European Scientific Journal April 2015 edition vol.11, No.
10 ISSN: 1857 – 7881 (Print) e - ISSN 1857- 7431
THE IMPACT OF APPLYING TOTAL QUALITY
MANAGEMENT PRINCIPLES ON THE OVERALL
HOSPITAL EFFECTIVENESS: AN EMPIRICAL
STUDY ON THE HCAC ACCREDITED
GOVERNMENTAL HOSPITALS IN JORDAN
Abd El-Moneim A. El-Tohamy
Professor, Finance and Investment, Faculty of
Commerce and Business Administration, Helwan University, Egypt
Atef T Al Raoush
PhD, Hospital Management, Faculty of Commerce and Business
Administration, Helwan University, Egypt
Abstract
The present study was conducted to bring the attention to the
importance of applying total quality management (TQM) and their effects on
organizational effectiveness, and particularly the hospital effectiveness. The
main objective of the present study was to investigate the impact of applying
TQM on the overall hospital effectiveness in the accredited governmental
hospitals in Jordan that accredited from Health Care Accreditation Council
(HCAC). The study population represented all health care professionals
working in the five HCAC accredited governmental hospitals who were
working for more than three years in the same hospitals. Study sample
included 1290 employees. The response rate was 83.6 % of the total
questionnaires distributed. TQM principles were: Leadership commitment to
quality, Customer focus, Continuous improvement, Teamwork, Employee
involvement, education and training. Study findings showed a significant
impact of all TQM principles on the overall hospital effectiveness (p< 0.05).
Using multiple linear regression analysis showed that TQM is a strong
predictor of hospital performance (Beta =0.818, t=46.613, R2= 0.669, and p
value = 0.000). Taken together, applying the principles of TQM increases
the overall hospital effectiveness in the HCAC accredited governmental
hospitals in Jordan.
Keywords: Total quality management, organizational effectiveness, hospital
effectiveness, Accreditation, Health Care Accreditation Council, Jordan.
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Introduction
Total Quality Management (TQM) is a management approach of an
organization centered on quality based on the participation of all of its
members aiming at long term success through customer satisfaction and
benefits to all members of the organization and to the society (ISO 8402,
2009). Accordingly, TQM is an approach to continuously improving the
quality of all the organizations, processes, products and services (Kotler,
2000).
TQM is based on a set of principles that seek to increase
stakeholders' satisfaction through best use of organizational resources. But
the impact of each of quality management principles on organizational
effectiveness is still debated. Several studies have investigated the impact of
applying TQM principles on overall organizational effectiveness and
performance. Many studies has found a strong and positive relationship with
performance, There is a general agreement that a successful TQM
implementation is leading to improve organization effectiveness (Hendricks
and Singhal, 2001; Hansson and Eriksson, 2002; Brah et al., 2002; and
Kaynak, 2003).
The success implementation of TQM in industry has encouraged
healthcare leaders to study whether it can be implemented in the healthcare
sector. Studies indicate that the TQM activites leads to improve patient
satisfaction, increased productivity, increase profitability, and improved
health care organization performance. (Alexander et al., 2006; Macinati.,
2008).
Principles of Total quality Management (TQM)
Several studies have addressed implementation failures to include the
selection of wrong TQM principles (Ahire, 1996), the lack of understanding
about the role of leadership competencies for implementing TQM principles
(Perles, 2002), and the lack of information about linkages between TQM
principles (Srdoc, Sluga, and Bratko, 2005).
Several studies suggested the existence of various principles of TQM
that are considered critical prerequisites to successful TQM implementation:
1. Leadership/top management commitment, as identified by (Rahman,
2001; Brah et al., 2002; Prajogo and Sohal, 2003; Karuppusami and
Gandhinathan, 2006; Tari et al., 2006; Sila, 2007; Ou et al, 2007; Al-
Khalifa et al., 2008; Salaheldin, 2009; Arumugam and
Mojtahedzadeh, 2011; Zehir et al., 2012).
