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Cost of quality in healthcare: A case study in a clinical laboratory

Article  in  International Journal of Productivity and Quality Management · January 2016

DOI: 10.1504/IJPQM.2016.075254

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536 Int. J. Productivity and Quality Management, Vol. 17, No. 4, 2016

Cost of quality in healthcare: a case study in a clinical

laboratory

Mouna Zahar*, Abdellah El Barkany and

Ahmed El Biyaali
Faculty of Sciences and Techniques,
Mechanical Engineering Laboratory,
Sidi Mohammed Ben Abdellah University,
B.P. 2202 – Route d’Imouzzer – FES – MAROC, Morocco
Email: mouna_svt@hotmail.com
Email: a_elbarkany2002@yahoo.fr
Email: biyaali@yahoo.fr
*Corresponding author

Abstract: In today’s environment, many laboratories are challenged to

maintain or increase their quality while simultaneously lowering their overall
costs. The objective of this research is to use the cost of quality (COQ) model
to estimate the COQ-related activities at a clinical laboratory located in
Morocco. Using data collected during six month, we allocated the direct costs
associated with quality-related activities in the laboratory across COQs cost
categories: prevention, appraisal, internal failures, and external failures. We
found that approximately 83% of total COQ was spent on costs of ‘good
quality’ (prevention and appraisal), while 17% was spent on costs of ‘poor
quality’ (internal and external failures). The high percentage of COQ spent on
prevention and appraisal activities is consistent with efforts to ensure high
quality laboratory results.

Keywords: cost of quality; COQ; appraisal cost; prevention cost; failure cost;
clinical laboratory; quality management.

Reference to this paper should be made as follows: Zahar, M., El Barkany, A.

and El Biyaali, A. (2016) ‘Cost of quality in healthcare: a case study in a
clinical laboratory’, Int. J. Productivity and Quality Management, Vol. 17,
No. 4, pp.536–548.

Biographical notes: Mouna Zahar is a PhD candidate of the Laboratory of

Mechanical Engineering at the University of Sidi Mohammed Ben Abdellah,
Fez. She received her MS in Quality Management and Health from the
University of Hassan II, Mohammedia. Her expertise includes quality
management, cost management, standards and certifications.

Abdellah El Barkany is a Professor in the Mechanical Engineering Department,

Faculty of Sciences and Techniques at the Sidi Mohammed Ben Abdellah
University. He obtained his PhD in Mechanical Engineering from University
Hassan II of Casablanca (2007). He received his Engineering degree in Quality
and Maintenance from the same university in 1997. He has published many
papers in different academic journals and his research interests span from
production, quality, maintenance and optimisation.

Copyright © 2016 Inderscience Enterprises Ltd.

 Cost of quality in healthcare: a case study in a clinical laboratory 537

Ahmed El Biyaali is a Professor in the Mechanical Engineering Department,

Faculty of Sciences and Techniques at the Sidi Mohammed Ben Abdellah
University. He holds a BS and PhD degrees in Mechanical Engineering. His
areas of interest include thermic mechanics, maintenance and optimisation.

