Why TQM does not work in Iranian healthcare organisations

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

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

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.

Benefits on productivity indicators after quality management implementation: evidence in the dairy industry

Purpose

This study aims to address two objectives: to analyse how the benefits of quality management (QM) are perceived on specific productivity indicators of the Colombian dairy industry and to analyse the degree of QM implementation.

Design/methodology/approach

The methodology used was a multiple case study and involved four companies in the Colombian dairy industry. The study variables were 32 QM practices and 7 productivity indicators. Data collection instruments were in-depth interviews and checklists.

Findings

Findings revealed that all productivity indicators exhibit changes after QM implementation. In addition, cases approaching ISO 9001 have the highest number of practices implemented, as well as evidence of control of all productivity indicators, which allows them to perceive greater benefits.

Originality/value

This research generates novel findings that contribute to the consolidation of theory by analysing changes in specific productivity indicators of the dairy industry after the QM implementation. At the same time, it provides valuable and useful information for managers, practitioners and policymakers.

Rethinking health services operations to embrace patient experience of healthcare journey

Patient experience is assumed pivotal for improving health services operations. The patient experience of healthcare services in Iran has been mostly assessed through the satisfaction and quality of single services or activities at individual providers, clinical departments, or health facilities. However, given the rise of chronic and multi-morbid conditions, health services for these conditions consist of several activities and interactions through a journey that patients take in the health system. To fill in this gap, we propose focusing on the assessment of patient experience on the patient journey through the health system. We advocate that there is much potential for improving the patient experience by rethinking the operations management of health services to embrace the patient experience of the healthcare journey. Rethinking health operations management may include an exhaustive list of interventions. Concisely, at the strategic level, policy-makers while understanding the need for shifting towards the patient experience, make sure that operational level management is experience oriented. This would be pursued through a strategic approach to patient experience, reconsidering qualifications for operational management, and benchmarking to identify and share best practices. Lessons learnt from previous quality improvement programmes are also considered as a capacity to establish the experience orientation.

Quality management effects on operating theater's productivity: a participatory action research

Purpose

The operating theater (OT) is resource-intensive, costly and assuring its productivity is a high priority. This study aimed to examine a quality management model's effects on a hospital's OT productivity.

Design/methodology/approach

The participatory action research approach was used for the intervention. A multidisciplinary quality improvement team was formed. The team improved OT operational processes using an eight-step quality management model. OT’s key performance indicators such as surgical cases, surgical cancellation, bill deductions, successful cardiopulmonary resuscitation, patients' complaints and employees' job satisfaction were collected before the intervention and compared with those of after intervention to determine the efficacy of the quality management model.

Findings

Applying a quality management strategy increased surgical patients' number by 14.96%, reduced surgery operations cancellation by 14.6 %, and decreased bill deduction by 44.9%. Besides, successful cardiopulmonary resuscitation increased by 21.17%, patients' complaints reduced by 61.5% and, finally, staff satisfaction increased by 15.6 %. Improved OT productivity resulted in improved financial performance. As a result, the OT revenue has risen by 68.8%.

Originality/value

This study highlights that implementing the right quality management model properly enhances hospitals' productivity. It also offers suggestions on how to implement a quality management model successfully in a hospital setting.

Making high quality care an organisational strategy: Results of a longitudinal mixed methods study in Australian hospitals

Significant resources are spent on monitoring and improving the quality and safety of hospital care; however, evidence suggests that this investment is achieving disproportionately limited results. Accreditation and expectations of funders have focused hospital service quality management on compliance, with an over emphasis on the 'control' aspect of Juran's Quality Trilogy. This study compared the impact of the implementation of a strategic quality management system with existing compliance-focused quality management systems in a sample of Australian hospitals. Through action research, mixed methods data were tracked and compared implementation progress and outcomes between four experimental and four control hospitals from 2015 to 2017. While three years was not enough time to observe quality changes resulting from the implementation, three experimental hospitals made high quality care a strategic priority for their organisation and developed organisation-wide processes to achieve it. These hospitals demonstrated that including a strategic quality planning component in quality system design and implementation, as advocated by Juran but absent in many hospital quality systems, was a positive lever for staff commitment to delivering consistently high quality care.

Conflict and conflict management in hospitals

PURPOSE

Hospitals are complex and complicated organizations and are prone to the conflict. The purpose of this paper is to identify the intensity and type of conflict experienced by hospital managers and explore their conflict management strategies in hospitals affiliated with Tehran University of Medical Sciences.

DESIGN/METHODOLOGY/APPROACH

This quantitative, descriptive and cross-sectional study was conducted in 2015. A self-administered questionnaire was used to collect data from top, middle and front line managers. In total, 563 managers from 14 hospitals responded to the questionnaires. Data were analyzed using SPSS software version 19.

FINDINGS

Hospital managers reported average level of conflict (2.73 score out of 5). Organizational factors produced more conflict for managers than personal factors. High workload, resource shortage, bureaucracy and differences in managers' personality, knowledge, capabilities and skills were the main causes of organizational and personal conflict. Top managers experienced more conflict than middle and front line managers. Conflict was higher in specialized hospitals compared to general hospitals. Less conflict was observed in administrative and support departments than diagnostic and therapeutic departments. Conflict was meaningfully associated with management level, education, size of hospital, number of employees and willingness to leave the hospital. The dominant conflict management style of managers was collaborating. There were significant relationships between collaborating style and management level, manager's age, work experience and management experience.

