Int. J. Services and Operations Management, Vol. 33, No.

1, 2019 49

An integrated conceptual model for achieving global

quality service in healthcare establishments

D. Gopi*
ULTRA College of Engineering and
Technology for Women,
Madurai, Tamil Nadu-625104, India
Email: gopidev@gmail.com
*Corresponding author

A. Pal Pandi
Bharath Niketan Engineering College,
Aundipatty, Theni Dist-625301,
Tamil Nadu, India
Email: me_pandee@yahoo.co.in

P.V. Rajendra Sethupathi

Higher College of Technology,
Muscat-133, Oman
Email: rajendra.s@hct.edu.om

K.P. Paranitharan
College of Engineering,
Anna University,
Guindy, Chennai, 600025, Tamil Nadu, India
Email: paranikp4@gmail.com

D. Jeyathilagar
Corporate Research Initiatives,
Madurai-625021, India
Email: d_thilagar@yahoo.co.in

Abstract: Ever rising patients’ expectations demand quality healthcare service

from healthcare establishments (HCEs) for its sustenance which necessitated
developing of a comprehensive quality healthcare model, for the measuring the
performance of HCEs. So, the authors developed a model called ‘integrated
quality healthcare system’ (IQHS). IQHS is a bundle of the various quality
management systems and concepts. It consists of ten important critical factors
(CFs), extracted from extant literature reviews. The result has revealed that the
critical factor ‘hospital culture’ plays an important role in quality healthcare
service, based on the mean values, calculated from the views of stakeholders
and customers and the remaining nine CFs should be given priority to attain

Copyright © 2019 Inderscience Enterprises Ltd.

50 D. Gopi et al.

excellence in healthcare service. The proposed comprehensive model may fulfil

the needs of stakeholders and customers in terms of upgraded quality of
service, improved healthcare environment, reduced operating cost of HCE,
patient satisfaction, patient safety and employees’ satisfaction.

Keywords: critical factors; healthcare establishments; HCE; integrated quality

healthcare system; IQHS; quality management concepts.

Reference to this paper should be made as follows: Gopi, D., Pal Pandi, A.,
Rajendra Sethupathi, P.V., Paranitharan, K.P. and Jeyathilagar, D. (2019)
‘An integrated conceptual model for achieving global quality service in
healthcare establishments’, Int. J. Services and Operations Management,
Vol. 33, No. 1, pp.49–68.

Biographical notes: D. Gopi is working as an Assistant Professor in the

Department of Mechanical Engineering, ULTRA College of Engineering and
Technology for Women, Madurai, Tamilnadu, India. He has published three
papers in international and national journals. He has published four papers in
international conferences and national conferences held across India. His area
of research is total quality management and healthcare management.

A. Pal Pandi is working as a Professor at the Bharath Niketan Engineering

College, Aundipatty, Tamilnadu, India. He has published more than 35 papers
in international and national journals including Inderscience, Elsevier and
Taylor and Francis. He has published 30 papers in international conferences
and national conferences held across India. His area of research is total quality
management and manufacturing management.

P.V. Rajendra Sethupathi is working as a Lecturer of the Higher College of

Technology, Muscat, Oman. He holds a Bachelor’s in Mechanical Engineering,
Master’s in Industrial Engineering and PhD in Industrial Engineering from the
Indian Institute of Technology Madras, India. He has more than 20 years of
experience in teaching and research. He has published five papers in various
international journals, and ten papers in international conferences. His areas of
research interest include quality management and supply chain management.

K.P. Paranitharan is doing his research in the Department of Industrial

Engineering, College of Engineering, Anna University, Chennai, India. He
holds a Bachelor’s in Mechanical Engineering. He holds a Master’s in Lean
Manufacturing from the Anna University. He holds a Master of Business
Administration in Production from the Madurai Kamaraj University, Madurai,
Tamil Nadu State, India. He has published various papers in international
journals including Springer, Taylor and Francis, Inderscience and conferences.
His area of research interest is manufacturing management, data mining and
data analytics.

D. Jeyathilagar is presently working as the Director-Research, Corporate

Research Initiatives, Madurai, India and formerly Professor, R.R. College of
Management Studies, Bangalore, India. He has a vast experience in both
academic and administration in the Madurai Kamaraj University, Madurai,
India. He has published more than ten papers in international and national
journals including Inderscience and Taylor and Francis. He has published
25 papers in international and national conferences. His research interests
include total quality management.
 An integrated conceptual model for achieving global quality service 51

