Best practices of total quality management implementation in health care settings

The characteristics of leadership and their effectiveness in quality management in healthcare - A systematic literature review and a content analysis

Effective quality leadership is identified as a critical factor for organisational success. Leadership style has an important role in the implementation of quality management. This systematic review describes the characteristics of leadership in quality management in healthcare, and analyses their association with successful or unsuccessful quality management by using content analysis. Papers published in peer-reviewed journals between 2011 and June 2023 were selected by exploring the Abi/Inform, Business Source Complete, Cinahl, Pubmed and Web of Science electronic databases. Altogether 3014 records were found. PRISMA-protocol was used for selection of studies. 12 original and three review articles were included. Six leadership characteristics were identified that were linked to successful or unsuccessful implementation of quality management. The six categories were strategic, knowledge-oriented, value-based, supportive, participatory and communicative leadership. Supercategories and subcategories of successful and unsuccessful implementation are described. The results can be used to identify the leadership characteristics that promote successful quality management in healthcare organisations. In education for leaders and managers, attention should be in the characteristics and style of leadership and their impact on the effectiveness of quality management.

Effect of total quality management intervention on nurse commitment and nurse performance: A quasi-experimental study

BACKGROUND

The purpose of this study is to design, implement, and evaluate the impact of a total quality management intervention on job performance and commitment among Jordanian nurses working in government hospitals.

METHODS

A quasi-experimental multiple time series was conducted starting in September 2017 and ending in June 2018. 140 nurses were sampled using the proportionate stratified random sampling technique; 132 were completed the study 67 the intervention group, while 65 in the control group.

RESULTS

There were no significant differences in nurses' job performance or commitment between the 2 groups (control and intervention). A repeated measure MANOVA test for both groups revealed that the interaction between group and time was statistically significant (F (4, 127) = 144.841; P = .001; Wilk's Λ = 0.180; η2 = .820), indicating that groups had a significantly different pattern of job performance and commitment over time. A repeated test The MANCOVA test for both groups across time revealed significant differences in nurses' job performance and nurses' commitment at a less than 0.05 significance level (F (2127) = 320.724; P = .001; Wilk's Λ = 0.165; η2 = 0.835), and the overall effect of time was significant for all dependent variables (F (4125) = 36.879; P = .001; Wilk's Λ = 0.459; η2 = 0.541).

CONCLUSION

The educational intervention was effective in improving nursing job performance among the study sample. The improved commitment of respondents in the intervention group was attributed to the improvement in job performance.

Common Quality Improvement Methodologies Including the Model for Improvement, Lean, and Six Sigma

This article reviews several common quality improvement methodologies, including the Model for Improvement, Lean, and Six Sigma. We demonstrate how these methods are based on a similar improvement science foundation. We describe the tools used to understand problems in the context of systems and the mechanisms to learn and build knowledge, using specific examples from the neonatology and pediatric literature. We conclude with a discussion on the importance of the human side of change in quality improvement, including team formation and culture.

Prioritizing enablers for service quality in healthcare sector - a DEMATEL approach

PURPOSE

The Healthcare sector is one of the important sectors of the Service Industry. It is believed that in this sector, the customer server relationship is very critical, and even the slightest gap in the people quality may have a huge impact on the delivered service quality. Some of these enablers are doctors, nursing staff and support staff. Furthermore, the nonpeople quality enablers such as diagnostic services, facilities, hygiene levels and so on are also likely to impact the delivered service quality. It was also felt that the degree of impact each enabler has on the service quality could vary. Therefore there is a need for structured and deep analysis. The paper attempts to identify, analyze and prioritize the enablers that impact the delivered service quality.

DESIGN/METHODOLOGY/APPROACH

The enablers have been identified through literature review and inputs from experts in the healthcare fraternity. The authors have explored different decision-making tools such as analytic hierarchy process (AHP), analytic network process (ANP), stepwise weight assessment ratio analysis, Hybrid Model and DEMATEL (Decision-Making Trial and Evaluation Laboratory) for the analysis of data in this paper. Based on the strengths of the approach and careful considerations by focus group discussions, DEMATEL was chosen as the best option. It is simple, unique, sparingly used in the healthcare sector, effective in prioritizing and gives meaningful insights on importance, cause and effect factors. DEMATEL approach converts the complex problem with interrelated factors into a clear structure that makes simple interrelationships among factors in the form of cause and effects digraph, and hence, the authors chose to use it. A case study in one of the hospitals has also been conducted to demonstrate the applicability of the developed index. The case study very strongly validates the developed index.

