skiti barriers 2009

8/2/2019 Skiti Barriers 2009

1/81

13

Barriers in implementing Total Quality Management in Kraaifontein

public health care facility in the Western Cape.

Vuyi Skiti

Mini Research report presented in partial fulfilment ofthe

requirements for the degree of Masters of BusinessAdministration

at the University ofStellenbosch

Supervisor: Ko nradVo n L eipzig

Degree of Confidentiality:A Date : December 2009


2/81

Declaration

By submitting this research report electronically, I, Vuyi Skiti, declare that the work contained

herein is in its entirety my own hence original work, that I am the owner of the copyright thereof

(unless to the extent explicitly otherwise stated) and that I have not previously in its entirety or in

part submitted it for obtaining any qualification.

VVB.Skiti June 2009

Copyright 2009 Stellenbosch UniversityAll rights reserved


3/81

Acknowledgements

First and foremost, I would like to thank God for granting me the wisdom, strength and

courage throughout this research report. I would like to express my sincere gratitude to my

study leader Konrad Von Leipzig for believing in me, whose expertise guided and assisted

me through the research and giving me invaluable insights. Thank you for your

understanding and patience.

This work would not have been possible without the assistance of Dr. Tony Booysen and

the staff at Kraaifontein day hospital, thank you for awarding me the opportunity to

conduct a study at your facility and for your contribution towards my study.

I must acknowledge my fellow class mates and study group, for their assistance and

insights throughout the course without you this was not going to be possible.

I am grateful to my husband, Steward for his unconditional and unselfish love and endless

support, understanding and tolerance throughout the research and for your unconditional

assistance throughout the MB program.

A special thanks to Ms. Jersusha Soomar, Mr. Willem Odendaal and Mr. Rajaan Naidoofor assisting with editing of the report.

In conclusion I would like to thank my family, my beloved siblings and mostly my son,

Thabang for your continued moral support and motivation.

I would like to dedicate this thesis to my late mother, without you this would have just been

a dream but now its a reality.


4/81

Opsomming

Doel Die gesondheidsorg sektor het vele uitdagings wat wissel van stygende mediese

kostes, lae standaarde in hospitale, die agteruitgang van gesondheidsorg dienste, en die

toename in sterftes in hospitale. Hierdie en ander probleme stel groot uitdagings aan

diegene verantwoordelik vir die lewering van gesondheidsorg, met die gevolg dat

diesulkes nuwe bestuursmetodes moet vind om te verseker dat hulle organisasies steeds

koste-effektief en doeltreffend funksioneer. Totale Gehalte Bestuur (TGB) is n geskikte en

toepaslike alternatief om genoemde probleme aan te spreek, en word toenemend as

oplossing gesien om organisasies se dienslewering te verbeter, en pasint-tevredenheid

te verseker. Die implementering van TGB blyk egter nie altyd suksesvol te wees nie. Daar

is spesifieke struikelblokke identifiseer wat as redes aangevoer word vir die onsuksesvolle

implementering van TGB in verskeie sektore, insluitend die van gesondheidsorg. Die hoof

doel van hierdie navorsing was om die struikelblokke te ondersoek wat verhoed dat TGB

suskesvol toegepas word in Kraaifontein gesondheidsdienste in die Wes Kaap, 2008.

Ontwerp/Metode/Benadering Die studie was n kwasi kwalitatiewe en kwantitatiewe

gevalle studie; vir die kwantitatiewe komponent is n 5 punt Likert tipe skaal gebruik om die

response (verskil beslis = 1; stem beslis saam = 5) te kwantifiseer. Die kwalitatiewe

komponent het n fokus groep bespreking behels, waartydends die resultate van die

vraelys geverifier is, wat die uitdagings van die implementering van TGB uitgewys het.

Die statistiese populasie vir hierdie navorsing was al die gesondheidsorg werknemers in

diens van die aptekers-departement; wat betrokke was in die implemetering van TGB in

hulle organisasie. Die data is analiseer met toepaslike statistiese metodes. Die

gemiddelde telling van elkeen van die dimensies was gebruik as n verteenwoordigendeaanduiding van prestasie, en die kofisint van veranderlikheid was gebruik as n

algemene maatstaf van die gestandardiseerde skeefheid soos gemeet op elkeen van die

dimensies. n Ho gemiddelde telling was n aanduiding van die beoogde uitkomste, en lae

tellings aanduidend van swak uitkomste.

Bevindinge Belangrike uitdagings wat ondervind is tydens die implementering van die

TGB in hierdie gevallestudie sluit in, die gebrek aan aktiewe betrokkenheid en toewyding

van die topbestuur vir hierdie inisiatief, rigiede organisatoriese strukture, die kultuur

teenoor gehalte veranderinge wat kommunikasie tussen bestuur en werknemers


5/81

belemmer, wat op sy beurt werknemer-bemagtiging verhoed. Ander struikelblokke wat

geidentifiseer is, was n afwesigheid van voortdurende verbeteringsprosesse en inisiatief,

swak evaluering, n gebrek aan n sisteem vir erkenning en vergoeding vir spanwerk, swak

data insameling en ontleding, wat tot probleme gelei het om die data in betekenisvolle

inligting te verwerk wat kon lei tot n verbetering in gehalte. Die afwesigheid van n

geintegreerde prestasie-beoordeling sisteem is ook as probleem indentifiseer omdat

werknemers nie ingelig was oor wat die prestasie-beoordelings behels nie. Die gebrek aan

navorsings-gesteunde besluitneming, swak kommunikasie, en onbuigsame

organisatoriese strukture en kultuur, was ook gesien as struikelblokke.

Navorsing-beperkinge/implikasies Alhoewel die studie in Kraaifontein gesondheidsorg-

fasiliteit gedoen is, word dit aanvaar dat die bevindinge van hierdie studie ook van

toepassing is op ander gesondheidsorg departmente en fasiliteite. Die resultate kan

gesondheidsorg bestuurders help om die uitdagings en struikelblokke te identifiseer in die

implementering van TGB Hierdie identifikasie kan lei tot n meer effektiewe en suksesvolle

implementering van TGB in gesondheidsorg fasiliteite.


6/81

Abstract

Purpose The health care industry is faced with numerous challenges ranging from rising

medical costs, poor state of hospitals, deteriorating health care services and an increasing

number of hospital deaths. All these disparities present tremendous challenges for the

health care managers in charge of the health care services. As a result, they are forced to

try new management methods that will assist their organizations to remain cost effective

and efficient. Total Quality Management (TQM) constitutes an appropriate response to

these challenges and it has become the strategy of choice to improve organizations

performance and patient satisfaction. However, in practice the implementation of TQM is

often unsuccessful. Certain barriers have been identified which prevent the successfulimplementation of TQM in other industries as well as in the health care industry. The main

aim of this research is to investigate the barriers to the successful implementation of Total

Quality Management in Kraaifontein health care service organization in the Western Cape

Province, 2008.

Design/methodology/approach The study employed a quasi- qualitative and quantitative

case study. For the quantitative section a questionnaire with a 5 point Likert style scale

was used to quantify the response (strongly disagree=1; strongly agree =5). For thequalitative section a focus group discussion was conducted to verify the results obtained

from the questionnaire which addressed the challenges of TQM implementation. The

statistical population of this research consisted of all health care workers working the

pharmacy department who were involved in the implementation of TQM in their

organization. Data was analyzed using appropriate statistical procedures. The mean

score of each of the dimensions was used as a representative performance indicator and

the coefficient of variation (CV) was used as a general measure of standardized skewness

on the performance of each dimension. A high means score indicated desired outcomes

while low scores indicated poor outcomes.

