identification of critical success factors of tqm implementation in health care sector of pakistan...

Sci.int.(Lahore),26(5),2603-2616,2014 ISSN 1013-5316; CODEN: SINTE 8 2603

IDENTIFICATION OF CRITICAL SUCCESS FACTORS OF TQM IMPLEMENTATION IN HEALTH CARE SECTOR OF PAKISTAN USING

PARETO ANALYSIS APPROACH 1,2

S.M. Irfan, 2Daisy Mui Hung Kee,

1Rashid Waheed Qureshi,

3Rashid Hussain

1Department of Management Sciences, COMSATS Institute of Information Technology, Lahore Pakistan 2School of Management, Universiti Sains Malaysia, Malaysia

3Leading Edge Human Capital Solutions, Inc., Canada

[email protected]

ABSTRACT: Due to the rising costs of health care, complexities in diseases and in its diagnostics, huge equipment and

treatment costs, high customer expectations for quality, has built a tremendous pressure on health care institutions in

almost all the developed and developing economies to transform their old fad working system to cost effective, patient

focus, efficient and high quality services. Thus to deliver high quality of health care services, to gain patient and their

families satisfaction, quality has taken a central position. To ensure quality, patient safety, preventive measures to

control infections, and gain patient and their families satisfaction, there is a growing trends among the health care institutions to implement quality standard and systems. Majority of the well know hospitals around the globe has

adopted or adapted quality management systems to address the above issues. Total Quality Management (TQM) is a

well proven strategic management system in all sectors of industry to achieve excellence in business by focusing on

customer needs and wants for superior quality and cost effective services or products. This study aimed to identify the

critical success factors (CSFs) of TQM for the successful implementation of TQM in health care sector of Pakistan.

After a careful and comprehensive review of 135 studies on TQM and also considering the importance of contextual

factors of hospital settings in Pakistan, this study proposed 9 CSFs of TQM for health care sector: top management

commitment and leadership role, human resource focus, process management, supplier quality management, quality

data and reporting, strategic quality management, patient focus, continuous quality improvement, and services focus.

Descriptive statistics and Pareto analysis were employed to identify the core CSFs of TQM for health care. Suggested

CSFs of TQM can be employed in order to achieve excellence in health care services.

Keywords: TQM, critical success factors (CSFs), health care in Pakistan, Pareto Analysis

1. INTRODUCTIONThe rising costs of healthcare, complexities in diseases and

in its diagnostics, huge equipment and treatment costs and

high customer expectations for quality, has built a

tremendous pressure on health care institution in the

developed and developing countries to transform their old

conventional working system with efficient quality

management systems. Rapid developments in medicines and

medical field, advancement of technologies for patient

diagnostics and treatment, cost effective, specialized and

high quality healthcare services have created a competitive

environment in the healthcare market. The increasing

demand for better quality of health care services, and patient

safety issues has put an immense pressure on health care

institution to develop a positive consumer culture, increased

efficiency, flexibility, and improved quality of healthcare

services [1, 2]. Thus old models of assuring quality through

self-defined quality standards by healthcare provider are no

longer sufficient to solve quality problems in the healthcare

sector. Thus, Health care institutions require immediate

reforms to address the quality and patient safety issues [3]

Some of the hospitals has adapted or adopted quality

management systems, standards, and also have been

accredited by quality and health care quality accreditation

agencies but still a large number of hospitals are providing

lower level of required health care services to the patient.

This issue has been of a major concern for health care

managers and they need to redesign strategies by focusing

on patient requirement for high quality of services at

affordable costs [4]. According to health care industry in

United States and Canada has also been passing through

transformational phase due to ever-increasing healthcare

costs and increased demands from dissatisfied patients and

third party payers and TQM is particularly useful to deliver

best quality of health care service through continuous

improvement at all levels in the hospitals [5]. TQM practices

in health care institutions provide a better way to resolve the

quality related issues more efficiently and are one of the best

ways to gain patient satisfaction [6, 7].

Numerous empirical studies are witnessed that effective

implementation of TQM helps to boost organizational

performance[8-10] , increased employees performance [11], efficiency and rapid delivery [12], increased productivity

and cost reduction [13, 14]. Due to the domination of

research from engineering and operations disciplines [15],

most of the TQM literature has been evolved from

manufacturing sector [16, 17]. TQM adoptability in service

firms is slower [18-20] and still slow in terms of strategic

commitment towards TQM as compare to manufacturing

sector [21]. However, it is widely believed that TQM

concepts and practices are equally relevant for service

organizations [22] but services firms have to apply TQM

selectively as compare to manufacturing firms [23].

Wardhani [24] reported that there are only 14 articles out of

533 published between 1992 to 2006 in which a limited set

of TQM practices has been considered in health care setup.

