Essentials of total quality management: a meta-analysis

Factor Analysis of Quality Management Systems Implementation in Healthcare: An Online Survey

This paper investigates the views of healthcare researchers and professionals on the implementation of the Quality Management System (QMS) approach using a 5-point Likert scale survey. Researchers and healthcare professionals who observed or participated in QMS implementation were surveyed. Multiple channels, including occupational societies, social networking, i.e., LinkedIn, hospital’s directories, award recipients, academic researchers, and professional connections, made it possible to reach this particular sample. Participants were surveyed using a series of questions with a total of 56 questions. The survey was administrated through the web portal of Qualtrics and then analyzed both on Qualtrics and SPSS software packages. Descriptive Statistics, Exploratory Factor Analysis (EFA), and Linear Regression were employed to draw conclusions. The final sample group consisted of 71 participants representing a range of healthcare settings. EFA was conducted, producing a model of 10 emergent factors and an outcome for total improvement. Regression modeling revealed the Critical Success Factors (CSFs) and the interaction between emergent factors. The results indicated that QMS Implementation Culture, Structure, and Managerial Training are critical to the QMS implementation success. This research helps quality professionals enhance their ability to prioritize elements affecting the successful implementation of the QMS.

Saudi Radiologists’ and Radiographers’ Perceptions of Accreditation Programmes in Clinical Radiology Departments: A Cross-Sectional Study

Purpose

The hospital accreditation programme is an assessment tool that involves a comprehensive evaluation by an external independent accreditation body to ensure consistency in clinical practice by adhering to the established standards and guidelines. The study aims to investigate Radiology professionals’ perceptions of the impact of accreditation and implementation of change towards the quality-of-service delivery in Radiology Departments.

Methods

A cross-sectional prospective study was conducted in Saudi Arabia among radiology professionals (ie, radiographers and radiologists) from July to September 2021. After obtaining institutional review board approval from the local ethics committee and using a non-probability convenient sampling technique, 335 participants completed the survey, which was distributed via social media channels, and through professional networks within hospitals across the country.

Results

A total of 335 participants agreed to participate. The study’s participants strongly agreed that the accreditation programmes have positively impacted customer satisfaction and care provided to patients. A significant difference was identified in the level of agreement on the effect of accreditation programmes when hospital types and personnel qualifications were tested (P < 0.05). Radiology personnel who worked in academic hospitals and who had diplomas and PhDs degrees showed a significantly higher level of agreement than other participants (P < 0.05).

Conclusion

Saudi radiologists and radiographers showed strong agreement or agreement towards hospital accreditation programmes domains’ criteria. The results of the study support the need to bridge the gap between higher-level management and employees in order to facilitate change and enhance the standards of quality and practice in radiology departments. Additional policies are needed to continue and strengthen quality improvement programmes.

The Relationships between the Pillars of TPM and TQM and Manufacturing Performance Using Structural Equation Modeling

This paper examines the direct and indirect relationships between the pillars of total quality management (TQM) and total productive maintenance (TPM) and investigates their effects on manufacturing performance (MPR) using structural equation modeling. Three structural models were developed with their corresponding hypotheses. Data were then collected from thirty industrial firms in Jordan. A descriptive statistical analysis was followed by an analysis of variance (ANOVA). The structural models were analyzed to draw conclusions about the model hypotheses and identify the most influential TPM and TQM pillars on MPR. Significant variations were noticed among firms in the implementation levels of the TPM, TQM, and MPR pillars. Further, it was found that TPM directly and indirectly influences MPR. Furthermore, TPM pillars have a larger impact on MPR than TQM. Research hypotheses are suggested to be tested individually on small-, middle-, and large-sized firms. This research provides valuable information on top management in the industrial sector, on the significant relationships between the pillars of TPM, TQM, and MPR and supports them in identifying important TQM/TPM pillars which they should focus on in order to enhance MPR.