1 Introduction

Development of a nation’s economy mainly depends on the growth of manufacturing and

service sectors, wherein the service sector plays a vital role. Service sector includes a
wide range of activities such as trade, hotel and restaurants, transport, storage and
communication, education, financing, healthcare, insurance, real estate, business services,
and tourism. They significantly attract foreign direct investment (FDI) which enhances
employability, export revenue and also assist in achieving social development through
various improvement activities. Now-a-days, healthcare sector gets more attention than
other service sectors, because it largely involves in promoting the activities like
protection of people from various diseases and to keep them healthy. Most of the
healthcare establishments (HCE) are vying for profitability rather than accountability.
Quality in healthcare service very much depends on the service process, i.e., adaptation
of structured system by the hospitals. It is not possible to satisfy the customers who
belong to various socio-economic and cultural backgrounds without adapting an
integrated approach in healthcare services. The healthcare sector in India at present
follows mostly the conventional quality management system by employing quality
structural assurance mechanisms driven by various certification, accreditation and quality
models which are seen not fully complying with the needs and requirements of
stakeholders and customers. A better performance with planned strategy is very much
needed to fulfil the expectations of stakeholders and customers. Performance in
healthcare has various dimensions such as patient-centeredness; efficiency; effectiveness;
timeliness and equity, which needs to be explored and improved: [Institute of Medicine,
(2001), p.63]. The Malcolm Baldrige criteria for performance excellence in healthcare
organisations define “performance excellence as an integrated approach to organisational
performance management”.
Talib and Rahman (2015) identified eight quality dimensions for performance
excellence namely, state of knowledge management (KM), services of HCE for disease
burden of society, patient expectation and perception of hospital services, priority area
management for critical care, treatment chain management including referral and
evacuation chain management, core quality dimension, associated supportive quality
dimension, clinical governance quality. In this regard they have developed an interpretive
structural model for sustainable healthcare quality dimensions (HCQDs) in hospital
services for identifying, ranking and to classify key quality dimensions for understanding
the contextual relationship between them. Agarwal and Ganesh (2016) conducted a study
for improving the service delivery of private hospitals in India and identified three
measures of quality namely structure, process and outcome and their findings reveal that
quality healthcare strategies in India have positive impact on service delivery. Ramadan
and Arafeh (2016) developed a healthcare quality maturity assessment model using six
quality drivers which diagnose the quality management status to ensure delivery of good
healthcare. The current practice of HCEs is mainly to earn huge profits from the
customers rather than to satisfy them by delivering high quality healthcare service.
Though most of the present healthcare models currently practiced by HCEs are interested
in improving the quality of healthcare delivery, they failed to incorporate, the concept
corporate social responsibility (CSR) in their model, which is at present the mostly
needed and mandatory one for sustenance of the HCEs. Therefore, the concept of quality
in healthcare service needs to be explored in the context of varying healthcare
52 D. Gopi et al.

environment. Presently, most of the HCEs have employed few quality management
systems and concepts either as a single one or integrated with two or three. It is
understood that this process could not satisfy the expectations of stakeholders and
customers.
In the context stated above, a need of a comprehensive system for achieving
excellence in healthcare service was felt and hence the authors proposed a new integrated
healthcare model namely ‘integrated quality healthcare system’ (IQHS). This model has
been structured by embedding all the quality management concepts namely total quality
management (TQM), Six Sigma (DMAIC methodology), lean management, KM,
ISO 9001:2008 QMS, ISO 14001:2000 EMS and occupational health and safety
management systems (OHSAS 18001:2007). This study is a maiden attempt to leverage
the quality in healthcare service through implementing the ten important critical factors
(CFs) of IQHS practice.
Presently, HCEs face many challenges from policy makers, stakeholders and
customers because of its global competition. The continuous revision of amendments in
health policy by the government regarding import of latest technologies from abroad
affects the delivery of good healthcare to the customers. Further, few common challenges
being faced by HCEs are unprecedented like uncontrollable cost of medicines, increase in
compensation to doctors, and other paramedical employees. The problematic individual
health insurance policies make HCEs to go for cumbersome efforts to claim the incurred
expenditure of treatment. Sometimes, the veined efforts taken by the HCEs were
misunderstood by customers, resulting in loss of a true customer. The above challenges
motivated the authors to propose the IQHS model which probably would help HCEs to
come out of most of the challenges by giving remedy to stakeholders and customers by
reducing time, waste and delivering proper and genuine treatment at affordable cost. This
proposed model was framed and constructed following few standard methodologies
discussed by various authors in order to confirm its applicability and veracity. However
this model is a unique one, by way of satisfying customers and stakeholders to meet their
own requirements and needs in spite of their different socio-economic culture. The model
gives prime importance to CSR activities, hospital culture (HC) and environment and in
particular, the healthcare insurance programme which most of the earlier healthcare
models have not yet been discussed so far. In view of the above, a few objectives were
framed for this study.
The objectives of this paper are listed below:
1 To study extant literature regarding various quality management practices and
contribution of CFs towards improving quality service in healthcare sector.
2 To find out the research gap in the literature.
3 To propose an integrated model to fill up the research gap.
4 To suggest the ways and means of effective implementation of IQHS model.