Talib, Rahman, and Qureshi [25] also reported the similar

results and identified only 15 studies out of 585 studies

where, a very limited set of TQM practices were discussed

2604 ISSN 1013-5316; CODEN: SINTE 8 Sci.int.(Lahore),26(5),2603-2616,2014

in a healthcare setup. However, there are some

commonalties in reporting of studies which brings to an

average of 14 studies from these two review articles.

Therefore, there is a need to conduct a comprehensive study

to identify the CSFs of TQM that are best suitable for public

hospitals in Pakistan by keeping in view the importance of

contextual factors in Pakistani hospital settings. There is a

substantial lack of detailed, up to date and comparative

research regarding CSFs of TQM in health care setting. In

addition, there are substantial variations in reported research

between different countries. Present study attempts to bridge

the gap between the national and international literature in

healthcare by introducing appropriate CSFs of TQM for

hospital setting. The paper is structured as follows. First we

briefly review prior research regarding TQM

implementation in various setting such as manufacturing,

services, and healthcare. We then suggest CSFs of TQM that

are best suitable in healthcare settings and its

implementation will leads to achieve excellence in health

care services for public and private hospitals, healthcare

bodies, professionals, academicians and make a significant

contribution in national as well as in international literature.

2. LITERATURE REVIEW

TQM has become the most comprehensive approach with

multiple characteristics and dimensions and is termed as a

philosophy, a systematic approach, a management approach

and now it is understood as a management innovation, if not management revolution[26]. TQM implementation has progressed through three different ways; by adopting quality

management system i.e. ISO-9001 series of standards [27],

quality awards criteria [28], and TQM practices, tools and

techniques or sometimes termed as CSFs of TQM [29, 30].

Successful implementation of TQM requires to identify

CSFs that are most suitable for continuous improvement in

all areas to increase the success rate of TQM implementation

by supporting prevention methods and cost reduction

techniques [31]. CSFs are set of enablers or variables that

ensure the success for organization as well as managers in

those critical areas of the organization that must require

special and continual attention to gain high performance

[32]. CSFs are those areas in the organizations that needs

attention and need to be addressed to ensure satisfactory

results and competitive organizational performance [33] and

also to gain greatest competitive influence [34]. Wali,

Deshmukh, and Gupta [35] concluded that it can be said that the CSFs are the selected few primary requirements that

must be present in an organization to attain its vision, and to

be guided towards its vision and success depends on

customer program, stakeholders, people and process. Saraph, Benson, and Schroeder [36] were the first who

introduced eight TQM practices. Later, numerous studies has

been conducted to examine what constitute TQM, what are

the common barriers for implementing TQM and what

factors are critical for the successful implementation of

TQM [37, 38]. Although these studies have reported

inconsistency in results. However, TQM practices or CSFs

of TQM are not industry specific and it is equally important

for manufacturing as well as for services [39], but there is no

universally accepted TQM framework [38]. TQM and

business excellence models are widely accepted TQM

framework.

2.1 TQM IN MANUFACTURING

TQM evolution and its success is manufacturing dominant

as its success is recognized by the Japanese manufacturing

industry and later admired by USA in 1980s. Early work on TQM is developed by quality gurus [40, 41]. Saraph,

Benson, and Schroeder [36] considered as a major

contributor by presenting the eight CSFs of TQM after a

comprehensive review of teachings of quality gurus which

are; role of management, leadership and quality policy, role

of quality department, training, product/service design,

supplier quality management, process management, quality

data and reporting, and employees relations. Thus these

authors laid the foundation of empirical studied in TQM and

further development of literature and this field.

Flynn, Schroeder, and Sakakibara [42] also made a

comprehensive review of literature and came up with 11

CSFs for manufacturing that includes; quality leadership,

quality improvement rewards, process control, feedback,

cleanliness and organization, new product quality, inter-

functional design process, selection for teamwork

management, teamwork, customer interaction. Motwani,

Mahmoud, and Rice [43] and Badri, Davis, and Davis [44]

tested Saraph, Benson, and Schroeder [30] instrument in

India and UAE respectively. Powell [45] presented 12 CSFs

based on literature that are; top management leadership,

empowerment, quality policies, quality measurement

system, training, statistical quality control, supplier quality

management, role of quality department, teamwork,

customer satisfaction, communication of information, and

benchmarking. Black, and Porter [46] included Malcom

Baldrige award criteria in their study after comprehensive

review of literature and came up with 10 CSFs i.e. strategic

quality management, customer satisfaction orientation,

people and customer management, communication of

improvement information, external interface management,

improvement measurement systems, corporate quality

culture, supplier partnerships, operational quality

management, teamwork structures for process improvement.

Meanwhile, Ahire, Golhar, and Waller [47] proposed an

instrument considering 12 TQM practices: top management

commitment, supplier quality management, supplier

performance, customer focus, SPC usage, employee

involvement, benchmarking, employee training, product

quality, employee empowerment, design quality

management, and internal quality information usage. Madu,

Kuei, and Jacob [48], first provided a conceptual model for

CSFs of TQM and organizational performance verified

empirically in manufacturing and services firms. However,

results of their studies present some irrelevance between

manufacturing and service firms about the values of quality

management activities. Joseph, Rajendran, and

Kamalanabhan [49] developed a measurement using 9

critical dimensions of TQM to evaluate the level of TQM in

Indian organizations and these dimensions are:

organizational commitment, role of the quality department,

product design, training, supplier quality management,


process management, quality data and reporting, human

resource management.