2. Customer focus, as identified by ((Karuppusami and Gandhinathan,
2006; Tari et al., 2006; Ou et al, 2007; Sila, 2007; Al-Khalifa et
al.,2008; Arumugam and Mojtahedzadeh, 2011; Zehir et al., 2012).
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3. Teamwork, as identified by (Brah and Lim, 2006; Karuppusami and
Gandhinathan, 2006; Tari et al., 2006; Ou et al., 2007; Sila, 2007; Al-
Khalifa et al., 2008; Arumugam and Mojtahedzadeh, 2011).
4. Continuous improvement, as identified by (Talavera, 2004; Zehir et
al., 2012).
5. Employee involvement, identified by ((Talavera, 2004), (Zehir et al.,
2012)).
6. Education and training, as identified by (Demirbag, 2006;
Karuppusami and Gandhinathan, 2006; Fryer et al., 2007; Al-Khalifa
et al., 2008; Salaheldin, 2009; Arumugam and Mojtahedzadeh, 2011;
Malik and Khan, 2011).
According to the point of view of some researchers, organizations
need a quality system and quality culture in the organization, and they
provide the core assumptions of TQM as a philosophy of management which
organizes, plans and continuously improves activities in which management
and employees have to participate to improve processes and outputs. Thus,
TQM is presented differently in different points of view, as there is no
general and formal definition of TQM which can fit or be implemented in all
organizations within all sectors. TQM definitions are different in each region
and each country, based on national and organizational culture and
perception of quality, and the requirement of that culture. In general,
however, it is preserved as a management philosophy and the majority of
authors relate the main role of TQM implementation to the management
level of commitment towards quality improvement (Wikipedia, 2015).
Impact of TQM on Organizational Effectiveness
The impact of each of quality management principles on
organizational effectiveness and performance is still debated. Several studies
have investigated the impact of applying TQM principles on overall
organizational effectiveness and performance. Large number of these studies
have indicated a strong and positive relations with Quality performance
(Terziovski and Samson 2000; Hendricks and Singhal 2001; Brah et al.,
2002; Kaynak 2003; Prajogo and Sohal, 2003; Rahman and Bullock, 2005;
Nair, 2006); Lakhal, Pasin, and Limam 2006; Sila 2007; Kumar et al., 2009;
Lam et al. 2011; Zehir et al., 2012; Gimenez et al., 2013).
Kaynak (2003) stressed that TQM practices are related to the
indicators of quality performance. Likewise, Kumar et al. (2009) concluded
that quality improvement in process, product and service quality resulting
from TQM activities, also Abdullah et al (2008) emphasized that
organizational performance increases when organizations implement more
TQM practices.
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In addition, there are empirical studies that measure organization
performance by TQM criteria (Wilson and Collier, 2000; Fynes and Voss,
2001; Montes et al., 2003; Sila and Ebrahimpour, 2005). These studies
investigate a variety of theoretical and empirical issues. If TQM activities are
implemented in proper way, it produces impact on organizational
performance including improved customer satisfaction, enhanced internal
communication, better problem solving and fewer errors.
In a study by Hendricks and Singhal (2001), the researchers
empirically investigate a causal link between applying TQM and
organization performance by demonstrating the significant performance
difference between the organizations that implemented TQM and the
organizations in the control group, the result showed a significant
relationship between applying quality management practices and
organizational performance.
TQM and Hospital Effectiveness
JCAHO (Joint Commission on Accreditation of Health care
Organizations) put emphasis on performance assessment and investigative
methodologies directed to improve patient health care outcomes and lead to
improve the effectiveness. Performance improvement in health care was
defined by JCI as: “Performance Improvement is continuous change to
improve process through measuring services, identifying areas for
improvement and developing improvements through multidisciplinary
teamwork. The goal of performance improvement is to support a
collaborative approach to patient centered care that focuses on improving
safety, performance, patient outcomes and identifying and promoting best
practices.” JCI (2013).
