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International Journal of Health Care Quality Assurance
Obstacles to TQM success in health care systems

Ali Mohammad Mosadeghrad
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Ali Mohammad Mosadeghrad, (2013),"Obstacles to TQM success in health care systems", International
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Obstacles to
Obstacles to TQM success in TQM success
health care systems
Ali Mohammad Mosadeghrad
School of Management and Medical Informatics, 147
Tehran University of Medical Sciences, Tehran, Iran
Received 17 March 2011
Revised 1 June 2011
Abstract Accepted 1 July 2011
Purpose – Many healthcare organisations have found it difficult to implement total quality
management (TQM) successfully. The aim of this paper is to explore the barriers to TQM successful
implementation in the healthcare sector.
Design/methodology/approach – This paper reports a literature review exploring the major

reasons for the failure of TQM programmes in healthcare organisations.
Findings – TQM implementation and its impact depend heavily on the ability of managers to adopt
and adapt its values and concepts in professional healthcare organisations. Unsuccessful TQM efforts
in healthcare organisations can be attributed to the strongly departmentalised, bureaucratic and
hierarchical structure, professional autonomy, tensions between managers and professionals and the
difficulties involved in evaluating healthcare processes and outcomes. Other obstacles to TQM success
include lack of consistent managers’ and employees’ commitment to and involvement in TQM
implementation, poor leadership and management, lack of a quality-oriented culture, insufficient
training, and inadequate resources. The review was limited to empirical articles written in the English
language during the past 30 years (1980-2010).
Practical implications – The findings of this article provide policy makers and managers with a
practical understanding of the factors that are likely to obstruct TQM implementation in the
healthcare sector.
Originality/value – Understanding the factors that obstruct TQM implementation would enable
managers to develop more effective strategies for implementing TQM successfully in healthcare
organisations.
Keywords Total quality management, Failure, Obstacles, Successful implementation, Health care
Paper type Literature review
Introduction
Healthcare organisations face a number of serious challenges, particularly concerning
effectiveness, efficiency and quality. Therefore, there is a pressing need for a new approach
in managing healthcare organisations to become more cost-effective in the delivery of high
quality healthcare services. Quality management constitutes an appropriate response to
these challenges. It is a potential way to improve systems and procedures as effectively as
possible by using scientific methods to achieve an optimum outcome. Total quality
management as a quality management strategy aims to enhance customer satisfaction and
subsequently organisational performance by providing high quality products and services
through the participation and collaboration of all stakeholders, teamwork, customer driven International Journal of Health Care
quality and continuously improving the performance of inputs and processes by applying Quality Assurance
Vol. 26 No. 2, 2013
quality management techniques and tools. pp. 147-173
Total quality management (TQM) became one of the competitive strategies of q Emerald Group Publishing Limited
0952-6862
choice during the 1990s. It has been widely implemented in various firms throughout DOI 10.1108/09526861311297352
IJHCQA the world for achieving greater profitability (Mosadeghrad, 2005). There is a
26,2 widespread consensus that a successful TQM implementation is related to economic
and performance success (Brah et al., 2002; Hansson and Eriksson, 2002; Hendricks and
Singhal, 2001; and Kaynak, 2003). The success of TQM in industry has encouraged
many healthcare managers to examine whether it works in the healthcare sector. As a
result, in the last 30 years, many healthcare organisations increasingly adopted the
148 TQM principles to improve the quality of outcomes and efficiency of healthcare
services delivery. An effective TQM implementation enables healthcare organisations
to identify clients’ requirements to deliver appropriate care, benchmark for best
practices and improve processes to reduce the frequency and severity of medical errors.
These activities lead tohigh quality healthcare services, patient satisfaction, and
increased productivity and profitability (Alexander et al., 2006; Macinati, 2008).
Nevertheless, the application of TQM in practice involves many difficulties. Many
healthcare organisations have found difficulties in implementing TQM successfully
(Bringelson and Basappa, 1998; Ennis and Harrington, 1999; Huq and Martin, 2000;
Zabada et al., 1998). Although some quality improvement projects were successful
(Chattopadhyay and Szydlowski, 1999; Francois et al., 2003; Jackson, 2001; Klein et al.,
1998; Motwani et al., 1996), most of these have been limited to a small number of
healthcare organisations or a few departments in a healthcare organisation or a narrow
aspect of organisational performance.
Total quality management has its roots in manufacturing sector. There are
questions regarding its applicability to the healthcare sector (Atchison, 1992; Zabada
et al., 1998). The concept of TQM consists of two components: values, concepts and
principles (i.e. management support, employee involvement, and teamwork), and
techniques and tools (e.g. statistical process control tools). TQM techniques and tools
may be applicable everywhere. However, its values and principles need to be adapted
to strong professional healthcare settings. Simply adopting TQM principles will not
guarantee its success. An application of hard factors of TQM without updating
organisational structure and improving its soft factors leads to an insignificant
improvement in organisational performance and early abandonment of this strategy. A
superficial implementation of TQM results in low or even no productivity
improvement. This causes a negative psychological effect on employees.
Subsequently, employees lose interest in TQM implementation.
Instances of failed TQM initiatives have led researchers to focus more directly on
the shortcomings and difficulties associated with TQM (Amar and MohdZain, 2002;
Bhat and Rajashekhar, 2009; Jun et al., 2004; Ljungstrom and Klefsjo, 2002; Salegna
and Fazel, 2000). However, obstacles to implementing TQM successfully in healthcare
organisations have not been fully addressed.
Aims
This study aims to identify factors underlying failures in TQM implementation in
healthcare sector. The aim is to get a better understanding of why such TQM
implementations fail so frequently. In addition, the study has endeavoured to present
reasons for their occurrence and to make recommendations that help healthcare
managers to develop more effective strategies that will enhance the chances of
achieving business excellence.
Method Obstacles to
A meta-analysis of TQM empirical implementation barriers studies in healthcare TQM success
organisations was undertaken. A total of 15 electronic databases were searched in this
systematic and meta-analysis literature review. These include PubMed, Academic
Journals Database, Directory of Open Access Journals, Ebsco research databases, Elsevier
science, Emerald, Google Scholar, JournalSeek, JSTOR, ScienceDirect, Social Science
Citation Index, SpringerLink, Social Science Research Network, Web of Knowledge, and 149
WorldWideScience. Keywords to search the literature included total quality management,
implementation, healthcare organisations, failure, barriers, and obstacles.
In addition, journals such as TQM Journal, Total Quality Management and Business