Findings Major barriers that were encountered during the implementation of TQM in this

case study included the lack of top management active involvement and full commitment

in the initiative, rigid organizational structure, culture towards quality changes that inhibited

communication between management and employees which in turn hindered employee

empowerment. Other obstacles that were encountered were lack of continuous

improvement processes and initiative, improper evaluation, the lack of a recognition and

reward system for of team work, poor collection and analysis of data that resulted in


7/81

difficulty to convert this data into meaningful information to improve quality. The absence

of an integrated performance measurement system also exhibited a problem as

employees were not aware what was being assessed during performance appraisals. Lack

of evidence based decision making, poor communication and inflexible organizational

structure and culture were also viewed as barriers.

Research limitations/implications Although conducted in Kraaifontein health care facility,

it is expected that the results of the study may be relevant on a broader scale to other

health care departments and facilities. The results could assist the health care managers

to develop a plan that addresses the barriers and challenges faced during the

implementation of TQM, yielding fruitful results which allow TQM to be implemented easily,

effectively, efficiently and successfully in health care facilities.


8/81

Table of contents

Conten

ts

Declaration .................................................................................................................................. ii

Acknowledgements ................................................................................................................... iii

Opsomming ................................................................................................................................ iv

Abstract ...................................................................................................................................... vi

List ofTables ............................................................................................................................... x

List ofFigures ............................................................................................................................ xi

ABBREVIATIONS .......................................................................................................................XII

DEFINITION OF TERMS ............................................................................................................XII

1 Patient.................................................................................................................................. xii

2 Health care........................................................................................................................... xii

3 Total Quality Management...................................................................................................xii

CHAPTER 1 : INTRODUCTION AND BACKGROUND...............................................................1

1.1 INTRODUCTION...............................................................................................................11.2 STATEMENT OF THE PROBLEM .........................................................................................3

1.2 AIM OF THE STUDY .............................................................................................................. 4

1.3 OBJECTIVES..........................................................................................................................4

1.5 ASSUMPTIONS AND DELIMITATIONS.................................................................................5

1.6 PLAN OF STUDY ................................................................................................................... 5

.........................................................................................ERROR! BOOKMARK NOT DEFINED.

CHAPTER 2 : LITERATURE REVIEW .......................................................................................7

2.1 INTRODUCTION TO TOTAL QUALITY MANAGEMENT.......................................................7

2.1.2 An introduction to TQM ....................................................................................................8

2.2 KEY CONCEPTS AND VALUES OF TQM...........................................................................10

2.2.1 Commitment to the customers satisfaction ...................................................................13

2.2.2 Commitment to continuous improvement:......................................................................14

2.2.3 Top management commitment ......................................................................................15

2.2.4 Commitment to employee involvement ..........................................................................16

2.2.5 Commitment to understanding and improving the organizations processes.................17

2.2.6 Evidence based decision making...................................................................................17

2.3 BENEFITS OF TQM ............................................................................................................. 18

2.4 DEFINITION OF TQM IN HEALTH CARE............................................................................20


9/81

2.5 SIGNIFICANCE OF TQM IN HEALTH CARE.......................................................................22

2.6 BARRIERS TO IMPLEMENTATION OF EFFECTIVE TQM INITIATIVES ........................... 24

2.7 QUALITY CHALLENGES IN SOUTH AFRICAN HEALTH SERVICE CONTEXT ................ 26

2.7.1 Lack of senior management commitment ......................................................................26

2.7.2 Organizational structure and culture ..............................................................................27

2.7.3 Lack of education and training of employees about TQM ..............................................29

2.7.4 Lack of employee empowerment ...................................................................................30

2.7.5 Leadership style .............................................................................................................30

2.7.6 Reward and recognition .................................................................................................31

2.8 LEAN PRODUCTION ...........................................................................................................31

CHAPTER 3 : RESEARCH DESIGN AND METHODOLOGY ...................................................35

3.1 SETTING .............................................................................................................................. 35

3.2 STUDY DESIGN................................................................................................................... 35

3.3 STUDY SAMPLE .................................................................................................................. 36

3.4. MEASUREMENTS............................................................................................................... 36

3.5 ETHICALASPECTS............................................................................................................. 36

3.6 DATA COLLECTION ............................................................................................................ 36

3.7 DATAANALYSIS.................................................................................................................. 37

3.8 ACCEPTANCE OF THE STUDY..........................................................................................37

3.9. RESOURCES ...................................................................................................................... 38

3.10 LIMITATIONS ..................................................................................................................... 38

CHAPTER 4 : STUDY RESULTS ..............................................................................................39

CHAPTER 5 : SUMMARY AND CONCLUSION.......................................................................49

5.1 INTRODUCTION .................................................................................................................. 49

5.2 DISCUSSION........................................................................................................................ 49

5.3 CONCLUSION...................................................................................................................... 55

5.4 RECOMMENDATIONS.........................................................................................................57

LIST OF SOURCES ................................................................................................................... 60


10/81

List ofTables

Table 2.1 : Essential elements of TQM 20

Table 4.1 : Results on top managements involvement 44

Table 4.2 : Summary of results on employee empowerment 45

Table 4.3 : The responses to the questions addressing data quality 48

Table 4.4 : Results on questions addressing use of quality data 49

Table 4.5.1 : Recommended actions to be taken 64


11/81

List ofFigures

Figure 2.1 : Deming Quality Chain Reactions 8

Figure 2.2 : Six values of TQM 15

Figure 2.3 : Benefits of TQM 22


12/81

ABBREVIATIONS

Abbreviation Full word

ISO International Organization for Standardization

SPC Statistical Process Control

TQM Total Quality Management

CSF Critical Success Factors

EQA European Quality Award

MBNQA Malcolm Baldrige National Quality Award

DEFINITION OF TERMS

1. Patient

A patient is any person who receives medical attention, care or treatment.

2. Health care

Is the prevention, treatment and the management of illness and the preservation of mental

and physical wellbeing through the services offered by medical, nursing and allied health

professionals.

3. Total Quality Management

It is a business management strategy geared to ensure that the organization processes

constantly meet or exceeds customer requirements. Total quality consists of two

qualities:


13/81

xiii

Quality aimed to satisfy the customers and share holders; and

Quality of the product or service itself

Put simply, TQM is as an action plan to produce and deliver commodities or

services, which are consistent with customers needs or requirements by better,cheaper, faster, safer and easier processing than competitors with the participation

of all employees under top management leadership (Dilber, Bayyurt, Zaim, Tarim,

2005).


14/81

13

CHAPTER 1

INTRODUCTION AND BACKGROUND

1.1 INTRODUCTION

In recent years, health care has been undergoing fundamental changes and restructuring.

Escalating health care costs, the emerging customer focus and consumerism has prompted

significant changes to the health care system and to the manner in which the health care

services are delivered. A study by Harvard Medical School Research in 1991, suggested

that as many as 80 000 people per year in the United States America alone died from

medical negligence, these results illustrates that the inefficiencies of the health care systemcost lives (Brashier, Sower, Motwani and Sovoie, 1996). Additionally poor medical care,

misdiagnosis, substandard surgery, improper drug therapies as well as hospital-acquired

infections are resulting in longer and more frequent hospitalization (Rad, 2005). All these

problems come at a cost that is financially draining on the Department of Health and life

threatening to the most vulnerable patients.

Looking at the South African context almost daily, newspapers and television news

broadcasts feature dramatic accounts of the critical poor state of health care facilities. In

some hospital the number of hospital bed has been reduced, some hospitals were

subjected to the closing down of entire floors. This has resulted in unreasonably long

waiting lists for surgery and other specialized medical treatment, as well as dissatisfied

health care workers that are underpaid and over worked. Coupled with this is the fact that

the majority of the population (75%) are dependent on public health services while, only

15% of the population is covered by medical insurance and relies mostly on private

hospitals. The high cost of private medical care results in large numbers of South African

citizens accessing health care from the public health care facilities (Mabope, Matsebula,

and Willie, 2005).