1 Introduction

Many companies promote quality as the central customer value and consider it to be a
critical success factor for achieving competitiveness. Any serious attempt to improve
quality must take into account the costs associated with achieving quality since the
objective of continuous improvement programmes is not only to meet customer
requirements, but also to do it at the lowest cost. This can only happen by reducing the
costs needed to achieve quality, and the reduction of these costs is only possible if they
are identified and measured. Therefore, measuring and reporting the cost of quality
(COQ) should be considered an important issue for managers.
There is no general agreement on a single broad definition of quality costs
(Machowski and Dale, 1998). However, COQ is usually understood as the sum of
conformance plus non-conformance costs. Cost of conformance is the price paid for
prevention of poor quality (inspection and quality appraisal). Cost of non-conformance is
the cost of poor quality caused by product and service failure (rework and returns).
According to Plunkett and Dale (1999) and Foster (2010), it is now widely accepted that
quality costs are the cost incurred in the design, implementation, operation and
maintenance of a quality management system, the cost of resources committed to
continuous improvement, the cost of system, product and service failures, and all other
necessary costs and non-value added activities required to achieve a quality product or
service.
Quality experts have different opinions on measuring COQ. Edward Deming, perhaps
the best-known advocate of quality management, believed that the cost of
non-conformance (and the resulting loss of good will) was so high that evaluating COQ
was unnecessary. He saw absolutely no value in financial measures related to quality.
While for Deming measuring COQ was a waste of time, Joseph Juran and Philip Crosby
saw a need for it. They believed that as defect prevention was increased, the cost of
rework would decrease by much more than the increase in prevention costs. The net
result was lower total cost, and thus ‘quality is free’ (Crosby, 1979).
COQ analysis links improvement actions with associated costs and customer
expectations, and this is seen as the coupling of reduced costs and increased benefits for
quality improvement (Ehsan, 2013). Expenditures on improvement and prevention
activities are considered as a form of investment, which should bring reduced failure
costs. Time and money may be wasted on prevention activities that do not bring
appropriate improvement. Deming may believe that the proper objective is to have zero
defects. However, for some it may be uneconomical to have a high level of quality; they
assume that absolute quality must be sacrificed to achieve other objectives, for example,
reduced development cycle time. Therefore, a realistic estimate of COQ and
improvement benefits, the correct trade off between the level of conformance and
538 M. Zahar et al.

non-conformance costs, should be considered an essential element of any quality

initiative, and thus, a crucial issue for any manager.
We begin with an overview of the COQ concept and its four main cost categories,
followed by an illustration of how the model of COQ can be applied in a clinical
laboratory setting. Finally, we discuss some of the advantages of this methodology.

2 Cost of quality

A failure to meet an expectation of the physician or patient is a failure to conform to their

requirements. Crosby defines quality as ‘conformance to requirements’ and says this
definition is necessary to allow us to measure quality.
Costs of quality result from non-conformance and include the costs of all activities
intended to enable conformance to requirements as defined by the physician or patient.
Conformance must be achieved the first time at each step in the value stream or else costs
of quality begin to accrue. Prevention, appraisal, and failure are the elements of the COQ
(Table 1) (Feigenbaum, 1956; Jaju et al., 2010).
Table 1 Quality cost categories, definitions, and elements

Types of cost Description Elements

Prevention cost Result from activities that keep
defects from ever occurring
Appraisal cost Result of activities that are
designed to identify deficiencies
at any point along the value
stream and maintain high quality
levels
Failure Internal Accumulated as defects are
cost failure costs found and corrected before
results are delivered to
physicians and patients
(Juran and Gryna, 1988)
External Accumulate as corrections are
failure costs made to defects found after
delivery of testing results to
physicians and patients
(Juran and Gryna, 1988)
• Planning for quality
• Quality improvement team
meetings
• Quality education and
training
• Auditing products,
processes, or services
• Calibrating measuring and
test equipment
• Validating instruments
• Repeat testing
• Lost specimens
• High inventory cost because
of over ordering of supplies
• Data entry error
• Unacceptable turnaround
time for test results
• Revised reports
• Recalled results

Most quality costs are not obvious and open (Durmaz, 2012; Tye et al., 2011). Failure
costs are like an iceberg (Figure 1). Some costs are easy to see and recognise, and some
(like the hidden part of an iceberg) are hard to see and identify (DeFeo, 2001). Some of
these hidden costs are found in functions that support the value stream such as failures
associated with billing, resource planning, supply chain, information technology, etc. It is
 Cost of quality in healthcare: a case study in a clinical laboratory 539

important that these functions are recognised for their contributions to the value stream
and to the costs of quality.

Figure 1 The iceberg as a metaphor of activities related to poor quality costs

3 The theory about COQ

This section presents a survey of published literature on various COQ models. According
to research carried out by Sandoval-Chávez and Beruvides (1997) six primary theories
were found:
1 Juran’s model
2 Lesser’s classification
3 PAF model
4 the economics of quality
5 business management and the COQ
6 Juran’s revised model.
Schiffauerova and Thomson (2006) classified COQ models into four groups of generic
models:
540 M. Zahar et al.