Hospitals have tried several approaches or modules for quality
improvement to document their effectiveness. In these days, hospitals work
to fulfill several goals which are directed towards serving customers
effectively and efficiently as stated by Minvielle et al. (2008). Hospital
performance obviously shows the output of the health care services which
are reflected obviously and effectively on the patients. Performance
measurement is an important instrument for evaluating overall quality of
health care service which should be carrying out in every unit and
department of the hospital as it reflects the overall quality (Duggirala et al.,
2008).
A variety of international organizations, which evaluate National
Health Care Systems, in addition offering certification and accreditation
processes, measure the performance of health structures in different
countries, taking into consideration three main quality dimensions:
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effectiveness, efficiency and customer satisfaction (Kaplan, and Roberts,
2001).
Deborah (2010) stressed that Health Care managers impact hospital
performance to create stability within the organizational structure, to
develop, implement, and sustain an environment of growth and competitive
advantage. Moreover Shipton et al (2008), stated that "Organizational leaders
shape effective quality performance outcomes by determining a vision and
developing a commitment by health care individuals and teams which
influences positive performance on quality activities set by the health care
organization".
There is a common agreement that a successful TQM implementation
is leading to improve organization performance success (Hendricks and
Singhal, 2001; Hansson and Eriksson, 2002; Brah et al., 2002; and Kaynak,
2003). The success implementation of TQM in manufacturing has
encouraged health care leaders to study whether it can be implemented in the
healthcare sector. The TQM activities lead to high quality health care
services, for example it leads to improve patient satisfaction, and increased
productivity and profitability, improved health care organization
performance. (Alexander et al., 2006; Macinati., 2008).
Methods and subjects
Design of the study
A cross sectional, quantitative design was employed.
Study Population and Sample
The study population represented all health care professionals
working in the five HCAC accredited governmental hospitals who were
working for more than three years in the same hospital. Study sample
included 1290 employees. Returned questionnaires were 1079, and the
response rate was 83.6%. Study sample included various health professionals
such as:
hospital managers, assistant hospital managers, heads of departments and
units, supervisors, physicians, dentists, pharmacists, pharmacist assistant,
staff nurses, midwifes, associated nurses, nurse assistants, nutritionists, lab
technicians, radiology technicians, anesthetic technicians, and sterilization
technicians.
Study Instrument
A structured questionnaire was used, consisting from three parts;
demographic data, total quality management, and hospital effectiveness
which was accompanied with a cover letter that contained a brief summary
of the study purpose and confidential considerations. The demographic data
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included (age, sex, profession, and experience), The second part consisted of
35 items within 6 constructs for total quality management principles, and the
third part consists from 20 items within one construct for overall hospital
effectiveness. Several similar studies were reviewed to construct the
questionnaire (Lai, 2003; Talavera, 2005; Demirbag et al., 2006; Sadikoglu
and Zehir, 2010; Khairul et al., 2012; Ul Hassan et al., 2012).
Validity and Reliability of the study instrument:
Tool validity was tested through taking into account questions
totalitarian and avoiding duplication, in addition the questionnaire had been
reviewed by academic and technical specialists to ensure its effectiveness.
The researcher conducted two pilot studies to identify the degree of
clarity and understanding of the questionnaire paragraphs from the
respondent viewpoint, also to determine possible problems with the design
and instrument used in this study. A convenience sample of 30 health care
workers was obtained using the identical selected criteria as planned for the
main study. All requirements for informed consent were met in the oral and
written explanation to the participants. The collection of data followed the
format identified in the main study and was found to be effective. The first
pilot study conducted, Cronbach's Alpha was calculated, in addition the
participants were asked about their opinions about understanding of
questionnaire statements, and to provide a feedback, comments and
suggestions. After receiving the feedback from the participant; the researcher
found that there was a need to do minor revisions in wording of several
questions and refinements in overall format so as to increase readability and
ease of answering. After one month the researcher asked the same participant
to fill the modified questionnaire, Cronbach's Alpha was calculated (table 1).