In addition, there has been an increase in medical costs, which is consistently outstripping

growth of the Gross Domestic Product. This increase has created a serious financial tension

resulting in less or no money available for important new health programs and cutbacks in

existing programs, which has lead to angry, highly stressed and overstretched health care

personnel, as they cannot deliver the services that they desire. As a direct effect, these

results in frustrated and anxious patients and their families, as they feel that their rights of


15/81

accessing good quality health care and needs are not being met (Grandin, Westwood,

Lagerdien, Maylene, 2006).

Finally, with the advent of democracy in South Africa consumers are increasingly becoming

aware of their rights and the gap between the actual and ideal health care practice. This has

led to the intensifying pressure for the Department of Health to improve quality of service

provision.

All these disparities present tremendous challenges for the health care managers in charge

of the health care services, and they are forced to try new management methods that will

assist their organizations to remain cost effective and efficient.

In the quest for solutions to these problems, the Department of Health has identified

improvements in quality of health care as one of its key challenges facing the health sector

in South Africa (Department of Health, 2007). Total Quality Management constitutes an

appropriate response to this challenge. It is an approach through which an organization

tries to implement procedures and techniques in a manner that satisfies the customers, and

employees needs as well as to achieve excellent overall performance. This means to

achieve the lowest possible cost for both the patient and the service provider while

achieving desired results (Dale, 1999; Dahlgaard, Kanji and Kristensen, 1999; Youssef and

Zairii, 1995). In the public health care environment, it has become abundantly clear that

there is an urgent need to improve the quality of care that health care providers are

providing to the patients.

Emerging interest in Total Quality Management has been propelled by the need to control

costs and the desire to improve the quality of care (Zabada, 1998; Hassan 2000; Rad

2005). These TQM processes and techniques are not only applicable to the administrative

functions, but also applicable to the clinical aspect of the organization as they contribute to

the prevention of costly and fatal mistakes that generate so much loss of life and lawsuits

(Brashieret al, 1996; Zabada, 1998).

A number of studies showed that TQM has been positively associated with performance

outcomes, such as financial performance and profitability, as well as with human outcomes,

including employee satisfaction, employee relations, and customer satisfaction (Hassan,

2003; Rad, 2005). However, the enthusiasm and the excitement for TQM seem to havefizzled over the years. The Department of Health, through health care organizations has a


16/81

sincere interest in providing quality services, but the majority of their organizations TQM

initiatives and ideas were not successful (Department of Health, 2007).

The majority of these organizations invested substantial amounts of time, energy and

money to develop and support TQM programs in order to enhance management, increase

efficiency and foster team spirit. Yet these TQM programs have lost momentum and the

status and success of TQM is questionable for many health care organizations (Anwar,

1996). Numerous studies have asked the question Why it is that health care has not

experienced overwhelming, "long term" success with TQM. The application of TQM

principle is faced with some basic obstacles that are apparently inherent to the nature of

healthcare organizations and to the process of change in general (Anwar, 1996; Rad, 2005).

Youseff and Zairii (1995) concur that a number of organizations that have tried to implement

TQM have experienced numerous obstacles ranging from management to structural

barriers. These findings were supported by Zabada et al, (1998) and Shortell, O'Brien,

Carman, Foster, Hughes, Boerstter, O'Connor, (1995), found adequate evidence in their

studies that, there were obstacles to the application of TQM in health care. Resistance to

the implementation of TQM in the health care industry is evident and it is well documented.

Ennis and Harrington (1999) survey in the Irish health care found that there were great

difficulties in the implementation of TQM in health care and these hospitals experienced

resistance to the implementation of TQM. Ovretviet (2000) reiterated and acknowledged

that there are difficulties that the hospitals are faced with when implementing TQM. The

need to persist with TQM for the improvement of the quality of life is empirical. However, the

need for TQM and for it to have full impact on the healthcare organizations, it is critical that

these present obstacles be removed.

1.2 STATEMENT OF THE PROBLEM

Although TQM has been an effective tool for improving quality of care in the health care

service industry (Yang and Christian, 2003), many hospitals are still struggling to provide

quality care that is desirable for all the stakeholders involved. It is well documented that

many organizations have attempted to implement TQM, but they were not successful in

their implementation (Zabada et al, 1998). Youseff and Zairii (1995) concur that a number of

organizations that have tried to implement TQM were faced with a number of obstacles

ranging from management to structural barriers. This is in agreement with Zabada et al

(1998) and Shortell et al(1995) who found out that there were obstacles to the application


17/81

of TQM in health care. Ennis and Harrington (1999) survey in the Irish health care found out

that there were major difficulties in the implementing TQM in the health care and these

hospitals experienced resistance to the implementation of TQM. Ovretviet (2000) supports

that there are difficulties that the hospitals are faced with when executing TQM and many

health care facilities have difficulties in implementing TQM initiatives. Furthermore, there are

no studies conducted in South Africa especially in public hospitals that assess and address

the barriers to the implementation of TQM. There is also minimal knowledge on and related

to the implementation of TQM in the public health care.

This research strives to contribute to the knowledge of barriers that prevent proper

implementation of TQM in the health care industry. It bridges the gap between the ideal

implementation of TQM and its benefits to the current reality of TQM implementation and

performance in the health care facilities. The results from this study could be used to

improve the implementation of TQM in other health care organization, as the barriers to

implementation of TQM will be better understood, subsequently allowing health care

managers to deal with barriers in an appropriate manner. The identification of these barriers

will assist the health care planners to plan better TQM strategies that will avoid some of the

problems identified by the research into the implementation of successful TQM initiatives.

This study will also lay a foundation for future TQM research in the Western Cape, then toSouth Africa.

1.2 AIM OF THE STUDY

This study attempts to investigate the barriers to successful implementation of TQM in Kraaifontein

public health care service facility.

1.3 OBJECTIVES

To establish the effects of TQM implementation on overall performance in health care

services organizations

To determine the expectations, preferences and perceptions of health care

stakeholders about quality of health care

To establish the limitations and barriers in the applicability of TQM in Kraaifontein

health care services organization


18/81

1.5 ASSUMPTIONS AND DELIMITATIONS

The questions addressed in the survey were designed on the principle and concept of TQM. It does

not contain the technical aspects towards implementation of TQM except for where the researcher

measures some quality activities that were frequently adopted in the health care environment. The

research did not address other hospitals, clinics and private clinics. In addition, it will not be

addressing the barriers to implementation of TQM in other departments in Kraaifontein clinic. It is

only focusing at the pharmacy department. This department is the only department that that has

implemented a quality improvement initiative.nThe period over which the study was conducted was

limited to only three months and this limited the extent and the scope of the detail of the study.


19/81

1.6 PLAN OF STUDY

HA

P

ER 1

Introduction

HAP

Literature

ER 2

Review

HAP ER 3

Methodology

CHAPTER4

Result

s

CHAPTER 5

Conclusion

& Recommendations


20/81

List of sources


21/81

CHAPTER 2

LITERATURE REVIEW

2.1 INTRODUCTION TO TOTAL QUALITY MANAGEMENT

This chapter reviews the literature relevant to the study. It deals with the key definitions of

quality, the key concepts of Total Quality Management, the influential factors of TQM and

their relevance to health care, relationship between TQM and Lean manufacturing will be

further explored and lastly the barriers that are often encountered in implementing TQM will

be examined.

In order to understand and appreciate the value of TQM, one needs to define and have a

clear understanding of the importance of quality. Quality has been defined differently by

different authors, practitioners as well as academics, with everyone having their own version

of definition depending on their beliefs and perceptions about quality informed by their

experiences. Experts of the quality management disciplines such as Garvin, Juran, Crosby,

Deming, and Ishikawa defined the concept of quality in different ways.

Despite these existing definitions of quality, for this report quality will be defined as having

two meanings:

1. The characteristics of a product or service that bear on its ability to satisfy stated or

implied needs (Griffin, 1995; Reeves and Bednar, 1993).