1 PAF or Crosby’s model

2 opportunity cost models
3 process cost models
4 ABC approach.
Furthermore, Banasik (2009) categorised the COQ models into:
1 Juran’s model
2 Lesser’s contribution
3 PAF model
4 Harrington PQC
5 Godfrey-Pasewak accounting COQ model
6 Carr’s service model
7 Juran’s revised COQ model
8 Beruvides and Sandoval Chávez opportunity cost model
9 Beruvides-Chiu capital budgeting model.
Later on Castillo-Villar et al. (2012) classified COQ with chronological order into ten
groups:
1 Juran’s model
2 Lesser’s contribution
3 PAF or Crosby’s model
4 PQC model
5 accounting COQ model
6 process cost model
7 ABC approach
8 Juran’s revised model
9 opportunity cost model
10 capital budgeting model.
Modern COQ models and theory have been developed from the works of Juran,
Feigenbaum, Crosby, and Freeman (Srivastava, 2008; Jourabchi et al., 2014). The COQ
models that serve for this study are the PAF classification as well as the revised Juran’s
model. A short background on the COQ models on which the proposed model is based is
presented in the following paragraphs.
Juran’s (1951) analogy of ‘Gold in the Mine’ is defined as the ‘total of avoidable
costs of quality’. According to Juran et al. (1974), this concept suggests that costs
resulting from defects were a gold mine in which lucrative digging could be done. Juran
also categories COQ elements as tangible and intangible.
 Cost of quality in healthcare: a case study in a clinical laboratory 541

Soon after, Feigenbaum develops the prevention-appraisal-failure (PAF)

classification. The PAF classification can add orderliness and uniformity to the ensuing
reports. The PAF classification offers specific advantages, such as its universal
acceptance, identification of different kinds of expenditures, and provision of criteria to
help in deciding whether costs are quality related. The last-mentioned advantage may be
the reason why neither Feigenbaum, nor the ASQC, defines the term quality costs.
Matters are quality-related if they meet the criteria set by each category (Dale and
Plunkett, 1991). The premise behind Feigenbaum’s classification is the following:
The reason for the favourable cost result of total quality control is that it cuts the two
major cost segments of quality (which might be called failure and appraisal costs) by
means of much smaller increases in the third and smallest segment (prevention costs).
According to Porter and Rayner (1992), the basic assumptions of the PAF model are
that
1 investment in appraisal will reduce failure costs and that
2 further, investment in prevention activities will also reduce failure costs.
The PAF classification allows practitioners to identify quality-related costs and express
each category in terms of percentages of the total cost.
Later, Juran et al. (1962) merge Feigenbaum’s PAF concept with Juran’s original
concepts, the result is what is known as the traditional COQ trade-off between
prevention, appraisal, and failure costs. Studies during the 1980s show that the traditional
COQ trade-off model of Juran is not completely valid. Schneiderman (1986) affirms that
the minimum quality cost could lie at zero defects if the incremental cost of approaching
a quality level of 100% is less than the incremental return from the improvement.
Schneiderman asserts that a proper way to view quality cost optimisation is on the basis
of incremental economics.
In response, Juran and Gryna (1993) revise the traditional COQ trade-off between
prevention, appraisal, and failure costs and eliminate the asymptotic behaviour of the cost
of appraisal plus prevention. They thus assert that 100% quality conformance might be
reached under finite prevention and appraisal cost under the conditions of the twentieth
century where a growth of manufacturing and automated inspection technologies
occurred. Juran and Gryna limit the application of the new model to certain instances:
1 industries demanding high safety or liability concerns
2 highly automated companies
3 companies selling to wealthy customers
4 companies struggling to optimise client’s expense.
Moreover, Juran and Gryna state that ‘while perfection is a goal for the long run, it does
not follow that perfection is the most economical goal for the short run, or for every
situation’ and that the minimal point would move close to zero defects if opportunity
costs are included in the failure costs. Juran and Gryna’s ideas have been challenged by
Schneiderman (1986), among others. These authors argue that there is no economic level
of quality, that spending on prevention can always be justified if the time horizon extends
far enough into the future and that the cost-minimal quality level is equal to quality
perfection.
542 M. Zahar et al.

