Q Manage Health Care Vol. 23, No. 1, pp. 59–63 C 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
The Impact of Critical Total Quality Management Practices on Hospital Performance in the Ministry of Health Hospitals in Saudi Arabia Mohammad Shamsuddin Alaraki, MQM, CPHQ Total Quality Management (TQM) offers a method for solving quality and patient safety problems and bringing significant improvement to hospital performance. However, only few studies have been conducted in this area in developing countries, particularly in Saudi Arabia. This research is carried out in an attempt to address this gap, exploring the impact of applying TQM practices on hospital performance in the Saudi Ministry of Health hospitals. The study has included 4 hospitals in Tabuk Region, namely, King Khaled Hospital, King Fahad Hospital, Maternity and Children Hospital, and Hagel General Hospital. The data collection was done by the researcher when 400 questionnaires were distributed using a convenient sampling technique to access the required data. The response rate was 67.25% of the total questionnaires distributed. The TQM practices used in the study were as follows: leadership, employee management, information analysis, training, customer focus, continuous improvement, process management, and supplier management. The findings of the research show a significant positive correlation between the 8 practices of TQM and hospital performance with a correlation coefficient r value of 0.9 (P = .0001). The study also reveals that Saudi hospitals are facing difficulties in engaging the clinical staff in their quality initiative. Moreover, our findings show that accredited hospitals have significantly applied TQM practices more than unaccredited hospitals.
T
Key words: hospital performance, Saudi Arabia, Total Quality Management
The author declares no conflicts of interest.
he quality and safety of the health care system remain a significant concern in many countries as evidence documenting gaps between actual and recommended practices continues to accumulate.1,2 Evidence suggests that the health care provided for most of the world’s population is of very poor quality and does not meet evidence-based standards.3 Several types of quality problems in health care were reported including variation in services and underuse, overuse, and misuse of services.4 Research has shown occurrence of significant avoidable patient injury in hospitals, increasing the risk of adverse outcomes and higher costs.5,6 The Saudi health care system is not an exception to this global quality and patient safety problem. A shocking reality is that despite the enormous fiscal expenditure and huge resources allocated to the Saudi Ministry of Health (MOH), the quality of care provided falls far away from the optimum.7,8 Health care institutions in Saudi Arabia and across the world encounter many challenges such as customer dissatisfaction, increasing cost of health services, limited resources, aggressive competition, increasing sophistication of medical technologies, and continuous change in the way medicine is practiced.9,10 All of these factors force the health care organizations to
Author Affiliation: Quality Management, King Khaled Hospital, Tabuk, Saudi Arabia. Correspondence: Mohammad Shamsuddin Alaraki, MQM, CPHQ, Quality Management, King Khaled Hospital, Tabuk, Saudi Arabia ([email protected]).
DOI: 10.1097/QMH.0000000000000018
59 Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
60
QUALITY MANAGEMENT
IN
HEALTH CARE/VOLUME 23, ISSUE 1, JANUARY–MARCH 2014
search for a system that can resolve these problems. Total Quality Management (TQM) has thus emerged as a potential solution to improve the efficiency and effectiveness of health care delivery and is becoming increasingly important for the successful operation of public hospitals.9 Total Quality Management is a management philosophy that focuses on the continuous improvement of systems and processes. It is characterized by the design and implementation of organization-wide quality improvement programs based on core principles of customer focus, reduction of variability, continuous improvement, and employee participation.11 Total Quality Management is an organization-wide process, where employees are motivated and empowered to do the right things, right first time and every time, to reflect on what they do and to improve what they do.12-14 The extensive review of the literature shows that the health care organizations that have implemented TQM have achieved mixed results. Many empirical studies suggested that the successful implementation of TQM had resulted in improved employee involvement, improved communication, increased productivity, improved customer satisfaction, and improved competitive advantage.15,16 While other authors argue that despite the substantial resources invested by many organizations to adapt and implement TQM programs, many of them did not achieve any improvement and some only a little. Of the hospitals and services that have implemented TQM, few have had great success and many have found difficulties sustaining their programs.17 It has been suggested that the number of successful implementations of TQM programs may be insignificant when compared with the number of failed implementations.18 Despite this lack of success, many researchers found that TQM programs can improve hospital performance in terms of increased economic efficiency (ie, length of stay, costs, and labor productivity), improved clinical outcomes, improved customer satisfaction, and increased market share.19,20 Reviews of the previous studies on successful TQM show that researchers have identified different sets of practices that are considered essential to the successful implementation of TQM.15,21,22 If these practices are
effectively managed, they will increase the success rate, reduce costs, and prevent disillusionment with continuous improvement programs.23 This study uses 8 critical practices of TQM implementation derived from previous research.15,24,25 These practices comprise the following: top management support and leadership; employee management, which involves employee involvement and employee empowerment; information and analysis; employee education and training; customer focus; continuous improvement; and process management. The aim of this study was to examine the relationship and influence of the critical TQM practices on hospital performance in the Saudi context.