2. A product or service free of deficiencies

Crosby in 1984 defined quality as conformance to requirements or specifications; in his

approach he explicitly highlights the importance of people and organizational change with

special reference to cultural change and commitment of top management to quality.

Demings (1988) point of view is that quality is a predictable degree of uniformity and

dependability, at low cost and suited to the market. His reference point is from a statistical

point of view which deals with the reduction in the variation of the product using statistical

process control. He also came up with 14 quality concepts which were the explanation to

the development of TQM concepts (Dilber et al, 2005). Juran (1993) defined quality as

fitness for use. He pays more attention on a trilogy of quality planning, quality control, and

quality improvement (Dilberet al, 2005). The quality of a product or service refers not only


22/81

to the manner in which the product or service is made and delivered, it also relates to the

perception of the degree to which the product or service meets the customer's expectations

(Reed, Leemark and Montgomery, 1996; Reeves and Bednar, 1993). They further stated

that quality has no specific meaning unless related to a specific function and or object, this

statement present quality as a conditional and somewhat subjective attribute. Asuboteng,

Mc Cleary and Munchus (1996) stated that in the Deming Model Quality is not a destination

but rather a journey. This means that organizations need to make sure that they keep up

with customer needs as their needs are constantly changing in order to remain in business.

This is illustrated by the figure below.

Improved quality Cost decrease of fewer network Productivity improvesfewer delays and snags

better use of machine time and material

Capture the market with Stay in business Provide jobs

better quality

Figure 2.1 Demings quality chain reaction (Asubonteng, Mc Cleary & Munchus, 1996)

Many different techniques and concepts have evolved to improve product or service quality,

these techniques include Statistical Process Control (SPC), Zero Defects, Six Sigma, Lean

production, Malcolm Baldrige National Quality Award, quality circles, Total Quality

Management (TQM), Theory of Constraints (TOC), Quality Management Systems, ISO

9000 continuous improvement and others (Hansson 2003). For the interest of this paper,

TQM will be reviewed in detail.

2.1.2 AN INTRODUCTION TO TQM

TQM was originally introduced as a quality management model or philosophy with methods

pioneered by quality management experts such as Deming, Juran, Crosby and Oacklands as a way

to eliminate waste in the use of resources. It mandated the involvement of all members of the

organization to work towards a common goal. As a result, it provided an ultimate way of quality

thinking shared by all personnel in the organization to meet the customers specified requirements(Kanji, Gopal, Asher, Mike, 1993; Adinolfi, 2003). The first industry that implemented TQM was the

manufacturing industry in the middle of the 1980s. It was later adopted by other industries following


23/81

its success in the manufacturing sector. It was then used in service industries followed by the

government (Yang and Christian, 2003).

TQM originated after quality control and quality assurance as a measure to improve quality. Sallis

(1993) differentiates the three quality ideas that are quality control, quality assurance and TQM.

According to him, quality control is the oldest concept that involves the detection and elimination of

some of the components of the final product or the actual final product if it does not meet the

required standard. This was not an ideal concept, because the production of defective product is

quite costly, as this product is manufactured close to completion or until it is completed, yet it is not

functional and it will be either discarded or reworked. This gave rise to the concept of quality

assurance. Quality assurance is done before, during and after the production of the product or the

service to prevent faults from occurring, to make sure that the product is made to meet a

predetermined specification. With quality assurance, there are individuals that are designated to

check the quality of the product throughout. Although this process is effective, it is costly in terms of

work force and time. TQM extended these concepts and involved the customer by creating a quality

culture where the main aim of every employee is to delight the customer. In addition, it provided the

structure and the environment where the employees work, enables them to delight the customers.

Worldwide research has indicated that there are many descriptions of TQM concepts. As with

quality, there are few variations in the definition of TQM. Dahlgaard et al. (1995) furnish two

definitions of TQM. The first definition used in Japan states that TQM is a management philosophy

that is characterized by the scientific base, systematic base and covers the whole organization. The

second definition is that used by European countries and it states that, Quality is a culture of the

organization and this culture is focused on customer satisfaction and continuous improvement.

According to Adinolfi (2003); Kanji et al(1993); Youssef and Zairii (1995), TQM is a comprehensive

system of continuous quality improvement that is used to make sure that the organizations

processes are fit to satisfy and exceed customer expectations and requirements. The Institute of

Management Services defines Total Quality Management as:

"A strategy for improving business performance through the commitment and involvement of all

employees to fully satisfying agreed customer requirements, at the optimum overall costs, through

the continuous improvement of the products and services, business processes and people

involved."(www.manag e rs-net.com).

Hellensten and Klefso (2000), confirm that, TQM is a management system that is in continuous

change, with comprehensive values, techniques and tools with the overall goal of this system are to

increase customer satisfaction with minimal resources. They state that TQM has three independent

units, these units consists of the values, tools and techniques. They argue that although these three


24/81

units are independent they support each other. This means that the core values must be supported

by the techniques that the organization employs to meet and exceed the needs and expectations of

the customer with minimum resources utilized. The interaction between the tools and the techniques

requires, the organization to provide appropriate tools that supports the techniques used to enhance

customer satisfaction. They concluded that, in order for the organization to implement TQM

successfully organization is required to identify the values that are applicable to the them, depending

on the values, select the appropriate set of tools and techniques that will complement the

organizations values. Smith and Offodile, (2008), concur with this as they state that, TQM

mandates that organizations processes utilize the correct tools and techniques that allow resources

to be used to the best of the organizations ability to achieve improvement of their product or service.

TQM is the process of enhancing the management system. Senior management should lead this

management system by clearly setting and stating the mission and vision of organization. TQM also

mandates that every employee be involved in continuous improvement activities. This is because

TQM organizations view continuous improvement processes as the way of doing daily activities

rather than a once off activity and this requires commitment from all employees and this should be

carried on throughout the life of the organization, as to make sure that the customers are kept

delighted. Continuous improvement assists the organization to become more effective and excel in

all dimensions of the products and services that they provide to meet the needs of both the internal

and external customers (Smith and Offodile 2008; Zairii and Matthew, 1995; Kanji et al, 1993).

In summary, the definition of TQM can be stated very simply: the term, total means everyone in the

organization should be involved, the involvement should not only be limited to management, and all

staff constituents must be actively involved in the process. This can only be achieved in an

organization where the core values are based on the culture of quality and everyone in the

organization shares those values.

2.2 KEY CONCEPTS AND VALUES OF TQMMany authors have contributed to laying foundation stones that form the fundamental

concepts and values of TQM. As the definition of TQM varies from one author to another,

the authors perceptions about the fundamental concepts and values of TQM also vary. The

number of values and their formulation also differs from author to author. Deming (1988)

highlighted the following as fundamental values and concepts the cornerstones of quality

(Kanji et al1993).

1. Constancy of purpose: create constancy of purpose for continual improvement ofproduct and service.


25/81

2. Cease dependence on inspection: eliminate the need for mass inspection as a way

to achieve quality.

3. The new philosophy: adapt the new philosophy.

4. Improve every process: improve constantly and forever every process for planning,

production and service.

5. End lower tender contracts: end the practice of awarding business solely on the

basis of price tags.

6. Institute training on the job: institute modern methods of training on the job.

7. Institute leadership: adopt and institute leadership aimed at helping people and

machines to do a better job.

8. Drive out fear: encourage effective two-way communication and other means to drive

out fear throughout the organization.

9. Eliminate exhortations: eliminate the use of slogans, posters and exhortations.

10. Break down barriers: break down barriers between department and staff areas.

11. Eliminate targets: eliminate work standards that prescribe numerical quotas for the

workforce and numerical goals for people in management.

12. Permit pride of workmanship: remove the barriers that rob hourly workers, and

people in management, of the right to pride of workmanship.