Later studies on TQM have established its linkage with

performance and a vast amount of literature has been

reported on it. Samson, and Terziovski [10] developed an

instrument based on MBNQA criteria and empirically tested

the reliability and validity of the constructs and further

investigated the relationship between these constructs and

operational performance in Australian and New Zealand

manufacturing companies. Zhang, Waszink, and Wijngaard

[50] identified 11 TQM constructs to implement TQM in

Chinese manufacturing companies and determined that this

framework can be implemented in any of the manufacturing

industry and also suggested that researcher can used this

instrument for TQM theory development. Sila, and

Ebrahimpour [51] made an review of TQM studies from

1989 to 2000, and identified 25 TQM construct. Similarly,

many empirical studies have been conducted to establish a

relationship among CSFs of TQM or TQM practices and

various performance measures that provides positive results

[52-54].

2.2 TQM IN SERVICE SECTOR

During the last decade a tremendous growth has been

observed in services sector and service sector is contributing

63.6% GDP of world economy according to international

Monetary Fund (IMF) World Economic Outlook database,

2012 [55]. Majority of the TQM literature is related to

manufacturing sector [56, 57] and later studies verified that

TQM approach is equally relevant to service organizations.

Silvestro [58] made an attempt to transform the

manufacturing dimensions of TQM for service organizations

and reported that majority of these TQM practices for

manufacturing are useful in services. Brah, Wong, and Rao

[59] developed a TQM and performance framework and

include 11 constructs and tested in Singapore service sector.

Sureshchandar, Rajendran, and Anantharaman [39] has

propose a holistic model for Total Quality in Services (TQS)

with 12 dimensions and tested these constructs in Indian

banking industry and analyzed a positive impact on

performance and these dimensions includes; top

management commitment and visionary leadership, human

resource management, technical system, information and

analysis system, benchmarking, continuous improvement,

customer focus, employee satisfaction, union intervention,

social responsibility, servicescapes, service culture.

Later, Saravanan, and Rao [60], and Al-Marri, Ahmed, and

Zairi [61] tested TQS and identified a positive relationship

among TQS and performance measure. Tsang, and Antony

[62] studied service organizations of UK and selected 11

CSFs of TQM identified that customer focus is the most

important whereas, supplier partnership is among the least

important factor. Fotopoulos and Psomas [63] conducted

studies in Greek companies by dividing CSFs of TQM into

soft (quality management principles) and hard (quality tools

and techniques) that provides a significant and positive

relationship among TQM and performance. The relationship

among critical dimensions of TQM and organizational

performance in services have been empirically tested and

validated that CSFs of TQM contribute in enhancing

organizational performance [61, 64].

2.3 TQM IN HEALTH CARE

Like the other sectors of service economy importance of

quality has been recognized quite late in health care sector. It

may be due to the complexity and nature of the services

deliver by the health care institutions. However, quality has

been an integral part of health care service since its

evolution as services here are linked with the life of the

patient. Lin, and Clousing [65] made an exploratory studies

on effectiveness of TQM program in US State of Northern

Louisiana hospitals and explored that hospitals recognize the

importance of TQM but are still in some phase of

implementation of quality management systems. Aly, and

Mark [66] has emphasized that leadership vision,

competency of quality leaders, quality council, physicians

involvement, a clear quality vision and strategy, customer

focus, timely and adequately management training,

education and awareness of all employees, define analyze

and improve processes, and integration of management

system must be in a sequence that are essential critical

dimensions of TQM in hospitals. Klein, Motwani, and Cole

[67] used TQM tools, PDCA approach and continuous

quality improvement at emergency care of Saint Mary

hospital USA and reported that these approaches are

essential in gaining customer satisfaction, time and cost

effectiveness, and employees satisfaction. Yang [7]

identified that there is an urgency for implementation of ISO

series of standards, quality management practices, tools and

techniques, healthcare quality improvement circles, and

continuous quality improvement of process and system at all

level to address the rising issues of healthcare quality.

Mosadegh Rad [68] has examined CSFs of TQM in Iranian

health care settings and Dilber [69] has tested TQM and

performance in Turkish health care settings. Later, Hazilah

[70] empirically tested five TQM practices in Malaysian

hospital settings, and Arasli, and Ahmadeva [71] introduced

10 dimensions for the Cyprus hospitals but they did not

include any TQM practices. Raja, Deshmukh, and Wadhwa

[72], Manjunath, Metri, and Ramachandran [6] tested

quality awards and Business Excellence Models (BEM)

criteria respectively to measure the performance of health

care institution. Sang, DonHee, and Chang-Yuil [73] tested

high-performance work systems (HPWS) as an instrument to

measure the effects of HPWS on service quality, employee

attitude, customer satisfaction and customer loyalty in

healthcare (public and private hospitals) settings of Korea.

