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1/19/2016 AcomparativestudyoftotalqualitymanagementofhealthcaresysteminIndiaandIran

BMCResNotes.20114:566. PMCID:PMC3260328
Publishedonline2011Dec28.doi:10.1186/175605004566

AcomparativestudyoftotalqualitymanagementofhealthcaresysteminIndiaand
Iran
AliMoradHeidariGorji 1andJamalAFarooquie1
1
DepartmentofBusinessAdministration,AligarhMuslimUniversity(AMU),Aligarh,India
Correspondingauthor.
AliMoradHeidariGorji:alifar_2004@yahoo.comJamalAFarooquie:jamalfarooquie@yahoo.co.in

Received2011Oct29Accepted2011Dec28.

Copyright2011GorjiandFarooquielicenseeBioMedCentralLtd.

ThisisanOpenAccessarticledistributedunderthetermsoftheCreativeCommonsAttributionLicense(http://creativecommons.org/licenses/by/2.0),
whichpermitsunrestricteduse,distribution,andreproductioninanymedium,providedtheoriginalworkisproperlycited

ThisarticlehasbeencitedbyotherarticlesinPMC.

Abstract Goto:

Background

Totalqualitymanagement(TQM)hasagreatpotentialtoaddressqualityproblemsinawiderangeofindustries
andimprovetheorganizationalperformance.Thegrowingneedtotakeinitiativesbyhospitalsincountrieslike
IndiaandIrantoimprovetheservicequalityandreducewastageofresourceshasinspiredtheauthorstodevelopa
surveyinstrumenttomeasurehealthcarequalityandperformanceinthetwocountries.

Methods

BasedontheBaldrigehealthcarecriteriaforperformanceexcellence20092010andtheguidelinesproposedby
theAmericanHospitalsAssociationforhospitalsinpursuitofexcellence,comparedhealthcareservicesinthree
countries.ThedataarecollectedfromthecapitalcitiesandtheirnearbyplacesinIndiaandIran.UsingANOVAs,
threegroupsinqualityplanningandperformancehavebeencompared.

Result

ResultsshowedthereissignificantlydifferencebetweengroupsandinnocasethehospitalsfromIndiaandIranare
foundscoringclosetothebenchmarks.TheaveragescoresofIndianandIranianhospitalsondifferentconstructsof
theIHCQPMmodelarecomparedwiththemajorresultsachievedbytherecipientsoftheMBNQaward.

Conclusion

InnocasethehospitalsfromIndiaandIranarefoundscoringclosetothebenchmarks(Baldrigehealthcarecriteria
forperformanceexcellence20092010andtheguidelinesproposedbytheAmericanHospitalsAssociationfor
hospitals).Theseresultssuggestedtohealthcareservicesmoreattempttoachievehighqualityinmanagementand
performance.

Background Goto:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3260328/ 1/6
1/19/2016 AcomparativestudyoftotalqualitymanagementofhealthcaresysteminIndiaandIran

Goodhealth,responsivenesstotheexpectationsofitspeople,andfinancialcontributiontothenationarethegoals
forhealthcaresystemsofacountry[1].Anoverviewofthehealthscenarioallovertheworldindicatesthatdespite
havingnumerousexcellenthealthcarefacilities,thereexistsasufficientlylargegapbetweenthedemandand
delivery.InIndianearly1millionpeopledieeveryyearduetoinadequatehealthcareandtwothirdpopulationis
deprivedofspecialistcare.Theglobalhealthobservatory[2].AlsoreportsapercapitaexpenditureofUS$215on
healthinIran.Thereareninephysiciansworkingforevery10,000personsinIran.