Excellence, Quality Progress, International Journal of Quality & Reliability Management,
International Journal for Quality in Healthcare, International Journal of Applied Quality
Management, International Journal of Healthcare Quality Assurance, Journal of Quality
Management in Healthcare, Journal of Quality and Safety in Healthcare, Journal of
Operations Management, and Journal of Managing Service Quality were searched for
articles not yet indexed in the databases. Furthermore, the reference lists of the retrieved
articles were evaluated to identify additional relevant research articles. The final step
was a general internet search using Google, and Yahoo search engines to find further
information relating to TQM failure and implementation obstacles in healthcare sector.
The selection was restricted primarily to the following studies (see the Appendix):
.
published between 1980 and 2010;
.
those written in English;
. examined TQM implementation in healthcare organisations using an empirical
approach (quantitative or qualitative); and
.
identified reasons for TQM failure.
After manually screening and evaluation of the related literature, a total of 16 empirical
studies reporting TQM implementation obstacles in healthcare organisations were
selected for this systematic and meta-analysis. The empirical studies were conducted in
nine countries. A total of ten studies were reported in developed countries and six in
developing countries. A questionnaire survey was used for data collection in 11 studies.
The rest of studies (five) used case study approach and interviews for collecting data.
Both qualitative and quantitative analyses were used in this study. Content analysis
was used to describe and explain the reasons for the failure of TQM programmes in
healthcare organisations. NVivo software (version 7) was used for qualitative data
analysis and retrieval. In addition, SPSS software (version 11.5) was used to provide
descriptive statistics such as frequency and percentage. Regression analysis was used
to determine which obstacles were perceived as significant in TQM failure.
Results
The reasons for TQM failure addressed in the literature can be categorised into three
groups:
(1) ineffective or inappropriate TQM model;
(2) ineffective or inappropriate TQM implementation method; and
(3) inappropriate environment for TQM implementation.
IJHCQA Ineffective or inappropriate TQM model
26,2 Successful TQM implementation requires a clear understanding of the concept and
principles of TQM. However, TQM does not provide an explicit theory. While it is
widely practiced, there is little agreement on what it is and what its essential features
are. TQM is a diffuse concept and an abstract term, with many vague descriptions, and
no generally accepted definition or agreed content. Mosadeghrad (2011) in an attempt
150 to define TQM found 73 different definitions of TQM in the literature. TQM has been
variously defined as an “Approach” (Flynn et al., 1994), a “Culture” (Kanji and Yui,
1997), a “Philosophy” (Joyce et al., 2006), a “System” (Hellsten and Klefsjö, 2000), a
“Strategy” (Harvey and Brown, 2001), a “Programme” (Joss and Kogan, 1995), a
“Process” (Almaraz, 1994), a “Technology” (Camison, 1996), and a “Technique” (Wong
et al., 2010). Consequently, TQM is used interchangeably with other terms such as
continuous quality improvement, quality assurance and total quality control.
Total quality management suffers from both theoretical problems and practical
difficulties (Mosadeghrad, 2012). TQM is partially developed (Singh and Smith, 2006;
Vouzas and Psychogios, 2007). Some complementary management theories must be
integrated with TQM to refine and develop it further to achieve competitive advantage.
An intensive knowledge of sociology, psychology and change management helps
introduce, institutionalise and manage the TQM change successfully. There is a need
for an empirically sound and comprehensive model of TQM to assist managers in
planning and executing TQM practices, and monitoring and improving the quality of
healthcare services. Nowadays, three major quality management frameworks –
standards-based approaches (e.g. ISO 9001); quality award models; and individual
developed models – are accepted as guides to TQM implementation.
The ISO 9001: 2000 offers a system of quality assurance to healthcare organisations.
It gives them a degree of standardisation and procedural control. ISO 9001 directs
managers to re-examine all their processes and identify any discrepancies between
what employees are actually doing and what the documentation asks to be done. It
focuses on processes rather than outcomes (Ozturk and Swiss, 2008). ISO 9001
encourages employees to demonstrate compliance with the procedures, rather than to
strive for continuous improvement. ISO focuses on doing things right, not necessarily
doing the right things right from a customer point-of-view. ISO 9001 only ensures that
a quality management system exists. It cannot guarantee its functionality. It is not a
guarantee of quality or better performance (Curkovic and Pagell, 1999; Martı́nez-Costa
et al., 2009). It is possible to have an ISO 9000 system and still manufacture/deliver
poor quality products/services. ISO 9001 also leads to an increased bureaucracy within
an already complex and highly bureaucratic healthcare system. It results in additional
paperwork related to new protocols and procedures (Poksinska et al., 2006; Singels
et al., 2001). ISO provides a generic guideline that comes from industry experience and
does not specifically address all areas relevant to healthcare. Therefore, quality
improvement is mainly limited to supportive and administrative functions, rather than
clinical and patient care activities. Simply implementing ISO alone does not appear to
be comprehensive enough to gain competitive advantages (Corbett et al., 2005; Najmi
and Kehoe, 2000; Sun et al., 2004; Terziovski et al., 2003). Therefore, healthcare
organisations should not solely rely on the ISO quality management system. ISO 9001,
through offering a set of policies and guidelines for quality management provides a
foundation to TQM. It could be a starting point for TQM implementation.
Quality award models provide a framework of essential quality management Obstacles to
practices for organisations to implement TQM programmes, benchmark best practices TQM success
and perform self-assessments against established criteria to identify their strengths
and weaknesses (Ghobadian and Woo, 1996). There are many quality award models all
over the world. Some of them are regional awards (e.g. Minnesota Quality Award) and
others are national (e.g. Malcolm Baldrige award) or international (e.g. European
Foundation Quality Management Award in Europe). These TQM frameworks are 151
extensively used in healthcare organisations for self-assessment and performance
improvement purposes (Foster et al., 2007; Nabitz et al., 2000; Vernero et al., 2007).
However, they have foundation in industry and have not been developed specifically
for the healthcare sector. Incorporating clinical standards in these quality award
models provides the potential to deliver high quality healthcare services. It encourages
healthcare organisations to improve clinical procedures, rather than being limited to
administrative activities.
Many quality gurus and researchers developed various TQM models (Baidoun and
Zairi, 2003; Hansson and Klefsjo, 2003; Kakkar and Narag, 2007; Srdoc et al., 2005;
Sureschchandler et al., 2001; Thiagaragan et al., 2000; Venkatraman, 2007). Their
effectiveness depends on how effectively they are developed and incorporated into
organisational policies and practices. Most of these TQM models are general guidelines
and do not specifically address all areas relevant to the healthcare system. Hence, there
is a need for a suitable TQM framework for the healthcare sector.
Ineffective or inappropriate TQM implementation method