Lee-DonHee [74] identified that quality of healthcare

services is critical for the healthcare institutions and

implementation of quality programs based on quality

standards ISO 9001-2008, Malcolm Baldrige Healthcare

Criteria for Performance (MBHCP), European Foundation

for Quality Management (EFQM), and Joint Commission

Model of Accreditation (JCI) helps hospitals to gain patient

satisfaction and safety and also a source to enter in the

international market to attract the international healthcare

tourism. It is further claimed by the author that quality

control and TQM are most widely used quality programs in

healthcare institutions. In a recent study, Lee, Lee, and


Olson [75] used MBHCP criteria as CSFs of TQM in data

analysis of 254 South Korean hospitals and observed that the

seven categories has strong and positive association with

each other.

2.4 QUALITY MANAGEMENT STANDARDS AND

AWARDS

Quality management standards like ISO-9000-2008 series of

standards are among the largest implemented standards

around the globe in almost all the industry. It can be

considered as a first step towards TQM implementation

[76].These quality management standards focuses on

management development and development of operating

procedures to ensure consistency in production/operations

that ultimately helps to ensure the services and product

delivery that meet and exceed customer stated and implied

requirements [77]. Colton [78] stated that healthcare

managers observed that quality management standards help

to improve the operational efficiency, services delivery and

cooperation among the departments as. Eight quality

management principles includes: customer focus, leadership,

involvement of people, process approach, system approach

to management, continual improvement, factual approach to

decision making, mutually beneficial supplier relationships.

TQM and BEMs are widely used quality management

framework to increase performance and excellence in

business. Numerous studies had empirically verified that

enablers of this model significantly contribute in achieving

quality and performance results [53]. Curkovic [79], also

agreed that MBNQA successfully addresses the major

dimensions of TQM envisioned by the quality Gurus. An

MBNQA [80] criterion for performance excellence consists

of seven items: leadership, strategic planning, customer

focus, measurement analysis and knowledge management,

workforce focus, operational focus, and results (products and

process, customer focus, workforce focused, leadership and

governance, financial and market results).

European Foundation for Quality Management (EFQM) was

established in 1991 and EFQM is also used as a framework

for quality performance measurement and this models has

been adopted in many countries around the globe [81]. This

model is considered as a valid representation of TQM in

European context [82, 83] and can be considered as

framework for TQM implementation [81]. The main

criterion according to European Foundation for Quality

Management (EFQM) [84] consists of nine performance

indicators from which five enablers and four result

indicators: leadership, strategy, people , partnerships &

resources, processes, products & services, result indicators

(customer, people, society, and business results).

JCI was established in 1997 in order to measure the standard

based evaluation of healthcare institution around the world

to improve patient quality of healthcare services, and patient

safety related issues. JCI standards are based on consensus

based standards in order to assess the operations and

management in all aspects of hospitals [85]. JCI (2008)

accreditation standards for hospitals are divided into two

broad categories as: patient-centered standards ( access to

care and continuity of care, patient and family rights,

assessment of patients, care of patients, anesthesia and

surgical care, medication management and use), health care

organization and management standards (quality

improvement and patient safety, prevention and control of

infections, governance, leadership, and direction, facility

management and safety, staff qualifications and education,

and management of communication and information).

Like the quality models, MBNQA, EFQM, JCI, and ISO

series of standards, Malcolm Baldrige Healthcare Criteria

for Performance (MBHCP) is specifically used to measure

the information and data available at hospital, and quality

results based on providing healthcare services to patients

through quality management activities provided by

organizational support [86]. MBHCP was introduced in

USA in 1995 based on MBNQA as a pilot program to

measure the quality and performance of the healthcare

institution. MBHCP is evaluated and updated every year by

keeping in view the changing global environment [75].

MBHCP award is considered to be the most prestigious

awards for organizational performance of healthcare around

the globe [87]. It also follows the MBNQA criteria for

assessment.

Thus keeping in view the above discussed review on

literature, this study analyzes that CSFs of TQM are not

industry specific and it may be implemented across any type

of services sector. However, core CSFs of TQM can easily

be identified from the above review of literature, which are

the integral part of all studies either it is in manufacturing,

services, healthcare or quality awards or models and ISO

series of standards and these are CSFs includes; top

management commitment and leadership role, human

resource focus, customer focus, improvement of processes

by adopting best techniques it may involve benchmarking,

improvement in product and service design, develop to

record, maintain, analyzes data using statistical methods and

then utilizes these results to make improvement at all levels,

development of suppliers, and finally achieve organizational

goals and objectives through a continual improvement

process at all levels.

