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TQM implementation practices and implementation

TQM

performance outcome of Indian practices

hospitals: exploratory findings

Biju Augustine Puthanveettil, Shilpa Vijayan and Anil Raj
Mechanical Engineering, Rajiv Gandhi Institute of Technology, Kottayam, India, and
Received 31 July 2020
Sajan MP Revised 9 October 2020
Mechanical Engineering, Government Engineering College Thrissur, Thrissur, India Accepted 29 November 2020

Abstract
Purpose – This paper explores and interprets the linkage between total quality management (TQM) practices
and organizational performance measures for improving the healthcare firms’ performance. Indian healthcare
firms are aware of TQM practices and their benefits, but the awareness level varies among the firms and staff.
The study looks into the effectiveness of quality awareness to meet quality performance in Indian hospitals.
Design/methodology/approach – A questionnaire based on previous research was circulated among the
managers and medical staff. The model linking TQM and organizational performance is analyzed with
structural equation modelling and confirmed the hypotheses stated. Interpretations to improve hospital
performance are made.
Findings – The study identified ten relevant TQM factors and confirmed their importance towards the
improved organizational performance of Indian hospitals. Top management initiative, continuous process
improvement and team work are the most contributing TQM factors. Differences in the awareness levels by the
management staff and medical staff are attributed. The managers and medical staff are aware of the benefits of
TQM towards firm performance, but it is to be improved further.
Research limitations/implications – Cross-validation and interpretation are affected due to the limited
sample size. Longitudinal study is recommended to explore the individual hospital as specific cases. Larger
sample size is suggested as an extended work to overcome the demographic and infrastructural limitations of
the firms included.
Practical implications – The management is more interested in TQM, but there is lack of awareness among
the staff. The quality awareness and customer focus by medical staff are the most weakly loaded factors, and
the weaknesses can be remedied by the lead role by the hospital management in providing proper training and
thereby improving the attitude of the medical staff.
Social implications – Effectiveness of hospital operations is highly dependent on customer focus. Properly
communicated, committed and trained staff with good-quality awareness can better implement TQM and
thereby improve hospital performance. Lead role by the management is very important, and the paper lists
ways to attain these outcomes.
Originality/value – Very little is reported from the Indian healthcare sector linking TQM and outcome
performance. The quality awareness, customer focus, communication and learning by the medical staff are to
be improved, and the paper suggests ways to link TQM more effectively to improve the performance in
hospitals. These findings may be useful to the managers, medical staff and researchers in healthcare to bring
better results.
Keywords Total quality management, Health care, Performance measurement
Paper type Research paper

1. Introduction
Over the last few decades, total quality management (TQM) has been become popular to
practitioners, managers and researchers because of its strong impact on business
performance, customer satisfaction and profitability (Bolboli and Reiche, 2013; Talib et al.,
2012). The success of TQM to deliver competitive advantage to manufacturing sector has
motivated academicians and managers to choose TQM in the service sector (Psomas and
The TQM Journal
© Emerald Publishing Limited
1754-2731
Conflict of interest: No potential conflict of interests. DOI 10.1108/TQM-07-2020-0171
TQM Jaca, 2016; Issac et al., 2004). The major service organizations worldwide have embraced TQM
as an effective management tool to improve their service quality (Lam et al., 2012; Alvarez
et al., 2012; Jaca and Psomas, 2015; Talib et al., 2012). In service sector, healthcare institutions
are nowadays being pressurized to improve the efficiency and competitiveness in relation to
cost-effectiveness and quality of care (Faisal Babu and Sam Thomas, 2020). Healthcare
quality has been the topic of research interest around the globe (Swain, 2019). However, based
on healthcare sector, limited empirical research were conducted and limited frameworks are
available on TQM, especially related to developing countries (G€oz€ ukara et al., 2019).
The changing market increases the complexity of healthcare institutions. Specialization of
healthcare providers, strengthening of the client position and accreditation pressures have
motivated healthcare organizations to implement TQM concepts (Mosadeghrad et al., 2019).
Some of the previous research indicated that adoption of TQM in healthcare has significant
impacts on service quality and on the satisfaction of external and internal stakeholders
(Karasa et al., 2008; Miller et al., 2009). Funds shortage, poor priority setting on quality of
service and lack of training and awareness are the obstacles in improving the health sector
(Ovretveit, 2000). Developing countries implement system improvement projects in health
institutions based on the continuous quality improvement (CQI) and total quality assurance
(TQA) programs (Huq and Martin, 2000).
One of the major services in the Indian economy is healthcare. Currently, the health sector of
India accounts for about 1.9% of its GDP and expected public spending in this sector is 2.5% of
GDP by 2025. The government policies have changed the healthcare scenario in India during
the past two decades. During the eleventh five-year plan, the Government of India has made
every effort to augment resources for health and state and to assign at least 7–8% of state
expenditure towards healthcare. The Indian healthcare sector is poised to grow with a strong
demand at a very fast jump to reach a market size of $372 billion by 2022. In continuation, the
hospital industry is likely to grow by 16–17% (132 billion in FY 2022) against 61.79 billion in FY
2017 (India Brand Equity Foundation, 2017). As the hospitals have been playing the key role in
healthcare sector in India, National Accreditation Board of Healthcare (NABH) focuses on
quality of operations and customer service in hospitals. Moreover, quality has been identified as
an important element in the consumer’s choice of hospitals (Karuppusami and Gandhinathan,
2007). However, many of the hospitals are still lacking the awareness related to TQM (Faisal
Babu and Sam Thomas, 2020; Mosadeghrad and Afshari, 2018). While organizing quality
management initiatives, the quality benchmarks, knowledge and skills needed for the
implementation and training facilities are to be adopted with care (Sadeh, 2017). Awareness of
quality is a prerequisite for creating a TQM-based culture in an industry (Talib et al., 2011;
Salaheldin, 2009). The effectiveness of quality awareness to meet the quality performance in
Indian hospital scenario is unknown. Few studies have attempted to investigate the
relationship between TQM practices and organizational performance (OP) of hospitals. This
paper explores the practical ways to link TQM more effectively to improve the Indian hospitals’
performance.
Hence, the research objectives are:
(1) To understand the effectiveness of quality awareness to meet quality performance.
(2) To measure the effectiveness of hospital quality management practices to meet
quality performance.
(3) To establish the relationship between TQM practices and organizational
performance in hospitals.
This paper describes the empirical findings of the study conducted to link TQM practices
with the performance of selected Indian hospitals. The next section describes the literature
review on quality management of hospitals. Details of the model, framework, questionnaire, TQM
sampling plan and analysis plan are illustrated thereafter. Then, the results are discussed. implementation
Conclusions and managerial implications are given in the end.
practices