Many of the failures of TQM are attributed to the methods of implementation (Bayazit,
2003; Hansson and Klefsjö, 2003; Seetharaman et al., 2006). The implementation of
TQM principles and practices (i.e. management commitment, teamwork, focus on
customers and continuous improvement) must be supported by techniques and tools to
achieve business excellence. There is no standard method for implementing TQM core
principles in an organisation to achieve good outcomes. This is left to the interpretation
of quality practitioners. Consequently, the same TQM programme may result in
different outcomes in different organisations.
There are three main reasons for an in-effective TQM implementation method,
i.e. over use, under use and misuse of quality management practices, techniques and
tools. Overuse occurs when managers apply sophisticated techniques and tools that are
beyond the understanding of the employees. Therefore, they cannot implement the
methods completely and properly. Under use occurs when organisations do not fully
implement all of the key values and principles of TQM. Most failures with TQM result
from partial implementations of its principles and practices. Misuse occurs when
managers implement practices, techniques and tools, which are not compatible with
the organisation’s cultures and operations (e.g. using participatory management
techniques in an organisation with authoritative leadership style and individualistic
culture).
Inappropriate environment for TQM implementation

Total quality management programmes will not succeed unless rooted in a supportive
environment (supportive leadership, quality culture and appropriate structure).
Overall, 39 barriers to implementing TQM successfully in healthcare organisations
IJHCQA were identified in the reviewed empirical studies. These barriers were categorised into
26,2 five groups:
(1) Strategic barriers:
.
poor management and leadership;
.
lack of top management support;
152 . management turnover;
.
middle-management resistance to change;
.
inappropriate planning;
.
placing a poor priority on quality improvement; and
.
unlimited demand for healthcare services.
(2) Human recourses barriers:
.
lack of employees’ interest in TQM;
.
lack of employees’ motivation and satisfaction;
.
lack of employees’ commitment and involvement;
.
physicians’ indifference towards TQM;
. professional autonomy;
.
incompetent employees;
.
employees’ resistance to change;
.
lack of good human resource management;
.
inadequate empowerment at all levels;
.
employee shortage, and increased work load;
.
poor education and training;
.
lack of recognition and reward for success; and
.
lack of union co-operation.
(3) Contextual barriers:
.
inappropriate organisational culture;
.
inter-departmental barriers;
.
difficulties in changing organisational culture;
.
lack of team orientation;
.
poor communication; and
.
mindset barriers.
(4) Procedural barriers:
.
lack of process focus;
.
lack of focus on patient satisfaction;
.
lack of customer awareness;
.
complexity of processes;
.
fragmentation of activities;
.
bureaucracy and paperwork; Obstacles to
.
lack of measurement, evaluation and self-assessment; and TQM success
.
difficulties in measuring quality.
(5) Structural barriers:
.
inappropriate organisational structure;
.
lack of physical resources; 153
. lack of information systems;
.
lack of financial support; and
.
time shortage.
Table I shows the ten most frequently mentioned environment-related reasons for TQM
failures in literature. Lack of employees’ and managers’ consistent commitment to and
involvement in TQM activities were the most cited barriers to TQM implementation in
healthcare organisations. Regression analysis showed that management turnover,
middle management resistance, lack of resources, inappropriate culture and short-term
thinking was the major barriers to implementing TQM in healthcare organisations.
Poor leadership, inappropriate organisational culture, lack of employee
involvement, lack of top management support, and lack of training were the most
mentioned barriers to successful TQM implementation in developed countries. In
contrast, lack of management support, lack of employee involvement, poor leadership,
lack of training, inappropriate organisational culture, lack of recognition and reward
for success, and hierarchical and authoritative organisational structure were the most
cited barriers to successful TQM implementation in developing countries.
According to Easton (1993), the moderate results of implementing TQM
programmes in some American companies were attributed to deficient leadership.
The importance of visionary leadership, including philosophy, style and behaviour in
TQM implementation was in fact addressed in the previous studies (Alexander et al.,
2007; Berwick et al., 2003; Maguerez et al., 2001; Mosadeghrad, 2005; Wardhani et al.,
2009). Top-down authoritative leadership style must be replaced with a more
supportive, democratic, charismatic and participative style that allows employees’
involvement in TQM activities.
Frequency of Prioritised
TQM failure reasons occurrence rank
Lack of employees particularly physicians’ involvement 10 1