METHODS Design of the study This study was conducted using a quantitative research method to determine the relationship between critical TQM practices and hospital performance in the MOH hospitals in Saudi Arabia. Sampling and data collection procedure The study was conducted in the MOH hospitals in Tabuk region, Saudi Arabia. In the region, there are 14 hospitals in total, 12 of which are MOH hospitals, 1 military hospital, and 1 private hospital. Of the 14 hospitals, 4 hospitals are selected for inclusion in this study, namely, King Khaled Hospital, King Fahad Hospital, Maternity and Children Hospital, and Hagel General Hospital. The reason for selection of these hospitals is because they either are accredited by the Central Board for Accreditation of Healthcare Institutions or are currently involved in the accreditation process. Convenient sampling was the technique used in accessing the respondents of this study. The use of convenience sampling was due to extreme difficulties faced by the researcher in gaining access to the respondents randomly in the 4 selected hospitals. Convenience sampling is appropriate when researchers are confronted with operational, regulatory, logistic, and financial limitations.26
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Impact of TQM Practices on Hospital Performance in Saudi Arabia
The total participant volunteers were 269 representing the staff of the 4 Saudi hospitals selected for this study. Seventy-two participants were from King Khaled Hospital, 63 from King Fahad Hospital, 65 from Maternity and Children Hospital, and 69 from Hagel General Hospital. The instrumentation This study used the questionnaire as the dominant tool for collecting survey information. To develop a suitable research questionnaire, the researcher reviewed several questionnaires used in previous studies. A structured questionnaire was developed using 66 items within 4 practices for hospital performance and 43 items within 8 constructs for total quality management that were adopted and modified from the works of Talib et al,15 Alolayyan et al,21 Arumugam,27 Maliki et al,28 and Sadikoglu and Zehir.29 The relationship between accreditation as an independent factor and the implementation of TQM practices as dependent factor is also added, which makes this study unique on its own.
RESULTS AND ANALYSIS A total of 400 questionnaires were distributed to the participant volunteers representing the staff of 4 Saudi hospitals selected for this study. Two hundred sixty-nine questionnaires were filled and returned by the respondents, with a response rate of (67.3%). Seventy-two participants (26.77%) were from King Khaled Hospital, 63 (23.42%) from King Fahad Hospital, 65 (24.16%) from Maternity and Children Hospital, and 69 (25.65%) from Hagel General Hospital. Counts and percentages were used to summarize all categorical characteristic variables, while means ± standard deviations were used for continuous variables. The 5-point Likert scale was used in the questionnaire with the following values: strongly disagree (1), disagree (2), neither (3), agree (4), and strongly agree (5). Analysis of variance revealed significant association between different hospitals and quality management, as well as significant association between
61
different staff positions and quality management. However, it showed nonsignificant association with other variables including gender, age, education, and experience. Correlation analysis was conducted and revealed direct positive association between total quality management practice and overall hospital performance, with a correlation coefficient r value of 0.9 (P = .0001) (Table).
DISCUSSION The first remarkable finding of our study is that it reveals a significant and positive relationship between TQM as an independent variable and hospital performance as dependent variable, with a correlation coefficient r value of 0.9 (P = .0001). Our findings confirm and support the findings of many researchers in different countries.21,28,30,31 The second important finding of this study is that it shows a significant and positive relationship between each of the 8 critical TQM practices and hospital performance, with a correlation coefficient r value of 0.84 (P = .0001). Many recent studies in different countries around the world indicated that Table ANALYSIS OF THE RELATION BETWEEN TOTAL QUALITY MANAGEMENT PRACTICES AND DIFFERENT AREAS OF PERFORMANCEa Hospital Performance Variables Leadership Training Employee management Information and analysis Supplier management Process management Customer focus Continuous improvement
r
P
0.838 0.758 0.802 0.782 0.739 0.719 0.817 0.612
.0001 .0001 .0001 .0001 .0001 .0001 .0001 .0001
a The
Tukey test showed that some hospitals applied quality management significantly more than the others. See the Figure.