Figure 2 compares the classical Juran model with the revised model. Although not
very adequate for current manufacturing processes, the old model still provides a frame
of reference for quality costs and quality improvement. Burgess (1996) carries out a
quality cost simulation whose results suggest that both views can be reconciled within
one model. Burgess supports the classical view in certain time-constrained conditions and
the modern view under an infinite time horizon. To sum up, the main difference between
the two models is the fact that 100% quality of conformance can be reached at a finite
cost in the revised model (Gershon and Christobek, 2006).

Figure 2 Classical view on the left and the modern view on the right

4 Application of the COQ model in a clinical laboratory

This study analysed cost data during six month to estimate the COQ in a clinical
laboratory located in Morocco. Costs were allocated across COQs four major cost
categories: prevention, appraisal, internal failures, and external failures (Table 2).
Prevention costs included the sum of the following costs: quality activities; training
for staff and personnel time of assurance team four employees at 100% effort. For
example, the cost of daily quality assurance final review of all laboratory results for any
given work day was calculated by multiplying the cost per hour of a quality assurance
employee by the average number of hours spent on the review of test results on an
average day.
Appraisal costs included the sum of the following costs: quality control and
calibrating measuring and test equipment (based on usage frequency and price per test).
Internal failure costs (detected prior to delivery of the service) were based on the sum
of the following costs: such as repeated quality control and calibration tests; correction of
data entry errors and specimen processing.
External failure costs were based on the sum of the following costs: correction of
pre-analytical errors including laboratory errors committed before analysing the samples,
such as requisition data entry errors; correction of analytical errors occurring at the
testing stage, such as doing the test incorrectly; and correction of post-analytical errors
occurring after testing, such as transcribing the wrong results, or a delay in reporting test
results to clients.
 Cost of quality in healthcare: a case study in a clinical laboratory 543

Table 2 COQ expenses by category

Cost of good quality

Prevention costs of quality (COQP) Total
• Preventive maintenance of laboratory equipment and $9,835 $22,821
instruments $481
• Office supply costs for quality-related preventive activities $10,996
• Total quality assurance and competence training, and $1,509
continuing education for laboratory staff
• Laboratory information system
Appraisal costs of quality (COQA)
• Cost of quality control and calibration reagents $11,598 $23,254
• Annual accreditation and inspection costs $7,317
• External quality assurance proficiency testing $3,074
• Other process improvements and quality activities $1,265

Cost of poor quality

Internal costs of poor quality (COQI)
• Costs of poor inventory management (wasted reagents) $3,085 $5,754
• Costs of quality control/calibration failures/repeats for all $2,317
analyses $303
• Estimated data entry errors and rework costs $49
• Processing and accessioning errors and rework costs
External costs of poor quality (COQE)
• Estimated costs of pre-analytical errors $1,833 $3,514
• Estimated costs of analytical errors $583
• Estimated costs of post-analytical errors $1,098

For the purpose of this analysis, we limited external failure costs to the cost of identifying
and correcting errors based on customers services concern forms received from clients.
Approximately 83% of total COQ was spent on costs of good quality (41%
prevention costs and 42% appraisal costs), and 17% of COQ was spent on costs of poor
quality (11% internal failure costs and 6% external failure costs) (Figures 3 and 4).

Figure 3 Distribution of quality costs (see online version for colours)