Lack of consistent top management support 10 2
Poor leadership and management 9 3
Lack of a quality-oriented culture 8 4
Insufficient education and training 8 5
Inadequate resources 5 6
Lack of a robust monitoring and measurement system 5 7 Table I.
Employee shortage 5 8 Prioritisation of barriers
Lack of a plan for change 4 9 to TQM implementation
Poor communication 4 10 in healthcare
IJHCQA Just as managers can support TQM, they can also obstruct it. Juran (1988) believed that
26,2 most of the problems associated with quality are attributed to management. Most
obstacles to TQM implementation such as lack of a vision, lack of a strategic plan, poor
organisational culture, poor communication, lack of employee empowerment, inadequate
resources, and employee resistance to change are linked to how effectively the TQM
programme is managed. The implementation of quality management itself requires
154 “management quality”. TQM implementation and its impact depend on the ability of
managers to adopt and adapt its values and basic principles in professional healthcare
organisations. It requires a change in management thought, attitude, behaviour and roles.
Managers must discard outdated management methods and accept the philosophy of
continuous quality improvement. The success of TQM depends largely on management
ability to create a vision, plan for, and lead the organisational change required for TQM
success. Top management needs to ensure that all facets of the organisation (i.e. the
organisational structure, leadership styles, incentive schemes, trainings, communications,
procedures and processes) reflect TQM values and principles.

As healthcare organisations are growing in number and complexity, there is a
growing need for professional managers and leaders who are accountable for
continuously improving corporate (clinical, operational and financial) performance.
The introduction of professional management into the healthcare system increases
managerial control of services and promotes organisational productivity. Healthcare
organisations can be managed better by having well-trained managers supporting and
leading the teams that manage the processes to deliver the best possible services for
patients. Managerial knowledge and skills are key success factors for the effective
management of healthcare organisations.
Lack of top management involvement in and commitment to TQM change is the
common reason for TQM failure (Hamidi and Zamanparvar, 2008; Kozak et al., 2007;
Mosadeghrad, 2005). Low management commitment and involvement can lead to failure
in as many as 80 per cent of organisations (Jaehn, 2000). Juran and Gryna (1993) attribute
the failure of the quality management initiatives in the West in the 1970s and 1980s to
lack of top management involvement in quality management. Top management should
be very committed to and fully involved in continuous quality improvement. The degree
to which employees adopt TQM strategy will be contingent upon the degree to which top
managers are involved in, and committed to the TQM principles. A lack of TQM
knowledge, frequent top management turnover, avoiding taking risks and ineffective
communication between managers and employees are the main reasons for the low
management commitment to TQM programmes (Deming, 1986; Mosadeghrad, 2005;
Soltani et al., 2005; and Psychogios and Priporas, 2007). Therefore, there is a need for
management transformation. Continuous education and training help managers to
understand the philosophy of TQM and implement it properly.
Management turnover is one of the most important obstacles to successful TQM
implementation. Management turnover increases the chance of subjective
management, leading to unfavourable outcomes. Managers may avoid taking risks
and making radical changes because they are afraid that it may cost them their jobs
(Soltani et al., 2005). Therefore, managers cannot plan for the long term and have to
maintain the status quo. The job security of managers encourages long-term planning
and their commitment to pursuing long-term objectives. Mobility of management was
in fact, considered a deadly disease for business by Deming (1986).
According to Manz and Sims (1993), middle managers are the biggest obstacle to Obstacles to
successful TQM implementation. Without middle manager’s support, the TQM TQM success
programme would be halted. Middle managers may see that the transition towards
TQM cost them in status, power and recognition. Lack of involving middle managers
in TQM initiative makes them resist the TQM change programme and react with
suspicion and uncertainty (Balding, 2005; Jacobsen, 2008; Harrington and Williams,
2004). Top management should clarify middle managers’ roles in relation to TQM 155
implementation, provide necessary education and training and empower them to
communicate the TQM message to employees (Dale and Cooper, 1994).
A successful TQM implementation needs a long-term strategic plan. According to
Newall and Dale (1991), lack of detailed planning prior to the introduction of TQM in
organisations is a key reason for its future difficulties there. Many TQM
implementation problems can be overcome by proper planning. Quality
management programmes will fail if quality objectives are not incorporated into the
organisation’s strategic planning process. Strategic quality planning is essential for