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
62
QUALITY MANAGEMENT
IN
HEALTH CARE/VOLUME 23, ISSUE 1, JANUARY–MARCH 2014
Estimate 180.00
170.00
160.00
150.00
140.00
130.00 King Khalid
King Fahad
Maternaty and Children
Hagel General
Hospital
Figure. The difference in quality management practice within different hospitals.
organizational performance was highly influenced by the effective implementation of TQM practices.15,21,29,30-33 The third important finding is that our results show a significant association between the staff position and quality management practice, with P value of .0024. Nurses and physicians reported the lowest scores in their perception of TQM compared with other hospital staff. These findings support the findings of Berwick and his colleagues,34 who reported that the challenge of involving clinical staff in TQM is pervasive and troublesome for health care organizations. The fourth finding of this study is that it shows that accredited hospitals have applied TQM practices more significantly than unaccredited hospitals (Figure). These results confirm the findings of AlQahtani and his colleagues,35 who found that accredited hospitals performed favorably compared with nonaccredited hospitals in public hospitals in Saudi Arabia.
Limitations Two important study limitations should be noted. The first limitation is that our sample is not statisti-
cally representative of the population of the MOH hospitals in Saudi Arabia. The second limitation is the nonrandom selection of participants. Hence, while our sample appears to be formally representative of the population with respect to several organizational and environmental characteristics, we cannot discount the possibility of sampling bias. This suggests that caution should be taken in generalizing our findings to a specific hospital population. Future research Future research could further explore the relationship between TQM practices and the clinical indicators newly introduced by the Saudi MOH. Another area of interest is the relationship between TQM implementation and patient safety.
REFERENCES 1. Leape LL, Berwick DM. Five years after to err is human: what have we learned? JAMA. 2005;293:2384-2390. 2. Pittet D, Donaldson L. Challenging the world: patient safety and healthcare associated infection. Int J Qual Health Care. 2006;18:4-8. 3. USAID Health Care Improvement Project. The Improvement Collaborative: An Approach to Rapidly Improve Health Care
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Impact of TQM Practices on Hospital Performance in Saudi Arabia
4.
5. 6. 7.
8.
9.
10.
11. 12.
13.
14. 15.
16.
17. 18.
19.
20.
and Scale Up Quality Services. Published by the USAID Health Care Improvement Project. Bethesda, MD: University Research Co LLC (URC); 2008. Agency for Healthcare Research and Quality. Improving Healthcare Quality. Fact Sheet. Rockville, MD: Agency for Healthcare Research and Quality; 2002. AHRQ Publication No. 02-P032. http://www.ahrq.gov/news/qualfact.htm. Accessed March 7, 2012. Leape LL. Error in medicine. JAMA. 1994;272(23):1851-1857. Institute of Medicine. To Err Is Human. Washington, DC: National Academies Press; 1999. Albejaidi FM. Healthcare system in Saudi Arabia: an analysis of structure, total quality management and future challenges. J Altern Perspect Soc Sci. 2010;2(2):794-818. Almalki M, Fitzgerald G, Clark M. Health care system in Saudi Arabia: an overview. East Mediterr Health J. 2011;17(10)784793. Ramseook-Munhurrum P, Munhurrum V, Panchoo A. Total quality management adoption in public hospital: evidence from Mauritius. Global J Bus Res. 2011;5(3):67-77. Dilber M, Bayyurt N, Zaim S, Tarim M. Critical factors of total quality management and its effect on performance in health care industry: a Turkish experience. Probl Perspect Manage. 2005;4:220-234. Oakland JS. Total Quality Management. Oxford, England: Heinemann; 1989. Rowe AK, de Savigny D, Lanata CF, Victora CG. How can we achieve and maintain high-quality performance of health workers in low-resource settings? Lancet. 