2. Quality management in hospitals

Quality improvement in hospitals is considered as a means to improve the needs and
expectations of patients (Wardhani et al., 2009). The quality methods used in most hospitals
were based on documentation or activities, which did not immediately improve the clinical
care (Xiong et al., 2016). Many hospitals are turning towards TQM for cutting costs and for
overall improvement in the quality of the services provided (Faisal Babu and Sam Thomas,
2020). The quality management in hospitals is mainly due to ethical reasons (Murale et al.,
2015; Farzadnia et al., 2017). Customer or client quality is measured through customer
satisfaction measures (Fatima et al., 2018). Professional quality relates to procedures and
techniques used to meet customer needs, and it is ensured by audits and standards (Ovretveit,
2000). The hospitals use a method of shared responsibility, everyone being accountable for
the quality of service rendered to the internal customer. However, TQM provides a model for
success through customer satisfaction, but there are obstacles in public and non-profit
organizations due to the bureaucratic culture and passive behaviour (York and Miree, 2004).
A quality management initiative is influenced by the organization culture, design, quality
leadership, physician involvement, quality structure and technical competence. The
organization culture is the shared belief, values, norms and behaviour of the organization
that may contribute to the quality management implementation throughout the organization
(Mensah et al., 2012). The hospitals face a dynamic culture, governed by physicians and
professional authority (Zehir et al., 2012). Physicians constitute a unique body of knowledge,
which confers a certain measure of autonomy in clinical decision-making (Overtveit, 2000).
The general role and authority of physicians is not clearly defined (Faisal Babu and Sam
Thomas, 2020). There is an organizational uncertainty in the management role of physician-
managers as top-level medical directors, middle-level heads of department and as heads of
clinics or teams. Physicians must lead and participate in quality programs, but it is difficult to
practice. Physicians are found to be reluctant to join in quality improvement projects due to
distrust of hospital motives, lack of time and fear of reducing attention in clinical processes.
By training and engaging them from the beginning, hospitals can instil a sense of physician
ownership of the TQM effort (Lee et al., 2002). Physician involvement including employee
empowering culture, a scientific decision-making paradigm and customer involvement are
the main characteristics of QMS implementation (Lee et al., 2002). Effort by the senior
leadership and management leads to integrate quality improvement into the entire
organization and to promote quality values and quality techniques in work practices
(Wardhani et al., 2009). The quality organizational structure and the technical capabilities
support the application of the quality management strategy (Aoun and Hasnan, 2017). The
top management leadership structure in the healthcare companies is very diverse due to an
integrated group of non-employee practitioners and a wider range of an organized body of
professionals who are not employees. There exist a broader set of stakeholder
accountabilities due to public status (Sadeh, 2017). A diffuse leadership structure may
come from the boards of directors and physician leaders (Wardhani et al., 2009). The hospital
board takes a role in creating a corporate culture for quality and is ultimately responsible for
developing and overseeing quality improvement.
Creation of values, goals and systems is needed to satisfy the customers and to improve
firm performance (Sajan et al., 2017; Clay et al., 2020). Based on this, critical success factors
(CSFs) are the crucial elements that require examination and categorization to ensure
effective management of an organization (Oakland, 1995; Aquilani et al., 2017). CSFs are not
TQM objectives, but they are the actions and processes that can be controlled/affected by
management to achieve the organization’s goals (Aoun and Hasnan, 2017; Biju et al., 2012).
CSF in healthcare include “management commitment” (Clay et al., 2020; Rad, 2006),
“Employee involvement”, “customer involvement” (Sila and Ebrahimpour, 2005; Fatima et al.,
2018), “teamwork” (Talib and Rahman, 2010; Thompson et al., 2015), “management of
processes” (Huq, 2005), “continuous improvement” (Huq, 2005; Salaheldin, 2009) and
“training and empowerment” (Huq, 2005; Zarei et al., 2019). Various studies have mentioned
the performance outcomes from TQM in various contexts. Studies identified and validated
three dimensions of firm performance in manufacturing, namely, “financial and market
performance”, “organizational effectiveness” and “customer and employee satisfaction”
(York and Miree, 2004; Fatima et al., 2018). According to other studies, the benefits of TQM
include reduced operational cost, higher productivity, efficiency and growth, increased
market share and profits (Taylor et al., 2020). TQM implementation in service companies used
the outcome measures such as improvement of financial performance, customer satisfaction,
product/service quality and operational performance (Bolboli and Reiche, 2013;
Mosadeghrad et al., 2019). The direct benefits such as company’s product/ service,
operations and financial situation are mostly evident (Agus et al., 2000; Brah et al., 2002). The
majority of TQM studies relate to TQM activities, relationship growth and model and system
development. Studies linking the positive use of TQM and the quality awareness of people are
very few (Emad, 2015). An evaluation of the quality management in the Indian healthcare
industries must be attempted to address the void.