Interprofessional, multitiered daily rounding management in a high-acuity hospital

PURPOSE

The purpose of this explanatory case study is to explain the implementation of interprofessional, multitiered lean daily management (LDM) and to quantitatively report its impact on hospital safety.

DESIGN/METHODOLOGY/APPROACH

This case study explained the framework for LDM implementation and changes in quality metrics associated with the interprofessional, multitiered LDM, implemented at Saint Francis Hospital and Medical Center (SFHMC) at the end of 2018. Concepts from lean, Total Quality Management (TQM) and high reliability science were applied to develop the four tiers and gemba rounding components of LDM. A two-tailed t-test analysis was utilized to determine statistical significance for serious safety events (SSEs) comparing the intervention period (January 2019-December 2019) to the baseline period (calendar years 2017 and 2018). Other quality and efficiency metrics were also tracked.

FINDINGS

LDM was associated with decreased SSEs in 2019 compared to 2017 and 2018 (p ≤ 0.01). There were no reportable central line-associated blood stream infection (CLABSI) or catheter-associated urinary tract infection (CAUTI) for first full calendar quarter in the hospital's history. Hospital-acquired pressure injuries were at 0.2 per 1,000 patient days, meeting the annual target of <0.5 per 1,000 patient days. Outcomes for falls with injury, hand hygiene and patient experience also trended toward target. These improvements occurred while also observing a lower observed to expected length of stay (O/E LOS), which is the organizational marker for hospital's efficiency.

RESEARCH LIMITATIONS/IMPLICATIONS

LDM may contribute greatly to improve safety outcomes. This observational study was performed in an urban, high-acuity, low cost hospital which may not be representative of other hospitals. Further study is warranted to determine whether this model can be applied more broadly to other settings.

PRACTICAL IMPLICATIONS

LDM can be implemented quickly to achieve an improvement in hospital safety and other health-care quality outcomes. This required a redistribution of time for hospital staff but did not require any significant capital or other investment.

SOCIAL IMPLICATIONS

As hospital systems move from a volume-based to value-based health-care delivery model, dynamic interventions using LDM can play a pivotal role in helping all patients, particularly in underserved settings where lower cost care is required for sustainability, given limited available resources.

ORIGINALITY/VALUE

While many hospital systems promote organizational rounding as a routine quality improvement process, this study shows that a dynamic, intense LDM model can dramatically improve safety within months. This was done in a challenging urban environment for a high-acuity population with limited resources.

Total quality management and sustainability in the public service sector: the mediating effect of service innovation

Purpose

This study aims to critically investigate the structural relationships between total quality management (TQM), service innovation and sustainability performance in the public service sector of the United Arab Emirates (UAE).

Design/methodology/approach

The study employed an online survey to collect data from 400 employees working in eight selected UAE public service sector organisations located in Abu Dhabi. The collected data were analysed using structural equation modelling (SEM) to empirically examine whether TQM practices improve service innovation and, subsequently, sustainability performance in the UAE's public service sector.

Findings

The results show that TQM has a significant impact on service innovation and sustainability performance in the UAE's public service sector. Additionally, service innovation partially mediates the relationship between TQM and sustainability performance.

Practical implications

The public service sector's TQM practices and service innovation in the UAE have a much greater impact on social and environmental sustainability than on economic sustainability performance. Adopting five dimensions of TQM (following the Abu Dhabi Award for Excellence in Government Performance [ADAEP] model) across the UAE's public organisations will enable government departments to deliver innovative services to its beneficiaries.

Originality/value

This study provides a substantial contribution by addressing the gaps in the literature. Very few studies have empirically investigated the possible association between TQM, service innovation and sustainability performance in public sector organisations, particularly in developing countries such as the UAE, where the increasing efforts in TQM practices are still in their emerging stages, mainly targeting innovative service offerings and sustainable performance.