Participants reported that the wording of the instruments and the instructions
were clear, and then the questionnaire appears in its final form.
Table 1: the reliability of the study main dimensions
Factor Number Cronbach's α for Cronbach's α for
of items first version second version
TQM Principles:
Organizational commitment to 12 0.86 0.88
quality
Customer focus organization 5 0.84 0.86
Employee Involvement 4 0.77 0.82
Teamwork 5 0.86 0.88
Continuous Improvement 4 0.61 0.71
Education and training 5 0.88 0.89
Hospital Effectiveness
Overall Hospital effectiveness 20 0.92 0.92
Total Cronbach's Alpha 0.82 0.85
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As shown in table 1, the reliability test value revealed that; all values
of Cronbach's alpha coefficient were greater than 0.6 which is the minimum
accepted value especially in social sciences.
Data Analysis
Data was represented as frequency and percentages for general
characteristics of study participants. The impact of TQM on hospital
effectiveness was tested using multiple regression analysis.
Study Findings
Distribution of study participants by study hospitals
The study participants included 1079 participants who were recruited
from five hospitals: Prince Hamza Hospital (24%), Prince Hussein Hospital
(21.3%), Princess Rahma Hospital (20.2%), Princess Badea’ Hospital
(19.9%), and Al- Shuneh South Hospital (14.6%) (table 2).
Table 2: Distribution of study participants by study hospitals
Hospital Frequency Percentage
Prince Hamza Hospital 259 24.0 %
Prince Hussein Hospital 230 21.3 %
Princess Rahma Hospital 218 20.2 %
Princess Badea’ Hospital 215 19.9 %
Al- Shuneh South Hospital 157 14.6 %
Total 1079 100 %
General characteristics of participants
About 39% of participants were males, whereas about 61% were
females. Within the age interval 20-35 years, there were 47.5% of
participants, this percentage slightly decreased in the age interval 36-50
years (44.9%), but dramatic decrease in percentage of participants occurred
in the age interval 51-65 years (7.9%). Education level of participants ranged
from diploma (36.4%), bachelor (53.8%), and the lowest percentage (9.8%)
was among participants with higher education. Experience years of
participants ranged from 3-5 years (22.5%), 6-10 years (29.6%), 11-15 years
(21.8%), 16-20 years (13.5%), 21-25 years (7.2%), and more than 25 years
(5.4%). According to profession of participants, there were 0.5% hospital
directors, 0.4% hospital director assistants, 9.6% heads of unit, 2.6%
supervisors, 10.8% physicians, 0.8% dentists, 4.4% pharmacists, 2.1%
pharmacist assistants, 31.6% staff nurses, 8.3% midwifes, 11.2% associate
nurse, 4.6% nurse assistants, 5.8% laboratory technicians, 3.6% radiology
technicians, 2.1% anesthetic technicians, 0.7% sterilization technicians, and
0.6% nutritionist (table 3).
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Table 3: General characteristics of participants
Variable Frequency Percentage
Gender
Male 422 39.1
Female 657 60.9
Age (years)
20-35 513 47.5
36-50 484 44.9
51-65 82 7.9
Education
Diploma 393 36.4
Bachelor 580 53.8
Higher education 106 9.8
Experience (years)
3-5 243 22.5
6-10 319 29.6
11-15 235 21.18
16-20 146 13.5
21-25 78 7.2
> 25 58 5.4
Profession
Hospital manager (Director) 5 0.5
Hospital manager assistants 4 0.4
Head of unit 104 9.6
Supervisor 28 2.6
Physician 117 10.8
Dentist 9 0.8
Pharmacist 47 4.4
Pharmacist assistant 23 2.1
Staff nurse 341 31.6
Midwife 90 8.3
Associated nurse 121 11.2
Nurse assistant 50 4.6
Lab technician 63 5.8
Radiology technician 39 3.6
Anesthetic technician 23 2.1
Sterilization technician 8 0.7
Nutritionist 7 0.6
Results of Testing Hypothesis
The main hypothesis is:
H1: There is statistically significant impact of the applying TQM
principles on the overall hospital effectiveness, as perceived by healthcare
professionals at the accredited governmental hospitals in Jordan.