3. Framework and research hypotheses

A research framework was developed showing the relationship between TQM and
operational performance, shown in Figure 1. This framework was developed from the
TQM model suggested by Singh et al. (2018). This particular study has linked the
dimensions of TQM implementation with the perceived business success of the

Quality Awareness

H1

Top Management Commitment

Customer Focus Satisfaction

Results
Knowledge & Training

Continuous Process
H3
H2
Employee Involvement OP
TQM

Process Management

Quality System & Culture

Business
Results
Employee Encouragement

Team Work
Figure 1.
Structural model Communication
manufacturing firms and service firms with the support of extensive collection of TQM
previous research (Talib and Rahman, 2010; Psomos and Jaca, 2016; Kaynik and Hartley, implementation
2008; Bolboli and Reiche, 2013; Agus et al., 2000; Jaca and Psomas, 2015). In the research
framework developed, quality performance is the dependent variable, with secondary
practices
constructs as business results and satisfaction results. The independent variable includes
“TQM practices” and “TQM awareness”. The ten variables shown in Figure 1 were
selected as independent TQM practices relevant for this study (Prajogo, 2005; Arumugam
et al., 2008; Singh et al., 2018; Thompson et al., 2015; Sila and Ebrahimpour, 2005;
Salaheldin, 2009; Jaca and Psomas, 2015; Talib et al., 2012; York and Miree, 2004; Meesala
and Paul, 2018).
The research hypotheses are formulated next. The primary objective of this study is to
understand the effectiveness of quality awareness to meet quality standards and relationship
between TQM practices and quality performances in Indian hospitals. Considering the first
two objectives, first and second basic hypotheses are formulated:-
H1. Quality awareness is a positive and significant indicator of quality management in
Indian hospitals.
H2. TQM is positively and significantly influencing the quality performance in Indian
hospitals.
In continuation with this, nine hypotheses statements for the relationship of individual
TQM practices selected for this study and quality performance are formulated based on
the previous work. Previous research on TQM emphasizes the critical role of top
management involvement in the organization’s overall adoption of TQM (Talib et al.,
2012). The dedication of top management is the fundamental drive, and it significantly
affects quality performance (Lam et al., 2012 and Delic et al., 2014). Therefore, it is
proposed that
H3.1. “Top-management commitment” to TQM is positively linked with quality
performance in Indian hospitals.
Organizations must be aware of customer requirements and must respond to customer
demands (Akdere et al., 2020) and assess customer satisfaction by implementing TQM (Voon
et al., 2014; Talib et al., 2012). Obtaining customer information is needed to increase
organizational quality performance (Meesala and Paul, 2018; Delic et al., 2014). Hence the
hypothesis:
H3.2. “Customer focus” for TQM practices is positively linked with quality performance
in Indian Hospitals.
Knowledge and training disseminate information on achieving quality delivery in service
process and play a critical role in maintaining high quality within the industry (Talib and
Rahman, 2010). TQM research shows a positive correlation between knowledge acquisition
and training and with quality performance (Delic et al., 2014). The H3.3 is stated as follows:
H3.3. “Knowledge and training” for TQM practices is positively linked with quality
performance in Indian hospitals.
Continuous process improvement (Huq, 2005) aims for continuous changes and improving
processes by enhanced methods of converting inputs into useful outputs. Hypothesis
stated is:
H3.4. “Continuous process improvement” for TQM is positively linked with quality
performance.
TQM Employee involvement and participation improve the quality of the product or service.
Employees can contribute well as they involve the processes of quality improvement and
decision-making (Huq, 2005). The hypothesis is stated as follows:
H3.5. “Employee involvement” for TQM practices is positively linked with quality
performance in Indian hospitals.
System management is a systematic approach in which all of an organization’s resources are
used to achieve the desired efficiency (Sit et al., 2009; Rad, 2006). Process management
increases each employee’s efficiency and thereby improves the performance (Voon et al.,
2014). The following hypothesis is proposed:
H3.6. “Process management” for TQM practices is positively linked with quality
performance in Indian hospitals.
Quality frameworks and culture create an environment for implementing TQM within an
enterprise. The organization’s output is positively correlated with the quality management
methods (Talib et al., 2012). Hence, the hypothesis is proposed as follows.
H3.7. “Quality systems and culture” for TQM practices is positively linked with quality
performance in Indian hospitals.
Employee benefits such as bonuses and appreciation inspire workers to perform, which, in turn,
affect customer satisfaction (Talib et al., 2012). Motivation of employees is positively linked to
the success of the company (Salaheldin, 2009). The following hypothesis is proposed:
H3.8. “Employee encouragement” for TQM practices is positively linked with quality
performance in Indian hospitals.
The application of teamwork strategies increases efficiency and promotes quality
enhancement activities (Talib et al., 2011; York and Miree, 2004). Team building within an
enterprise is critical to the success of TQM (Lam et al., 2012; Thompson et al., 2015). The
following hypothesis is proposed:
H3.9. “Team work” for TQM practices is positively linked with quality performance in
Indian hospitals.
Effective communication affects the company to systematically step towards employee
engagement and customer satisfaction and improve organization performance (Lam et al.,
2012; Akdere et al., 2020). The following hypothesis is proposed.
H3.10. “Communication” for TQM practices is positively linked with quality
performance in Indian hospitals.

4. Research methodology
A descriptive cross-sectional research design was adopted for this study. The previous
studies on quality management and performance outcome in various sectors have been
extensively referred. The suitable independent and depend variables were defined as
mentioned in research framework.