2005;366:10261035. Rennie W, Phetsouvanh R, Lupisan S, et al. Minimising human error in malaria rapid diagnosis: clarity of written instructions and health worker performance. Trans R Soc Trop Med Hyg. 2007;101(1):9-18. Mohanty RP, Behera AK. TQM in the service sector. Work Study. 1996;45(3):13-17. Talib F, Rahman Z, Qureshi MN. Pareto analysis of total quality management factors critical to success for service industries. Int J Qual Res. 2010;4(2):155-168. Kumar V, Choisne F, Grosbois D, Kumar U. Impact of TQM on company’s performance. Int J Qual Reliability Manage. 2009;26(1):23-37. Øvretveit J. Total quality management in European healthcare. Int J Health Care Qual Assur. 2000;13(2):74-80. Parry S. The missing “M” in TQM. Training. September 1, 1993. http://business.highbeam.com/137618/article-1G114477163/missing-m-tqm. Accessed February 24, 2012. Swinehart K, Ronald F, Green RF. Continuous improvement and TQM in health care: an emerging operational paradigm becomes a strategic imperative. Int J Health Care Qual Assur. 1995;8(1):23-27. Carman JM, Shortell SM, Foster RW, et al. Keys for successful implementation of total quality management in hospitals. Health Care Manage Rev. 2010;35(4):283-293.
63
21. Alolayyan MN, Mohd Ali KA, Idris F. The impact of operational flexibility on hospital performance in Jordanian hospitals: some empirical evidences. J Global Manage. 2011;1(2):3954. 22. Saraph JV, Benson PG, Schroeder RG. An instrument for measuring the critical factors of quality management. Decis Sci. 1989;20(4):810-829. 23. Fryer KJ, Antony J, Douglas A. Critical success factors of continuous improvement in the public sector. TQM Mag. 2007;19(5):497-517. 24. Sila I, Ebrahimpour M. Examination and comparison of the critical factors of total quality management (TQM) across countries. Int J Prod Res. 2003;41(2): 235-268. 25. Talib F, Rahman Z. Critical success factors of total quality management in service organization: a proposed model. Serv Mark Q. 2010;31(3):363-380. 26. Anselmi ML, Peduzzi M, Dos Santos CB. Errors in the administration of intravenous medication in Brazilian hospitals. J Clin Nurs. 2007;16(10):1839-1847. 27. Arumugam VC. Critical success factors of total quality management and their impact on performance of Iranian automotive industry: a theoretical approach. Eur J Econ Finance Adm Sci. 2011;33:25. 28. Maliki SA, Iqbal MZ, Shaukat R, Yong J. TQM practices & organization performance: evidence from Pakistani SMEs. Int J Eng Technol. 2010;10(4):20-25. 29. Sadikoglu E, Zehir C. Investigating the effects of innovation and employee performance on the relationship between TQM practices and firm performance: an empirical study of Turkish firms. Int J Prod Econ. 2010;127: 13-26. 30. Hassan M, Mukhtar A, Qureshi S, Sharif S. Impact of TQM practices on firm’s performance of Pakistan’s manufacturing organizations. Int J Acad Res Bus Soc Sci. 2012;2(10):232259. 31. Yusuf Y, Gunasekaran A, Dan G. Implementation of TQM in China and organizational performance: an empirical investigation. Total Qual Manage. 2007;18(5):509-530. 32. Demirbag M, Tatoglu E, Tekinkus M, Zaim S. An analysis of the relationship between TQM implementation and organizational performance: evidence from Turkish SMEs. Manufact Technol Manage. 2006;17(6):829-847. 33. Zakuan N, Yusof S, Laosirihongthong T, Shaharoun A. Proposed relationship of TQM and organizational performance using structured equation modeling. Total Qual Manage Bus Excell. 2010;21(2):185-203. 34. Berwick DM, Godfrey AB, Roessner J. Curing Health Care. San Francisco, CA: Jossey-Bass; 1990. 35. Al-Qahtani MF, Al-Medaires MA, Al-Dohailan SK, Al-Sharani HT, Al-Dossary NM, Khuridah EN. Quality of care in accredited and nonaccredited hospitals: perceptions of nurses in the Eastern Province, Saudi Arabia. J Egypt Publ Health Assoc. 2012;87(3/4):39-44.