Quality management practices as a driver of employee satisfaction: exploring the mediating role of organizational image

Purpose

Total quality management (TQM) has been a universally applienod management strategy to improve organizational performance and thereby to achieve competitiveness. Compared with the scholarly and practical attention paid to identify the consequences of implementing TQM practices, little is known about how those practices enhance organizational image and employee satisfaction. This paper aims to address that research gap and is designed to empirically prove the relationship between TQM practices, organizational image and employee satisfaction.

Design/methodology/approach

A questionnaire-based survey of 285 employees including administrators, managers and heads of departments of 21 National Accreditation Board for Hospital and Healthcare providers-accredited hospitals in India was conducted. The proposed research model was tested using partial least squares based structural equation modelling.

Findings

The results revealed that TQM practices have positive direct and indirect effects on employee satisfaction, confirming the partial mediation role played by organizational image in the relationship between TQM practices and employee satisfaction.

Research limitations/implications

From the findings, leaders can understand that by implementing TQM practices, organizations can enhance image of the organization and bring high level of employee satisfaction.

Originality/value

The study tries to answer questions largely ignored in the TQM literature: the effect of TQM practices on organizational image and employee satisfaction, and the mediating role of organizational image on TQM practices and employee satisfaction.

Can institutional entrepreneurship strengthen clinical governance and quality improvement: a case study of a district-based clinical specialist team in South Africa

We present an interpretive qualitative account of micro-level activities and processes of clinical governance by recently introduced district-based clinical specialist teams (DCSTs) in South Africa. We do this to explore whether and how they are functioning as institutional entrepreneurs (IE) at the local service delivery level. In one health district, between 2013 and 2015, we carried out 59 in-depth interviews with district, sub-district and facility managers, nurses, DCST members and external actors. We also ran one focus group discussion with the DCST and analysed key policies, activities and perceptions of the innovation using an institutional entrepreneurship conceptual lens. Findings show that the DCST is located in a constrained context. Yet, by revealing and bridging gaps in the health system, team members have been able to take on certain IE characteristics, functioning-more or less-as announcers of reforms, articulating a strategic vision and direction for the system, advocating for change, mobilizing resources. In addition, they have helped to reorganize services and shape care practices by re-framing issues and exerting power to influence organizational change. The DCST innovation provides an opportunity to promote institutional entrepreneurship in our context because it influences change and is applicable to other health systems. Yet there are nuanced differences between individual members and the team, and these need better understanding to maximize this contribution to change in this context and other health systems.

The relationship between TQM and SMEs’ performance: The mediating role of organizational culture

Purpose

The purpose of this paper is to empirically test the association between total quality management (TQM) and small and medium enterprises’ (SMEs) performance. In particular, it examines whether organizational culture (OC) has a mediating effect on the TQM–SME performance relationship.

Design/methodology/approach

The conceptual model for this study was developed based on the literature review of TQM, OC and SME performance. As the research framework, a self-administered questionnaire was used to collect data from managers/owners of SMEs in the Riyadh, Mecca and Eastern regions of the Kingdom of Saudi Arabia. The instrument was evaluated for its validity and reliability. A structural equation model was designed to examine the relationships, using PLS 3.0.

Findings

Statistical outcomes add to the literature through displaying a positive direct effect of TQM and OC on SMEs’ performance, and a significant and positive indirect effect of TQM on SMEs’ performance through OC.

Research limitations/implications

The quantitative cross-sectional research design investigated a sample of manufacturing SMEs. Future research could use qualitative techniques or a case study approach for further information analysis.

Practical implications

The findings of this research provide insights into SMEs’ owners/managers in today’s dynamic manufacturing environment, focussing on TQM as a mechanism for improving their performance. The results can help SMEs by providing guidance on OC, because of its effect on the successful implementation of TQM, therefore improving the level of performance.

Originality/value

The research extends the literature of TQM with a comprehensive understanding of TQM from the perspective of SMEs in Saudi Arabia. It fills the gap in empirical studies that investigate the joint effect of TQM and OC on SMEs’ performance. This paper highlights the theoretical contribution and managerial implications as well as making recommendations for future research.