Withincreasingcompetition,advancesinmedicalsciences,andrisingpatientexpectations,thehealthcaresystems
havebecomecomplexorganizations.Theyneedtoobtainanoptimumbalancebetweentheresourcesandpatient
satisfaction.Totalqualitymanagement(TQM)hasagreatpotentialtoaddressqualityproblemsinawiderangeof
industriesandimprovetheorganizationalperformance[3,4].Juran(1995)hasdefinedTQMasthesystemof
activitiesdirectedatachievingdelightedcustomers,empoweredemployees,higherrevenues,andreducedcosts.It
isaphilosophyaimedatcontinuouslyimprovingthequalityandprocesstoachievecustomersatisfaction[5].
Simplystated,itisthebuildingofqualityintoproductsandprocessmakingqualityaconcernandresponsibilityfor
everyoneintheorganization[6].Thetermorganizationalexcellenceappearstobeusedasasynonymofbusiness
excellenceinthequalityrelatedliterature.Tracingtheevolutionoforganizationalexcellenceasaconcept,
McAdam[6]reportsthatactivitiesdirectedtowardsorganisationalexcellencegainedmomentumintheearly1990s
aftertheadventofqualityawardslikeEuropeanQualityAwardandMalcolmBaldrigeAward.Thishasbeen
definedasakeystageontheTQMjourneyandmeasurestheeffectivenessofTQMimplementation[6].Kelleyand
Hurst[7],intheirprojectonhealthcarequalityindicators,refertothemanualofOrganisationforEconomic
CooperationandDevelopment(OECD)andInstituteofMedicine(IOM)todefinethequalityofhealthcareas"the
degreetowhichhealthservicesforindividualsandpopulationsincreasethelikelihoodofdesiredhealthoutcomes
andareconsistentwithcurrentprofessionalknowledge".TheMalcolmBaldrigecriteriaforperformanceexcellence
inhealthcareorganizationsdefine[7]performanceexcellenceasanintegratedapproachtoorganizational
performancemanagementthatresultsin(a)deliveryofeverimprovingvaluetopatientsandstakeholders,
contributingtoimprovedhealthcarequalityandorganizationalsustainability,(b)improvementofoverall
organizationaleffectivenessandcapabilitiesasahealthcareprovider,and(c)organizationalandpersonallearning.

Studieshavesuggestedquitealargenumberoffactors/elements/constructs/dimensionsofTQMimplementation.
Manyofthemhaveappearedmorefrequentlythanothers.TQMandperformanceimprovementhaveapositive
relationship,particularly,theMalcolmBadrigequalityawardcriteriaconfirmssuchrelationshipbetweenquality
managementpracticesandbusinessresults.

AstudybySalaheldin(2009)indicatesthattherearemanyempiricalstudieswhichexamineTQMpractices
performancerelationshipsinlargefirmsbutthesmallandmediumfirmsstillneedalittlemoreattentionof
researchers[8].Whiletheliteratureconcerningservicequalitydimensionsinthehealthcareindustryisrepletewith
studiesfromthedevelopedworld,researchersfromdevelopingcountrieshavebeenexploringtheapplicabilityof
therelatedmodelsandframeworksintheirspecificcontext.InIndiancontext,thereisadearthofanindependent
modelofservicequalityasalmostalltheexistingstudiesappliedSERVQUALframework,exceptthatof
Duggiralaetal.[9,10].Irantoodoesnotseemtohaveanyestablishedframeworkformeasuringqualityeffortsand
performanceofitshealthcareindustry.

Zakuanetal.[4]suggestthatdespitethenumberofpublicationsandquantityofresearchonTQM,thereisactually
littleempiricalworkthathasbeencarriedoutindevelopingcountries,particularlyintheASEANregion.Though
thereareevidencesofrecentstudiesinIndiaandIranpertainingtototalqualitymanagementandperformancein
healthcare[913],noneofthemclaimsforhavingaddressedtheissueintotality.Thecurrentstateofresearchinthe
areaofhealthcarequalityalongwiththeinadequacyandcostofhealthcareservicesinIndiaandIran[2]seemto
justifythepresentstudyentitled"AComparativeStudyofTQMPracticesinIndiaandIran".Thepurposeof
includingtheUnitedStatesinthisstudyistolearnfromtheirexperiencesandbenchmarktheIndianandIranian
servicesagainstthoseintheUnitedStates.
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1/19/2016 AcomparativestudyoftotalqualitymanagementofhealthcaresysteminIndiaandIran

Methods Goto:

TheprimarydataarecollectedfromIndiaandIran.InIndia,theresearcherhascontactedtheMinistryofHealth
andFamilyWelfareinNewDelhiseekingitspermissionandrequestingthesupportrequiredforthispurpose.With
thehelpofthisoffice,43hospitalsfromalloverthecapitalcityandrepresentingthegovernment,semigovernment,
private,small,medium,andlargetypeswereinitiallycontactedonconveniencebasis.Thecontactpersonswere
mainlyadministratorsandmangers.32responsescouldbeobtainedfromthiscity.Another25hospitalswere
approachedfordatacollectioninAligarh,adistrictheadquarterinthestateofUttarPradesh,wheretheresearcheris
pursuingtheworkattheAligarhMuslimUniversity.Thesehospitalswereidentifiedusinganofficialdirectoryand
thebasisofincludingtheminthesamplehasagainbeentheconveniencesamplingmethod.21respondents
completedthequestionnaire.AsimilarprocedurewasadoptedinIrantocollectdatafromthecapitalcity,Tehran
andthestateMazandaran,theresearcher'shometown.Afterscrutinizingandeditingthefilledinquestionnaires,
110werefinallycompliedforfurtherprocessing.Outofwhich,50arefromIndiaandtheremaining60fromIran.
Consentobtainedfromallparticipated.Priortotheactualcollectionofdata,apilotsurveywasdoneinAligarhto
judgethesuitabilityofthequestionnaire.ForIranianrespondents,thequestionnairewastranslatedinPersianto
makeitmorecompatiblewiththeirsystem.Thetranslatedquestionnairewasfirsttestedforitsvalidityusingapilot
studyof10experts.