13. Encourage education: institute a vigorous program of education and encourage self-

improvement for everyone.

14. Top management commitment: clearly define top management's permanent

commitment to ever-improving quality and productivity.

Another concept of TQM was that of Anderson, Rungutusanatham, and Schroeder (1994)

who proposed a TQM theory based on the Deming management method. They emphasise

that the theoretical essence of TQM concerns the creation of an organizational system thatfosters the implementation of process management practices. They believe that process

management leads to the continuous improvement of product and services and to employee

fulfilment. They also state that these outcomes are critical to customer satisfaction and

ultimately to the organizational survival (Manley, 2000).

Later in 1994, Sitkin, Sutcliffe, and Schroeder attempted to modify such theory, opposing

Andersons theory and stating that TQM encompasses both control and learning and the

management do not have the luxury of pursuing one or the other in isolation. They further

state that these must balance the conflict between goals of stability and reliability (control)


26/81

with those of exploration and innovation (learning) within the organization, as exploration

and innovation propels continuous improvement.

According to Dale (1999), TQM consists of eight key concepts or values. Dahlgaard et al,

(1999) suggest that TQM is characterised by five values. A survey of TQM and continuous

improvement programs by the Malcom Baldrige National Quality Award indicates eleven key

concepts. These are as follows: Committed leadership, adoption and communication of

TQM, closer customer relationships, benchmarking, increased training, open organization,

employee empowerment, zero defects mentality, flexible manufacturing, process

improvement, and measurement to determine critical factors of total quality management. A

study by Youssef and Zairii in 1995 was conducted to benchmark the critical factors for

TQM and the results demonstrated that top management commitment, customer

satisfaction, employee involvement, a change in organizational culture and continuous

improvement were critical aspects and corner stones for TQM.

Flynn, Schroeder and Sakakibara (1994) developed another instrument to determine critical

factors of total quality management. They identified seven quality factors; these are top

management support, quality information, process management, product design, workforce

management, supplier involvement, and customer involvement (Dilber et al, 2005).

Following a comprehensive literature based on the comprehensive analysis and

examination of existing TQM frameworks and literature, Metri (2005) proposes ten critical

success factors (CSFs) of TQM for construction industry. According to Metri (2005), the

method that was used to select the critical success factors was based on the TQM

frameworks developed by researchers. In total, fourteen important TQM frameworks which

are Deming prize, MBNQA, EQA, Saraph et al., Oakland, Flynn et al., Babbar and Aspelin,

Ahire et al., Black and Porter, Pheng and Teo, Ang et al., Zhang et al., Nwabueze andThiagarajan et al., were chosen from the TQM literature for the purpose of establishing TQM

CSFs. Therefore, the following ten CSFs have emerged out of the above analysis: top

management commitment, quality culture, strategic quality management, design quality

management, process management, supplier quality management, education and training

empowerment and involvement, Information and analysis of customer satisfaction (Metri,

2005).

Soltani, Merr, Gennerd and Williams (2003) confirmed that the important aspects of TQM

include the above-mentioned commitments and argued that top management leadership


27/81

eand commitment, fast response, actions based on facts, and a TQM culture need to be

included in the development of TQM. Metri, (2005) also alluded that the core principles of

TQM are: focus on customers, employees participation and teamwork, continuous

improvement and learning. Swinehart and Green (1995) concluded that TQM applicationsare unique and they depend of the organizations preferences. They found that the above

four fundamental principles were common to all organizations that implemented successful

TQM. They also included strong quality leadership as another imperative principle. Huq and

Martin (2000),concur and stated that the common set of principles and relationship

considered important for successful implementation of TQM include strong top management

and physician leadership and commitment, customer and patient satisfaction focus,

employee

involvement and empowerment, a focus on continuous improvement, supplier

partnership, and the recognition of quality as a strategic management issue.

It has been noticed that there are six popular or more common values in the literature

reviewed.

These values are also extensively addressed in the TQM definition (Hasson,

2003; Bergman and Klefsj, 2003). For the purpose of this study, the values below will be

examined in detail. The six selected values are:

Top

management

commitment

Employee commitment

Based decision onfact

Focus on processes

Figure 2.2: Six values of TQM (Bergman and Klefsj, 2003)

2.2.1 Commitment to the customers satisfaction

Most of the TQM experts agree that customer focus is the cornerstone and a core principle

of TQM (Soltaniet

al, 2003; Yangand Christian, 2003;


28/81

Alavi and Yasin, 2007; Hasson,

2003, Bergman and Klefsj, 2003). The TQM model begins by understanding that quality

definition

has in more ways than one moved away from conforming to standard and


29/81

specification to meeting and or exceeding customers requirements. By adopting the norm

that the preferences of internal and external customers are the primary determinants of

quality (delight the customer), has led to the belief that customer satisfaction is the most

important requirement for long term success and sustainability of any organization and

these organization understand and acknowledge that customers will be satisfied if they

receive what (product or the service) they are to receive, when they have to receive it (at the

right time), in an appropriate manner that meet their needs.

In a study conducted by Huq (1996), the observations from his study concluded that

hospitals that were better performers had a high score on customer focus among other

factors, and he concluded that customer focus whether final consumer or the next process,

is the most important of all TQM principles (Huq, 1996). Failure to include customers in the

process of product or service delivery is detrimental. The organization can design and

manufacture a product or service that perfectly meets the standards and conforms to

specification but that is too irrelevant to the consumer of the product or service.

Thus the basic rationale of TQM is valuing the customer by understanding the basic

customer needs and by maximizing customer satisfaction. This is visible in organizations

with successful TQM implementation as these organizations have processes that

continuously collect, analyze and act on the customers information (Lai, 2003). It is

therefore clear that organizations that implement TQM initiatives achieve full customer

satisfaction which in turn is demonstrated through business excellence and prosperity. Any

decline in customer satisfaction due to poor service quality would be detrimental to the

organization and it easily takes the organization out of business. Therefore for the

organization to remain in business it is imperative to make certain that customers are kept

satisfied all the time and all their improvements initiatives should be centered around the

customer.

2.2.2 Commitment to continuous improvement:

Quality is a moving target; it is a never ending process. On ongoing bases it creates new

standards for the organization. TQM organizations are aware that the best performance

and best practices of today may be unaccepted and obsolete performance in the future. It

is well known that products that used to be high quality in the past are now standard quality.

Therefore organizations are continuously seeking ways and means to up their game all the


30/81

time through the process of continuous improvement. Continuous improvement of all

operations and activities is at the heart of TQM (Adinolfi, 2003; Hanna, and Newman, 1995;

Metri, 2005; Hansson, 2003). In order for continuous improvement to be effective, it

requires that employees acquire and apply new knowledge, skills and values to improve the

organizations performance. Therefore the process of continuous improvement is cyclic

iterative and a never ending activity (Crosby, 1984).

TQM mandates zero defect in production and in services, in other words employees must

be motivated to complete the job on the first attempt of the task to prevent rework and

wastage. Elimination of waste is a major component of the continuous improvement

approach. There is also a strong emphasis on prevention rather than detection, and an

emphasis on quality at the design stage. The customer-driven approach helps to prevent

errors and achieve defect-free production. When problems do occur within the product

development process, they are generally discovered and resolved before they can get to the

next internal customer.

2.2.3 Top management commitment

In order for TQM to work it is empirical that the top management assume a leadership role

and commit strongly and actively to the implementation TQM (Hansson, 2003; Soltani et al,

2005; Yang and Christian, 2003; Alavi and Yasin, 2007; Bergman and Klefsj, 2003). The

leadership needs to articulate a powerful strategic vision for the organization that defines

the organizations existence and the organizations overall goal. They should at all times

place emphasis on motivating and convincing the employees, so it is clear to the employees

that TQM is not just the program of the year, but rather an ongoing process. Effective

leadership empowers the employees and they give these employees a sense of pride and

sense of the belonging so that employees can take ownership of the organization (Bergman

and Klefsj, 2003). It is also of outmost importance that top management provides an

environment and resources that supports and facilitates the growth of everyone in the

organization regardless of the level that they are in and the organization as a whole and

ultimately to achieve customer satisfaction (Brashieret al, 1996; Huq, 2005).