FINDINGS

This research paper has found that there are people quality enablers such as the doctor, nursing staff, support staff and nonpeople quality enablers such as facilities, diagnostic services and hygiene levels maintenance, which impact the delivered service quality. It also concludes that the delivered service quality depends not only on the quality but also on the availability of these enablers. The inputs received from the experts have been run through the DEMATEL methodology and importance computed for each. The top five priority enablers are Quality of Doctor, Availability of Doctor, Quality of Support Staff, Quality of Nursing Staff and Availability of Support Staff.

RESEARCH LIMITATIONS/IMPLICATIONS

The weights of the enablers have been obtained using the DEMATEL tool. These weights have been calculated using the inputs from 22 experts, which meets the statistical requirement (Skulmoski, 2007). However, a larger group of experts can be reached, and based on the inputs received from them, the tool can be revalidated for repeatability and reproducibility. Using Fuzzy DEMATEL can also be explored for further analysis.

PRACTICAL IMPLICATIONS

The proposed framework to assess the service quality level of a healthcare organization is based on a sound approach of DEMATEL. The service index arrived, thereafter, can be used to rate the delivered service quality by any healthcare organization. It can be used to compare the similar type of healthcare organizations across locations. This Index can facilitate improvements in the healthcare organization through internal and external benchmarking. It also helps the organization to know the gaps, understand the root cause, improve upon them and become the best in class. This Index uses the inputs from the end customers to calculate the rating, which makes it more reliable and accurate. The overall scores obtained from the Index can provide the ranking to the healthcare providing organizations and options to customers to choose from best. The service quality index can be used by an organization to continuously monitor their delivered service quality scores and improve them to become the best in class. The research paper highlights the significant role played by the people quality and its strong impact/contribution on the delivered service quality. Hence, it is believed that it will encourage the healthcare organizations to prioritize the improvement and upgrade of the people quality over the nonpeople quality aspect.

ORIGINALITY/VALUE

Putting people and nonpeople quality enablers in one single model and assigning weights to them using the DEMATEL approach is a new application in healthcare. Developing an Index to measure the delivered service quality in the healthcare sector is also different and new.

What are healthcare workers' preferences for hand hygiene interventions? A discrete choice experiment

OBJECTIVES

To understand the key attributes in designing effective interventions for improving healthcare workers' (HCWs') hand hygiene compliance and HCWs' preference for these attributes.

DESIGN

A discrete choice experiment (DCE) was conducted with five attributes extracted from the framework of Total Quality Management that can be applied in the design of hand hygiene interventions. They were hand hygiene monitoring, open discussion, message framing, resources accessibility and top management involvement. An addition attribute, peer hand hygiene performance, was considered as a contextual factor. Data were analysed by a conditional logit model to evaluate how these attributes impact HCWs' hand hygiene compliance.

SETTING

The DCE was conducted with participants from a university hospital in Taichung.

PARTICIPANTS

HCWs involved in daily patient-care activities (N=387).

RESULTS

To enhance their compliance, HCWs had strong and consistent preferences in having open discussion of hand hygiene problems ([Formula: see text], [Formula: see text]), easy access to hand hygiene resources ([Formula: see text], [Formula: see text]) and top management involvement ([Formula: see text], [Formula: see text]). For hand hygiene monitoring ([Formula: see text], [Formula: see text]), HCWs preferred to be monitored by infection control staff over their department head if their peer hand hygiene performance was low. On the other hand, when the peer performance was high, monitoring by their department head could improve their hand hygiene compliance. Similarly, how educational messages were framed impacted compliance and also depended on the peer hand hygiene performance. When the peer performance was low, HCWs were more likely to increase their compliance in reaction to loss-framed educational messages ([Formula: see text],[Formula: see text]). When the peer performance was high, gain-framed messages that focus on the benefit of compliance were more effective in inducing compliance.

CONCLUSIONS

Each intervention design has its unique impact on HCWs' hand hygiene compliant behaviour. The proposed approach can be used to evaluate HCWs' preference and compliance of an intervention before it is implemented.

Severe Maternal Morbidity in California Hospitals: Performance Based on a Validated Multivariable Prediction Model

BACKGROUND

Severe maternal morbidity (SMM) is under development as a quality indicator for maternal health care. The aim of this study is to evaluate California hospital performance based on a standardized SMM measure.

METHODS

California maternal hospital delivery discharge data from 2016 to 2017 were used to develop logistic regression models for SMM, adjusted for clinical risk factors at admission. Data from 2018 were used to test the models and evaluate hospital performance. SMM was defined per the Centers for Disease Control and Prevention, including (excluding) blood transfusion. Independent models were developed for each hospital type: community, teaching, integrated delivery system (IDS), and IDS teaching. Within each type, model-based expected SMM values and observed-to-expected (O/E) ratios were calculated for each hospital. For each hospital type, hospitals were ranked by O/E ratio, and over- and underperforming hospitals were identified using 95% confidence intervals.