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
The Impact of Critical Total Quality Management Practices on Hospital Performance in the Ministry of Health Hospitals in Saudi Arabia Mohammad Shamsuddin Alaraki, MQM, CPHQ Total Quality Management (TQM) offers a method for solving quality and patient safety problems and bringing significant improvement to hospital performance. However, only few studies have been conducted in this area in developing countries, particularly in Saudi Arabia. This research is carried out in an attempt to address this gap, exploring the impact of applying TQM practices on hospital performance in the Saudi Ministry of Health hospitals. The study has included 4 hospitals in Tabuk Region, namely, King Khaled Hospital, King Fahad Hospital, Maternity and Children Hospital, and Hagel General Hospital. The data collection was done by the researcher when 400 questionnaires were distributed using a convenient sampling technique to access the required data. The response rate was 67.25% of the total questionnaires distributed. The TQM practices used in the study were as follows: leadership, employee management, information analysis, training, customer focus, continuous improvement, process management, and supplier management. The findings of the research show a significant positive correlation between the 8 practices of TQM and hospital performance with a correlation coefficient r value of 0.9 (P = .0001). The study also reveals that Saudi hospitals are facing difficulties in engaging the clinical staff in their quality initiative. Moreover, our findings show that accredited hospitals have significantly applied TQM practices more than unaccredited hospitals.
T
Key words: hospital performance, Saudi Arabia, Total Quality Management
The author declares no conflicts of interest.
he quality and safety of the health care system remain a significant concern in many countries as evidence documenting gaps between actual and recommended practices continues to accumulate.1,2 Evidence suggests that the health care provided for most of the world’s population is of very poor quality and does not meet evidence-based standards.3 Several types of quality problems in health care were reported including variation in services and underuse, overuse, and misuse of services.4 Research has shown occurrence of significant avoidable patient injury in hospitals, increasing the risk of adverse outcomes and higher costs.5,6 The Saudi health care system is not an exception to this global quality and patient safety problem. A shocking reality is that despite the enormous fiscal expenditure and huge resources allocated to the Saudi Ministry of Health (MOH), the quality of care provided falls far away from the optimum.7,8 Health care institutions in Saudi Arabia and across the world encounter many challenges such as customer dissatisfaction, increasing cost of health services, limited resources, aggressive competition, increasing sophistication of medical technologies, and continuous change in the way medicine is practiced.9,10 All of these factors force the health care organizations to
Author Affiliation: Quality Management, King Khaled Hospital, Tabuk, Saudi Arabia. Correspondence: Mohammad Shamsuddin Alaraki, MQM, CPHQ, Quality Management, King Khaled Hospital, Tabuk, Saudi Arabia ([email protected]).
DOI: 10.1097/QMH.0000000000000018
59 Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
60
QUALITY MANAGEMENT
IN
HEALTH CARE/VOLUME 23, ISSUE 1, JANUARY–MARCH 2014
search for a system that can resolve these problems. Total Quality Management (TQM) has thus emerged as a potential solution to improve the efficiency and effectiveness of health care delivery and is becoming increasingly important for the successful operation of public hospitals.9 Total Quality Management is a management philosophy that focuses on the continuous improvement of systems and processes. It is characterized by the design and implementation of organization-wide quality improvement programs based on core principles of customer focus, reduction of variability, continuous improvement, and employee participation.11 Total Quality Management is an organization-wide process, where employees are motivated and empowered to do the right things, right first time and every time, to reflect on what they do and to improve what they do.12-14 The extensive review of the literature shows that the health care organizations that have implemented TQM have achieved mixed results. Many empirical studies suggested that the successful implementation of TQM had resulted in improved employee involvement, improved communication, increased productivity, improved customer satisfaction, and improved competitive advantage.15,16 While other authors argue that despite the substantial resources invested by many organizations to adapt and implement TQM programs, many of them did not achieve any improvement and some only a little. Of the hospitals and services that have implemented TQM, few have had great success and many have found difficulties sustaining their programs.17 It has been suggested that the number of successful implementations of TQM programs may be insignificant when compared with the number of failed implementations.18 Despite this lack of success, many researchers found that TQM programs can improve hospital performance in terms of increased economic efficiency (ie, length of stay, costs, and labor productivity), improved clinical outcomes, improved customer satisfaction, and increased market share.19,20 Reviews of the previous studies on successful TQM show that researchers have identified different sets of practices that are considered essential to the successful implementation of TQM.15,21,22 If these practices are
effectively managed, they will increase the success rate, reduce costs, and prevent disillusionment with continuous improvement programs.23 This study uses 8 critical practices of TQM implementation derived from previous research.15,24,25 These practices comprise the following: top management support and leadership; employee management, which involves employee involvement and employee empowerment; information and analysis; employee education and training; customer focus; continuous improvement; and process management. The aim of this study was to examine the relationship and influence of the critical TQM practices on hospital performance in the Saudi context.