4.1 Questionnaire design

For data collection, a questionnaire survey method via email was adopted. The questionnaire
designed has four sections. The first part focuses on the demographic profile of the
respondents like gender, designation, department and so forth. The second part includes 11
items for assessing the awareness level of TQM (Talib et al., 2011; Brah et al., 2000 and TQM
Ovretveit, 2000). The third part includes 54 items, developed from the studies by Brah et al. implementation
(2000), Sila and Ebrahimpour (2005), Saravanan and Rao (2007), Talib et al. (2012) and
Salaheldin (2009). TQM practices included ten constructs, namely, “top management
practices
commitment”, “customer focus”, “knowledge and training”, “continuous process
improvement”, “employee involvement”, “process management”, “quality system and
culture”, “employee encouragement”, “team work” and “communication”. The fourth part
measured the quality performance of the hospital, using nine items (Jaca and Psomas, 2015;
Talib et al., 2011; Salahldin, 2009 and Singh et al., 2018). Seven items are based on the
“satisfaction results” and two are based on “business results” (Prajogo, 2005; Singh et al.,
2018). A five-point Likert scale was adopted to measure the responses. Discussion with two
academic experts, two industry experts and two peer group members helped to shape the
questionnaire. For the pilot survey, 30 data sets were collected from the randomly selected
respondents from the target population. Based on their feedbacks, questionnaire was
finalized.

4.2 Sampling frame and sampling method

Sampling frame consists of a list of hospitals in Kollam district of the state of Kerala, India.
From this list, 60 hospitals were selected randomly. Formal permission letters were drafted
and sent to each hospital to seek permission for collecting data. Total 52 hospitals cooperated
with the study. Multiple respondents including physicians, managers, nurses and
paramedical staff were selected from each of the sample hospitals. Simple random
sampling was also followed. Questionnaire was distributed via email. The questionnaires
were emailed to a total of 630 respondents. On continuous follow-ups, altogether 302
responses were received with a response rate of 47.9 %. After screening, 288 responses were
found to be useful.

5. Data analysis and results

Structural equation modelling (SEM) was adopted to analyze the connection with
independent and depended variables to test the hypotheses statements. SEM is an
effective method to analyze the relationship between multiple variables (Hair et al., 2011). The
hypotheses statements were tested using maximum likelihood estimates. Initially,
preliminary descriptive statistics analysis was conducted. The data structure was
examined with exploratory factor analysis and confirmatory factor analysis. IBM SPSS
Statistics and AMOS 25 were used for analysis.

5.1 Preliminary descriptive statistics

The preliminary descriptive statistics shows that 172 respondents belong to
administrative posts and 116 staff belong to medical staff including physicians, nurses
and so forth. Almost 60% of respondents have more than 6 years of experience working in
the sample hospital. Univariate analysis was used to assess the normality of the data
skewness and kurtosis. Here, skewness and kurtosis are found to be below 2, which are
within the acceptable limit according to Hair et al. (2011), and hence normality is assumed.
Data reliability in terms of Cronbach’s alpha above 0.6 is considered acceptable, 0.7 is
considered very good and values above 0.8 are considered excellent (Hair et al., 2011;
Norman, 2003). All constructs are reported with Cronbach’s alpha values in the range 0.8
and above.
The indicator items are reduced to separate factors while carrying out EFA. These
reduced factors are used in the SEM model to test the hypotheses. Content validity is
TQM established from the studies of Singh et al. (2018), Brah et al. (2000), Sadikoglu and Olcay
(2014), Zakuan et al. (2010), Zarei et al. (2019) and Zehir et al. (2012). Inter-item correlations of
the items of all constructs are found between 0.2 and 0.7, which indicated adequate
multicollinearity. To establish discriminant validity, item-total correlation is calculated. All
the constructs satisfied adequate item-total correlations. Kaiser–Meyer–Olkin (KMO) is a
criterion used to test the sample adequacy. KMO values are obtained ranging from 0.735 to
0.904, which shows the sample adequacy (Hair et al., 2011). Bartlett’s test of sphericity is
significant at p 5 0.001 (Hair et al., 2011). All constructs reduced to the respective single
factors with very good factor loading.

5.2 Measurement model, validity and reliability

The first-order measurement model is developed and validated by calculating the fit values
using AMOS 25. The models developed are recursive and overidentified. Figure 2 shows the
measurement model developed.
Three categories of fit indices were used to validate the model, namely, chi- square
goodness of fit; other fit indices such as CFI, NFI, GFI and TLI; and badness of fit RMSEA and
RMR. The obtained fit values from the model are listed in Table 1 and are found to be within
the recommended ranges.
The factor loadings should be more than 0.5 for establishing construct validity (Hair et al.,
2011). As shown in Table 2, all factor loadings are more than 0.50. The critical ratios in the
AMOS 25 text output were verified. Critical ratio for a variable is the estimated parameter
divided by its standard error. It is the t-value used for estimation. The t-value should be more
than 1.96 or less than 1.96, for establishing significant difference at 5% significance level
(Byrne, 2013). From Table 2, it is clear that all the critical values exceeded 1.96, were
significant at p 5 0.001 and are indicative of acceptable model fit.
The value of average variance extracted (AVE) should be above 0.5, establishing
convergent validity. Construct reliability (CR) values were calculated, and all CR values are
above 0.6. Hair et al. suggest that CR value above 0.6 indicates acceptable model fit. The
values of CR, AVE, maximum shared variance (MSV) and average shared variance (ASV) are
shown in Table 3. Thus, the model established the convergent validity and reliability.