2.5 HEALTH CARE SYSTEM IN PAKISTAN

With the rapid growth in Pakistan population exceeding by

184.2 million people and indeed it is a great challenge for

government to make reasonable efforts and concurrent

planning for the development of healthcare system for its

citizen. According to Economic Survey of Pakistan (2012-

2013), government allocates only 0.35 percent of its entire

GDP on health care expenditures. At present there are 1,207

hospital, 5,382 dispensaries, 5,404 basic healthcare units,

and 696 maternity and child care units in the country.

Majority of the public and private hospitals are located in

urban areas and especially, in main cities of Pakistan.

Therefore, the people living in rural areas are deprived off to

avail the normal healthcare facilities and have to travel long

distances to avail the healthcare facilities. In short, the

available healthcare system is inadequate, inefficient, and

underfunded. More efforts by government need to be done in

order to enhance the health indicator in the country. Table 1

provides a snapshot of shortage healthcare workers and

facilities in Pakistan for 184.4 million people of Pakistan.

The statistics of these recent four years also suggest that due


to rapid growth in population, the demand for both

healthcare workers and the facilities (e.g., the number of

person per bed/doctor/nurse) is also increasing each year.

Still no significant efforts or planning at government level is

visible for further development of healthcare sector

especially public hospitals.

These authors further conclude that healthcare reforms

require quick initiative and immediate attention to address of

various domains of healthcare system [88]. This include:

health financing imperatives, governance imperatives,

service delivery imperatives, human resources imperatives,

health information imperatives, medicines and technology

imperatives, and information communication technology

imperatives.

Nishtar [88] provided a snapshot of current healthcare

system in Pakistan and it is shown in the Figure 1.

3 RESEARCH METHODOLOGY Main aim of this study is to identify the CSFs of TQM in

health care keeping in view, the contextual factors of

Pakistani working environment, organizational structures,

and organizational culture. First step is to identify the

appropriate research articles for this study, we used

academic journals and databases like; Science Direct and

Scopus, Taylor Francis, EBSCO Host, Emerald, Willey on

line library, and Google Scholars. For specific articles we

used phrases, Critical Success Factors for TQM, TQM implementation, Instrument for TQM implementation, CSFs of TQM, TQM in health care/manufacturing/services, and TQM practices. After a detailed review of articles only those articles were

selected where, TQM CSFs or TQM practices were

discussed and tested either theoretical or empirically and

selection process is given in the Figure 2.

To avoid duplication of the selected articles, researchers

import references into reference manager Endnote X7. For

this a total of 593 articles were downloaded and after a

careful selection only 134 articles were selected and a

check sheet was developed to record the TQM practices

used in selected articles. This study has identified

application of TQM in all sectors of economy, 71 selected

articles were from manufacturing sector, 28 from service

sector, 20 studies from health care, and 16 studies tested

TQM in both manufacturing and service sector as given in

the Figure 3.

Figure 3: TQM Practices across Industry

Selection of the construct under relevant category was

another complex task because majority of the TQM

construct were used with different captions and there was a

slight difference in some items of these constructs but core

concept was almost same. Therefore, researchers of this

study have selected the relevant construct under one

caption and details of some of the major constructs are

given in the Table 2.

The data recorded for this study identify more than 100

CSFs of TQM and majority of the practices are the

subcategories of some main categories meaning that with

different captions but presenting the core concept of the

major construct as discussed in the Table 1, and therefore

this study includes 35 CSFs of TQM representing the

broader categories of CSFs of TQM. However, the

construct which were rarely used and not representing the

TQM philosophy were rejected. The total frequency of

occurrence was 876 [89] and final list of these 35 TQM

practices with frequency, percent frequency, and percent

cumulative frequency of each of the TQM practices are

shown in the Table 3.

Frequency of occurrence of each TQM practices is

presented in the Figure 4.

Researchers also made industry specific analysis of CSFs

of TQM as given in Figure 5.

Pareto analysis is one of the important quality tools that

helps us in decision making and is employed to identify the

vital few and useful many items. It ranks the data

classification in descending order by placing the highest

frequency of occurrence to lowest frequency of occurrence

and the total frequency is considered to be 100%. It works

on famous Pareto principle (80/20) i.e. vital few items are

representing the 80% of cumulative frequency of the data

and useful many items occupy the remaining 20%


Table 2: TQM Practices with Different Captions

Labels Captions

Top Management

Commitment and

Leadership role

top management commitment and visionary leadership, role of top management, visionary leadership, leadership

and policy, top management implication, executive commitment, quality leadership, top management leadership, top executive support, top management philosophy, senior executive involvement, leadership and support from top

management, top management commitment

Human Resource

Focus

employee relations, workforce management, human resource management, human resource focus, hiring and selection, employees empowerment and involvement, rewards and recognition, training, teamwork, quality teams,

workforce management, employee participation, quality circles, employee focus, employee satisfaction