RESULTS

Rates of SMM including (excluding) transfusion by hospital type were 1.7% (0.9%) for community, 2.7% (1.5%) for teaching, 2.3% (1.2%) for IDS, and 3.0% (1.6%) for IDS teaching hospitals. In higher-volume community hospitals (≥ 500 births/year), the proportion of underperformers including (excluding) transfusion was 20.7% (11.0%). Summing over all hospital types, 25.3% (14.9%) of hospitals were identified as underperformers in that they experienced significantly more SMM events than expected including (excluding) transfusion.

CONCLUSION

California hospital discharge data demonstrated significant hospital variation in standardized childbirth SMM. These data suggest that a standardized SMM measure may help guide and monitor statewide quality improvement efforts.

Effect of TQM educational interventions on the management policy standard of health promoting hospitals

The purpose of this study was to manage total quality management (TQM) to increase the standard of management policy and contribute to achieve the standards for health promotion hospitals (HPHs). This was a quasi-experimental intervention study. A total of 35 managers participated in this study were selected in the census. Based on the TQM components, educational items were provided as lectures, posters and pamphlets. The TQM questionnaire and HPHs checklist used to collect data in three different periods: before the interventions, immediately after the interventions and 3 months after the interventions (follow-up). The data analysis was done by means of SPSS software (version 23). The results showed that the average difference of the components of the qualitative groups (p < 0.001), education (p = 0.004), evaluation and feedback (p < 0.001), customer-orientation (p < 0.001), suggestion system (p = 0.024), leadership commitment (p < 0.001) was significant over the three periods. Excluding the employment status before the educational intervention (p = 0.002), there was no significant relationship between the demographic characteristics and mean score of TQM (p > 0.05). Based on the findings of this study, the educational interventions had a positive effect on quality management and management policy. Therefore, educational interventions should be accompanied by changes in the culture and management policies of the hospital to meet HPH standards.

Modelling enablers of efficiency and sustainability of healthcare: a m-TISM approach

Purpose

It would not be an exaggeration to say that healthcare is the most crucial one in today's perspective. The healthcare sector, in general, is engaged in working on various dimensions simultaneously like the safety, care, quality and cost of services, etc. Still, the desired outcomes from this sector are far away, and it becomes pertinent to address all such issues associated with healthcare on a priority basis for sustaining the outcomes in a long-term perspective. The present study aims to explore the healthcare sector and list out the directly associated enablers contributing to increasing the viability of the healthcare sector. Besides, the interrelationship among the enlisted enablers needs to be studied, which further helps in setting-out the priority to deal with individual enablers based on their impedance in the contribution towards viability increment.

Design/methodology/approach

The authors have done an extensive review to list out the enablers of the healthcare sector to perform efficiently and effectively. Further, the attempt has been made on the enablers to rank them by using the modified Total Interpretative Structure Modelling (m-TISM) approach. The validation of the study reveals the importance of enablers based on their position in the hierarchical structure. Further, the MICMAC analysis on the identified enabler is performed to categorize the identified enablers in the different clusters based on their driving power and dependence.

Findings

The research tries to envisage the importance of the healthcare sector and its contribution towards national development. The outcomes of the m-TISM model in the present study reveal the noteworthy contribution of the organizational structure in managing the healthcare facilities and represented it as the perspective of future growth. The well-designed organizational structure in the healthcare industry helps in establishing better employee–employer cooperation, workforce coordination and inter-department cooperation.

Research limitations/implications

Every research work has limitations. Likewise, the present research work also has limitations, i.e. input taken for developing the models are from very few experts that may not reflect the opinion of the whole sector.

Practical implications

The healthcare sector is the growing sector in the present-day scenario, and it is essential to keep the quality of treatment in check along with the quantity. The present study has laid down the practical foundations for improvement in the healthcare sector viability. Besides, the study emphasized on accountability of the healthcare sector officials to go with the enablers having the strong driving power for effective utilization of all the resources. This would further help them in customer (patients) satisfaction.

Originality/value

Despite an increase in demand for good quality healthcare facilities worldwide, the growth of this sector is bounded by the economic, demographic, cultural and environmental concerns, etc. The present study proposed a unique framework that provides a better understanding of the enablers. It would further help in playing a key role in increasing the viability of the healthcare sector. The hierarchy developed with the help of m-TISM and MICMAC analysis will help the viewers to recognize the important enablers based on their contribution to the viability improvement of the healthcare sector.