METHODS Design of the study This study was conducted using a quantitative research method to determine the relationship between critical TQM practices and hospital performance in the MOH hospitals in Saudi Arabia. Sampling and data collection procedure The study was conducted in the MOH hospitals in Tabuk region, Saudi Arabia. In the region, there are 14 hospitals in total, 12 of which are MOH hospitals, 1 military hospital, and 1 private hospital. Of the 14 hospitals, 4 hospitals are selected for inclusion in this study, namely, King Khaled Hospital, King Fahad Hospital, Maternity and Children Hospital, and Hagel General Hospital. The reason for selection of these hospitals is because they either are accredited by the Central Board for Accreditation of Healthcare Institutions or are currently involved in the accreditation process. Convenient sampling was the technique used in accessing the respondents of this study. The use of convenience sampling was due to extreme difficulties faced by the researcher in gaining access to the respondents randomly in the 4 selected hospitals. Convenience sampling is appropriate when researchers are confronted with operational, regulatory, logistic, and financial limitations.26
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Impact of TQM Practices on Hospital Performance in Saudi Arabia
The total participant volunteers were 269 representing the staff of the 4 Saudi hospitals selected for this study. Seventy-two participants were from King Khaled Hospital, 63 from King Fahad Hospital, 65 from Maternity and Children Hospital, and 69 from Hagel General Hospital. The instrumentation This study used the questionnaire as the dominant tool for collecting survey information. To develop a suitable research questionnaire, the researcher reviewed several questionnaires used in previous studies. A structured questionnaire was developed using 66 items within 4 practices for hospital performance and 43 items within 8 constructs for total quality management that were adopted and modified from the works of Talib et al,15 Alolayyan et al,21 Arumugam,27 Maliki et al,28 and Sadikoglu and Zehir.29 The relationship between accreditation as an independent factor and the implementation of TQM practices as dependent factor is also added, which makes this study unique on its own.
RESULTS AND ANALYSIS A total of 400 questionnaires were distributed to the participant volunteers representing the staff of 4 Saudi hospitals selected for this study. Two hundred sixty-nine questionnaires were filled and returned by the respondents, with a response rate of (67.3%). Seventy-two participants (26.77%) were from King Khaled Hospital, 63 (23.42%) from King Fahad Hospital, 65 (24.16%) from Maternity and Children Hospital, and 69 (25.65%) from Hagel General Hospital. Counts and percentages were used to summarize all categorical characteristic variables, while means ± standard deviations were used for continuous variables. The 5-point Likert scale was used in the questionnaire with the following values: strongly disagree (1), disagree (2), neither (3), agree (4), and strongly agree (5). Analysis of variance revealed significant association between different hospitals and quality management, as well as significant association between
61
different staff positions and quality management. However, it showed nonsignificant association with other variables including gender, age, education, and experience. Correlation analysis was conducted and revealed direct positive association between total quality management practice and overall hospital performance, with a correlation coefficient r value of 0.9 (P = .0001) (Table).
DISCUSSION The first remarkable finding of our study is that it reveals a significant and positive relationship between TQM as an independent variable and hospital performance as dependent variable, with a correlation coefficient r value of 0.9 (P = .0001). Our findings confirm and support the findings of many researchers in different countries.21,28,30,31 The second important finding of this study is that it shows a significant and positive relationship between each of the 8 critical TQM practices and hospital performance, with a correlation coefficient r value of 0.84 (P = .0001). Many recent studies in different countries around the world indicated that Table ANALYSIS OF THE RELATION BETWEEN TOTAL QUALITY MANAGEMENT PRACTICES AND DIFFERENT AREAS OF PERFORMANCEa Hospital Performance Variables Leadership Training Employee management Information and analysis Supplier management Process management Customer focus Continuous improvement
r
P
0.838 0.758 0.802 0.782 0.739 0.719 0.817 0.612
.0001 .0001 .0001 .0001 .0001 .0001 .0001 .0001
a The
Tukey test showed that some hospitals applied quality management significantly more than the others. See the Figure.