5.3 Structural model

After validating the measurement model, the structural model is analyzed and the
hypotheses are tested. The output of the structural model is shown in Figure 3. The fit indices
are found within the acceptable ranges. Table 4 gives a summary of the hypothesis test
results.
The test results are discussed below.
(1) The Hypothesis H1 linking the quality awareness with the TQM implementation is
confirmed with a positive and significant β score (β 5 0.36 at p 5 0.001. This result
agrees with the previous findings of Lam et al. (2012) and Jaca and Psomas (2015).
Talib explained the importance of quality awareness for the success of TQM
implementation in the manufacturing context. Psomas and Jaca validated the same
in the context of Spanish service firms. The above-mentioned findings are valid in
the healthcare also.
(2) Hypothesis H2 is proposed as a positive and significant association between TQM
and OP. It is confirmed with β 5 0.51 (t-value 3.321, p 5 0.001), which is in agreement
with the studies of Jaca and Psomas (2015) and Zakuan et al. (2010). All studies have
established that the TQM practices lead to improved organizational performance.
 TQM
implementation
practices

Figure 2.
The
measurement model

(3) The hypothesis H3.1, that is, a positive and significant link between top
management commitment and TQM, is confirmed with a β value 0.635 (t-value
8.503, p 5 0.001). The research by Lam et al. (2012), Delic et al. (2014) and Clay et al.
(2020) established the positive link between TQM and commitment by the top
management by taking the lead role. The theoretical validation of this finding is
justified based on practical grounds of the healthcare sector (in the Discussion
section).
TQM Recommended
Indices Abbreviation Observed values range References

Chi-square χ 2
3649.7 at p < 0.05 Hair et al. (2011)
p 5 0.000
Goodness-of-fit index GFI 0.805 >0.80 Singh et al.
(2018)
Comparative fit index CFI 0.861 >0.90 Byrne (2013)
Tucker–Lewis index TLI 0.847 0 < TLI < 1
Table 1. Normed fit index NFI 0.864 >0.90
Goodness of fit values Root mean square error RMSEA 0.074 <0.05 good fit
of CFA approximation <0.08 acceptable fit

(4) Hypothesis H3.2, that is, a positive and significant link between customer focus and
TQM, is confirmed with β 5 0.37 (t-value 5.730, p 5 0.001). The findings agree with
the observations of Singh et al. (2018), Fatima et al. (2018) and Meesala and Paul
(2018). Compared to manufacturing and service sector, the healthcare sector is very
much dependent on customer focus (Meesala and Paul (2018), Fatima et al. (2018).
Patient care and satisfaction are very important. In this study, customer focus is
revealed by a moderate loading of 0.37, and the reason for this moderate value is
discussed in the practical implication’s s section.
(5) The hypothesis H3.3, that is, positive and significant link between knowledge and
training and TQM, is confirmed (β 0.57, t-value 7.88, p 5 0.001 l). Findings agree with
Singh et al. (2018) and Kaynak and Hartley (2008). The importance of learning and
training by the practitioners in TQM environment is understood from all TQM-
based studies, and this study confirms the same. However, cross-validation of the
data reveals some differences in the learning and training by the managers and
medical staff, when studied as two groups.
(6) Hypothesis H3.4 linking continuous process improvement and TQM is confirmed
with a positive β coefficient of 0.603 (t-value 9.371, significant at p 5 0.001). Findings
agree with Singh et al. (2018), Zehir et al. (2012) and Jaca and Psomas (2015). This is
also a general requirement of TQM theory.
(7) The Hypothesis H3.5 links employee involvement and TQM. It is confirmed with a
positive β coefficient of 0.522 (t-value 8.049, significant at p 5 0.001). Findings agree
with Singh et al. (2018), Zakuan et al. (2010) and Sadeh (2017). TQM practices, from
the basics, advocate the commitment and involvement by all staff.
(8) The Hypothesis H3.6 links process management and TQM. The hypothesis is
confirmed with positive and significant β coefficient 0.557, with t-value 8.554,
significant at 0.001 level. Findings agree with the observations of Singh et al. (2018)
and Zakuan et al. (2010).
(9) Hypothesis H3.7 linking quality systems and culture and TQM is confirmed with a
positive β coefficient of 0.485 (t-value 7.827, significant at p 5 0.001). Findings agree
with Agus et al. (2000) and Kaynak and Hartley (2008). In healthcare firms, standard
procedures and documentation for the purchase of medicines, tests, surgical
procedures and so forth are mandatory and are monitored by many agencies, the
hospital management and accreditation systems such as NABH. There exists a
favourable culture and system.
 Standardized factor Standard
TQM
Constructs and items loadings error t - value p - value implementation
practices
A) TQM
1) Top management commitment (TM)
TM1 (level of commitment) 0.936 0.108 13.257 ***
TM2 (interest) 0.826 0.106 12.091 ***
TM3 (importance) 0.732 0.098 10.996 ***
TM4 (focus on quality) 0.917 0.106 13.351 ***
TM5 (priority on quality) 0.668 0.101 10.159 ***
TM6 (active leading) 1.000
2) Customer focus (CF)
CF1 (understand patient needs) 0.949 0.027 35.311 ***
CF2 (collecting patient complaints) 0.940 0.029 34.259 ***
CF3 (use patient feedbacks) 0.935 0.029 33.229 ***
CF6 (service information) 0.949 0.027 36.202 ***
CF7 (caring attention) 1.000
3) Knowledge and training (KT)
KT1 (work–skill training) 0.900 0.101 13.551 ***
KT2 (continuous training) 0.943 0.098 13.686 ***
KT3 (training on soft skills) 0.756 0.094 11.682 ***
KT4 (training on problem solving) 1.000
4) Continuous process improvement (CP)
CP1 (management focus) 0.921 0.050 22.245 ***
CP3 (accepting programs) 0.884 0.051 20.667 ***
CP4 (belief) 0.776 0.059 16.374 ***
CP5 (assessment) 1.000
5) Process management (PM)
PM1 (streamlined procedures) 0.671 0.053 13.444 ***
PM2 (technical capability) 0.681 0.054 13.744 ***
PM3 (tracking and maintenance) 0.928 0.046 22.977 ***
PM4 (clear set of instructions) 1.000
6) Quality system and culture (QS)
QS1 (employee suggestion schemes) 0.948 0.025 38.923 ***
QS2 (employee participation) 0.733 0.045 17.345 ***
QS3 (developing procedures) 0.918 0.028 32.881 ***
QS4 (measuring patients complaints) 0.978 0.021 48.068 ***
QS5 (emphasis on quality 0.966 1.000
improvement)
7) Employee encouragement (EE)
EE1 (recognition and rewards) 0.687 0.056 13.937 ***
EE2 (value innovative ideas) 0.584 0.059 10.956 ***
EE3 (grievance redressal) 0.948 0.045 23.019 ***
EE4 (use of non-financial incentives) 0.900 1.000
8) Team work (TW)
TW1 (right the first time and every 0.939 0.099 13.765 ***
time)
TW2 (feeling – my hospital) 0.670 0.098 10.421 ***
TW3 (comfortable environment) 0.931 0.101 13.706 *** Table 2.
TW4 (priority on housekeeping) 0.667 1.000 Validation of the
measurement model
(continued ) (TQM with OP)
TQM Standardized factor Standard
Constructs and items loadings error t - value p - value