544 M. Zahar et al.

Figure 4 External costs of poor quality

5 COQ analysis results

The total COQ expenses for our laboratory during the six month study period were
$55,343, approximately 30% of the total direct laboratory expenses.
Total costs in the prevention category were estimated to be $22,821. The highest
prevention costs were the expenses associated with the maintenance of the laboratory
instruments and equipment ($9,835). Preventive maintenance contract costs are relatively
high and turnaround time on repairs can take up to 30 days or more.
Appraisal costs of quality were estimated to be $23,254. Almost 50% of the costs in
the appraisal category are associated with COQ control and calibration reagents, which
are necessary to confirm the accuracy and reliability of test results.
Costs of poor quality, including both internal and external failures, were $9,268.
Internal failure costs were estimated to be $5,754. In addition, $3,085 in reagents had
expired or was wasted. We identified many of the internal failures using process
improvements reports, a tool used by the staff for internal reporting of errors and
problems.
External failure costs were estimated to be $3,514. Customer service concern forms,
which laboratory customers can complete to voluntarily report problems, were used to
identify external failures. We classified the errors according to the following three stages
of the testing process: pre-analytical, analytical, and post-analytical (Table 3). The costs
of correcting errors in the pre-analytical phase were estimated to be $1,833. The costs of
errors in the analytical phase were estimated to be $583. Costs of post-analytical phase
errors were estimated to be $1,098 (Figure 5).
The optimal level of COQ has been the source of much debate. Under the traditional
P-A-F view, optimal COQ is reached at the point when the costs of improved quality
exceed the benefits. More recent quality economic models argue that spending on
prevention can be justified until the point where there are 0 defects or deficiencies.
Despite disagreement on the optimal level of COQ, the high proportion of spending on
costs of good quality relative to poor quality at the laboratory (83% costs of good quality
versus 17% costs poor quality) is consistent with the goal of ensuring high quality
outcomes.
 Cost of quality in healthcare: a case study in a clinical laboratory 545

Table 3 Reports by category of external failures

Category Item Jan Feb Mar Apr May Jun Total % total
Pre-analytical Inappropriate 1 2 2 55 57%
errors specimen
Wrong 1 1 1
anticoagulant
Improper 1 1 1
conservation
method
Inappropriate 1 1 1 3
patient’s
preparation
Mistakes in 2 2 3 7 15 9
patients’
identification
Analytical Expired reagents 1 1 15 16%
errors which may lead to
erroneous results
Expired controls 1 2 3
or calibrators
Failure in 1 1 2
sampling system
Failure in 1 1 1
aspiration system
of reagents
Post Wrong matching 1 1 2 26 27%
analytical between sample
errors and laboratory’s
files
Wrong copy of 1 2 2
results from the
analyser’s report
to the laboratory
report
Delay in 1 2 2 2 3 6
delivering the
results to the
physicians, clinics
or patients
Loss of the results 1
Total per 6 9 7 14 29 31 96 100%
month
546 M. Zahar et al.

Figure 5 External failures in the period Jan–Jun of the studies

In this case, we will examine ways to invest in prevention to hopefully decrease overall
appraisal and failure costs. This model would allow one to measure the outcome of
making such changes.
In terms of external comparisons, the costs of good quality (poor quality) in our
laboratory appear to be higher (lower) than other comparable studies. For example, the
COQ study at a hospital clinical laboratory in the USA found that the overall COQ was
about 35% of the operating expenses, the cost of good quality was 10%, and the cost of
poor quality was 25% of the operating expenses (Menichino, 1992).

6 Conclusions

This is the first study to quantify COQ in a Moroccan clinical laboratory our analysis
indicates that 30% ($55,343) of total laboratory expenses and 83% of total COQ were
spent on creating and following processes that ensure good laboratory practices and
contribute to high-quality outcomes.
The COQ methodology has a number of advantages. First, it can be a useful
management tool for identifying and focusing on areas of poor performance and can
provide a basis for benchmarking progress and overall spending on quality-related
activities over time. Another key advantage of COQ is that it translates quality-related
activities into monetary terms that can be easily understood by executives making overall
financial decisions. COQ can be a powerful tool by illustrating the true costs of
quality-related activities to upper management, which can in turn help them in the
budgetary process and making decisions about implementation of cost-control measures.
However, COQ also has some important limitations. It is difficult to identify and
quantify ‘hidden’ failure costs associated with poor quality (Yang, 2008), such as adverse
events resulting from inaccurate laboratory results, loss in customer confidence,
deterioration in reputation.
Suggestions for future applications of this model include the attempting to quantify
hidden failure costs, and relating COQ to patient outcomes.
Ultimately, more widespread use of COQ and other similar quality costing models
can help healthcare organisations identify quality deficiencies and benchmark their
quality costs over time.
 Cost of quality in healthcare: a case study in a clinical laboratory 547

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