31/81

2.2.4 Commitment to employee involvement

Another key determinant for the success of TQM is the degree to which everyone in an

organization is involved in the decision-making processes. The total element of TQM

implies that every organizational member is involved in quality improvement processes

(Vouzas and Psychogios, 2007). A successful TQM requires a committed and well-trained

work force that participates fully in quality improvement activities. It is widely accepted that

the increase of employee participation in the overall quality strategy brings an increased

flow of information and knowledge and contributes in the distribution of intelligence to the

bottom of the organization for resolving problems (Vouzas and Psychogios, 2007).

Employee involvement is generally taken to refer to any management practice that gives

employees influence over how their work is organized and carried out.

According to Solanti et al(2003) the involvement factor influences employees decision on

whether or not to fully engage in the job. The examples of employee involvement

techniques are well documented in the literature and they involve the use of taskforces, self-

managing teams, employee surveys, and suggestion boxes (Wilkinson, Godfrey

Marchington, 1997). The positive effects of employee involvement on job satisfaction and

productivity are also well documented and confirmed in literature (Solanti et al, 2003,

Ahmadi, and Helms, 1995). These authors claim that the staff involvement is the key to

motivating staff and improving performance in any business and at any level. According to

Solanti et al (2003) involvement is one of the ten commandments of management which

Kaizen has termed the people enablement index. Kaizen also points out that being

consulted and involved in decision making encourages employees be committed to what

they are doing. This enables them to offer and share ideas to improve organizationsperformance. Such participation is reinforced by reward and recognition systems which

emphasize the achievement of quality objectives (Wilkinson et al, 1997).

Although top management is responsible and is a key driver of TQM initiatives they are not

the only people that should be familiar with TQM. All other employees should be familiar

with TQM. Quality is not just management responsibility, it is recommended that everyone in

the organization should fully participate, be involved and take responsibility for quality or

else TQM will not even get off the ground (Huq and Martin, 2000). A lack of involvement, in

contrast, hinders staff from highlighting obvious problem areas or identifying improvements.


32/81

Different authors argue that team work is another method of getting employee involvement

and satisfaction. This is because teams collective effort is better than the individual effort

given that diverse knowledge always works better (Huq and Martin, 2000; Lawer, 1994;

Youssef and Zairii, 1995, Dilberet al, 2005 and Metri, 2005). Therefore TQM mandates that

staff members in all levels of the organization, from the onset be involved and take

responsibility and ownership of the quality initiatives implementation.

2.2.5 Commitment to understanding and improving the organizations processes

According to TQM theory, the best way to improve organizational output is to continually

improve performance, not just holding the status quo (Vouzas and Psychogios, 2007). The

TQM concept is well known for the recognition of the link between product quality and

customer satisfaction. Furthermore it recognizes that product quality is the result of process

quality. When organizations standardize their processes they are able to take proper quality

control in the key steps of the operation procedures to prevent any defects in the process

(Yang and Christian, 2003). As a result, TQM focuses on continuous improvement of the

company's processes, leading to an improvement in process quality, which in turn leads to

an improvement in product quality which ultimately leads to an increase in customer

satisfaction.

2.2.6 Evidence based decision making

TQM advocated the need to base decision on data (Lai, 2003). Decisions that are made

based on data produces remarkable results than decisions that are thumb sucked or based

on a hunch or intuition. With data based decisions, the needs and the desires of the

customer are well known as, a result they can be incorporated into the product or service

design. Hence meeting and mostly exceeding the requirements of the customer. This

greatly enhances customer satisfaction in the product and or service and improves the

quality and efficiency of the company itself. The use of quality data also allows the

organization to benchmark their service or product offerings, in order for them to establish

areas that need improvements so that they can excel in whatever they are doing. The table

below represents the authors and their view on the essential elements of TQM

Table 2.1 Essential Elements of TQM


33/81

Essential elements of TQM Authors

Commitment to quality concepts Crosby, Deming , Juran, Huq and Martins,

Continuous improvements Anderson, Manley, Youssef, Metri Solanti et al

Bergman and Klefsj ,Adinolfi P et al

Focus on customers Crosby, Deming , Juran, Dilber et al, Bergman

Focus on employees and Klefsj Metri, Solanti et al, Badyopadhyay,

Team work Huq and Martin , Ovretviet Vouzas F et al,Yong

Evidence based decision making and Christian

Process improvements

Control of unwanted variation Youssef, Flynn et al, Dilber et al, Metri,

Leadership support/ top management Swinehart and Green, Huq and Martin,

commitment Asuboteng at al Bergman and Klefsj

Communication

2.3 BENEFITS OF TQM

TQM leads to a synergy of benefits. The General Accounting Office (GAO, 1991), studied

the link between organizations that had TQM processes in place and their performance.

Their study revealed that there is a positive relationship between the two. Organizations

that had TQM processes were better performers that those that did not have TQM

processes in place. The study indicated that these organizations have improved employees

relationships and retention, improved operating processes, greater customer satisfaction

and increase market (Eriksson, 2003). This was because in these organizations senior

management empowered all levels of management, including self management at workers

level, this was done to manage quality systems, improved quality ultimately resulting in

decreased costs and increased productivity.

The use of TQM in organizations reduces mistakes and produces monetary savings through

more efficient use of scarce resources. This enables the company to be a leader not a


34/81

follower which results in increased market share which in turn leads to increase profitability

(Nagaprsad and Yogesha, 2009).

TQM also makes an organization sensitive to customer needs, which makes it more readily

adaptable to the ever changing customer needs. TQM fosters team work, by working

together and communicating and most departmental barriers are then broken down. This

results in easy access to other department information which leads to a better

understanding of how the systems work, by all employees. This allows for the standard of

service to be set, maintained and then improved. Improving the standards of the product

and the services provided has a direct effect on the quality of the end product which

ultimately increases customer satisfaction.

TQM also views suppliers as customers, and as a result the suppliers view themselves as

part of the organization, they start to work with rather than working for the organization,

which also increases profit margins (Eriksson, 2003). TQM mandates the standard of

employees and management to improve through education and empowerment, this leads to

employees being able to think for themselves. The adoption of this new attitude to work;

results in everyone embracing the ideas of TQM, which in turn increases productivity and

profitability.

There are numerous approaches to evaluating the possible benefits of TQM. Estimating the

cost of poor quality has been used extensively in the past as a method to quantify the

benefits of TQM. Recently TQMs customer satisfaction has been used as one of the

indicators of the benefits of TQM, as it has a positive impact on market value and

accounting returns (Eriksson, 2003). The benefits of TQM are shown in the figure below.


35/81

Benefits for the organization

Benefit to the customer

Benefits to the staff

Figure 2.3 Benefits of TQM (Nagaprasad and Yogesha, 2009)

2.4 DEFINITION OF TQM IN HEALTH CARE

According to Lohr (1991), quality is the degree to which health services for individuals and

population increases the likelihood of desired health outcomes and is consistent with the

current professional knowledge. This was followed by the modified version of quality in

health care by Zairii and Matthew, (1995) as well as Asuboteng et al(1996). They described

quality care as a service that is designed to meet the present and the future requirements of

the customer in respect to the use, quality and satisfaction; and address the problems that

are likely to be encountered in the use of the service and resolve them prior to delivery.