2 Literature review

The quality systems practiced globally so far in manufacturing industry was later
extended to other service industries particularly to healthcare industry considering its
importance in generating national economy to a new high level by maintaining health of
 An integrated conceptual model for achieving global quality service 53

the people. In spite of availability of various quality models in healthcare industry, the
authors were motivated to develop a new and a comprehensive quality healthcare model
to meet all the requirements, needs and expectations of stakeholders as well as customers
(patients) who belong to different cultural and socio-economic systems. Pursuant to this
interest, the authors have gone for a survey of extant literature to pick up important
dimensions from all the quality systems and concepts which play an important role in
influencing healthcare quality in HCEs. Few of the important studies which brought the
quality management systems and concepts in healthcare services have been reviewed are
presented here.
• Total quality management
The healthcare mainly revolves around customers (patients). Therefore, customer
satisfaction has to be considered as one of the main aspect in delivering quality
healthcare service. The TQM gives importance to customer satisfaction and is a
management approach to long-term success through customer satisfaction.
Therefore, it takes a central role in the healthcare quality management (McLaughlin
and Simpson, 1999). Hence, the TQM concept has been widely embraced by health
services and manufacturing industry in Japan, Europe, and North America (Gaucher
and Coffey, 1995). The concepts of TQM helps transform the HCEs from traditional
quality improvement system to customer oriented systems through a framework
involving customer focus, process management, new tools and techniques, and
teamwork (Klein et al., 1998), further focused on creating physical, psychological,
and social environment that is conducive to their patients and staff (Ovretveit, 2000).
Some of the positive aspects of TQM systems as suggested by Alexander et al.
(2006) and Chesteen et al. (2005) are quality improvement, financial performance,
competitive advantage, and employee commitment. It is considered to be one of the
best approaches in resolving the issues more effectively and practically, and in
bringing better quality for healthcare institutions (Short and Rahim, 1995; Kim and
Johnson, 1994; Yang, 2003; Manjunath, 2007). Lee et al. (2007) and Ahuja (2012)
have advocated developing an incorporated performance measurement system, and
reducing process defects through adoption of appropriate control mechanism in
hospitals which are very much necessitated. In compliance with the process, Awuor
and Kinuthia (2013) have identified the following factors which affect TQM in
healthcare organisations. Those are customer satisfaction, top management
commitment, employee involvement, teamwork, continuous improvement,
processes, training and cultural change. Similarly, Mosadeghrad (2015), developed a
TQM model for Iranian healthcare organisations, He validated the level of success of
TQM implementation and concluded that the dimension: customer management was
ranked first, followed by the dimensions: leadership and employee management. The
study by Schoten et al. (2016), demonstrated how the quality managers of healthcare
institutions can apply TQM philosophy to achieve higher quality of care and
provides new insights into the long-term benefits of applying the EFQM model as a
framework for TQM in healthcare. Ju and Park (2016) investigated the service
performance associated with nurses by adapting TQM practices and highlighted the
impact on nurses’ attitude, and its effect on service performance, prevailing in the
healthcare service organisations of South Korea. There are many other quality
54 D. Gopi et al.

systems associated to bring support for this study. One among which is ISO 9001
QMS which also mainly focus on customer satisfaction as that of TQM.
• ISO 9001 quality management system
ISO 9001:2008 is an important quality management system which aims at meeting
customer expectations to achieve consistent results in service processes. The benefits
of the ISO quality management system are: operational benefits (improved operating
systems, enhanced operating practices, errors and defects; order processing;
reliability; costs; on-time-delivery; cost savings; lead time; stock rotation), marketing
benefits (improved customer satisfaction, gained competitive edge, complaints;
repeat purchases nation-wide recognition), financial benefits (market share; sales;
return on sales; return on assets) and human resources benefits (work satisfaction,
suggestions system, health/safety, turnover, gained more committed work force,
reduction in staff turnover) in any organisation (Nield and Kozak, 1999, Casadesús
and Giménez, 2000; Casadesús and Karapetrovic, 2005). Also the impact of ISO
9001 QMS practice on firm performance was much more unanimous compared with
the impact of other QM (Martínez-Costa et al., 2008). Stoimenova et al. (2014) have
studied the hospitals in Bulgaria about the availability of ISO 9001 QMS and
confirmed its implementation was useful for the hospitals, as it helped in increasing
the operational efficiencies, reducing errors and improving patient safety to produce
a more preventive approach instead of a reactive environment.
While satisfying the customers and stakeholders through delivering quality products
and services, the organisations, especially, HCEs have to follow and adapt
voluntarily or mandatory the positive and conducive environment within
organisation for which the ISO 14001-environmental management system may be of
a good tool to be used.
• ISO 14001-EMS
ISO 14001-environmental management system (EMS) is a systemic approach that
specifies the requirements of an EMS for small and large organisations to handle
environmental issues within an organisation, but do not refer to the compliance with
a given goal or result (Delmas, 2001; Braun, 2005). In other words, they are not
performance standards measuring the quality of a firm’s products or services or a
firm’s environmental results; rather, they are standards setting out the need to
systematise and formalise a large number of corporate processes within a set of
procedures, and to document such implementation. The effectiveness of the
ISO 14001 EMS when made a part of daily work in the organisations could be
measured in terms of the degree to which ISO 14001 rules, policies, and procedures
which govern the managing of organisational environmental issues (Naveh and
Marcus, 2004; Link and Naveh, 2006). Apart from healthcare industry, the benefits
of ISO 14001 implementation in other industries like chemical, mechanical and
electronic industries in Brazil was detailed by Gavronski et al. (2008). The four types
of benefits of ISO 14001 standard for chemical, mechanical and electronic industries
in Brazil were classified as: productivity benefits (resource usage reduction,
optimisation of process flows, production cost-reduction, better employee
motivation), financial benefits (opportunity to obtain investment funds from
governmental organisations, access to special credit with reduced interest rates,
 An integrated conceptual model for achieving global quality service 55