Determining Factors That Influence Nurses' Perceptions of Quality Implementations Conducted in Hospitals in Turkey

BACKGROUND

Quality management program implementations in health services are team endeavors that involve all health service personnel. Because they are direct providers of care, nurses are best able to evaluate the influence of quality management program implementations on the health services and quality of care provided by hospitals.

PURPOSE

The aim of this study was to develop an instrument to determine how nurses perceive the implementation of quality management programs in hospitals. Furthermore, the nurses' perceptions of the influence of these implementations on the quality of patient care and their job satisfaction were examined.

METHODS

A descriptive, comparative, cross-sectional online survey was conducted using a convenience sample (N = 388) of practicing nurses working at public and university hospitals where quality management programs were implemented. Nurses' perceptions of the implementations were analyzed using confirmatory factor analysis, whereas the influence of nurses' perceptions of quality management implementations on patient care and job satisfaction was measured using structural equation modeling approaches.

RESULTS

This study revealed that the instrument is valid and reliable for the measurement of participant perceptions of quality management program implementations. Nurses' perceptions were generally negative, and they exhibited negative attitudes toward the implementation of quality management in the institutions where they work. However, the quality management program implementations had little influence on perceptions of the quality of patient care. Participant job satisfaction was lower than average, and the quality management program implementations conducted in the hospitals negatively affected job satisfaction. On the other hand, participants who worked at university hospitals perceived quality management program implementations more affirmatively; patient care quality and job satisfaction were viewed more positively as well.

CONCLUSIONS/IMPLICATIONS FOR PRACTICE

Because nurses do not participate effectively in quality management program implementations, they perceive these efforts as unnecessary and the responsibility of the quality control department. It is very important to ensure that all care-service providers participate to effectively implement quality management programs in hospitals and to encourage the adoption of a culture of patient safety in all institutions.

Partnering with patients in quality improvement: towards renewed practices for healthcare organization managers?

Background

Around the world, many healthcare organizations engage patients as a quality improvement strategy. In Canada, the University of Montreal has developed a model which consists in partnering with patient advisors, providers, and managers in quality improvement. This model was introduced through its Partners in Care Programs tested with several quality improvement teams in Quebec, Canada. Partnering with patients in quality improvement brings about new challenges for healthcare managers. This model is recent, and little is known about how managers contribute to implementing and sustaining it using key practices.

Methods

In-depth multi-level case studies were conducted within two healthcare organizations which have implemented a Partners in Care Program in quality improvement. The longitudinal design of this research enabled us to monitor the implementation of patient partnership initiatives from 2015 to 2017. In total, 38 interviews were carried out with managers at different levels (top-level, mid-level, and front-line) involved in the implementation of Partners in Care Programs. Additionally, seven focus groups were conducted with patients and providers.

Results

Our findings show that managers are engaged in four main types of practices: 1-designing the patient partnership approach so that it makes sense to the entire organization; 2-structuring patient partnership to support its deployment and sustainability; 3-managing patient advisor integration in quality improvement to avoid tokenistic involvement; 4-evaluating patient advisor integration to support continuous improvement. Designing and structuring patient partnership are based on typical management practices used to implement change initiatives in healthcare organizations, whereas managing and evaluating patient advisor integration require new daily practices from managers. Our results reveal that managers at all levels, from top to front-line, are concerned with the implementation of patient partnership in quality improvement.

Conclusion

This research adds empirical support to the evidence regarding daily managerial practices used for implementing patient partnership initiatives in quality improvement and contributes to guiding healthcare organizations and managers when integrating such approaches.

Ranking model of total quality management enablers in healthcare establishments using the best-worst method

Purpose

Recent years have witnessed a significant rise in Indian healthcare establishments (HCEs) which indicate that there is a constant need to improve the healthcare quality services through the adoption and implementation of TQM enablers. The purpose of this paper is to identify such enablers and then propose a ranking model for TQM implementation in Indian HCEs for improved performance.

Design/methodology/approach

The study identifies 20 TQM enablers through comprehensive literature survey and expert’s opinion, and classifies them into five main categories. The prominence of these enablers is established using a recently developed novel multi-criteria decision making (MCDM) method, i.e. best-worst method (BWM). The importance of the various main category and sub-category enablers is decided on the basis of their weights which are determined by the BWM. In comparison to other MCDM methods, such as analytical hierarchy process, BWM requires relatively lesser comparison data and also provides consistent comparisons which results in both optimal and reliable weights of the enablers considered in this paper. Further, a sensitivity analysis is also carried out to ensure that the ranking (based on the optimal weights) of the various enablers is reliable and robust.