Inadditiontotheinformationgatheredthroughliteraturesurvey,twodocuments,namely,guidelinesforhospitalsin
pursuitofexcellence[1],andtheBaldrigehealthcarecriteriaforperformanceexcellence[7]havebeenusedas
sourcesforsecondarydata.Theprimarydataaregatheredthroughastructuredquestionnairethatwasinitially
developedbasedonthesesecondarydata.TheresponsesaregatheredonafivepointLikertscale[14,15].This
questionnairethenhasbeenmodifiedusingfactoranalysisandvalidated.Theprimarydataforthispurposewere
collectedfromthesamplehealthcareorganizationsinIndiaandIran.Theprimarydatawerefurtheranalysedfor
thesecondobjectiveusinganalysisofvariance(ANOVA)andposthocTurkeytest.Theresultssoobtainedare
compared,withthatofthetenAmericanhealthcareorganizations,whichhavereceivedtheMalcolmBaldrige
NationalQualityAwardduringtheperiod20022009.

Analysis

Usingfactoranalysis,amodelhasbeendevelopedandvalidatedformeasuringqualityandperformanceinhealth
careorganizations.Anullhypothesisthat"IndiaandIranarenotdifferentinpracticingthephilosophyoftotal
qualitymanagementforperformanceexcellenceinhealthcare"istestedusingtheanalysisofvariance

Results Goto:

Themeansindicatethatprivatelyrunorganizationshavebeenthebestfollowedbythegovernmentonesinthe
contextofnonfinancialperformance,patientfocus,workforceandprocess,andworkenvironment.Government
organizationsarefoundlaggingbehindtheothertwocategoriesinleadershipandqualityplanning.Theresults
relatedtogoalsettingandcommunicationshowamixedpattern.AposthocTurkeytest[16]isusedtocompare
thethreetypesofhealthcareorganizationswitheachother(twoatatime).Thepvaluessoobtainedindicatethat
theprivateandsemigovernmenthospitalsaresignificantlydifferentinpatientfocus,whereas,theleadershipaspect
isfoundsignificantwhenprivatehospitalsarecomparedwiththegovernmentones.Comparisonbetweenthe
governmentandsemigovernmenthospitalsdidnotshowanysignificantdifferencebetweenthem.

Thenullhypothesisofequalmeansamongthethreetypesofhealthcareservicesisalsotestedforthetwocountries
separately.TheANOVAindicatesthatthethreetypesaresignificantlydifferentinIndiaonknowledge
management(p=.032)withthegovernmentservicesbeingthebestfollowedbythesemigovernmentsetups.In
Iranitistheleadershipthatmakesasignificantdifference(p=.010)amongthethreetypes.Privateserviceshave
gotthebestmeanonthisconstruct.

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1/19/2016 AcomparativestudyoftotalqualitymanagementofhealthcaresysteminIndiaandIran

Usingfactoranalysis,amodelhasbeendevelopedandvalidatedformeasuringqualityandperformanceinhealth
careorganizations.Themodelisreferredtoasinstrumentforhealthcarequalityandperformancemeasurement.
Theinstrumentconsistsoftenconstructs,namely,nonfinancialperformance,patientfocus,qualityplanning,
workforceandprocess,goalsetting,leadership,workenvironment,communication,knowledgemanagement,and
financialperformance.TheconstructsarethencomparedwiththeBaldrigeframework[7],aguidesuggestedby
theAmericanHospitalAssociation[1],andthebackgrounddocumentofthe

WHOEuropeanconference(2008)onhealthsystems[2].Thecontentsoftheinstrumentarealsoverifiedwithone
oftheseminalstudiesusingtheMalcolmBaldrigenationalqualityawardforcomparingqualitypracticesin
differentcountries[16].Theconstructsarefoundmatchingwiththestandardsreferredaboveandtakingcareofall
majorrequirementsoutlinedforhealthcareperformancesystems(Table1).