reduction of insurance premiums), market benefits (competitive advantages, positive

effects on the market and with customers, opportunity to set an example for
suppliers) and societal benefits (improved corporate image for society in general,
reduced environmental liability, improved cooperation from environmental
authorities). After the success of the ISO 9000 standards, they followed the
ISO 14000 family of standards on environmental issues. Over the past years,
ISO 14001 certification has experienced a great international growth (Marimón et al.,
2010). Campion et al. (2015) discussed the life-cycle impacts of disposable supplies
and its design in the healthcare environment. They suggested that by streamlining the
usage of custom packs and cotton products lead to environmental and economic
savings in healthcare institutions which can also bring environmental improvements.
• Occupational health and safety management system – OHSAS 18001
An important aspect to be covered after implementing ISO 9001 quality management
system and ISO 14001-EMS is the OHSAS 18001 which is an occupation health and
safety assessment series for health and safety management systems. It is intended to
control occupational health and safety risks, within an organisation as most of the
works in the aspect of satisfying demands and needs, policy and practice
development aspects of input, process and output and efficacy. Accomplishment of
the OHSAS 18001 relies upon the commitment of all levels in the organisation
(Sadhra et al., 2001) and acts as a proactive control mechanism to minimise risks and
improve safety performance (Matias and Coelho, 2002). Further, the reputation of
the organisation, work place safety, and employee orale are improved by
implementing OHSAS 18001 (Ledesma et al., 2009). Malaysian automotive industry
continued to perform more efficiently and effectively to become the best among its
competitors in other countries, when implemented the OHSAS 18001 system
(Desa et al., 2013). Pojasek (2012), attempted to integrate PDCA approach to
implement OHSAS 18001 along with the other quality systems, as being the most
straightforward approach to adopt a management system structure. Dragomir et al.
(2013) have contended that ISO 9001, ISO 14001 and OHSAS 18001 standards are,
the most relevant standardised tools for organisational management and are also the
most widely used in industry as bases for integrated management systems. The
certification to OHSAS 18001 lead to significant increases in abnormal performance
on safety, sales growth, labour productivity, and profitability and that these benefits
increase as complexity and coupling (Lo et al., 2014). Hosny et al. (2014) have
recommended the OHSAS 18001 standards which specify the requirements for
implementing an OHS management system that allows the organisation to develop
and implement a safety policy, establish objectives and processes for achieving the
commitments of the policy, and take the actions necessary to improve system
performance. Yorio et al. (2014) have recommended that organisations may use all
the activities like: safety training, behavioural safety observations, safety meetings,
safety inspections and audits. They also suggest hazard and risk assessments and
safety awareness campaigns.
• Lean manufacturing
Lean manufacturing (LM) involves never ending efforts to eliminate or reduce the
waste in any form. This concept is very much related to healthcare industry. More
56 D. Gopi et al.