Findings

The results of this study reveal that out of five main category enablers, the “leadership-based enablers (E1)” and the “continuous improvement based enablers (E5)” are the most and the least important enablers, respectively. Similarly, among the 20 sub-category enablers, “quality leadership and role of physicians (E14)” and “performing regular survey of customer satisfaction and quality audit (E52)” are the most and the least dominating sub-category enablers, respectively.

Research limitations/implications

This study does not explore the interrelationship between the various TQM enablers and also does not evaluate performance of the various HCEs based on the weights of the enablers.

Practical implications

The priority of the TQM enablers determined in this paper enables decision makers to understand their influence on successful implementation of the TQM principles and policies in HCEs leading to an overall improvement in the system’s performance.

Originality/value

This study identifies the various TQM enablers in HCEs and categorizes them into five main categories and ranks them using the BWM. The findings of this research are quite useful for management of the HCEs to properly understand the relative importance of these enablers so that managers can formulate an effective and efficient strategy for their easy and smooth implementation which is necessary for continuous improvement.

Assessing hospital quality management systems: evidence from Iran

PURPOSE

A quality management system (QMS) is defined as interacting activities, methods and procedures used to monitor, control and improve service quality. The purpose of this paper is to describe the QMS status using the Quality Management System Index (QMSI) in hospitals affiliated to Shahid Beheshti Medical Sciences University in Tehran, Iran.

DESIGN/METHODOLOGY/APPROACH

In this cross-sectional study, 28 hospitals were investigated. A validated 46-item questionnaire was used for data collection. Data were analyzed using descriptive statistics, Pearson correlation, independent student's t-test and regression analysis.

FINDINGS

The mean QMSI score was 18.4: 15.3 for public and 20.9 for non-public hospitals ( p=0.001). The lowest (1.96) and the highest (2.14) scores related to "Quality policy documents" and "Quality monitoring by the board," respectively. The difference between public and non-public hospitals was significant in all nine QMSI dimensions ( p=0.001). The QMSI score was higher in non-public and small hospitals than in public and large ones ( p=0.05).

ORIGINALITY/VALUE

Most QMS studies come from developed countries, and there is no systematic information about the mechanisms and processes involved in implementing QMS in developing countries like Iran. This is the first study on Iranian hospital QMS using a newly developed tool (QMSI), and results showed that QMS maturity in these hospitals was relatively good, but the non-public hospitals status (private and charity) was far better than public hospitals.

Benchmarking life quality support interventions in long-term care using the Long-Term Care Quality of Life scale

We aimed to develop a graphical procedure for benchmarking quality of life care results using the Long-Term Care Quality of Life (LTC-QoL) scale. While clinical care quality benchmarking is now well established, similar research for quality of life (QOL) aged care benchmarking has received scant attention. Data from 10 facilities utilizing the LTC-QoL scale were analysed to establish baseline statistics for developing a graphical procedure for QOL benchmarking. Client LTC-QoL records were tested with varimax rotation factor analysis revealing three viable benchmarking themes: B1 (Self-efficacy), B2 (supporting relationships), and B3 (outlook on life) were selected for benchmark development utilizing Analysis of Means to generate graphical outputs using Minitab version 17.3.1. In this way, in the absence of verified industry standards, it is possible to compare organizations providing similar services using the same indicators, against group averages. In conclusion, the benchmarking protocol produced comparative information on three benchmarks for 10 facilities. Similar analysis is feasible for a single facility over time. The results of these analyses provide evidence for on-site discussion of quality of life care quality performance.

The impact of TQM practices and KM processes on organisational performance

Purpose

The purpose of this paper is to investigate the impact of total quality management (TQM) practices in terms of leadership, strategic planning, customer focus, teamwork, process management, information, and analysis on organizational performance in Jordanian telecommunications companies. In addition, the mediating effect of knowledge management (KM) processes is tested.

Design/methodology/approach

A survey instrument was used to gather empirical data, and it was distributed to all managerial and non-managerial employees. A total of 477 questionnaires were valid for analysis, resulting in a response rate of (97 percent). Factor analysis and multiple regression analyses were used to test the study’s hypotheses.

Findings

Customer focus and process management were found to have an insignificant impact on organizational performance, while teamwork had the strongest impact on KM processes. The results also revealed that only knowledge sharing and application processes had a significant impact on organizational performance. More importantly, KM processes fully mediated the impact of TQM practices on organizational performance, except for teamwork, which had a partial mediating effect.