TQM initiatives to be successful (Chan and Ho, 1997; Francois et al., 2003; Hamidi and
Zamanparvar, 2008). Strategic quality planning is necessary for integrating quality
objectives, requirements and targets into organisational operations and activities.
Poor education and training are also major obstacles to the development and
implementation of TQM initiatives. Training and education are key components in the
TQM programme, and have an important role in establishing a common language of
quality, and securing commitment and behaviour change towards continuous quality
improvement. The review of literature corroborates the importance of appropriate
education and training in the process of TQM implementation (Chow-Chua and Goh,
2002; Huq and Martin, 2000; Maguerez et al., 2001). Education and training enhance
employees’ job-related skills, communication and teamwork, and help to overcome
employees’ resistance to TQM change (Kaynak and Hartley, 2008). Education and
training can result in a more satisfied workforce and an environment for innovation
and creativity. Healthcare managers should develop the technical capabilities of
employees and enable them to improve the quality of services continuously. Education
and training provide the necessary knowledge, skills and abilities for employees to do
their job effectively, diagnose and correct their daily problems.
Organisational culture is one of the most important influencing factors in the
implementation of TQM in healthcare sector. Cultural variables are found responsible
for more than 50 per cent of the variance in TQM implementation (Mosadeghrad, 2006;
Wakefield et al., 2001). The most difficult obstacles to the application of TQM in health
sector are cultural (Huq and Martin, 2000; Zabada et al., 1998). Creating a supportive
culture is one of the most frequently mentioned difficulties to TQM implementation in
healthcare sector. Therefore, organisational culture is the most often ignored
component of TQM during the course of TQM implementation. There are powerful
sub-cultures such as physicians, nurses and paramedics who have their own interests.
They define quality differently and follow specific ways to achieve it. Consequently,
healthcare managers have little control over TQM implementation (Natarajan, 2006;
Piligrimiene and Buciniene, 2008; Zabada et al., 1998). Therefore, cultural changes are
required to implement TQM successfully. A “corporate culture of quality” should be
developed. This involves building and enhancing trust, motivation, empowerment,
co-operation, risk taking, innovation, and continuous improvement through job
IJHCQA security, teamwork, support and equitable compensation (Mosadeghrad, 2006;
26,2 Wardhani et al., 2009). To create a quality culture, a change in organisational
factors, both soft (i.e. shared vision, values and believes) and hard (i.e. systems and
structures) is needed. Strong and inspirational leadership has a key role in changing
the organisational culture. Continuous and widespread education and training provide
a good foundation for cultural change required for TQM implementation. However, it
156 needs to be supplemented by appropriate supportive systems to encourage effective
communication and people involvement in TQM projects.
The success of TQM also depends on its fit with organisational structure. Structure
has to follow the strategy. The very complexity of the healthcare system and its
bureaucratic and highly departmentalised structure can pose a significant obstacle to
the implementation of TQM and decrease its effectiveness (Adinolfi, 2003; Badrick and
Preston, 2001; Jabnoun, 2005; Lim and Tang, 2000; Naveh and Stern, 2005).
Mechanistic, bureaucratic and authoritative structures, risk aversion, and complexity
impede successful TQM implementation. McLaughlin and Kaluzny (1990) and Short
and Rahim (1995), argue that the complex, bureaucratic and highly departmentalised
structure, and the multiple layers of authority are the most difficult barriers to
implement TQM in healthcare organisations. The traditional hierarchical structure of
healthcare organisations exemplifies bureaucratic and authoritative cultures that are
not conducive towards employee empowerment and commitment, which are crucial to
the successful implementation of TQM (Abd-Manaf, 2005; Shortell et al., 1995; Zabada
et al., 1998). Moreover, healthcare settings are structured in departments with
significant autonomy of action, which further enhances their ability to resist change
(Francois et al., 2003; McNulty and Ferlie, 2002). Such a structure makes it difficult to
achieve horizontal coordination and vertical integration, which are necessary for
effective TQM implementation.
Specialised accountability combined with professional autonomy segment the work
processes. As a result, efforts to improve the quality of healthcare services are
stratified hierarchically. Physicians take responsibility for one aspect, nurses for
another and managers for still another. No single group is held accountable for the total
health care delivery process (Kaluzny et al., 1992; Moss and Garside, 1995). The
professional bureaucracy and paternalism (e.g. physician power), and work on human
beings limit hierarchical authority and make it difficult for managers to use scientific
quality management principles.
Institutionalisation of TQM in healthcare requires building a supportive
infrastructure to enhance the effectiveness of implementing its practices. It is very
difficult to implement TQM in a rigid mechanistic and bureaucratic structure. Organic
structures with low centralisation and formalisation are more conducive to the success
of TQM implementation ( Jabnoun, 2005; Moreno-Lozon and Peris, 1998; Tata and
Prasad, 1998). Decentralisation improves employees’ involvement and participation in
TQM activities and reduces power distance within healthcare organisations
(Mosadeghrad, 2006). A quality management infrastructure should be established to
implement and manage a TQM programme. This should consist of a quality
management council, a quality management department, a quality steering committee,
functional and cross-functional quality improvement teams, and quality audit teams.
Total quality management should be implemented by the frontline employees. They
must take the responsibility for delivering high quality healthcare services. Employee
empowerment, commitment and involvement are key factors in the successful Obstacles to
implementation of TQM and, were indeed included in previous TQM studies. Various TQM success
studies have shown that human resources problems such as lack of employees’
motivation and involvement in TQM activities, their low knowledge and experience
about TQM implementation, changing employees’ work habits, lack of team
orientation, lack of linkages between employees’ compensation and their performance
and lack of time are human resource barriers in implementing TQM successfully in 157
healthcare organisations (Alexander et al., 2007; Francois et al., 2003, Huq and Martin,
2000; Kozak et al., 2007; Mosadeghrad, 2005; Ozturk and Swiss, 2008; Withanachchi
et al., 2007).
Effective, frequent and immediate recognition and reward improves employee
morale, self-esteem, and interest in TQM (Brashier et al., 1996). When employees feel
that they are not recognised for their efforts, they become resistant to the TQM
programme. This acts as a barrier to the success of the TQM initiative. TQM must be
result-oriented in order for employees to believe in it. The TQM implementation should
lead to an increase in employee satisfaction and motivation. Financial incentives
increase employees’ motivation and involvement in quality management activities.
Incurring too much work without providing tangible benefits is the most significant
reason for employees’ apathy.
Physicians play an important role in facilitating or impeding TQM implementation.
However, getting them involved in TQM programmes is a challenge for managers.
Potter et al. (1994) believe that without physicians’ involvement, quality improvement
would be limited to issues marginal to the central problems of health care
organisations. Physicians have remained divided from managers. They believe that
TQM adds unnecessary bureaucracy and is used mainly for cost control and it is,
therefore, applicable only to administrative and support functions (Ennis and
Harrington, 1999; Moeller, 2001; Zabada et al., 1998). As a result, physicians do not feel
that TQM activities are part of their responsibilities. Subsequently, they are less likely
to participate in TQM activities, less likely to receive education and training in quality
improvement methods and to use quality improvement methods in their daily work
(Cohen et al., 2008). Physicians are not likely to be distracted from their patients in a
fee-for-service payment system towards a quality management system that expects
them to be more transparent, more responsible, more customer-oriented, and to follow
managerial rules and standards.
Lack of time is the main barrier for physicians’ low participation in TQM activities.
They are more devoted to patient treatment than to TQM. They perceive a conflict
between allocating time for treating patients and performing TQM activities
(Maguerez et al., 2001; Valenstein et al., 2004). Physicians by tradition expect more
autonomy and do not accept changes that might limit their power (McLaughlin and
Kaluzny, 1990; Ruiz and Simon, 2004). Hence, perceived loss of autonomy is another
reason for the high resistance among physicians. They think the standardisation
concept in TQM may limit their freedom to diagnose and prescribe freely. Physicians’
relative inexperience and unwillingness to work as team members are also
contributing to their apathy to TQM (Zabada et al., 1998).
Managers must develop systems to encourage and reward physicians’ commitment
and participation though training and financial incentives. Physicians would be more
involved in TQM activities if they realised its benefits to them. The active involvement
IJHCQA of top management can also encourage physician participation in TQM projects. It is
26,2 not necessary to include every physician in all TQM activities. Incorporating
well-respected and knowledgeable physicians into quality management roles
facilitates physicians’ involvement in TQM programmes (Glickman et al., 2007; and
Wakefield and Wakefield, 1993). They then act as models, mentors and motivators for
other physicians.
158 People’s resistance to change is the primary barrier to implementing TQM in an
organisation. TQM can be a source of fear and anxiety (Matherly and Lasater, 1992).
The reasons for employees’ resistance to a TQM programme may include fear of losing
jobs or related benefits, personal uncertainty, group pressure, perceived loss of control,
a lack of knowledge of the nature and the impact of the proposed change, and a lack of
adequate planning (Alas, 2007; Carter, 2008; Harrington and Williams, 2004; Self and
Schraeder, 2009). Many TQM programmes fail because too little attention is paid to the
human factor. The implementation of TQM results in more demands on employees and
more work pressure. This is often caused by standardisation, increased bureaucracy,