and genuine services have to be offered at the affordable cost. Providing such
services to the patients would be of the greatest advantage to the HCEs as well the
customers. Moreover, the lean process would help HCEs in fluid way reducing the
time, work, and go for accuracy. Considering the importance of the lean process, few
important lean related factors were studied by many authors, of which few selected
studies have been presented below:
Lean techniques can lead an organisation towards better performance in all areas. In
this regard, a study conducted by Alsmadi et al. (2012) clearly indicated the positive
correlation found between lean techniques and organisation performance in the
manufacturing and service sectors. The lean initiative in healthcare organisations is
an alternative methodology for achieving improvement with available resources
(Bahensky et al., 2005). Lesslie et al. (2006) defined lean healthcare practice (LHP)
as a strategy focused on efficiencies and thereby allowing more time for patient care
activities. Ultimately, the LHP is a process which eliminates waste in various areas
of operation and to develop a HC by delivering higher quality patient services
(Dahlgaard et al., 2011). Shazali et al. (2013) have studied LHP and healthcare
performance (HP) in Malaysian healthcare industry. They identified leadership,
employee involvement, organisational culture (OC) and customer focus as LHP
dimensions and financial performance, customer satisfaction and employee
performance as HP dimensions. Further, they have found that there was a positive
and direct significant relationship between LHP and HP in the Malaysian healthcare
industry. Salam and Khan (2016) have analysed and evaluated the factors associated
with running an effective healthcare system through a case study in Thai medical
centre by applying lean thinking and concluded that the lean practice improves
system wide process improvement and patient satisfaction.
• Six Sigma (DMAIC methodology)
The other important quality concept tried for inclusion in the integrated quality
model is Six Sigma (DMAIC) which is a disciplined and data-driven approach for
eliminating defects in the manufacturing process for bringing virtually error-free
business performance. Few important benefits of Six Sigma practice is the
satisfaction of patients, employees and doctors (Volland, 2005). Six Sigma (DMAIC)
can be applied to hospital service which helps to optimise the scheduling of hospital
resources (Bandyopadhyay and Coppens, 2005). Further, Six Sigma (DMAIC)
approach was found to be significant methodology to overcome turnover problem of
doctors in medical emergency services (Taner et al., 2007). In this context, Celano
et al. (2012) have structured a theoretical framework based on a road map of Six
Sigma (DMAIC) to assist quality practitioners and healthcare professionals. Chiarini
(2013) has attempted and proposed a Six Sigma (DMAIC) model for the Italian
public healthcare sector and compared with the manufacturing sector and highlighted
that improvements are met with patient satisfaction with good organisational climate.
The quality of healthcare delivery mainly depends on error-free diagnosis of
diseases, which will otherwise increase the complexity of medicine and disease
itself. Quality management system like the Six Sigma helps to achieve realistic
solutions to reach practical levels of perfection when a patient avails treatment
(Kalra and Kopargaonkar, 2016). To bring those benefits as emphasised in the
 An integrated conceptual model for achieving global quality service 57

studies reviewed above, the Six Sigma concept was brought in while developing the
proposed healthcare quality model.
• KM
KM is the process of creating, sharing, using and managing the knowledge and
information of an organisation. It refers to a multi-disciplinary approach for
achieving organisational objectives by making the best use of knowledge. A study
conducted by Devi et al. (2007), in the higher educational service setting, revealed
the significant relationship between OC and KM. How KM is conceived and
practiced in healthcare was studied by Nicolini et al. (2008), in terms of how the
recurrent issues are addressed. Embedding of healthcare services with various
service systems was mooted out by Talib and Rahman (2015). They say that since,
all these system and process are knowledge intensive, KM in healthcare is an
essential aspect of the service. As a result this could enhance service quality,
especially core quality and client satisfaction making it competitive. Further, they
have concluded that KM in HCE like any other industry revolves around its core
competency and its managerial competency, both existing together complementing
each other to achieve its primary aim of patient satisfaction. Sujatha and Krishnaveni
(2015) have emphasised that KM practices would yield capacity building of the
employees and hence better performance and sustainability in their work could be
achieved.
• Integrated quality model
Some researchers carried out their work by integrating few of the quality
management concepts for achieving better results and they are discussed here as
integrated quality model. An attempt was made by Celano et al. (2012), to integrate
Six Sigma with discrete-event simulation models which are commonly used to
improve the key performance measures of patient care delivery and concluded that
the two approaches could be successfully integrated to carry out quality
improvement programs. The integration of lean and queuing for the transformation
of healthcare process was studied by Chadha et al. (2012), and the study revealed
that Lean integration to queuing methodology frees up capacity in the healthcare
system, providing necessary flexibility of response and resulted in improved
process-flow and increased capacity and also decreased the time of patients’ stay in
the emergency department. The value stream mapping was found to be useful in
detecting opportunities to decrease patient turn around. Sørensen et al. (2012) have
developed an integrated conceptual model containing 12 dimensions, referring to the
knowledge, motivation, and competencies of accessing, understanding appraising
and applying health-related information with the healthcare, disease prevention and
health promotion setting respectively. Neufeld et al. (2013) have analysed the
discharge paperwork of patients of a comprehensive integrated inpatient
rehabilitation programme and concluded that lean Six Sigma is a well-established
process improvement methodology that can be used to make significant
improvements in complex healthcare workflow issues.
Koh et al. (2013) have proposed a health literate care model that would weave health
literacy strategies into the widely adopted care model (formerly known as the
chronic care model). Their model calls for first approaching all patients with the
58 D. Gopi et al.