Quality Data and Reporting

quality data, quality data and reporting, process measurement, quality measurement, information and analysis,

measurement and feedback, quality improvement measurement systems, quality information availability, and quality information usage, quality measurement, quality improvement measurement systems, work information

sharing, measurement analysis and knowledge

Customer Focus customer focus, customer focus and satisfaction, customer analysis, close cooperation with customers, customer service, customer orientation, customer satisfaction orientation, customer feedback, customer and market focus,

customer relationship, customer satisfaction orientation, customer involvement, closeness to customers

Process management

process management, management of process quality, quality of product, process and service, processes, internal

process management, external process management, systems and processes, process improvement, process assurance system, process control management, process improvement, process control management, process

control, process quality management, process quality, management process

Supplier Quality

Management

supplier quality management, supplier relationship, supplier quality involvement, supplier quality, supplier management, supplier relationship management, supplier satisfaction, supplier involvement, supplier performance,

suppliers cooperation, supplier quality assurance

Product /Service

quality Design

product design, service design, design management, design and development of new products, product or service

design process

Continuous quality

improvement

continuous improvement, continuous support, continuous process improvement

Strategic quality planning

quality strategy, strategy and innovation, strategic quality planning, strategic integration, policy and strategy, strategy for TQM, operational quality planning, strategic quality management, and quality goals and policy

Benchmarking benchmarking, competitive benchmarking, benchmarking on quality and service, benchmarking and quality

measurement

Quality management system

quality systems, role of quality department, quality assurance, quality control, quality councils, quality monitoring, quality policy, mission statement, quality focus

Figure 4: Most Frequently used TQM Practices

Fig. 5


Table 3: TQM Practices in Manufacturing, Services and Healthcare

Labels TQM Practices Frequency % Frequency

%Cumulative Frequency

1. TMC Top Management Commitment 127 14.481 14.481

2. HRF Human Resource Focus 129 14.709 29.19 3. QDR Quality Data and Reporting 94 12.657 41.847 4. CSF Customer Focus 111 10.718 52.566 5. PRM Process Management 84 9.578 62.144

6. SQM Supplier Quality Management 66 7.526 69.669

7. CIM Continuous Quality Improvement 39 4.561 74.23

8. SDG Product /Service Quality Design 36 4.105 78.335

9. SQP Strategic Quality Planning 35 3.991 82.326 10. BEN Benchmarking 30 3.535 85.861 11. QCL Quality Culture 13 3.421 89.282

12. QMS Quality Management System 31 1.482 90.764

13. COM Communication 9 1.026 91.79 14. SPC SPC Usage 9 1.026 92.816 15. SRP Social Responsibility 8 0.912 93.729 16. CUL Cultural Change 6 0.684 94.413 17. RCM Resource Management 6 0.684 95.097 18. JIT Just In Time 5 0.570 95.667 19. SER Servicescapes 3 0.456 96.123 20. TCM Technical Competencies 4 0.456 96.579 21. CQL Cost Of Quality 4 0.342 96.921 22. TSY Technical System 3 0.342 97.263 23. ZDF Zero Defect 3 0.342 97.605 24. FLX Flexibility 3 0.342 97.948 25. COP Cooperation 2 0.342 98.29 26. OPQ Operational QM 2 0.228 98.518 27. OBH Organizational Behavior 2 0.228 98.746 28. QCR Quality Circles 2 0.228 98.974 29. IPT Improvement Tools 2 0.228 99.202

30. EIM External Interface Management 3 0.228 99.43

31. DCM Design Of Conformance 1 0.114 99.544 32. DSI Design Instrument 1 0.114 99.658 33. SRM Service Marketing 1 0.114 99.772

34. OPS Operational Support System 1 0.114 99.886

35. STF Stakeholder Focus 1 0.114 100

cumulative frequency of the data. Results of Pareto analysis

and their descriptions are reported in Figure 6.

4. RESULTS AND DISCUSSION Results of the analysis shows that top management

commitment, human resource focus, quality data and

reporting, customer focus, process management, supplier

quality management, continuous improvement, product or

service design, strategic quality planning, quality

management system, and benchmarking are most

frequently used in the literature. Thus these practices may

be considered as core practices, and applicable and

acceptable in all type of industry. As there is no exhaustive

research work in health care due to its late acceptance in

health care like the other service sectors. There seems to

dearth to develop a holistic model for TQM from

management perspective particularly in hospital settings.

Thus this studies proposed 9 CSFs of TQM mainly based

on literature derived from [59, 30, 39]. For this study, we

included 9 CSFs of TQM for healthcare; top management

commitment and leadership role, human resource focus,

supplier quality management, strategic quality planning,

patient focus, process management, quality data and

reporting, continuous improvement, and servicescapes.

Reliability and validity of the proposed constructs has been

empirically verified in various studies. It has also been

observed in the literature that all these factors significantly

contributes in increasing financial as well as non-financial

performance of the organizations.