9) Communication (C)
C1 (communication channels) 0.573 0.051 11.178 ***
C2 (communication of strategies) 0.947 0.035 27.936 ***
C3 (effectiveness of communication) 0.500 0.053 9.340 ***
C4 (top-down, bottom-up 0.959 1.000
communication)
10) Employee involvement (EI)
EI1 (suggestions and innovations) 0.868 0.034 26.002 ***
EI2 (active involvement) 0.818 0.037 21.967 ***
EI3 (quality circles, etc.) 0.946 0.025 36.795 ***
EI5 (coordination) 0.807 0.038 21.196 ***
EI6 (participation on strategy 0.966 1.000
formation)
11) Quality awareness (QA)
QA3 (awareness on TQM practices) 0.828 0.051 17.661 ***
QA5 (need on TQM training) 0.886 0.050 19.751 ***
QA6 (TQM leads to quality service) 0.600 0.059 11.056 ***
QA7 (tool for continuous improvement) 0.792 0.052 16.436 ***
QA9 (aware of quality parameters) 0.866
1.000
B) Organizational performance (OP)
1) Satisfaction results (SR)
SR1 (reduced absenteeism) 0.953 0.062 19.365 ***
SR2 (good image by patients) 0.935 0.062 18.956 ***
SR3 (reduced patient complaints) 0.794 0.066 15.119 ***
SR5 (increased supplier quality) 0.791 1.000
2) Business results
BR1 (performance on industry norms) 0.806
Table 2. BR2 (reduction in errors) 0.721 0.130 7.592 ***

Construct CR AVE MSV ASV

TM 0.768 0.634 0.296 0.230

CF 0.954 0.893 0.05 0.043
KT 0.754 0.681 0.389 0.222
CP 0.837 0.748 0.243 0.146
PM 0.796 0.651 0.258 0.167
QS 0.888 0.834 0.312 0.105
EE 0.754 0.629 0.364 0.205
TW 0.753 0.661 0.357 0.216
C 0.732 0.599 0.406 0.220
QA 0.790 0.793 0.294 0.169
EI 0.846 0.780 0.225 0.142
SR 0.871 0.759 0.176 0.112
Table 3. BR 0.763 0.584 0.229 0.182
Validity and reliability Note(s): *For acceptable composite reliability, CR > 0.60; for convergent validity, (CR > AVE > 0.50)
of the model Discriminant validity; MSV > ASV
 TQM
implementation
practices

Figure 3.
Factor loadings of the
SEM model (N =288)

(10) Hypothesis H3.8 linking employee encouragement and TQM is confirmed with a
positive β 5 0.522 (t-value 8.049, p 5 0.001). Findings agree with Singh et al. (2018)
and Zakuan et al. (2010). This shows that the attempts to encourage the employees
are followed.
(11) Hypothesis H3.9 linking team work and TQM is confirmed with a positive β
coefficient of 0.631 (t-value 8.499, significant at p 5 0.001). Findings agree with
Zakuan et al. (2010), Emad (2015) and Thompson et al. (2015), who established the
importance of team work.
(12) Hypothesis H3.10 linking communication and TQM is confirmed with a positive β
coefficient of 0.473 (t-value 7.436, significant at p 5 0.001). Findings agree with
Zakuan et al. (2010) and Aoun and Hasnan (2017).
TQM Construct Loading CR Result

TQM–OP 0.515 3.321 *** All the hypotheses are supported

OP–SR 0.618 2.699 ** (0.007)
TQM–EI 0.554 8.997 ***
TQM–QA 0.356 5.303 ***
TQM–C 0.473 7.346 ***
TQM–TW 0.631 8.499 ***
TQM–QS 0.485 7.827 ***
TQM–PM 0.557 8.664 ***
TQM–CP 0.603 9.371 ***
TQM–KT 0.573 7.888 ***
TQM–CF 0.368 5.730 ***
TQM–TM 0.635 8.503 ***
Table 4. TQM–EE 0.522 8.049 ***
Hypotheses results Note(s): ***p < 0.0001