assumption that they are at risk of not understanding their health conditions or how
to deal with them, subsequently confirming and ensuring patients’ understanding.
This model would be of value infused one for the healthcare organisations. An
integrated approach of the human factors and ergonomics (HFE) and quality
improvement science (QIS) for safety in healthcare was done by Hignett et al.
(2015). From their study, they believe that there will be considerable advantages in
integrating HFE and QIS as suggested by the national quality board (UK). Further,
they found that a wider understanding of HFE principles and practices will
contribute significantly for improving the quality of care for patients. In healthcare,
there is a long tradition of multidisciplinary team working and they hope that this
culture would promote the integration of QIS and HFE as complementary rather than
competing disciplines. The quality principles such as TQM, lean, Six Sigma and lean
Six Sigma and its implementation in different organisations like, manufacturing,
service, healthcare, government, non-profit organisations, transportation and
logistics, process industry, etc., have been reviewed by Sreedharan et al. (2017), and
found that the effectiveness of the organisations has improved after implementation
of these quality techniques. From their study it could be noted that an integrated
model would greatly help organisations to improve the quality. Based on the
literature cited above, the selected CFs drawn from extant literature has been
described in Table 1.
Table 1 Description of ten CFs of IQHS

Sl. no. Critical factors (CFs)
1 Top management
commitment (TMC)
2 Customer satisfaction
(CS)
3 Healthcare work
force (HCWF)
Description of critical factors (CFs) Authors
TMC is the direct involvement and Chakravarty et al.
participation of top level people in the (2001), Minkman
healthcare organisations for making et al. (2007),
decisions and strategic planning to D’Souza and
implement a suitable healthcare quality Sequeira (2011),
model for meeting the demands and Shazali et al.
requirements of stakeholders and (2013) and Kamra
customers. et al. (2016).
CS is the cognitive response of Dey et al. (2009)
customers and the result of a customer and Kamra et al.
centric process through which the need (2016).
and requirements of customers are met
out through effective healthcare
service systems.
HCWF are the people engaged in Chakravarty et al.
performing and implementing the (2001), Talib and
given task of healthcare quality Rahman (2015),
process. The team is equipped to D’Souza and
whole-heartedly accept the necessary Sequeira (2011),
changes by engaging and involving Backström et al.
themselves for promoting healthcare (2014) and Kamra
activities to achieve competitive et al. (2016).
advantage.
 An integrated conceptual model for achieving global quality service 59

Table 1 Description of ten CFs of IQHS (continued)

Sl. no. Critical factors (CFs)
4 Healthcare
infrastructure (HCI)
5 Corporate social
responsibility (CSR)
6 Knowledge
management (KM)
7 Hospital culture (HC)
8 Healthcare insurance
program (HCIP)
9 System for
sustainability (SS)
10 Hospital environment
(HE)
Description of critical factors (CFs) Authors
HCI provides necessary and required Koh et al. (2013)
infrastructure in HCEs by and Kamra et al.
accomplishing the needs and (2016).
requirements of stakeholders and
customers who belong to various
demographic and cultural
backgrounds.
CSR is an integral part of business Marrewijk (2003),
strategy wherein the responsibilities of Zadek (2004),
HCEs to meet out the socio-economic Jones (2005),
and environment concerns in their Tsang et al.
organisational operations. (2009), Aaarndt
and Brettel, (2010)
and Mohan (2013).
KM is the systematic management Minkman et al.
process of an organisation to store and (2007) and Sujatha
develop knowledge assets for the and Krishnaveni
purpose of creating value, to meet out (2015).
tactical and strategic requirements for
improving quality of healthcare service
in HCEs.
HC represents the culture to be Chakravarty et al.
followed in hospitals in order to meet (2001), Shazali
the demands and requirements of et al. (2013),
customers and stakeholders to achieve Backström et al.
competitive advantage in a given (2014) and Talib
internal and external environment and Rahman
(government policy). (2015).
HCIP helps patients (customers) by Gaag (2015).
reducing the economical burden
whereas the cost incurred for the
treatment is directly paid back to the
HCEs.
SS is the system committed to attain Shazali et al.
sustainability in HCEs, in terms of (2013).
socio-economic and environmental
protection.
HE maintains healthy, conducive and Koh et al. (2013),
stress-free environment in the hospitals Backström et al.
to meet the needs of internal and (2014), Carroll
external customers. et al. (2015) and
Kamra et al.
(2016).

To ensure the key components of a well functioning health system declared by

World Health Organization and from the quality dimensions discussed in the literatures,
the authors developed an integrated quality model namely IQHS which responds in a
balanced way to serve different population’s needs and expectations. This proposed
model may improve the health status of individuals, families and communities, defending
60 D. Gopi et al.

the population against health threats, protecting people against ill-health, providing
equitable access to patient-centred care.