new responsibilities and increased accountability to managers (Parker and Slaughter,
1993; Senge, 2006; Walston et al., 2000). Human resource systems must support the
TQM programme through the development of the necessary motivation, attitudes and
the competencies.
Managers must minimise the sense of ambiguity among employees using effective
communication and planning. Managers must justify TQM implementation in the
organisation. They should persuade employees that they are serious about TQM.
Communication is needed to clarify the future state for employees. Managers must let
employees know what would happen and how they would be affected by the TQM
programme (Abraham and Crawford, 1997). Managers should create the belief among
employees that the appropriate training and education will be provided. Hence,
employees will be able to perform well and take advantage of opportunities that may
arise from implementation of the TQM initiative (Self and Schraeder, 2009).
According to Sewell (1997), serious problems in TQM implementation are likely to
occur if there is any attempt to achieve quality without a full understanding of the
customers’ needs and requirements. However, the paternalistic attitude among many
healthcare professionals that only they can define quality attributes limits the
application of customer-driven TQM programmes (Milakovich, 2005). Customer focus
in TQM requires that customers are identifiable and can define and recognise quality.
However, it is difficult to identify customers and satisfy their needs in healthcare
sector. Unlike in most other industries, purchasing decisions, payment and receipt of
healthcare service are separate. The patient is not necessarily the ultimate “external”
customer in healthcare. Other external groups such as the government, employers and
third party payers affect patient expectations and this makes it difficult to anticipate
patient needs. Patients, in general, lack the ability to judge the technical aspects of
healthcare services (Cheng and Chung, 2002; Naveh and Stern, 2005). Many patients do
not even know their own healthcare needs (Berwick et al., 1992) or even their rights in
healthcare organisations (Mosadeghrad and Esna-ashary, 2004). Therefore, healthcare
organisations tend to focus on their internal quality requirements rather than
customers’ needs (Yang, 2003).
Failure to provide adequate resources to support quality improvement programmes
is another cause for the failure of TQM (Alexander et al., 2007; Lee et al., 2002; Moeller,
2001). Allocating necessary resources are essential for TQM programmes to be Obstacles to
continued effectively. Those healthcare organisations struggling financially will not be TQM success
able to sustain the benefits of TQM programmes. Purchased materials are often a
major source of quality problems (Flynn et al., 1994; Zhang et al., 2000). An effective
supplier relationship management system reduces procurement costs, enhances the
quality of purchased products and provides differentiated and customized services for
healthcare organisations (Rao et al., 1999; Slaight, 1999). 159
Several studies reported that a lack of good information system and information
required for quality management, influenced the success of quality improvement
(Hamidi and Zamanparvar, 2008; Lee et al., 2002; Moeller, 2001). Fundamental to TQM
is collecting timely, reliable and relevant data and information from both inside and
outside the organisation for assessing, improving and evaluating purposes (Joss and
Kogan, 1995; O’Brien et al., 1995). Such information is necessary for the appropriate
usage of resources, identification of customer requirements, evaluating the
effectiveness and efficiency of the operations and determining the cause of quality
problems. Using a quality-oriented information system helps in studying the processes
and identifying and then prioritising quality problems. It allows the sharing of best
practices among departments and across organisations, and enables the widespread
automated collection of data to support quality improvement efforts (Dewhurst et al.,
2003; Ransom et al., 2005). Using information technology supports TQM
implementation (Rivers and Bae, 1999).
Total quality management focuses on studying, understanding and improving the
processes. Many TQM writers have pointed out the importance of focusing on the
effective management of processes (Huq and Martin, 2000; Mosadeghrad, 2005; and
Raja et al., 2007). Quality should be incorporated in the organisation’s processes and
practices. The prevalent processes, procedures and practices in healthcare can promote
or hinder efforts to improve performance. Major procedural problems that healthcare
organisations may encounter during the TQM implementation tend to be as follows:
complexity of processes, bureaucracy, and difficulties in measuring and controlling
healthcare outcomes (Buciuniene et al., 2006; Huq, 2005; Mosadeghrad, 2005;
Seetharaman et al., 2006).
Implementing TQM in healthcare organisations requires an understanding of the
particular nature of the sector, which influences the applicability of TQM practices.
Healthcare systems are among the most complex systems serving humans. Delivery of
healthcare services represents a complex collection of diagnostic, therapeutic and
logistic processes, all of which must be highly coordinated to ensure the delivery of
quality healthcare services. The professional dominance environment of healthcare,
the complex nature of healthcare practices and ethical considerations add to the
complexity (Kimberly and Minvielle, 2000). The complexity in health care is an
obstacle to systems thinking, which is critical in successful TQM implementation.
Appropriate measurement of processes and outputs/outcomes is key element of
TQM success. However, it is difficult to define, measure and control outcomes in
healthcare due to the intangibility of healthcare services (Morrison and Heineke, 1992).
Every patient is different. Patients cannot be treated like manufactured products. It is
difficult to establish a link between the inputs and the outcomes in the health sector as
it is done in manufacturing sector. Many variables affect the outcomes in healthcare.
The outcomes are also dependent on the compliance and co-operation of patients
IJHCQA themselves. Appropriate models should be used to measure quality healthcare
26,2 services. A clinical governance system should be incorporated in such models for
defining clinical standards and monitoring performance against standards.
Healthcare problems also tend to be more complex and require a high degree of
customised solutions (Abd-Manaf, 2005). This aspect of healthcare is in contradiction
with the concept of variation control and standardisation in TQM. Furthermore,
160 customers in health sector are powerless to alter healthcare providers’ behaviour
through market transactions (Zabada et al., 1998). Patients depend on physicians and
nurses. Cultural and socio-demographic factors such as age and gender, severity of
illness, and psychosocial factors such as patient fears and dependence on the
healthcare providers prevent the expression of dissatisfaction (Arnetz and Arnetz,