5. DISCUSSION AND CONCLUSION In this paper, we have addressed the identification of the

critical dimensions of TQM in healthcare sector. To explore

this issue in depth, we have further investigated TQM in

manufacturing, service and healthcare settings. Key

dimensions of TQM in healthcare specifically for public

and private hospitals in Pakistan has been identified after a


Fig. 2

Fig. 6

comprehensive review of literature and these dimensions

are best fit in the context of Pakistani public as well as

private hospitals. The model developed in this paper

provides a promising theoretical perspective to explore

CSFs of TQM in Pakistani health care sector. We have

attempted to tie various literature reviews and research

regarding on TQM and CSFs together to identify the CSFs

in healthcare setting. Ultimately, we believe that nine CSFs

which are considered as core CSFs of TQM and provides a

guarantee for its success provided the barriers and obstacles

discussed in literature should be addressed first.

5.1 Top Management Commitment and Leadership

Role

Role of top management is the foremost important and

considered as a fist enabler in TQM implementation in any

organization. The key challenge for the top management is

to effectively manage the relationships among companys vision, mission, strategies, quality values, and to make a

clear understanding among the employee. Any strategic

movement is likely to be fail without positive commitment

of the top management [90]. Top management has to

perform certain roles, provision of resources, developing

quality policy, setting quality goals, quality trainings, and

motivation for improvement efforts [91]. In healthcare

setup, top management role is more crucial as compare to

the other service environment and is responsible for quality

of care and overall hospital system [86, 92]. TQM

practitioners and researchers have recognized the

importance of top management role in driving

companywide quality management efforts and also a major

factor for successful achievement of quality performance

[40, 93, 94]. Leadership at all levels in the organization has

to set quality goals, develop system that guide and pursuit

for organizational performance through a continuous

quality improvement process [95, 63]. Physician, surgeons,

pharmacists, and other healthcare professionals in a

leading role are effective in implementation process and

also have to encourage their subordinates to contributes in

its success [72, 96].

5.2 HUMAN RESOURCE FOCUS

Core concept of TQM is strictly focuses on employee

participation, empowerment, training and education,

teamwork, and reward and recognition as advocated by all

the quality gurus [like; 97, 40]. Thus employees are now

recognized as valuable asset and effective management of a

human resources leads to gain sustainable competitive

advantage. A strong linkage between these practices and

organizational performance outcome has been verified in

numerous studies. Instead of looking at the impact of single

HR practice, our model suggests that the HR practices

needed to be bundle into meaning group of practices. This

study propose that it is not practice per se that make the

different but the degree to which they align with each other

to create meaningful of bundle of practice [98]. This study

assumes that the presence of strong HRM system may bring

a better impact on TQM success. HRM may be additive

and synergistic whereas, single HRM practice may not

deliver the similar effect. Thus this study includes; training

and education, employee involvement and empowerment,

rewards and recognition system has been considered in this

construct. All these practices are representing the soft

dimensions of TQM and TQM cannot be achieved by

proper addressing the soft aspects of TQM [99, 100].

5.3 PATIENT FOCUS

Major reasons to implement best strategies and deliver high

quality of product or services is to gain customer

satisfaction. the key component that should be properly

address to get success in the market, gain financial benefits,

competitive edge and better market orientation. Customer

focus can be defined as the degree to which an organization

understand the needs and wants of the customer proactively

and gain their satisfaction through continuous quality

improvement of the product/service deliver to them [39,

101]. Deming [40] argued that organizations must

understand customer needs and current and future wishes,

so that designed product or services meet customer

satisfaction level. Successful companies always put

customer needs first before any decision making [102].


Flynn, Schroeder, and Sakakibara [103] suggested that

customer should be involved at all level in designing phase

and process development which will help to reduce error

level when full production begins. Timely response to

customer requirements is the major factor to gain

competitiveness [104] and employee quick response to

customer complaints causes to improve service quality

[105]. In healthcare setup customers are patients and

majority of them have a sound knowledge and information

before availing any healthcare services and to avail best

services they are ready to travel long distances [106]

because every patient needs sound diagnostics, consultation

of best doctor and best specialized treatment and care [72].

In many countries, healthcare sector have become an

industry and healthcare institutions has developed their

systems to offer specialized healthcare services to attract

the healthcare tourist and local patient and start addressing

patient needs while designing their healthcare facilities.

5.4 CONTINUOUS IMPROVEMENT

Development of TQM field is incremental not exhaustive,

and it has developed over a time starting from inspection to

TQM and continuously developed using continuous quality

improvement as an important driver and contributes in

business excellence [107]. Continuous improvement is also

among the core concept of TQM as advocated by all the

quality gurus. It is most important enabler to increase

productivity [108] and there exist a positive relationship

between continuous improvement and productivity [109].