Table1
Differencesoftwocountriesincaseoftencriteria

Discussion Goto:

Allthetendimensionsofqualityandperformancecorrelatesignificantlywitheachother.Amongthestrong
correlationsarequalityplanningworkforceandprocess,patientfocusworkforceandprocess,and
communicationworkenvironment.Nonfinancialperformancehasgotrelativelybetterrelationshipwith
communication,patientfocus,andfinancialperformance.Theleadershipnonfinancialperformancecorrelation
hasbeencomparativelylowerthanthatwithfinancialperformance.ThestudybySchniederjansetal.[16],
involvingmanufacturing,processing,andservicecompanies,hasalsogotsignificantcorrelationsamongallthe
ninedimensions,theyhaveevolved.Anullhypothesisthat"IndiaandIranarenotdifferentinpracticingthe
philosophyoftotalqualitymanagementforperformanceexcellenceinhealthcare"istestedusingtheanalysisof
variance.ExceptforgoalsettingandworkenvironmenttheFvaluesdidnotshowanysignificantdifference
betweenthetwopopulations.ThemeanvaluesonthetenconstructsforIndianhospitalsexhibitthefollowing
hierarchyoftheconstructsinorderoftheirdecreasingimportanceworkenvironment,leadership,goalsetting,
patientfocus,knowledgemanagement,qualityplanning,financialperformance,workforceandprocess,non
financialperformance,communication.IncaseofIran,thishierarchyappearsasfollowingnonfinancial
performance,patientfocus,workenvironment,knowledgemanagement,communication,financialperformance,
leadership,qualityplanning,workforceandprocess,andgoalsetting.Comparativeanalysesofthemeansofthe
averagescoresonthetenconstructsarealsoconductedbysizeandtypeoftherespondingorganizations.The
ANOVAindicatesthatthewhetherahospitalisprivate,semigovernment,orgovernment,itdoesnothaveany
significanteffectonitsperceptionandassessmentaboutthequalitymeasures.AposthocTurkeytest,comparing
thethreetypesofhealthcareorganizationswitheachotherindicatesthattheprivateandsemigovernmenthospitals
aresignificantlydifferentinpatientfocus,whereas,theleadershipaspectisfoundsignificantwhenprivatehospitals
arecomparedwiththegovernmentones.Comparisonbetweenthegovernmentandsemigovernmenthospitalsdid
notshowanysignificantdifferencebetweenthem.Analysisofvarianceisalsoconductedtotestthenullhypothesis
ofequalmeansamongthethreetypesofhealthcareservicesconsideringthetwocountriesseparately.

Conclusion Goto:

FinallyithasbeenfoundthatthethreetypesofhospitalsaresignificantlydifferentinIndiaonknowledge
managementwiththegovernmentservicesbeingthebestfollowedbythesemigovernmentsetups.InIranitisthe
leadershipthatmakesasignificantdifferenceamongthethreetypes.PrivateservicesinIranhavegotthebestscore
onthisconstruct.Keepingthethemeofthethesisinmind,theperceptionsandassessmentsoftheIndianand
IranianhospitalsonTQMarebenchmarkedagainsttheperformanceofthosehospitalsintheUSAwhichhave

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receivedtheMalcolmBaldrigeNationalQualityAwardinthehealthcaresector.TheaveragescoresofIndianand
IranianhospitalsondifferentconstructsoftheIHCQPMmodelarecomparedwiththemajorresultsachievedby
therecipientsoftheMBNQaward.InnocasethehospitalsfromIndiaandIranarefoundscoringclosetothe
benchmarks.

Healthcareorganizationsaresupposedtobemorecustomerorientedthanallotherorganizationsowingtothe
natureofservicetheyaremeanttooffer.Thequalityoftheirservicesiscrucialtothepatientsandthecommunity.
Regularsurveysofsatisfactionfromallthestakeholdersaswellastheemployeesneedtobeconductedto
continuallyassess,monitor,andimprovetheperformance.

Competinginterests Goto:

Theauthorsdeclarethattheyhavenocompetinginterests.

Authors'contributions Goto:

AHGandJFcontributedtothestudydesign.DataacquisitionwascarriedoutbyAHGcontributedtodata
analysis.JFwassupervisorofthethesisandrevisedthemanuscript.Allauthorsreadandapprovedthefinalversion
ofthemanuscript.

Acknowledgements Goto:

AuthorsarethankfultoAligarhUniversitiesstaffandrespondedhospitalsfortheircooperation.

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