5.4 Cross-case validation

Cross-validation is done by dividing the population into administration staff (size N 5 172)
and medical staff (size N 5 116), and evaluated as two separate SEM models. Larger path
coefficients (higher β coefficients) for the TQM practices and awareness are observed for the
medical staff than for the administrative staff. But the correlation between TQM and OP
is higher (β coefficient 0.59) for the administrative staff than the for the medical staff
(β coefficient 0.41). These conflicting results need logical interpretation (see Figures 4 and 5).
The model of the administrative staff reports poor correlation (β 5 0.32) for the TQM
awareness and customer focus (β 5 0.23) than that for the medical staff (0.40 and 0.41). The
medical staff is more aware of the service benefits to be offered to the customer. Similar
differences are observed for all the paths of TQM constructs. The medical staff are aware of
TQM and practice it in a better way. It is attributed to two reasons. The first one is insufficient
learning by the administrative staff about the purpose and practice of TQM. Though the top
management is interested, the same may not be properly transferred to the administrative
staff. The second reason is because of the practice of systematic work and keeping records in
order (the practice of the profession), the medical staff use team work, customer focus and
communication in a better way. A comparison of the two models is shown in Table 5.
The correlation between TQM and OP is more among the administrative staff (β 5 0.59)
than among the medical staff (β 5 0.41). The administrative staff is more engaged in the
business aspects, while medical staff engages on the service aspects. The administrative staff
is able to link TQM with the business results and satisfaction results in realistic terms, while
the medical staff focuses on TQM with the benefits in the service offer. Two path estimates,
namely, TQM-OP and OP-SR for medical staff, are not significant and fail to accept the
respective hypotheses. Many of the path coefficients (β) for the medical staff are greater than
OP of the administrative group. In both cases, the management has to exert more time and
effort to educate and train the staff for providing better outcome by implementing TQM.

6. Discussion and conclusions

The study confirms the importance of all TQM factors and quality awareness to improve the
organizational performance of Indian hospitals. It is observed that the linkage between all
constructs with the TQM is positive and significant. The constructs top management
initiative (TM), continuous process improvement (CP) and team work (TW) are ranked top in
influencing the organizational performance, with β coefficients above 0.6. Other constructs
 TQM
implementation
practices

Figure 4.
Cross validation
(Group 1:
Administrative staff)

KT, PM, EE and EI are also loaded above 0.5. The loading shows that the TQM constructs
strongly influence OP. Among the two constructs of OP, the business result (BR) influences
more on the OP, (β 5 0.77) than the satisfaction result (SR) (β 5 0.62). In hospitals,
paramedical staff, nurses and physicians give importance to patient care and dedication to
their duties, rather than focusing on the upkeep of records and continuous improvement of
their working environment. Continuous improvement requires management by facts and
commitment of employees with good teamwork to promote a bottom-up thrust for quality
improvement.
Quality systems and communication are loaded below 0.50. These two factors are
important, but the respondents are not aware of such factors. It may be due to their inexperience
or due to lack of utilizing such practices in their daily work life. Rad (2006) had pointed out that
the process of creating values, goals and systems for customer satisfaction and firm
performance is responsible for providing direction and encouragement to the organization. Huq
(2005) pointed out that TQM requires total management commitment to ensure employees
indulge in quality work culture. This creates good corporate image by providing quality
TQM

Figure 5.
Cross validation
(Group 2: Medical staff)

services. Communication and quality systems are the important channels to attain the said
objectives. The weakest constructs (loading of the range 0.36–0.37) are observed for the quality
awareness and customer focus. Customer focus is necessary in the administrative and
operational process, and interaction with the customers is needed to know their requirements,
because a corporate culture values the customer (Manjunath et al., 2007; Nithya, 2018).
From the study, it is observed that the customer focus has to be improved. The poor loading
of the factor “Quality Awareness” shows that the respondents are not much aware of the TQM
practices, roles and benefits. Employee training and learning are to be enhanced. Increased
 Type of respondent (group)
TQM
Path Overall model Administrative CR Significance Medical CR Significance implementation
practices
TQM–OP 0.515 0.59 2.612 *(0.009) 0.41 1.876 0.06
TQM–QA 0.356 0.23 2.388 *(0.017) 0.40 3.390 ***
TQM–EE 0.522 0.44 3.891 *** 0.60 4.599 ***
TQM–TM 0.635 0.66 4.714 *** 0.61 4.509 ***
TQM–CF 0.368 0.32 3.318 *** 0.41 3.664 ***
TQM–KT 0.573 0.52 4.167 *** 0.58 4.620 ***
TQM–CP 0.603 0.49 4.334 *** 0.71 5.473 ***
TQM–PM 0.557 0.48 4.349 *** 0.61 4.880 ***
TQM–QS 0.485 0.51 4.574 *** 0.46 4.127 ***
TQM–TW 0.631 0.60 4.505 *** 0.66 4.889 ***
TQM–C 0.473 0.40 3.861 *** 0.57 4.938 ***
TQM–EI 0.554 0.50 *** 0.63 *** Table 5.
OP–SR 0.618 0.991 10.778 *** 0.64 1.549 0.121 Comparative statistics
OP–BR 0.77 0.856 *** 0.76 *** of the factor loadings of
Note(s): ***Significant at p < 0.001 two models