Research limitations/implications

This study was limited to a survey of the headquarters of three telecommunication companies: Zain, Orange, and Umniah, in Amman City.

Originality/value

Originality of the paper lies in testing the influence of TQM practices on organizational performance in a novel context, where most TQM initiatives fail for one reason or another.

Building Systemwide Improvement Capability: Does an Organization's Strategy for Quality Improvement Matter?

OBJECTIVES

Health care organizations have used different strategies to implement quality improvement (QI) programs but with only mixed success in implementing and spreading QI organization-wide. This suggests that certain organizational strategies may be more successful than others in developing an organization's improvement capability. To investigate this, our study examined how the primary focus of grant-funded QI efforts relates to (1) key measures of grant success and (2) organization-level measures of success in QI and organizational learning.

METHODS

Using a mixed-methods design, we conducted one-way analyses of variance to relate Veterans Affairs administrative survey data to data collected as part of a 3.5-year evaluation of 29 health care organization grant recipients. We then analyzed qualitative evidence from the evaluation to explain our results.

RESULTS

We found that hospitals that focused on developing organizational infrastructure to support QI implementation compared with those that focused on training or conducting projects rated highest (at α = .05) on all 4 evaluation measures of grant success and all 3 systemwide survey measures of QI and organizational learning success.

CONCLUSIONS

This study adds to the literature on developing organizational improvement capability and has practical implications for health care leaders. Focusing on either projects or staff training in isolation has limited value. Organizations are more likely to achieve systemwide transformation of improvement capability if their strategy emphasizes developing or strengthening organizational systems, structures, or processes to support direct improvement efforts.

Interrelationships among quality enablers, service quality, patients’ satisfaction and loyalty in hospitals

Purpose

The purpose of this paper is to clarify how enablers of quality management can secure the satisfaction and loyalty of patients through increasing service quality in hospitals.

Design/methodology/approach

The current study conducted a review of the existing literature to identify operational dimensions of the research variables. As a result of the review, 17 dimensions were identified; five European foundation for quality management enablers, five SERVQUAL service quality dimensions, four patients’ satisfaction elements and three patients’ loyalty components. To evaluate interrelationships among these 17 research dimensions, decision-making trial and evaluation laboratory technique was applied using experts’ opinions.

Findings

Several key relations were found among research dimensions. Research findings could provide a scientific insight for hospital managers to understand how they could increase the level of patients’ satisfaction and loyalty through high-quality services provided by quality management enablers.

Research limitations/implications

This study has been conducted based on the expert’s opinions from private hospitals located in Tehran and Alborz provinces, Iran. Although the results could be useful for hospital managers in different places and could provide them a valuable insight and knowledge, findings are limited to Iranian private hospitals.

Originality/value

It is taken for granted that patients’ satisfaction and loyalty could increase as a result of high-quality medical and treatment services in hospitals. On the other hand, offering excellent services meeting all the needs and expectations of customers could be consequence product of quality management enablers. Even though satisfaction and loyalty of customers, i.e. patients, is the primary target of quality management, there is little research in the literature as to how enablers of quality management can secure the satisfaction and loyalty through increasing service quality in hospitals. The gap is more critical because the specialized dimensions of four research variables have not been previously integrated into a coherent framework and interrelationships among them have not been studied and clarified in detail. The current study attempts to bridge this gap.

Analyzing perceived healthcare service quality on patient related outcomes

Purpose

Through the lens of a total quality management approach, this paper aims to examine the effects of health-care service quality on patient satisfaction, repatronage intention (RI) and positive word-of mouth (PWOM) at a public hospital specialized in women and children’s diseases. The contribution is to measure and compare patient expectations and perceptions related to the public health service quality.

Design/methodology/approach

A structured questionnaire was distributed to in-patients who stayed at a public training and research hospital for at least three days. To analyze the relationship between variables, multiple regression analysis was used. To test the difference between expected and perceived service quality, the paired-sample t-test was used.

Findings

The findings provided empirical evidence that perceived service quality significantly influenced patient satisfaction, RI and PWOM. The “responsiveness and reliability” factor was found to be the most influential on patient RI and PWOM. The “tangibility” dimension had the strongest influence on patient satisfaction.

Practical implications

The results reveal that a reliable and responsive service, empathic personnel behaviors and appropriate tangibles are the outstanding factors for high levels of patient satisfaction, RI and PWOM.

Originality/value

Although the concepts of perceived service quality, patient satisfaction, RI and PWOM are explored frequently in service literature, there are few researches that focus on specialized health services for women and children’s diseases. By evaluating the service quality, it is hoped to provide an insight to health-care managers about the service quality dimensions and their relationship with patient satisfaction, RI and PWOM, specifically based on women patients.