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
62
QUALITY MANAGEMENT
IN
HEALTH CARE/VOLUME 23, ISSUE 1, JANUARY–MARCH 2014
Estimate 180.00
170.00
160.00
150.00
140.00
130.00 King Khalid
King Fahad
Maternaty and Children
Hagel General
Hospital
Figure. The difference in quality management practice within different hospitals.
organizational performance was highly influenced by the effective implementation of TQM practices.15,21,29,30-33 The third important finding is that our results show a significant association between the staff position and quality management practice, with P value of .0024. Nurses and physicians reported the lowest scores in their perception of TQM compared with other hospital staff. These findings support the findings of Berwick and his colleagues,34 who reported that the challenge of involving clinical staff in TQM is pervasive and troublesome for health care organizations. The fourth finding of this study is that it shows that accredited hospitals have applied TQM practices more significantly than unaccredited hospitals (Figure). These results confirm the findings of AlQahtani and his colleagues,35 who found that accredited hospitals performed favorably compared with nonaccredited hospitals in public hospitals in Saudi Arabia.
Limitations Two important study limitations should be noted. The first limitation is that our sample is not statisti-
cally representative of the population of the MOH hospitals in Saudi Arabia. The second limitation is the nonrandom selection of participants. Hence, while our sample appears to be formally representative of the population with respect to several organizational and environmental characteristics, we cannot discount the possibility of sampling bias. This suggests that caution should be taken in generalizing our findings to a specific hospital population. Future research Future research could further explore the relationship between TQM practices and the clinical indicators newly introduced by the Saudi MOH. Another area of interest is the relationship between TQM implementation and patient safety.
REFERENCES 1. Leape LL, Berwick DM. Five years after to err is human: what have we learned? JAMA. 2005;293:2384-2390. 2. Pittet D, Donaldson L. Challenging the world: patient safety and healthcare associated infection. Int J Qual Health Care. 2006;18:4-8. 3. USAID Health Care Improvement Project. The Improvement Collaborative: An Approach to Rapidly Improve Health Care
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Impact of TQM Practices on Hospital Performance in Saudi Arabia
4.
5. 6. 7.
8.
9.
10.
11. 12.
13.
14. 15.
16.
17. 18.
19.
20.
and Scale Up Quality Services. Published by the USAID Health Care Improvement Project. Bethesda, MD: University Research Co LLC (URC); 2008. Agency for Healthcare Research and Quality. Improving Healthcare Quality. Fact Sheet. Rockville, MD: Agency for Healthcare Research and Quality; 2002. AHRQ Publication No. 02-P032. http://www.ahrq.gov/news/qualfact.htm. Accessed March 7, 2012. Leape LL. Error in medicine. JAMA. 1994;272(23):1851-1857. Institute of Medicine. To Err Is Human. Washington, DC: National Academies Press; 1999. Albejaidi FM. Healthcare system in Saudi Arabia: an analysis of structure, total quality management and future challenges. J Altern Perspect Soc Sci. 2010;2(2):794-818. Almalki M, Fitzgerald G, Clark M. Health care system in Saudi Arabia: an overview. East Mediterr Health J. 2011;17(10)784793. Ramseook-Munhurrum P, Munhurrum V, Panchoo A. Total quality management adoption in public hospital: evidence from Mauritius. Global J Bus Res. 2011;5(3):67-77. Dilber M, Bayyurt N, Zaim S, Tarim M. Critical factors of total quality management and its effect on performance in health care industry: a Turkish experience. Probl Perspect Manage. 2005;4:220-234. Oakland JS. Total Quality Management. Oxford, England: Heinemann; 1989. Rowe AK, de Savigny D, Lanata CF, Victora CG. How can we achieve and maintain high-quality performance of health workers in low-resource settings? Lancet. 