Edward (1997) quoted Donabedien (1988) and defined high quality care as "that kind of

care which is expected to maximize an inclusive measure of patient welfare, after one has


36/81

taken account of the balance of expected gains and losses that attend the process of care

in all its parts. Lai, (2003) reiterated that quality in health care involves sustaining an

acceptable outcome through an appropriate process or service to meet and exceed the

customers expectation The South African department of health (2007) describes quality

care as an interface between the health care provider and the patient and the interface

between health services and the community. It further defines quality of care as doing the

right thing (providing effective care, right time (efficiently) right away (meeting patient

expectations of prompt care). In order to deliver quality service and for any quality initiative

to be successful, customer requirements must be establish and they should also be fulfilled.

TQM in health care is therefore, regarded as management technique that is designed to

provide product or services that will deliver the kind of health care that meets and exceeds

the customers requirements (Zairii and Matthews, 1995).

The definition of quality improvement in the medical literature focuses on improving patient

outcomes. Most quality initiatives in the health care field focus on improving productivity,

cost-effectiveness, market share, employee morale, and efficiencies of processes. With

improved process efficiencies there are less rework, fewer mistakes, fewer delays, snags

and better use of equipment or materials, which in turn increases productivity and therefore

enables the hospitals to become more competitive, with better chances of survival and more

jobs provided (Brashier et al, 1996). In other words, quality of care involves both the

provider and the user of the health services and both plays a significant role in defining

quality of care. Therefore, quality of care is that care that meets an integrated view of both

the required and acceptable clinical standards while meeting the requirements and

perception of the patient (user) as well as the communities they live in Ovretviet (2000) adds

on to say that quality in health care has to be considered from three dimensions. The first

dimension involves patients quality, this is concerned with whether the service provided,

renders to the patient what they want and desire. The second dimension is the professional

quality. This is a professionals view of whether the services rendered by the professional as

asses by the professional health board and the practitioner meets the need of the patient

and whether the personnel correctly selected and carried out procedures which are believed

to be necessary to meet patients needs. The third dimension is the organizational

management quality dimension. This determines whether there is efficient and productive

use of resources in order to meet the patients need without wastage and within thedirectives set by higher authority (Ovretviet, 2000).


37/81

Thornber (1991) developed a TQM model for health service organizations, which is very

similar to the Deming model. In his model, TQM is defined as a method of leadership and

management which:

o defines quality in terms of customer perceptions of both the content and

delivery of the service

o analyzes systems for errors and variation, and prevents them from

occurring rather than correct the errors when they occur or blame people

o develops long-term partnerships with external and internal suppliers

o uses accurate data to analyze processes and measure system

improvement

o sets up effective collaborative meetings as the basis of teamwork

o trains supervisors and managers in leading the on-going improvement

process

o engages staff in setting targets and ensures that results are fed back to the

relevant people

o highlights the need for senior executives to plan strategically

o achieves long-term improvement through small incremental steps

2.5 SIGNIFICANCE OF TQM IN HEALTH CARE

Over the years, one of the fastest growing industries in the service sector has been the

healthcare industry. This growth has put the health care industry under tremendous

pressure to change and reform for the past decade. The pressure to change has been

driven by escalating costs, and increased demands from both dissatisfied patients and third-

party payers (medical aids) (Norlund, 1991). The consumers of health care i.e. patients and

their families as well as the health insurance companies believed that the health care

providers were not taking their health needs seriously. In addition, their health needs were

not being met adequately based on access, cost, or quality (Gaucher and Coffey, 1993).

This has prompted the hospitals to strive and achieve service excellence. These hospitals

needed to strive for zero defects so that they satisfy every customer that they can. A large

number of hospitals attempted to enhance their service delivery and adding value to their

customers. In many instances, this was achieved by using the zero defect processes that

necessitated continuous efforts to improve the quality of the service delivery systems in


38/81

order to prevent costly and fatal mistakes which results and litigations (Brashier et al, 1996;

Lim and Tang, 2000). In essence the use of zero defect process resulted in reduction of

unnecessary wastage as reported by Hamilton (1993) that 90% of drugs prescribed result in

waste of money and risk of serious side effects. He added that unnecessary surgery wasted

billions of dollars and caused thousands of deaths each year.

Hospitals have a great challenge, in order to be successful they need to take a closer look

at their operations and find a suitable and a more efficient way to perform their business.

These difficulties are not only affecting developed countries, they also affect developing

countries and their impact is much more severe due to lack of resources, higher rate of

infections and poor health as well as work force shortfalls. The high volume of unnecessary

medical expenditures resulting from wastage of material and resources creates a serious

financial burden for the government that has an already overstretched budget. Annually the

medical expenditure are increasing and some of the most important health programs are

unable to find funding because the governments budget cannot keep up with the escalating

medical expenses. Due to this financial strain, it becomes difficult for the government to

recruit and retain medical personnel as they feel that the government is not remunerating

them properly. In turn, this has a huge and debilitating effect on the running as well as the

quality of the service that is being provided at the public health care institutions. The

government has the dire desire to provide high quality medical care despite its limited

resources, in order to meet this challenge they must be able to try to pursue different

management approaches. These health care crises were felt to be delicate and urgent in

the health care sector, most organizations implemented TQM as a frantic attempt to solve

most of the problems that they were facing to improve their operational posture. TQM has

been used as a tool to attack wastage, inefficiencies and mistakes that in turn saved the

system (Burda, 1991, Yang and Christian, 2003, Huq and Martin 2000), as it saved

Japanese industry after World War II, and it has contributed to some remarkable and well-

publicized successes in American industry. In addition, TQM showed promising results in

improving the quality of American health care (Berwick, Godfry, and Roessner, 1990).

TQM has gained popularity in the health care industry for many reasons; it has been a

widely adopted strategy for the improvement of patient satisfaction. This is because it

provides a health care environment that focuses on quality of patient care and continuousquality improvement at all levels of the organization, from the top management down to the


39/81

lower level staff. TQM deals directly with operational issues culminating into better

employee morale, high quality care and this in turn leads to fewer patient returns, which

further translates into a reduced burden on the health care institutions (Yang and Christian,

2003).

As health care organizations are striving to provide health care services with limited

resources, it is obvious that adopting TQM will not only help the government with the

financial crisis, but also it will overcome many urgent problems that are a challenge to the

health care system. Although studies have demonstrated there are obstacles to the

successful implementation of TQM, and the outcomes of the implementation are not always

as desired, numerous studies have demonstrated that implementing TQM results in ongoing

improvement by identifying areas of weaknesses and correcting them as required

(Swinehart and Green, 1995; Yang and Christian, 2003; Huq 1996). The improvements will

enhance the quality of health care delivery while in the same breath; it will cut the cost by

increasing health care efficiency and effectiveness. In the advent of rising medical cost and

limited resources organizations that implement TQM will be able to achieve both efficiency

and effectiveness; this means to provide better quality health care with the resources that

the organization already has or with even less.

2.6 BARRIERS TO IMPLEMENTATION OF EFFECTIVE TQM INITIATIVES

In practice, TQM initiatives are not easy to achieve (Bergquist, Frederiksson and Svensson,

2005). Despite its theoretical promise and enthusiastic response from different industries,

recent evidence suggests that attempts to implement it are often unsuccessful (Bergquist et

al, 2005). Many organizations and companies have difficulties in implementing TQM.

Reports of the variances in the success and failures are well documented (Dahlgaard and

Dahlgaard, 2006; Rad 2005; Bergquist et al, 2005) Huq and Martin in 2000 reported high

failure rates (60-70%) of implementing TQM, on the 36 articles that the reviewed. It is

generally accepted that these failures are not because of the basic flaws in the principles of

TQM. It is also not the characteristics of quality of the program, but mainly to the ineffective

implementation of the system. According to Huq (2005), there are various reasons for the

failure of TQM implementation, the majority of the cited reasons boil down to managements

inability to implement a total system. It is evident that management implements TQM

partially and not as a full system. Many organizations apply TQM concepts selectively and

are not committed to apply the full range of TQM procedures. Seetharaman, Sreenivanash


40/81

and Boon (2006) argued that the main reason why TQM failed was the lack of knowledge

concerning the proper TQM implementation. In their research, they discovered that TQM

fails because of the following reasons:

Lack of management commitment and management understanding on Quality

Lack of awareness on the benefits of TQM implementation in the organization

Inadequate knowledge of TQM and improper understanding of the measurement

techniques that are used to measure the effectiveness of TQM implementation.