To test the primary hypothesis, we used multiple regression analysis.
As shown in table (4), there was a positive correlation between TQM
principles and overall hospital effectiveness (B =0.881, t= 46.61, R= 0.818,
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R2 =0.669, F=2172.78, p=0.000). Furthermore, the regression equation
predicted almost 66.9% contribution of total quality management to Hospital
effectiveness in the accredited governmental hospitals in Jordan.
Table 4: The impact of applying TQM principles on overall hospital effectiveness
Dependant Variable (Overall Hospital Effectiveness)
Sig(t
t-
Independent R* Be Sig( ) Decisi
R2 B F valu VIF
Variables * ta F) p- on
e
(TQM value
Principles) .81 .66 0.8 .81 2172.7 0.00 46.6 1.0 Accept
.000
8 9 81 8 84 0 13 00 ed
** Correlation is significant at the 0.05 level (2-tailed).
Discussion
This study purposed to find out the impact of applying Total Quality
Management (TQM) on over all hospital effectiveness in the accredited
governmental hospitals in Jordan. Several studies have argued that TQM
principles should be applied in every organization (Li et al., 2006). It has
been emphasized that all departments have to collaborate together to
accomplish the required level of the performance throughout TQM
implementation, and it is not just top management responsibility, or quality
unit, it is an integration of leadership commitment, employees involvement,
team work, continuous improvement to provide high quality outcomes which
include customer satisfaction (Li et al., 2006). According to a study of
Salameh, Alzyadat, and Alnsour (2011), the adoption of TQM as a modern
approach still limited in the Arab countries. Teamwork, continuous
improvement, integrated coordination, creativity and innovation are the bases
of TQM philosophy. The competent administrative leadership is the
backbone for implementing (TQM) methodology.
The findings of the present study revealed a significant positive
relationship between TQM principles and hospital effectiveness. This finding
confirmed and supported the findings of other studies including (Brah et al.,
2000; Terziovski and Samson, 2000; Hendricks and Singhal, 2001; Brah et
al., 2002; Kaynak, 2003; Prajogo and Sohal, 2003; Rahman and Bullock,
2005; Demirbag et al., 2006; Lakhal, Pasin, and Limam 2006; Nair, 2006;
Sila, 2007; Abdullah et al., 2008; Kumar et al., 2009; Sadikoglu, 2010; Lam
et al., 2011; Khairul et al., 2012; Ul Hassan et al., 2012; Zehir et al., 2012;
Gimenez-Espin, Jiménez-Jiménez, and Martinez Costa 2013). All of these
studies found that TQM has a significant positive relationship with
organizational performance and effectiveness in direct or in indirect way.
The findings of the study also revealed that total quality management
principles had a significant positive impact on hospital effectiveness in the
HCAC accredited governmental hospital in Jordan which led to an increase
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in the hospital performance. This finding supported the findings of other
studies such as (Yusuf et al., 2007; Eker and Pala, 2008; Zakuan et al., 2009;
Irefin, Abdul-Azeez, Hammed, 2011; Khairul et al., 2012; Ul Hassan et al.,
2012), in which their findings showed that TQM had a positive impact on
the organizational effectiveness and performance. The findings emphasized
that the importance of adapting TQM philosophy as a managerial approach
and using accreditation as a tool for quality improvement in the health care
sector.
Conclusion
Implementation of TQM principles on health organizations has
positive impacts in the overall hospital effectiveness.
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