PRACTICAL IMPLICATIONS

The nature of hospitals requires that managers use collaborating, compromising and accommodating styles to interact better with different stakeholders. Managers by acquiring necessary training and using the right conflict resolution strategies should keep the conflict in a constructive level in hospitals.

ORIGINALITY/VALUE

This is the first study conducted in Iran examining the level of conflict, its types and identifying managers' dominant conflict resolution strategies at front line, middle and top management levels.

The impact of leadership churn on quality management in Australian hospitals

Purpose

The purpose of this paper is to explore the relationship between frequent turnover (churn) of the chief executive officer (CEO), quality manager and members of the governing board with the management of quality in eight Australian hospitals.

Design/methodology/approach

A mixed method three-year longitudinal study was conducted using validated quality system scales, quality indicators and focus groups involving over 800 board members, managers and clinical staff.

Findings

There were unexpected high levels of both governance and management churn over the three years. Churn among CEOs and quality managers was negatively associated with compliance in aspects of the quality system used to plan, monitor and improve quality of care. There was no relationship with the quality of care indicators. Staff identified lack of vision and changing priorities with high levels of churn, which they described as confusing and demotivating. There was no relationship with quality processes or quality indicators detected for churn among governing board members.

Practical implications

Governing boards must recognise the risks associated with management change and minimise these risks with robust clinical governance processes.

Originality/value

This research is the first that we are aware of that identifies the impact of frequent leadership turnover in the health sector on quality management.

Total quality management in the health-care context: integrating the literature and directing future research

Background

Synergistic integration of predictors and elements that determine the success of total quality management (TQM) implementations in hospitals has been the bane of theoretical development in the TQM research area. Thus, this paper aims to offer a systematic literature review to provide a foundation on which research on TQM can be built and to identify the predictors of successful TQM in the health-care context.

Materials and methods

A systematic literature survey was adopted in this paper, involving the review of 25 relevant researched articles found in the databases Science Direct, EBSCO, MEDLINE, CINAHL and PubMed.

Result

The systematic literature survey reveals five variables to be core predictors of TQM, signifying how important these variables are in the successful implementation of TQM in the health-care context. Also, it is revealed that the identified core predictors have positive effects on an improved health-care system. However, the systematic survey of the literature reveals a dearth of studies on TQM in the health-care context.

Conclusion

As TQM has become an important management approach for advancing effectiveness in the health-care sector, this kind of research is of value to researchers and managers. Stakeholders in the health sectors should introduce and implement TQM in hospitals and clinics. Nevertheless, this study has limitations, including that the databases and search engines adopted for the literature search are not exhaustive.

Testing the readiness of an organisational culture profile to a TQM implementation

Purpose

The purpose of this paper is to apply an existing theoretical model of organisational culture contextualised for total quality management (TQM) as a means of assessing the readiness for implementing TQM in the workplace. The “Amalgamated Model” is a hybrid that encapsulates organisational culture traits and their relative contribution as indictors of effective TQM implementation.

Design/methodology/approach

A questionnaire that would test the theoretical model was devised and administered to a sample population in a production facility located in Central Europe, Organisation X.

Findings

A profile of the organisation was derived which revealed the strengths and weaknesses of the organisation in relation to the cultural traits of the theoretical model.

Research limitations/implications

The research population comprised management/supervisory staff only and thus provides a partial view of Organisation X.

Practical implications

For practitioners, particularly those who specialise in quality management, the practical implications of this research are twofold: first, it provides insights into aspects of organisational culture and TQM implementation; and second, it demonstrates how a theoretical framework may be applied in the workplace to assess readiness for TQM implementation.

Originality/value

This research contributes to the subject area body of knowledge by applying a recent theoretical model to assess readiness for implementing TQM.

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.

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.

Recent Iranian Health System Reform: An Operational Perspective to Improve Health Services Quality

The operational management of healthcare services is expected to directly touch patient experiences. Iranian Ministry of Health and Medical Education (MoHME) for the first time, as such, has sought to improve the operational management of healthcare delivery within a reform agenda by setting benchmarks for ‘number of visit per hour’ and waiting time in outpatient clinics of about 700 affiliated hospitals. As a new initiative, it has faced with mixed reactions and various doubts have been cast on its successful implementation. This manuscript aims to shed some light on the operational challenges of the initiative and the requirements of its successful implementation.

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.

Developing and validating a total quality management model for healthcare organisations

Purpose

– The purpose of this paper is to develop a total quality management (TQM) model for healthcare organisations and validate it using a sample of Iranian healthcare organisations.

Design/methodology/approach

– A validated questionnaire was used to collect data from all healthcare organisations that implemented TQM in Isfahan province, Iran.

Findings

– Using the proposed model, TQM implementation was measured in healthcare organisations. The level of TQM success in Isfahan healthcare organisations was medium. The highest score was achieved in the dimension of “customer management”, followed by “leadership” and “employee management”. Employee management, information management, customer management, process management and leadership had the most positive effect on TQM success. Using a series of quality management techniques had “synergistic” effect on TQM success.

Practical implications

– Top management support, effective management of human resources, full involvement of the entire workforce including physicians, education and training, team working, continuous improvement, a corporate quality culture, customer focus and using a combination of management techniques under a quality management system are necessary for TQM successful implementation.

Originality/value

– A healthcare context-specific model of TQM was developed and tested and suggestions were provided for its successful implementation.

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.