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.

Factors affecting quality management at the Thai national institute of health

Purpose

The purpose of this paper is to confirm and examine organization-related factors that could affect quality management at the Thai national reference laboratory known as National Institute of Health.

Design/methodology/approach

The authors invited 340 laboratory staff members to complete a questionnaire that enquired about their skills, opinions, perceptions, leadership, work environment, organizational culture and organizational commitment in relation to quality management. Confirmatory factor analysis (CFA) and multiple linear regression were used to analyze the data.

Findings

In total, 65 percent of institute members responded to the questionnaire. CFA revealed that all factors were related to quality management. Three factors, leadership, organizational commitment and work environment, significantly affected quality management, but organizational culture did not.

Research limitations/implications

Other data types should be collected for an in-depth understanding, i.e. focus groups or in-depth interviews. A longitudinal study could also enhance quality management understanding to see how each variable changes over time.

Originality/value

Analyzing quality management through confirmatory factor and regression analysis showed that the four analyzed variables are statistically significant in relation to quality management at the laboratory. Managers could apply this information to revise the current policy.

Effective quality systems: implementation in Australian public hospitals

PURPOSE

The purpose of this paper is to review the implementation of seven components of quality systems (QSs) linked with quality improvement in a sample of Australian hospitals.

DESIGN/METHODOLOGY/APPROACH

The authors completed a systematic review to identify QS components associated with measureable quality improvement. Using mixed methods, the authors then reviewed the current state of these QS components in a sample of eight Australian hospitals.

FINDINGS

The literature review identified seven essential QS components. Both the self-evaluation and focus group data suggested that none of the hospitals had all of these seven components in place, and that there were some implementation issues with those components that were in use. Although board and senior executives could point to a large number of quality and safety documents that they felt were supporting a vision and framework for safe, high-quality care, middle managers and clinical staff described the QSs as compliance driven and largely irrelevant to their daily pursuit of safe, high-quality care. The authors also found little specific training in quality improvement for staff, lack of useful data for clinicians on the quality of care they provide and confusion about how organisational QSs work.

PRACTICAL IMPLICATIONS

This study provides a clearer picture of why QSs are not yet achieving the results that boards and executives want to achieve, and that patients require.

ORIGINALITY/VALUE

This is the first study to explore the implementation of QSs in hospitals in-depth from the perspective of hospital staff, linking the findings to the implementation of QS component identified in the literature.

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.

Role of a hospital accreditation program in developing a process management system

Purpose

The purpose of this paper is to clarify the effects of the Iranian Hospital Accreditation Program (IHAP) on hospital processes from the viewpoint of the staff charged with establishing the program.

Design/methodology/approach

This qualitative study is based on the data collected in semi-structured interviews conducted in 2016, which involved eight questions. Interviews were held with 70 staff members at 14 hospitals. Managerial staff were purposively interviewed based on their familiarity and involvement with the program. The hospitals were divided into five groups, comprising public, private, charity, military and social service hospitals. A thematic analysis was carried out using the collected data.

Findings

Three themes emerged from the data, which together comprise a process management cycle: the establishment, implementation, and control phases of the program. For each phase, various positive trends, as well as hurdles for establishing the program, declared which were framed two sub-themes as positive effects and challenges.

Originality/value

The findings contribute to the body of evidence used by policy-makers and hospital managers to improve the change management processes related to the Iranian IHAP. Although positive changes in the process management cycles at Iranian hospitals were noted, successful implementation of the program demands a thorough assessment of the hospitals’ technical and financial needs (taking into account disparities between hospitals), and there is an urgent requirement for a plan to meet these needs.