The EFQM Model as a framework for total quality management in healthcare

Purpose

– To guide organizations toward total quality management (TQM), various models have been developed such as the European Foundation for Quality Management Excellence Model (EFQM Model). The purpose of this paper is to conduct a longitudinal investigation of whether the EFQM Model can serve as a framework for TQM in healthcare.

Design/methodology/approach

– Data on a national representative survey about quality management (QM) in the hospital population in the Netherlands were used to conduct this study. The survey had five measurement points between 1995 and 2011.

Findings

– The results of the study show that applying the EFQM Model in hospitals is related to improvement in organizational performance over time, a feedback loop in which hospitals use their results to further improve their organizational processes is established, and improvement is stronger when all the model’s elements are considered simultaneously.

Practical implications

– The results of the study can be applied by quality managers of healthcare institutions to achieve higher quality of care.

Originality/value

– Previous research on the relationship between the EFQM excellence model and TQM neglects two essential characteristics of the TQM philosophy, namely, the holistic perspective on QM and the presumed feedback loop of organizational performance that feeds a cycle of continuous quality improvement. The study provides new insights into the long-term benefits of applying the EFQM Model as a framework for TQM in healthcare.

Understanding the factors that influence patient satisfaction with ambulance services

The quality of ambulance services has an immense impact on patients' future well-being and quality of life. Patient satisfaction is one of the key metrics for evaluating the quality of this service. Yet, the patient satisfaction measurement may be limited in its ability to accurately reflect this service quality, and even reflect factors beyond the patient experiences. We analyze 10 years of survey data to reveal a number of factors that systematically bias ambulance satisfaction ratings. Taking into account these biases provides more robust comparison of ambulance performance over time or across different jurisdictions.

How best practices are copied, transferred, or translated between health care facilities: A conceptual framework

INTRODUCTION

In spite of significant investment in quality programs and activities, there is a persistent struggle to achieve quality outcomes and performance improvements within the constraints and support of sociopolitical parsimonies. Equally, such constraints have intensified the need to better understand the best practice methods for achieving quality improvements in health care organizations over time.This study proposes a conceptual framework to assist with strategies for the copying, transferring, and/or translation of best practice between different health care facilities.

PURPOSE

Applying a deductive logic, the conceptual framework was developed by blending selected theoretical lenses drawn from the knowledge management and organizational learning literatures.

FINDINGS

The proposed framework highlighted that (a) major constraints need to be addressed to turn best practices into everyday practices and (b) double-loop learning is an adequate learning mode to copy and to transfer best practices and deuteron learning mode is a more suitable learning mode for translating best practice. We also found that, in complex organizations, copying, transferring, and translating new knowledge is more difficult than in smaller, less complex organizations. We also posit that knowledge translation cannot happen without transfer and copy, and transfer cannot happen without copy of best practices. Hence, an integration of all three learning processes is required for knowledge translation (copy best practice-transfer knowledge about best practice-translation of best practice into new context). In addition, the higher the level of complexity of the organization, the more best practice is tacit oriented and, in this case, the higher the level of K&L capabilities are required to successfully copy, transfer, and/or translate best practices between organizations.

PRACTICE IMPLICATIONS

The approach provides a framework for assessing organizational context and capabilities to guide copy/transfer/translation of best practices. A roadmap is provided to assist managers and practitioners to select appropriate learning modes for building success and positive systemic change.

Combined quality function deployment and logical framework analysis to improve quality of emergency care in Malta

Purpose

– The purpose of this paper is to develop an integrated patient-focused analytical framework to improve quality of care in accident and emergency (A & E) unit of a Maltese hospital.

Design/methodology/approach

– The study adopts a case study approach. First, a thorough literature review has been undertaken to study the various methods of healthcare quality management. Second, a healthcare quality management framework is developed using combined quality function deployment (QFD) and logical framework approach (LFA). Third, the proposed framework is applied to a Maltese hospital to demonstrate its effectiveness. The proposed framework has six steps, commencing with identifying patients’ requirements and concluding with implementing improvement projects. All the steps have been undertaken with the involvement of the concerned stakeholders in the A & E unit of the hospital.

Findings

– The major and related problems being faced by the hospital under study were overcrowding at A & E and shortage of beds, respectively. The combined framework ensures better A & E services and patient flow. QFD identifies and analyses the issues and challenges of A & E and LFA helps develop project plans for healthcare quality improvement. The important outcomes of implementing the proposed quality improvement programme are fewer hospital admissions, faster patient flow, expert triage and shorter waiting times at the A & E unit. Increased emergency consultant cover and faster first significant medical encounter were required to start addressing the problems effectively. Overall, the combined QFD and LFA method is effective to address quality of care in A & E unit.