employee’s involvement in the overall quality strategy will increase the flow of information and
knowledge and contribute to increased quality outcome of the hospital (Overveit, 2000). The
results thereby confirm the previous research findings reported from the previous works
service sector (Huq, 2005) and healthcare sector (Lee et al., 2002; Clay et al., 2020; Nithya, 2018;
Mosadeghrad and Afshari, 2018; Thompson et al., 2015 and Wardhani et al., 2009).
Results of this study show some differences from the research findings of the models of services,
manufacturing and construction. In civil construction, the products are unique and changes arise
during the final execution stage (Bubshait and Al-Atiq 1999). In manufacturing, repeated
production enables standard settings and certainty in operations (Singh et al., 2018). In healthcare,
the situation differs due to difference in the management structure (physicians and conventional
managers), patient arrival, the complexities of product and service and delivery of services. The
quality awareness and communication are poor and need to be improved. It is also observed that the
employee encouragement and employee involvement are moderate, which can be improved by the
top management initiative and by improving the quality systems and process management. Cross-
validation revealed that the medical staff use TQM in a better way and that they are more aware of
TQM than the administrative staff. But to lead as a team and to reap the benefits, the top
management has to exert more strategic moves to train, learn and communicate with all people.
The low scores of the medical staff compared to the managers and physician of the hospitals
indicate the passive nature / lack of awareness of the staff such as nurses and paramedical staff.
They lack the understanding of the requirements and benefits of TQM implementation. The
second aspect is the priority given by the staff on patient care than on the importance of
documentation and improved quality in the operations. The staff are not aware of the leading
management role expected in RQM implementation. These limitations are to be resolved by
giving frequent training and knowledge to the staff. Quality consciousness is to be imparted to
the lower-level staff by the focused attention and lead role by the management. Clear action
plans for employee education and soliciting cooperation by the lower level staff can be created
by the frequent and repeated training / education schemes. Associations of the management
and quality forums must address this issue with a clearly designed action plan.
The conclusions of the study can be summarized as follows:
(1) Lead role by the top management and strategies based on continuous improvement
and team work are the chief factors towards the success of TQM and the subsequent
benefits to the hospitals
TQM (2) The managers and physicians are more aware about this. More awareness,
motivation and encouragement are required among the medical staff. Motivation
and encouragement of medical staff may change their present passive style to a
focused and effective attitude. Management commitment is needed in this respect.
(3) Adequate quality system and employee involvement exist at present. What is
required is a motivating and comprehensive system for integrating the effort and
team work of managers and medical staff.
(4) Customer focus, quality awareness and effective communication are to be given more
priority by the hospitals. For the success of TQM methods and better firm
performance, documentation is equally important. Correction and improvement is
possible only through proper documentation.

7. Managerial implications, limitations and directions for future research

The positive and significant relationship between TQM and organizational performance
shall motivate the top management to move ahead with TQM implementation initiatives. The
respondents perceive that the top management leadership is a key factor in the TQM
implementation. Even though some structural conflicts exist among conventional
management and physicians, their lead role is very crucial. Suitable methods are to be
formulated to transform physicians to physician leaders and managers, and their knowledge,
skill and expertise have to be utilized to gain quality outcome.
Continuous process improvement and process management are subjected to the
structural / policy formation by the top management. The respondents are aware of the
benefits of team work and training. Moderate correlation is observed for the paths
connecting employee encouragement, employee interaction and quality systems with OP.
Quality systems may be well formulated, but the awareness of the role of quality system is
not up to the mark. Similar is the case with employee engagement and employee
involvement. The respondents are not aware of the importance of these two factors in TQM
initiative. It may be due to poor experience, involvement or exposure in TQM initiatives by
the people.
Customer focus and communication are given low priority by the respondents. But the TQM
concepts advocate the importance of communication and customer support. Effectiveness of
hospital operations is highly dependent on customer focus. Top management must consider the
strategic importance of customer care, support and satisfaction and should value customer
focus for implementing TQM for better organizational performance.
This study is conducted with 288 samples, including managers and workers. Cross-
examination validation results are affected because of low sample size. The difference in
the views of private and public sector managements needs to be studied. With larger
sample size, the moderating effect of factors such as ISO certification, investment,
number of employees and turnover, needs to be studied. The limitations of geographical
restriction have to be addressed with a wider sample. Findings of this study can explore
to initiate longitudinal researches and more cross-case examinations to different
demographic and infrastructural variables to reveal more useful findings for hospital
sector.

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Further reading
Brah, S.A. and Lim, H. (2006), “The effects of technology and TQM on the performance of logistics companies”,
International Journal of Physical Distribution and Logistics Management, Vol. 36 No. 3, pp. 192-209.
Ebrahimi, Z.F. and Rad, R.H. (2017), “The relationship between TQM practices and role stressors”,
International Journal of Management Practices, Vol. 10 No. 3, pp. 295-325.
Lin, C. and Chow, W.S. (2006), “A Structural Equation Model of supply chain quality management and
organizational performance”, International Journal of Production Economics, Vol. 17 No. 4, pp. 460-84.
Naser Alolayyan, M., Anuar Mohd Ali, K. and Idris, F. (2011), “The influence of total quality
management (TQM) on operational flexibility in Jordanian hospitals: medical workers’
perspectives”, Asian Journal on Quality, Vol. 12 No. 2, pp. 204-222.

About the authors

Biju Augustine Puthanveettil is a professor, Mechanical Engineering Department,
Govt. Rajiv Gandhi Institute of Technology, Kottayam, India. The author has 21 years
teaching experience and 9 years of industrial experience. The research areas of Biju
Augustine include SMEs, manufacturing strategy and operations management. The
author has published 6 international journal papers and has more than 40 publications.
Biju Augustine Puthanveettil is the corresponding author and can be contacted at: biju.
augustine@rit.ac.in

Shilpa Vijayan is a PG student (M.Tech. Industrial Engineering and Management), Mechanical

Engineering Department, Govt. Rajiv Gandhi Institute of Technology, Kottayam, India. She is a crafter
and runs a parallel business of online paper craft retail of the paper craft items designed by her, and that
is the motivation for this author to focus study in this area. She has published one conference paper and a
journal paper as part of this study.
Anil Raj is a PhD scholar of the Industrial Engineering and Management division, Mechanical
Engineering Department, Govt. Rajiv Gandhi Institute of Technology, Kottayam, India. He is a
postgraduate in economics and currently doing research in the area of SMEs.
Sajan MP is an associate professor in the Mechanical Engineering department of the
Government Engineering College, Trichur, Kerala, India. The research areas focused
by Sajan are lean manufacturing and SMEs. Sajan has published 4 international
journals and more than 10 conference publications in the area of lean manufacturing
and SMEs.

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