The success of strategic planning in health care organizations of Iran

Purpose Although strategic planning promised to boost organizational performance, many health care managers found it difficult to implement it successfully. The purpose of this paper is to investigate the success of strategic planning in health care organizations of Iran. Design/methodology/approach This descriptive and cross-sectional study was conducted in 2016 using a valid and reliable questionnaire completed by 99 health care managers in Tehran province, Iran. Findings Strategic planning was positively related to organizational performance including employees' and patients' satisfaction and organizational productivity. However, strategic planning was moderately successful in enhancing organizational performance of Iranian health care organizations (score of 2.84 out of 5). The most and least success was observed in the planning and employee management constructs of organizational performance. Process management, organizational culture and customer management constructs had the most effect on the success of strategic plans in health care organizations. Practical implications Strategic planning is effective and provides a clear focused direction for health care organizations. Understanding the success factors of strategic planning would enable managers to develop more effective methods for developing, implementing and evaluating strategic plans in health care organizations. Originality/value This paper highlights the relationship between strategic planning and organizational performance and offers suggestions on how to develop and implement strategic plans to achieve higher organizational performance.

Rationing in health systems: A critical review

Background: It is difficult to provide health care services to all those in need of such services due to limited resources and unlimited demands. Thus, priority setting and rationing have to be applied. This study aimed at critically examining the concept of rationing in health sector and identifying its purposes, influencing factors, mechanisms, and outcomes. Methods: The critical interpretive synthesis methodology was used in this study. PubMed, Cochrane, and Proquest databases were searched using the related key words to find related documents published between 1970 and 2015. In total, 161 published reports were reviewed and included in the study. Thematic content analysis was applied for data analysis. Results: Health services rationing means restricting the access of some people to useful or potentially useful health services due to budgetary limitation. The inherent features of the health market and health services, limited resources, and unlimited needs necessitate health services rationing. Rationing can be applied in 4 levels: health care policy- makers, health care managers, health care providers, and patients. Health care rationing can be accomplished through fixed budget, benefit package, payment mechanisms, queuing, copayments, and deductibles. Conclusion: This paper enriched our understanding of health services rationing and its mechanisms at various levels and contributed to the literature by broadly conceptualizing health services rationing.

The impact of health information technologies on quality improvement methodologies' efficiency, throughput and financial outcomes: a retrospective observational study

BACKGROUND

To evaluate whether or not the utilization of Health Information Technologies (HITs) in Quality Improvement Methodologies (QIMs) has impacts on QIMs' efficiency, throughput and financial outcomes at healthcare organizations and physician practices in the United States.

METHODS

This is a retrospective observational study that was conducted between the years of 2014 and 2015 and relied on two data sources: the Dorenfest Institute dataset and the Healthcare Information and Management Systems Society (HIMSS) Analytics data source. In addition, questionnaires were submitted to collect data about how healthcare settings in the United States had been utilizing QIMs in the last 10 years. The submitted questionnaire invitations yielded 144 responses from 134 hospitals and 10 physician practices. Descriptive statistics were used to assess the condition of the data. This involved the utilization of Box-Whisker plots to visualize the data shape, outliers and variation. The Gamma correlation analysis method was used to evaluate the statistical relationships between the QIM outcomes, efficiency, throughput and financial outcomes, and the employment of HIT systems in QIMs.

RESULTS

The study found that 99.3% of the healthcare organizations and physician practices had implemented at least one QIM over the last 10 years. In the QIM implementations, the total numbers of reported utilization instances of manual data collection, electronic health records, lab information systems, pharmacy information systems, computerized provider order entry and radiology information systems were 387, 352, 205, 185, 180 and 158, respectively. Based on a 95% confidence limit, the Gamma statistical test has shown an inverse correlation between the exclusive utilization of manual data collection and the overall QIM efficiency (p = 0.047, Gamma = -0.388) and throughput (p = 0.012, Gamma = -0.593) outcomes. However, the overall QIM financial outcomes were found to have a statistically insignificant correlation (p = 0.159).