2005;366:10261035. Rennie W, Phetsouvanh R, Lupisan S, et al. Minimising human error in malaria rapid diagnosis: clarity of written instructions and health worker performance. Trans R Soc Trop Med Hyg. 2007;101(1):9-18. Mohanty RP, Behera AK. TQM in the service sector. Work Study. 1996;45(3):13-17. Talib F, Rahman Z, Qureshi MN. Pareto analysis of total quality management factors critical to success for service industries. Int J Qual Res. 2010;4(2):155-168. Kumar V, Choisne F, Grosbois D, Kumar U. Impact of TQM on company’s performance. Int J Qual Reliability Manage. 2009;26(1):23-37. Øvretveit J. Total quality management in European healthcare. Int J Health Care Qual Assur. 2000;13(2):74-80. Parry S. The missing “M” in TQM. Training. September 1, 1993. http://business.highbeam.com/137618/article-1G114477163/missing-m-tqm. Accessed February 24, 2012. Swinehart K, Ronald F, Green RF. Continuous improvement and TQM in health care: an emerging operational paradigm becomes a strategic imperative. Int J Health Care Qual Assur. 1995;8(1):23-27. Carman JM, Shortell SM, Foster RW, et al. Keys for successful implementation of total quality management in hospitals. Health Care Manage Rev. 2010;35(4):283-293.
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21. Alolayyan MN, Mohd Ali KA, Idris F. The impact of operational flexibility on hospital performance in Jordanian hospitals: some empirical evidences. J Global Manage. 2011;1(2):3954. 22. Saraph JV, Benson PG, Schroeder RG. An instrument for measuring the critical factors of quality management. Decis Sci. 1989;20(4):810-829. 23. Fryer KJ, Antony J, Douglas A. Critical success factors of continuous improvement in the public sector. TQM Mag. 2007;19(5):497-517. 24. Sila I, Ebrahimpour M. Examination and comparison of the critical factors of total quality management (TQM) across countries. Int J Prod Res. 2003;41(2): 235-268. 25. Talib F, Rahman Z. Critical success factors of total quality management in service organization: a proposed model. Serv Mark Q. 2010;31(3):363-380. 26. Anselmi ML, Peduzzi M, Dos Santos CB. Errors in the administration of intravenous medication in Brazilian hospitals. J Clin Nurs. 2007;16(10):1839-1847. 27. Arumugam VC. Critical success factors of total quality management and their impact on performance of Iranian automotive industry: a theoretical approach. Eur J Econ Finance Adm Sci. 2011;33:25. 28. Maliki SA, Iqbal MZ, Shaukat R, Yong J. TQM practices & organization performance: evidence from Pakistani SMEs. Int J Eng Technol. 2010;10(4):20-25. 29. Sadikoglu E, Zehir C. Investigating the effects of innovation and employee performance on the relationship between TQM practices and firm performance: an empirical study of Turkish firms. Int J Prod Econ. 2010;127: 13-26. 30. Hassan M, Mukhtar A, Qureshi S, Sharif S. Impact of TQM practices on firm’s performance of Pakistan’s manufacturing organizations. Int J Acad Res Bus Soc Sci. 2012;2(10):232259. 31. Yusuf Y, Gunasekaran A, Dan G. Implementation of TQM in China and organizational performance: an empirical investigation. Total Qual Manage. 2007;18(5):509-530. 32. Demirbag M, Tatoglu E, Tekinkus M, Zaim S. An analysis of the relationship between TQM implementation and organizational performance: evidence from Turkish SMEs. Manufact Technol Manage. 2006;17(6):829-847. 33. Zakuan N, Yusof S, Laosirihongthong T, Shaharoun A. Proposed relationship of TQM and organizational performance using structured equation modeling. Total Qual Manage Bus Excell. 2010;21(2):185-203. 34. Berwick DM, Godfrey AB, Roessner J. Curing Health Care. San Francisco, CA: Jossey-Bass; 1990. 35. Al-Qahtani MF, Al-Medaires MA, Al-Dohailan SK, Al-Sharani HT, Al-Dossary NM, Khuridah EN. Quality of care in accredited and nonaccredited hospitals: perceptions of nurses in the Eastern Province, Saudi Arabia. J Egypt Publ Health Assoc. 2012;87(3/4):39-44.
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