Continuous improvement is not one time activity but it is

an ongoing process. In hospitals, due to complexities of

diseases and changing pattern of diseases, it requires most

advance equipment, technical system, methods that helps in

right diagnostics and also continuously updating the

knowledge and skill of all involved human resource. It is a

consider as a dynamic process that focuses on improvement

and it build relationship with other elements and also

effects the organization environment [110]. Therefore,

hospitals needs to have continuously monitor and upgrade

knowledge base of its people as well as infrastructure for

delivering quality of healthcare services to the patients to

gain their delight.

5.5 QUALITY DATA AND REPORTING

Quality data and reporting is as a part of information and

analysis system and in TQM literature these terms are used

alternatively. It involves costs of poor quality because of

scarps, reworks, and due to warranty costs and this

information is further analyze using quality tools control

charts to identify the potential and minor problems and it

also provides us feedback on possible improvement [111,

112]. Quality of data is most crucial element in effective

decision making and designing customer focused services.

It contains customer feedback for improvement, detailed

information about services delivered and also influence the

firm performance throughout the product/service life cycle

and has a positive effect on product or service design,

process management and supplier quality management

[113].

Proper reporting and storing data helps to measure the

supplier performance and work as a data base in the

organization. It is also important that it must be accessible

to the assigned managers or staff that provides them an

opportunity to make best decision and also a tool to

increase material quality, reduction in costs, identification

key problematic areas and also helpful in supplier

development [114]. Therefore, availability of accurate data

and maintaining a databases can accurately identify the

different measurements like; percent part rejection, process

capability ratios, amount of scrap, cost of warranties and

reliability [115]. Monitoring the material and all inputs and

throughputs can be easily measured and monitored. In

hospital context this factor requires more importance as

investigation in right diagnostics; doctors need accurate

data regarding lab reports, previous medical examinations,

reports, and patient history. It also allows us to record and

report errors, cost of quality, defects in order to improve the

quality of services.

5.6 PROCESS MANAGEMENT

Process management is a systematic approach of managing

all the organizational resources efficiently and effective in a

systematic way to achieve organizational performance

objectives [116, 117]. Elusive management of all the major

business processes is essential for the successful

implementation of TQM to improve quality and

performance in the organization [39]. In health care setup it

is of more critical in nature due to the health care service

environment because hospitals are delivering both the

tangible and intangible services. Service delivery processes

should be comprehensive in order to deliver error free

services to the customers [39]. Thus key aspect of this

construct requires carefully focus on service design and

benchmark best practices, processes, and system that helps

the hospitals to deliver best quality, error free, focuses on

patient safety, efficient methods of hospital waste disposal,

and a healthy, hygienic environment to the patient and their

families. Thus process management addresses and meeting

the patient perceptions and expectations during a treatment

process and final outcome of the treatment process [118].

5.7 SUPPLIER QUALITY MANAGEMENT

Supplier quality improvement, supplier development and a

comprehensive measurement and evaluation system is an

integral part of quality implementation and over all service

improvement. In health care set up suppliers includes, the

equipment manufacturers, pharmaceutical companies and

the medical universities providing valuable human

resources to the hospitals. Thus, in health care setup

hospitals and health care agencies needs to look this issue

more critically as it is linked with the human life. Thus

strategies should be developed and communicate to the

suppliers and comprehensive system is required to measure

their performance at regular intervals.

5.8 STRATEGIC QUALITY PLANNING All quality improvement efforts in the organizations are

strongly depending upon the organizational strategic

quality plans. Thus it requires a strong commitment of

management and leadership at all levels for its future

quality vision and initiatives taken towards internal and

external customer satisfaction, supplier quality

improvement efforts, and its benefits to the community.


Thus strategic quality planning process should be

embedded with the quality planning of all processes [119].

5.9 SERVICES FOCUS

Service quality is quite complex phenomenon as majority of

the services are intangible in nature. Customer has to buy the

services first and then he is able to percieve its quality. In

health care setup, customer (patient) are receiving both

intagible (diagnostics) and tangibles (surgical procedures)

services. Thus hosptials have to focus on tangibles as well

intangibles at the same time. In service sector physical

enviornment is of most importance because it influences the

behaviors and also create an image of the organization [39].

Thus in hospitals tangibles includes machinery and

equipment, hygene conditions in the hospital as well as in

the wards, sitting areas, standarized laboartories,

pharmacies, canteens, well equiped operation theators etc.

Other than this, highly qualified surgions, phycians, and

other supporting staff also influences the patient behaviors

as it creat assurance among them. Johnston [120] suggested

that service organizations must deliver promised services,

provides persoanl touch, proactive approach to resolve

customer issues and problems, and try to provides comfort in

service beyond their expectation is a way to gain customer

delight. Thus a careful addresses these factors leads to gian

excellence in healh care services.

In conclusion, these CSFs of TQM we have suggested

provides an underlying mechanism to boost the operational

and organizations performance of health care sector and thus

leading to excellence in health care services in Pakistan.

More broadly, CSFs of TQM discussed in this paper will

direct future research towards the development of TQM and

performance model for the health care sector in Pakistan to

deepen our understanding of TQM.

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