1996; Fung and Cohen, 1998; and Satia and Dohlie, 1999).
Total quality management should be institutionalised in healthcare organisations.
The Ministry of Health should incorporate TQM concepts as a strategic issue in its
agenda for change. A Quality Act should be established at the Ministry of Health level to
oblige all healthcare organisations to set up a quality management system (QMS) based
on customer focus and continuous quality improvement to ensure high quality
healthcare services. A National Quality Board should be formed to ensure the overall
alignment of the quality management system. This involves the direct involvement and
support of the minister, considering quality as a key national health priority, setting the
national quality goals, formulating national quality management policies, allocating
resources and clarifying responsibilities. A quality management institute should be
formed in the Ministry of Health to oversee quality improvement of healthcare services
delivered by healthcare organisations. This involves creating a quality management
system for quality improvement and performance assessment, setting quality standards,
providing incentives for the introduction and implementation of quality management
programmes, training healthcare professionals in quality management concepts, and
supporting healthcare organisations to improve their services. Such a structure should
also be established formally in healthcare organisations. To sustain this structure and,
consequently, the quality improvement activities, support (physical, financial and
human resources) should be provided.
The challenges to adopting TQM in healthcare organisations suggest that
managers should take a cautious and an incremental approach in its implementation.
Radical transformation of processes has been found to have negative and detrimental
effects on many organisations (Singh and Smith, 2006). TQM does not produce results
in the short term. It does not offer quick answers to all organisational problems
(Hendricks and Singhal, 1997; and Huq, 1996). Implementation of TQM is a
comprehensive and long-term process. It can take an organisation years to put TQM
fundamental principles, procedures and systems into place, create an organisational
structure and culture which is conducive to continuous improvement and change the
values and attitudes of its people to adopt the new behaviour as a consistent way of
working (Dale et al., 1997). The process of adapting and institutionalising TQM is a
difficult, long-term, comprehensive and continuous process that needs patience,
constant top management support and commitment. It may take five years or longer to
implement and institutionalise TQM properly throughout an organisation to achieve
the benefits (Satia and Dohlie, 1999; and Saravanan and Rao, 2007). Organisations
should be patient and realistic about what to expect from TQM.
Discussion Obstacles to
Managers should minimise five gaps to maximise the benefits of a TQM programme TQM success
(Figure 1). These gaps include: information-related gap, plan-related gap,
implementation-related gap, perception-related gap, and expectation-related gap.
Gap 1 is the gap between management perception of the TQM model and the actual
specification of the TQM model. It shows the distance between what the TQM model
contains and what managers think the model is. Proper education and training help to 161
narrow this gap. Gap 2, shows the gap between management perception of the TQM
model and the plan designed to implement the model. Despite careful planning, a TQM
initiative can still fail. Gap 3, plan-implementation gap, shows the gap between what
the plan says for implementing the TQM model and what actually has been
implemented. Gap 4, perceived results- manager’s expected results, is the gap between
perceived results of implementing the TQM model and managers’ expected results
from its implementation. Finally, Gap 5 is the gap between perceived results of
implementing the TQM model and the expected results of the actual TQM model.
The model proposed in Figure 2 helps explain why TQM initiatives fail in practice
(Gap 3). Many of the obstacles identified in this study that hinder TQM efforts are
leadership factors, or strongly influenced by leadership. Top management involvement
and continuous support through setting goals, training, creating a quality culture, and
allocating resources improve employees’ satisfaction, which leads to their commitment
to quality improvement.
Theoretical implications
From the theoretical point-of-view, this study contributes to the literature in terms of
identifying and ranking obstacles to TQM implementation in healthcare organisations.
TQM does deliver better performance when an appropriate model of TQM is
appropriately implemented in a supportive environment (i.e. supportive infrastructure,
appropriate leadership and quality culture).
Figure 1.
A gap model for TQM
implementation
IJHCQA
26,2
162
Figure 2.
Factors inhibiting TQM
successful implementation
Managerial implications
From a practical point-of-view, the findings of this paper provide policy makers and
managers with a practical understanding of the factors that are likely to obstruct TQM
implementation. A thorough understanding of these factors increases the probability
of TQM success by predicting and avoiding those barriers during TQM
implementation. Consequently, this provides direction and guidance in developing
strategies for an effective and efficient TQM transformation. Health care managers will
be able to plan better TQM strategies that will avoid some of the problems identified
by this article into the implementation of successful TQM initiatives.
Conclusion
This paper uncovers the main impeders to successful TQM implementation in
healthcare organisations. The limited success of TQM efforts in healthcare
organisations are due to a lack of consistent managers’ and employees’ commitment
to and involvement in TQM implementation, poor leadership and management, a lack
of a quality-oriented culture, insufficient training in TQM principles and methods, poor
planning for TQM deployment, inadequate resources to implement the TQM initiative,
limited time to devote to TQM implementation and improper evaluation. Inflexible
organisational structure, departmentalised, bureaucratic and hierarchical structure,
physician-oriented healthcare systems, inadequate focus on patients and clients and Obstacles to
the difficulties involved in evaluating healthcare processes and outcomes are also TQM success
barriers to successful TQM implementation in healthcare organisations. These
perceived barriers could be overcome by healthcare managers’ and providers’
willingness to change, and a strong clinical and managerial leadership emphasising
planning, training, and developing a quality structure and culture. The study suggests
a need for a model of TQM to serve as a guide for the holistic implementation of TQM 163
in healthcare organisations. Such a quality management system should not involve
extra work for employees, but should rather be incorporated into the existing work
schedules.
Limitations and implications for future research