Lack of clarity in the guideline, implementation plan and implementation methods

Lack of understanding about the positive results of continuous improvement

Ignoring the importance of customers

The department of health 2007 reported that most provincial authorities are struggling with

the mechanism to integrate TQM into the health system as a whole. This has prompted the

need to identify these barriers in order to improve the TQM implementation model to reduce

the variance between the success and failure of TQM initiatives.

Numerous barriers to successful implementation of TQM in the health care services

organizations have been identified. According to the survey of health care organizations in

Isfahaan province of Iran, a substantial number of barriers were identified. These barriers

included: the lack of senior management commitment and involvement, inability to change

the organizational culture, inflexibility of or cultural toward quality changes, incorrect

planning (policy development and effective goal deployment), lack of education and training

for employees and managers, inadequate knowledge and understanding of TQM

philosophy, poor team work, poor accessibility of data and results as well as the lack of

attention to the needs of the internal and external customers (Rad, 2005). Brashier et al

(1996) as well identified the lack of management commitment and employee interest, lack of

good plans and lack of focus. They also added physician indifference towards TQM as a

critical barrier. Although Huq and Martin (2000) highlighted some of the barriers mentioned

above, they emphasized work force culture as the major barriers in implementing TQM

initiatives in health care service organizations. Whereas Mc Fadden, Stock and Gregory,

(2006) identified that, internal barriers such as lack of incentives, lack of knowledge and

understanding of the TQM philosophy were major barriers to TQM initiatives

implementation.


41/81

According to McLaughlin and Kaluzny (1990), the most difficult barrier to implementing TQM

in hospitals is their complex, bureaucratic and highly departmentalized structure, and the

multiple layers of authority. Other barriers that were mentioned in literature include unclear

strategy and conflicting priorities, leadership style, poor coordination, inadequate skills to

implement TQM and lack of communication.

2.7 QUALITY CHALLENGES IN SOUTH AFRICAN HEALTH SERVICE CONTEXT

According to the department of health, 2004 the following were the major quality challenges

that the South African health service facilities are faced with:

A number of health facilities do not have quality management systems in place,

including data collection, analysis, teams to monitor quality, and continuouseducationAttitudes of providers are often poor, with few avenues for user complaints

and redress.

Little or no accountability of the health personnel for their practicesLittle or no data

processes and outcomes of care ( facility level and higher)

Rigid and inefficient management structures that limit what hospital management can

doFacility infrastructure and supplies are often too poor and inefficiently managed

Inadequate and inappropriate systems of facility supervision, punitive and

authoritarian system management

It is clear that all the barriers that have been mentioned above have the following factors in

common

2.7.1 Lack of senior management commitment

Numerous studies by Youssef, and Zairii, (1995); Flynn et al, (1994);Dilber et al, (2005);

Metri (2005); Swinehart and Green (1995); Huq and Martin, (2000); Asuboteng et al, (1996);

Bergman and Klefsj,(2003), have indicated that for TQM to be introduced successfully the

top management commitment is a prerequisite. TQM has to be introduced and led by the

top management. A strong management support and commitment should be shown through

various activities such as creating and setting clear quality vision and values that are

aligned to the organization mission and vision. It is important that top leaders communicate

with their employees and explain the reasons and the value of adopting and integrating


42/81

TQM to the mission and the vision of the organization. In most cases where TQM initiatives

have failed it has been due to the lack of management involvement or top management

doesnt lead or get committed, and in these cases management only pays a lip service and

not act on the initiative. Therefore lack of management commitment is seen as the most and

the biggest barrier in implementing TQM.

2.7.2 Organizational structure and culture

Many hospitals are structured in elements of the functional-hierarchical fashion (Huq and

Martin, 2000; Johnson, and Omachonu, 1995). Successful TQM program fits perfectly in an

organization that exhibit a structure that is more flat and with minimum layers of

management. TQM success is obtained through a shift from the ordinary traditional

approach to the new TQM way of life (Schein, 2004; Soltani et al, 2005; Rad, 2005). This

structural change enables, empowers and motivates employees; it installs new values,

beliefs and assumptions to the new ways of thinking. This allows the breaking down of

communication barriers and fosters the creativity of the workforce. Resulting in a style that

is based on efficiency and efficient communication and high performance ethic, without

taking away authority and responsibility rather sharing decision making, and encouraging

members of the team to work together within the facility and across all levels of work

(Hamilton, 1993; Koch, 1991)

When organizations are structured along strict departmental lines (clinical services, food

services, laboratory, nursing, etc.) problem identification and solutions are

departmentalized. This leads to poor communication rivalry among functional and

professional groups, and partial problem identification and solution (Rad, 2005). For TQM

programs to be successful, it requires decentralization of power to be considered and form

part of the quality culture. Decentralization will improve employees' involvement,

communication and participation in decision-making and will reduce power distance within

organization.

If the hospital culture is refusing to embrace the change needed for TQM implementation,

these initiatives will not succeed regardless of the desire and effort of the people involved

(Huq and Martin, 2000). The change in the structure is required to improve quality of health

care services.


43/81

Administrators wishing to introduce TQM will have to find ways of ensuring that a positive

culture exists. Cultural change is the most effective way to manage TQM within an

organization. The change in the structure is required to improve quality of health care

services.

According to Huq and Martin (2000), organizations have individual and unique dominant

cultures that are fundamental to all actions, operations and relationships in the organization.

A more precise definition of culture is that by Schein (2004) who define culture in a

development context, meaning that culture is:

a pattern of shared basic assumptions that has been learnt whilst solving problems, that

has worked well enough to be considered valid, and therefore, to be taught to new members

as the correct way to perceive, think, and feel in relation to those problems

This culture is the key driver of the underlying assumption that employees have the rules of

the organizations, and the way of thinking which then become the norm of behaviour for the

group about accepting a TQM initiative, that will determine the success or the failure of the

implementation (Huq and Martin, 2000; Johnson and Omachonu, 1995). The organizational

dictates whether the organizations will accept or reject the changes brought about TQM.

When the organizational culture is formed it becomes they way of doing things. It plays a

significant role in how the organization runs and ultimately the culture is passed through

generations. As new employees become absorbed into the workforce, the new workforce

acquires the new culture through the process of adaptation (Johnson and Omachonu,

1995). It is imperative that organizations monitor their culture to ensure that it is conducive

and it supports TQM implementation, as organizational culture is one of the major barriers in

implementation of TQM. The critical challenge for top management is the creation of a work

culture that unites every employee around the needs, wants and expectations of customers.

In a mature TQM culture, every employee treats every customer as if he or she is the only

customer (Johnson and Omachonu, 1995).

According to Johnson and Omachonu, (1995) if the concept of TQM is to have any chance

of success, most or all of the individuals in the organization must be culturally socialized on

the importance of the customers.


44/81

2.7.3 Lack of education and training of employees about TQM

Education and training are fundamental for the successful implementation of TQM (Deming,

1988). TQM requires employees participation, each employee needs to learn and

understand the underlying principles of TQM. Employees need to have the right skills and

they should be granted a platform that enables them to implement the principles of TQM.

They need to have the right attitude for participating in TQM and they also need to be able

to apply this understanding and attitude in their area of work so that the process of

continuous improvement can be achieved. Clearly adequ

skiti barriers 2009

Documents