CONCLUSIONS

The study has revealed statistically significant negative impacts on QIMs' efficiency and throughput outcomes when the manual data collection is the sole method used in QIM implementations. This also indicates a positive correlation between the QIMs' efficiency and throughput outcomes and the HIT utilization in QIMs.

Adopting total quality management to enhance service delivery in medical records

Purpose

The purpose of this study is to determine the extent to which total quality management (TQM) initiatives can improve the quality of services delivery at the medical records unit of the Korle-Bu Teaching Hospital (KBTH) to help meet the expectations and aspirations of patients and customers of the hospital.

Design/methodology/approach

This research adopted the survey strategy as its research design. The total study population consisted of 114 medical records staff of the KBTH. Questionnaires and personal observations were employed as the data collection instruments. The study recorded a response rate of 98 per cent. Data gathered from respondents were analysed in qualitative terms.

Findings

The overall finding of this study was that, although the medical records department of the KBTH had a fair degree of understanding on the benefits of TQM to records management service delivery, the exiting values for TQM did not meet the framework of good TQM practice, principles and standards.

Research limitations/implications

Even though the subjects for the study were from the biggest hospital in Ghana, the findings of this study may not be generalised to the whole country.

Practical implications

The study has demonstrated the need for the medical records department of the KBTH to have and develop good TQM standards to improve the quality of services to patients and varied customers of the hospital.

Originality/value

The literature reviewed indicated that this study is a maiden attempt to examine how TQM initiatives including sensitivity, customer satisfaction, commitment of top management, team work, effective leadership and participatory management, people development and effective and open communication can improve the quality of medical records service delivery at the KBTH in Ghana.

Implementing hospital quality assurance policies in Iran

Purpose

– The purpose of this paper is to provide an overview of applied hospital quality assurance (QA) policies in Iran.

Design/methodology/approach

– A mixed method (quantitative data and qualitative document analysis) study was carried out between 1996 and 2010.

Findings

– The QA policy cycle forms a tight monitoring system to assure hospital quality by combining mandatory and voluntary methods in Iran. The licensing, annual evaluation and grading, and regulatory inspections statutorily implemented by the government as a national package to assure and improve hospital care quality, while implementing quality management systems (QMS) was voluntary for hospitals. The government’s strong QA policy legislation role and support has been an important factor for successful QA implementation in Iran, though it may affected QA assessment independency and validity. Increased hospital evaluation independency and repositioning, updating standards, professional involvement and effectiveness studies could increase QA policy impact and maturity.

Practical implications

– The study highlights the current QA policy implementation cycle in Iranian hospitals. It provides a basis for further quality strategy development in Iranian hospitals and elsewhere. It also raises attention about finding the optimal balance between different QA policies, which is topical for many countries.

Originality/value

– This paper describes experiences when implementing a unique approach, combining mandatory and voluntary QA policies simultaneously in a developing country, which has invested considerably over time to improve hospital quality. The experiences with a mixed obligatory/voluntary approach and comprehensive policies in Iran may contain lessons for policy makers in developing and developed countries.

Factors influencing healthcare service quality

BACKGROUND

The main purpose of this study was to identify factors that influence healthcare quality in the Iranian context.

METHODS

Exploratory in-depth individual and focus group interviews were conducted with 222 healthcare stakeholders including healthcare providers, managers, policy-makers, and payers to identify factors affecting the quality of healthcare services provided in Iranian healthcare organisations.

RESULTS

Quality in healthcare is a production of cooperation between the patient and the healthcare provider in a supportive environment. Personal factors of the provider and the patient, and factors pertaining to the healthcare organisation, healthcare system, and the broader environment affect healthcare service quality. Healthcare quality can be improved by supportive visionary leadership, proper planning, education and training, availability of resources, effective management of resources, employees and processes, and collaboration and cooperation among providers.

CONCLUSION

This article contributes to healthcare theory and practice by developing a conceptual framework that provides policy-makers and managers a practical understanding of factors that affect healthcare service quality.