3 Research questions

The following research questions were formulated regarding this theoretical work.
• Is it necessary to develop a comprehensive integrated quality model to measure and
implement in order to maintain healthcare quality in HCEs?
• Are the selected qualities dimensions CFs actually support to implement IQHS
model for achieving excellence in healthcare service?

4 Research gap

The customers belonging to different socio-economic and cultural background with

various demographic profiles need to be satisfied by HCEs. It is likely that the HCEs
have failed to address the quality standards in a holistic way and in an integrated manner,
both at the national or international level leaving the healthcare stakeholders unsatisfied.
Talib and Rahman (2015) suggested that HCEs, still lags behind other service industries
counterpart in terms of extensive research studies on HCQDs in Indian context. Further,
varying customer expectations, increase in competition, and pressures from government
agency in the healthcare delivery system has been undergoing many challenges since
early 1990s (Chow-Chua and Goh, 2002). Most of the administrators of HCEs are
striving hard to reduce the catastrophic operating costs in hospitals and at the same time
to provide good quality patient care consistently (Griffith, 2000). It was also revealed that
very few measures were taken to identify, classify and analyse the HCQD and their
relationships. One can clearly understand that both effects (direct and indirect) of each
critical factor on HCEs are not clearly discussed. This big gap was identified by the
authors on how to deliver excellent quality healthcare service at a competitive and
affordable cost. This investigation made to propose a suitable quality model to satisfy the
customers, as well as the stakeholders of HCEs. In the context of importance given to
healthcare sector, the quality concepts so far used could not satisfy the different segments
of customers due to integration of few quality management systems. Since, there is a lack
of a comprehensive integrated quality healthcare model; the proposed IQHS model may
fully bridge the gap to deliver improved healthcare excellence in service, satisfying both
the stakeholders and customers of HCEs.

5 Methods

It was decided to rank the CFs as per the importance to be given by stakeholders and
customers. For this purpose, a questionnaire was constructed incorporating the ten
selected CFs. Before distributing the questionnaire to the respondents, few experts from
academic, clinical and top management of HCEs were consulted to fine tune the
questionnaire and to confirm the content validity. Since, this study is purely a theoretical
one, other validities and reliabilities which involve applying of various statistical tools
 An integrated conceptual model for achieving global quality service 61

were not tested. For conducting survey, customers and stakeholders representing all types
of profiles of both the segments were randomly selected and administered the
questionnaire regarding to offer their opinion on the importance of ten selected CFs of
IQHS for attaining excellence in healthcare service in HCEs. In this context, 50 samples,
each from stakeholders (clinical side – doctors and specialists; clinical support staff –
nurses, physiotherapists, laboratory technicians, radiographic technicians and other
technical personnel; non-clinical staff – administrative executives and front line
employees) and customers (attendants, parents, relatives, and friends) were consider for
survey. Further, their views on the significance of ten CFs of IQHS practice in HCEs
were obtained in five point Likert scale and transformed to numerical data. The mean and
standard deviation values were obtained and shown in Tables 2 and 3. Also the CFs was
ranked according to the mean value, which has been shown in Table 4.
Table 2 Descriptive statistics according to CFs (global score) as perceived by stakeholders

Sl. no. Critical factors of IQHS Mean Std. deviation

1 Top management commitment (TMC) 3.418 0.579
2 Customer satisfaction (CS) 3.269 0.579
3 Healthcare work force (HCWF) 3.460 0.508
4 Healthcare infrastructure (HCI) 3.473 0.678
5 Corporate social responsibility (CSR) 3.000 0.797
6 Knowledge management (KM) 3.260 0.656
7 Hospital culture (HC) 3.532 0.600
8 Healthcare insurance program (HCIP) 3.210 0.387
9 System for sustainability (SS) 2.949 0.603
10 Hospital environment (HE) 3.424 0.657

Table 3 Descriptive statistics according to CFs (global score) as perceived by customers

Sl. no. Critical factors of IQHS Mean Std. deviation

1 Top management commitment (TMC) 4.116 0.647
2 Customer satisfaction (CS) 3.918 0.719
3 Healthcare work force (HCWF) 3.941 0.668
4 Healthcare infrastructure (HCI) 3.974 0.796
5 Corporate social responsibility (CSR) 3.370 0.943
6 Knowledge management (KM) 3.555 0.862
7 Hospital culture (HC) 4.394 0.597
8 Healthcare insurance program (HCIP) 3.445 0.490
9 System for sustainability (SS) 3.951 0.807
10 Hospital environment (HE) 3.950 0.657

Table 4 clearly shows that the critical factor ‘HC’ was highly perceived to place it in first
rank by both segments of respondents (customers and stakeholders). The perceptions of
the two distinct types of respondents with regard to remaining nine CFs were different.
This clearly shows the differences in their expectations, requirements and needs. The
62 D. Gopi et al.