This literature review has examined the last 30 years of quality management systems
implementation literature. One reviewer carried out this literature search, and this may
have introduced bias into the search process. The review was limited to articles written
in the English languages. Relevant information from books, journals and websites
written in other languages would provide additional valuable information.
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Appendix Obstacles to
TQM success
Author/s Country TQM obstacles
Abd-Manaf (2005) Malaysia Lack of management knowledge to successfully
implement quality management
Time-consuming quality improvement efforts 171
Difficulties in implementing quality improvement
efforts
Mindset barriers
Alexander et al. (2007) USA Lack of sustained leadership
Lack of extensive training and support
Lack of robust measurement and data systems
Lack of incentives and human resources practices
Lack of supportive context
Brashier et al. (1996) USA Lack of management commitment

Lack of employee interest
Lack of good plans
Physician indifference towards TQM
Lack of focus on the process
Financial constraints
Chan and Ho (1997) USA and Canada Insufficient quality improvement skills
Poor planning
Placing a poor priority on continuous quality
improvement
Lack of employee participation
Ennis and Harrington (1999) Ireland Organisational resistance to culture change
Lack of financial resources
Employee resistance to change
Lack of human resources
Middle management resistance to change
Inter-departmental barriers
Difficulties in measuring quality
Unlimited demand for healthcare services
Quality not seen as an issue by staff
Lack of top management commitment
Lack of union co-operation
Lack of enthusiasm
Huq and Martin (2000) USA Lack of planning
Lack of a conducive and supportive culture
Lack of physicians and nurses involvement
Lack of employee empowerment
Poor education and training
Inadequate methods to measure the cost of quality
An emphasis on quality of care outcomes rather
than both outcomes and the process of care services
Joss and Kogan (1995) UK Lack of leadership
Lack of senior management commitment
Lack of adequate planning Table AI.
Professionalism/turf battles TQM implementation
Lack of education and training obstacles in healthcare
(continued) organisations
IJHCQA Author/s Country TQM obstacles
26,2
Kozak et al. (2007) Turkey Lack of support of top management
Lack of employees’ participation
Lack of a measurement system
Lack of a reward system
Lin and Clousing (1995) USA Lack of top management involvement and
172 commitment
Lack of employee involvement
Lack of focus on patient satisfaction
Matherly and Lasater (1992) USA Lack of managers’ participation
Overlapping of responsibilities of leadership
Limited resources
Fear of change
Work overloads
Mosadeghrad (2005) Iran Lack of qualified and competent employees
Lack of employees’ involvement in quality

management activities
Employees’ shortage
Lack of top management commitment
Lack of a strategic plan for change
Frequent top management turnover
Lack of a quality culture
Ineffective communication
Complexity of processes
Lack of a quality audit system
Lack of financial resources
Nwabueze (2001) UK Poor communication
Employee shortage
Lack of up-to-date facilities
Lack of customer awareness
Lack of effective leadership
Fragmentation of activities
Poor scheduling
Ozturk and Swiss (2008) Turkey Lack of outcome measures
Lack of participative decision-making
Distorted incentive systems
Rewarding the wrong people
Rewarding the wrong things
Limited managerial, financial and organisational
autonomy
Lack of doctors’ participation in quality
improvement efforts
Potter et al. (1994) UK Involving only particular individuals or groups in
quality improvement projects
Inadequate team-briefing approaches
Lack of staff knowledge of quality management
approaches
Communications barriers
Lack of customer focus
Authoritarianism
Lack of medical staff active involvement
Incorporating quality approaches in managerial
tasks
Lack of involvement of middle managers
Table AI. (continued)
Author/s Country TQM obstacles
Obstacles to
TQM success
Withanachchi et al. (2007) Sri Lanka Lack of leadership
Lack of top management support
Lack of continuous monitoring and measurement
Inadequacy of knowledge and training about TQM
Lack of employee specially doctors’ involvement
Difficulty in allocating time for activities 173
Work load of preparing TQM related documents
Lack of financial and other resources
Difficulty of changing work habits
Yang (2003) Taiwan Functional, bureaucratic and hierarchical structure
Authoritarian culture
Leadership style
Professional autonomy
Lack of consensus for TQM adoption among
physicians
Internal requirement domination
Manpower shortfall Table AI.
About the author

Ali Mohammad Mosadeghrad, BSc, MSc, PhD, is Assistant Professor, School of Management
and Medical Informatics, Tehran University of Medical Sciences, Tehran, Iran. Ali Mohammad
Mosadeghrad can be contacted at: mosadeghrad@yahoo.com
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International Journal of Health Care Quality Assurance

Obstacles to TQM success in health care systems

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Design/methodology/approach – This paper reports a literature review exploring the major

Ineffective or inappropriate TQM implementation method

Inappropriate environment for TQM implementation

Lack of employees particularly physicians’ involvement 10 1

procedures and processes) reflect TQM values and principles.

organisation’s strategic planning process. Strategic quality planning is essential for

more work pressure. This is often caused by standardisation, increased bureaucracy,

Limitations and implications for future research

framework to understand high-performing clinical microsystems”, Quality and Safety in

Currency Doubleday, New York, NY.

(2001), “Organizational culture, continuous quality improvement, and medication

Brashier et al. (1996) USA Lack of management commitment

Lack of employees’ involvement in quality

About the author

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