness of quality among employees and improving processes through thedevelopment of work procedures (Gotzamani and Tsiotras, 2001; Martínez-Costa andLorente, 2004). Therefore, implementing ISO 9000 and TQM jointly has more impact onorganisational performance. However, there is still a long journey from ISO to TQM.

One encouraging finding from this study was that, where TQM was used with othermanagement initiatives and strategies, these organisations were likely to have agreater appreciation of the benefits of TQM and a higher level of performance. Thefinding is supported by the earlier studies which show that using an integrated qualitymanagement model and applying several quality management practices in acomplementary way is usually more effective than single practices (Dey and Hariharan,2006; Revere and Black, 2003; Sun et al., 2004). Managers can use a number of qualitymanagement strategies and techniques and enjoy the synergistic impact of them oneach other. Quality management systems should be chosen based on the needs of theorganisation. One system is not a perfect fit for any organisation. However, pulling thebest of each quality management system may be of better benefit to an organisation.TPM and 5S have always been the least favoured quality activities adopted in Iranianhealthcare settings. It is important for managers to use these two techniques as well inorder to develop and sustain a quality culture.

Quality management requires the cooperation and collaboration of all those peopleinvolved in the delivery of healthcare services. The results have shown that TQM hadbetter effects on performance in organisations using participative management.Nevertheless, the use of suggestion scheme did not lead to good results, though qualitycircles and autonomous groups had more synergistic effects. It seems that healthcaremanagers do not use the suggestion system appropriately and systematically.Therefore, employees are not interested in this participative management techniqueand prefer to do quality efforts together in quality teams. Managers should giveemployees more autonomy to do their own works.

The findings of this study showed that smaller healthcare organisations tend toimplement TQM more successfully than larger ones. There is a debate in the literatureabout the influence of the size of a firm on TQM implementation. While Ghobadian andGallear (1996) and Taylor and Wright (2003) did not find operational differences inTQM implementation attributable to firm size, other studies found a significantdifference between TQM success and the size of the firm (Eng and Yusof, 2003;Hendricks and Singhal, 2001).

Private Iranian healthcare organisations experienced higher success in their TQMprogramme than public ones. Despite the potential benefits, several scholars suggestdifficulties in adopting the principles of TQM in the public sector. A short-termperspective due to frequent political changeovers, a highly centralised structure, a lackof management autonomy, inter-organisational politics, complex inter and intra-organisational relationships, financial pressures, an emphasis on due process overefficiency, lack of market incentives, external constraints, resistance to change, littleincentive to innovate and reduce costs in the public sector and rising demand for publicservices contribute to the difficulty of adopting and implementing TQM in the publicsector (Bowman and Hellein, 1998; Morgan and Murgatroyd, 1994).

TQM must be modified substantially to fit the public sector’s uniquecharacteristics. The public sector will also need to change many of its attitudes,

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behaviours and even its culture to be compatible with the principles underpinningthe TQM approach. It requires long-term commitment, changes in organisationalgoals and performance indicators, changes in management roles and practices, andmajor work and organisational redesign. It requires accountability by professionalmanagers and leaders, an emphasis on results rather than on procedures, explicitstandards and performance measures, an emphasis on competition and performance-oriented reward schemes to improve productivity and more enlightened financialmanagement that uses resources efficiently rather than “spending up a given annualbudget” (Brysland and Curry, 2001; Scharitzer and Korunka, 2000).

The challenges to adopting TQM in healthcare organisations suggest that managersshould take a cautious and an incremental approach in its implementation. Radicaltransformation of processes has been found to have negative and detrimental effects onmany organisations (Singh and Smith, 2006).

ConclusionsThe findings indicated that TQM was less successful in Iranian health sector due to lackof a quality management system, low employees participation in quality managementactivities and inappropriate strategies for managing quality. The research suggests thatTQM implementation practices could result in better organisational performance. Thefindings revealed that the primary constructs of TQM were the strongest predictors oforganisational performance. The most important contributing factors to successful TQMimplementation in the Iranian health sector were Employee management, Informationmanagement, Customer management, Process management and Leadership.Furthermore, using a combination of quality management techniques has “synergistic”effect on TQM success.

TQM demonstrates some potential for successful implementation in Iranianhealthcare organisations as far as its principles and practices can be adaptedin an ethnocentric manner tailored to the Iranian context and culture. Successfulimplementation of TQM depends on a number of factors such as, top managementcommitment and involvement, strategic quality planning, focus on customers(both internal and external), quality awareness training, employee commitment andcontinuous improvement.

The findings of this study contribute to the quality management and healthcareliterature in several ways. First, a valid and reliable instrument was developed andused to assess TQM practices in the Iranian health sector. Second, this researchdocumented the extent to which Iranian healthcare organisations utilised TQM. Asnoted earlier, there is very little information in the current literature on the extent ofquality management implementation in the healthcare organisations of this country.This study contributed to theory about the nature of quality management practices inIranian healthcare organisations.

From a practical point of view, the findings provide managers and researchers witha practical understanding of the critical success factors of TQM implementation inhealthcare organisations. The results will help managers in planning more effectiveTQM designs. They will be able to re-allocate more resources to those constructs ofTQM that have the most significant impact on organisational performance. Thefindings will provide decision makers with quantifiable benchmarks on TQMimplementation in Iranian healthcare organisations. Managers and researchers canemploy the survey instrument to evaluate TQM implementation initiatives and identifyproblem areas requiring improvement.

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This study may serve as a foundation for future research in different countries anddiverse cultural settings. Researchers will be able to use the findings for developingquality management theory and constructing a suitable model of TQM. The results ofsuch studies can be very helpful for developing a model of TQM that can beimplemented successfully in a cross-cultural context.

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Further readingKaynak, H. (2003), “The relationship between total quality management and their effects on firm

performance”, Journal of Operations Management, Vol. 21 No. 4, pp. 405-435.Weiner, B.J, Alexander, J.A and Shortell, S.M. (1996), “Leadership for quality improvement in

health care: empirical evidence on hospital boards, managers and physicians”, MedicalCare Research and Review, Vol. 53 No. 4, pp. 397-416.

Corresponding authorDr Ali Mohammad Mosadeghrad can be contacted at: mosadeghrad@gmail.com

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