complications and wide-range in healthcare delivery could be clearly seen from the
Table 4. The framework of the model is thus presented.
Table 4 Comparative table showing the ranks of CFs as perceived by stakeholders and
customers

Rank
Sl. no. Critical factors of IQHS
Stakeholders Customers
1 Top management commitment (TMC) 5 2
2 Customer satisfaction (CS) 6 7
3 Healthcare work force (HCWF) 3 6
4 Healthcare infrastructure (HCI) 2 3
5 Corporate social responsibility (CSR) 9 10
6 Knowledge management (KM) 7 8
7 Hospital culture (HC) 1 1
8 Healthcare insurance program (HCIP) 8 9
9 System for sustainability (SS) 10 4
10 Hospital environment (HE) 4 5

6 Framework of IQHS model

The uniqueness of the IQHS model is that it describes to achieve excellence in healthcare
quality by deploying the ten CFs.
The framework of the model comprises of three stages namely input stage (bundle of
quality management systems), process stage (practice of ten CFs) and output stage
(achieving excellence in healthcare service). The input stage comprises of all quality
management systems. It helps the HCEs for continuous quality improvement activities
based on customer needs by creating physical and psychological environment that is
conducive to patient and staff. It helps achieve consistent result through operational,
marketing and human resources benefits. Further a systematic process approach helps to
address environmental issues successfully along with controlling occupational health and
safety issues. These inputs are more important in the way of doing more and effective
quality service by eliminating waste in any form by implementing lean management. The
Six Sigma methodology tries to eliminate data driven technology defects (diagnosis, lack
of infrastructure, lack of workforce, etc.) in the HP. KM helps to update the latest
technology, giving awareness regarding health literacy, health insurance benefits and
CSR activities. The second stage deals with execution of ten CFs of IQHS in the HCEs.
These CFs need to be implemented to uplift and meet out the structural, functional and
operational benefits of the HCEs. The third stage deals with the end result of IQHS
practice in terms of upgrade quality of healthcare service (Talib and Rahman, 2015 and
Agarwal and Ganesh, 2016), improved healthcare (Desa et al., 2013; Sreedharan et al.,
2017), reduced operating cost of HCE (Schweikhart, 2009; Dahlgaard et al. 2011), patient
safety (Stoimenova et al., 2014; Hignett et al., 2015), patient satisfaction (Chiarini, 2013;
Salam and Khan, 2016) and satisfaction of HCEs’ employees (Shazali et al., 2013;
Awuor and Kinuthia, 2013) and on whole the healthcare service excellence is achieved.
 An integrated conceptual model for achieving global quality service 63

Figure 1 An integrated conceptual model for achieving global quality service in HCEs

7 Conclusions

Healthcare delivery is a complicated process which involves large numbers of workers to

look after different types of customers. It is essential to satisfy the stakeholders’ and
customers’ expectations in order to maintain performance excellence and sustainability.
Therefore, the quality of healthcare service needs systematically and continuous
evaluation through suitable quality mechanism like IQHS. Two research questions were
formulated from this theoretical model. Few gaps have also been found and a sincere
attempt was also made to fill up the gaps. This theoretical approach helps in finding a
64 D. Gopi et al.

solution to fill up the gaps and provide answers to the research questions. Further, the
objectives initially framed have also been met out. Hence, the authors have proposed the
IQHS model which endowed with ten internationally discussed CFs in order to enhance
the quality of healthcare service in HCEs and for sustainability of quality through
continuous implementation in a holistic manner. If this model is implemented in full
fledged manner, it may improve the health status of individuals, families and
communities, defending the population against health threats, protecting people against
ill-health, providing equitable access to patient-centred care and improving the brand
value of HCEs. The proposed IQHS model may give opportunity to top management to
measure the prevailing quality in healthcare service and evaluate the expectations of
stakeholders and customers and thus serve as a suitable tool to compare their service with
the similar healthcare organisation.
In the context of brewing a healthy nation by way of maintaining healthy population,
this model gets more importance. Further, the awareness on health and the awakening of
literacy among people and also ever increasing population mandates Government, and
private healthcare organisation to go for a quality model suitable for everybody. Further,
the Government as well as the private healthcare providers have the responsibility to
deliver quality healthcare service to people. However, this study is a theoretical one, an
exercise with stakeholders and customers was taken up to obtain primary data to conduct
an empirical study in order to ascertain the importance of the selected CFs and the result
revealed that the HC plays an important role in the quality healthcare service and the
remaining nine CFs, need to be given importance for implementation of IQHS model. In
future IQHS model can be validated by empirical means through validated structured
questionnaire, and the model fit can also be established by structural equation modelling
(SEM) approach.

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