Practical/implications

– The proposed framework can be easily integrated within any healthcare unit, as well as within entire healthcare systems, due to its flexible and user-friendly approach. It could be part of Six Sigma and other quality initiatives.

Originality/value

– Although QFD has been extensively deployed in healthcare setup to improve quality of care, very little has been researched on combining QFD and LFA in order to identify issues, prioritise them, derive improvement measures and implement improvement projects. Additionally, there is no research on QFD application in A & E. This paper bridges these gaps. Moreover, very little has been written on the Maltese health care system. Therefore, this study contributes demonstration of quality of emergency care in Malta.

The rise and decline of TQM in the NHS

Purpose

– The purpose of this paper is to delineate the factors responsible for the decline of total quality management (TQM) in the National Health Service (NHS). It is suggested that if these factors were initially identified and eliminated prior to implementation, the decline of TQM as a strategy for improving the provision and delivery of quality patient care could have been prevented.

Design/methodology/approach

– The case study approach was chosen because it is the preferred method when “how” or “what” questions are being posed. It is applicable as is evident in this paper where the researcher has little control over events and when the focus is on a contemporary phenomenon within some real-life context. The case study enables the researcher to give an accurate rendition of actual events; it contributes uniquely to the knowledge of individual, organisational, social, and political phenomena. The semi-structured face-to-face interview constituted the main data collection technique of the research. Interviews were held with 23 quality management managers in the British NHS. The central focus of the interview was on “what” factors contributed to the rapid decline of TQM in the NHS. The respondents were chosen because they were directly involved with the implementation of TQM. They were in the vintage position to offer a full insight into the TQM initiative. The analysis of the case is based on Yin's analytic technique of explanation building.

Findings

– The decline of TQM in the NHS could have been prevented if top executives in hospitals had adopted the sequential steps to quality improvement: In the authors opinion, to land a man on the moon needed a belief in the possibility and breakthrough in the attitudes that viewed space travel as pure science fiction as opposed to a practical reality, and so it should have been with TQM in the NHS. However, the attitude of many NHS managers was that TQM was all right for “other institutions” because “they need it” whereas in the NHS, “we don’t”. This negative attitude should have been overcome if TQM was to be accepted as a corporate, all encompassing philosophy.

Research limitations/implications

– The limitation of the research may be the sample size of the respondents, which was limited to 23 quality managers that had hands-on experience and the leadership role to lead and implement TQM in the NHS. Future research may consider a broader sample size. It may also be considered for new research to use surveys to identify a broader set of reasons why TQM declined in the NHS.

Practical implications

– This paper is the first constructive insight to determine reasons for the decline of TQM in the NHS from the individuals who had the sole responsibility for implementation. Any other, group would have amounted to hearsay. Therefore, to constructively delineate the reasons for failure, it was pertinent to learn from the quality managers directly and to ensure that the reasons was representative of their experiences with TQM. The practical implication is to prepare future managers about how to avoid failure.

Originality/value

– The paper clearly suggests the systematic process required for effective implementation of TQM in a healthcare setting by identifying factors that must be avoided to ensure the successful and sustainable implementation of TQM.

Quality assessment systems in rehabilitation services for people with a disability in Greece: a critical review

BACKGROUND

Despite international interest on quality assessment systems (QAS) and their importance in health care accreditation, implementation of a Rehabilitation Services Quality Measurement System still remains a neglected subject in Greece.

OBJECTIVE

To identify appropriate tools for researchers and policy makers to assess the quality of rehabilitation services in Greece, within the current active debate on national health care reform.

METHODS

A critical review methodology was undertaken, using a systematic approach, aiming to identify the most appropriate tools in the field. Multi-step strategy was followed to gather relevant data, including bibliographical database, internet and hand searches.

RESULTS

Twenty-two studies, articles and documents were identified as meeting all inclusion criteria, representing four QAS, compared according to appropriateness, efficiency, and feasibility for general use. The European Quality in Social Services (EQUASS) was evaluated as meeting all of the desired features, such as proper certification, objective measuring, equality, education and training, established guidelines and person-centered approach.

CONCLUSIONS

EQUASS initiative, developed according to European standards and implemented in resource-limited settings, was recognized as the most adaptive and appropriate system for Greek rehabilitation settings. Health policy makers are urged to take findings into consideration in establishing an integrated, quality-assured rehabilitation system throughout the country.