The TQM Journal

Developing and validating a total quality management model for healthcare

organisations
Ali Mohammad Mosadeghrad
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for healthcare organisations", The TQM Journal, Vol. 27 Iss 5 pp. 544 - 564
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TQM
27,5
Developing and validating a total
quality management model for
healthcare organisations
544 Ali Mohammad Mosadeghrad
Received 4 May 2013
School of Public Health,
Revised 15 January 2014 Tehran University of Medical Sciences, Tehran, Iran
20 July 2014
Accepted 25 September 2014
Abstract
Purpose – The purpose of this paper is to develop a total quality management (TQM) model for
healthcare organisations and validate it using a sample of Iranian healthcare organisations.
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Design/methodology/approach – A validated questionnaire was used to collect data from all

healthcare organisations that implemented TQM in Isfahan province, Iran.
Findings – Using the proposed model, TQM implementation was measured in healthcare
organisations. The level of TQM success in Isfahan healthcare organisations was medium. The highest
score was achieved in the dimension of “customer management”, followed by “leadership” and
“employee management”. Employee management, information management, customer management,
process management and leadership had the most positive effect on TQM success. Using a series of
quality management techniques had “synergistic” effect on TQM success.
Practical implications – Top management support, effective management of human resources, full
involvement of the entire workforce including physicians, education and training, team working,
continuous improvement, a corporate quality culture, customer focus and using a combination of
management techniques under a quality management system are necessary for TQM successful
implementation.
Originality/value – A healthcare context-specific model of TQM was developed and tested and
suggestions were provided for its successful implementation.
Keywords Total quality management, Success, Healthcare organizations
Paper type Research paper

Introduction
In the past two decades the acknowledgement of medical errors, leading to patient injury
and even death, has generated potential healthcare legislation and consumer awareness
about considering and integrating quality in healthcare (Becher and Chassin, 2001; Ruiz and
Simon, 2004). Concepts like clinical governance, clinical effectiveness, clinical audit, peer
reviews, accreditation and continuous professional development are examples of attempts to
monitor and improve the quality of healthcare services. Many healthcare organisations
utilised various industrial quality management strategies such as quality assurance,
continuous quality improvement, total quality management (TQM), business process
reengineering, six sigma and quality function deployment to improve the quality of care.
TQM enables healthcare organisations to identify customer requirements, benchmark
for best practices and improve processes to deliver appropriate care and reduce the
frequency and severity of medical errors. TQM implementation may lead to higher
quality care, improved patient satisfaction, better employee morale and increased
productivity and profitability (Alexander et al., 2006; Cauchick Miguel, 2006; Kunst and
The TQM Journal
Vol. 27 No. 5, 2015
pp. 544-564 The author would like to thank all those who kindly agreed to participate in the survey.
© Emerald Group Publishing Limited
1754-2731
The author is also grateful to the editor and anonymous reviewers of TQM journal for their
DOI 10.1108/TQM-04-2013-0051 constructive comments and guidance for improving this paper.
 Lemmink, 2000; Macinati, 2008). The TQM success in industry has encouraged Developing
healthcare managers to examine whether it can work in the health sector. Accordingly, and validating
many healthcare organisations increasingly implemented TQM principles to improve the
quality of outcomes and efficiency of healthcare service delivery (Boerstler et al., 1996;
a TQM model
Kunst and Lemmink, 2000; Macinati, 2008).
Iran healthcare system faces serious challenges concerning efficiency and quality
(Aghamollaei et al., 2007; Mohammadi and Shoghli, 2008; Tabibi et al., 2009). Reports of 545
the successful TQM implementation in the world encouraged Iranian policy makers to
introduce this strategy to healthcare organisations there in the hope of improving
quality and efficiency. Consequently, TQM has been implemented in several healthcare
organisations in the country (Askarian et al., 2010; Hamidi and Tabibi, 2004;
Mohammadi et al., 2007). Many managers began to apply the concept of TQM within
healthcare organisations using the Deming quality improvement approach called
FOCUS-PDCA. Besides, ISO 9001:2000 quality management system was accepted as a
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model for TQM implementation (Mosadeghrad, 2014).

Despite numerous attempts to incorporate TQM/CQI in Iranian healthcare organisations,
relatively little is known about its effectiveness. In order to bridge this gap, an investigation
into the effects of TQM implementation in Iranian healthcare organisations is truly needed.
Such a study helps in identifying problem areas and possible remedies.

Theoretical framework
Many researches were undertaken investigating TQM critical success factors during the
last two decades (Black and Porter, 1996; Dayton, 2001; Metri, 2005; Sila and Ebrahimpour,
2002). All of these researchers developed their TQM frameworks based on their own
research purposes. TQM is a western management concept, which evolved out of Japanese
management practices. Hence, it may not integrate well into a different context (e.g. Iran)
and industry (e.g. health). Each organisation may require different approaches for TQM
implementation (Mosadeghrad, 2013). Indeed, many of the theories developed in the
western developed countries may need to be reassessed in developing countries such as
Iran. For instance, Iran according to Hofstede’s (2003) cross-cultural dimensions, highly
scored on “power distance” and “uncertainty avoidance”. Therefore, the country may need
a different quality management model compared to Denmark which scored low on both.
Thus, an extensive review of literature on quality management models and frameworks
was performed to identify critical factors for successful TQM implementation in healthcare.
A generic model of TQM has been proposed based on the literature review and informal
interviews with quality management experts (see Figure 1). From each study, a list of
constructs of TQM was created. Quality management experts’ opinions were used in
completing this list. In total, 15 most common constructs of TQM were chosen for inclusion
in the model, of which ten are enablers and five are results. Enablers direct and drive the
results. The model starts from the logical point of leadership and management and ends
with overall performance results. The belief is that “excellent results with respect to
organisation, customer, employee, supplier and society are achieved through leadership and
management, strategic quality planning, quality culture, education and training, employee
management, customer management, supplier management, resource management,
information management and process management”.

Leadership and management

The success of TQM depends largely on managers’ ability to create a vision, plan
for and lead the organisational change required for TQM success. The literature both
 TQM Enablers Results
27,5
Strategic quality planning Customer management Customer results

Leadership and management

Process management
Employee management Employee results

546
Education and training Information management Organisation results

Supplier management Supplier results

Figure 1.
A conceptual
framework of TQM Quality culture Resource management Society results
for healthcare
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organisations Evaluation, improvement and organisational learning

in general industry and healthcare, addressed and emphasised the importance of

visionary leadership, including philosophy, style and behaviour in the implementation
process of TQM initiatives (e.g. Kunst and Lemmink, 2000; Mosadeghrad, 2005). The
leadership and management construct examines how senior managers as leaders are
personally involved in developing and implementing a quality management system,
inspire and drive the quality management change and support a culture of continuous
improvement. Accordingly, I postulate:
P1. Leadership and management are positively and significantly related to
organisational performance.
Strategic quality planning
Quality improvement can only result from planned management action. The successful
implementation of TQM requires careful strategic planning based on total quality.
Including specific objectives for quality, as part of the strategic planning process, is
associated with the degree of TQM success (Dayton, 2001; Francois et al., 2003; Taylor
and Wright, 2003). Healthcare managers should integrate quality as a strategic priority
in their organisations’ vision, policies and long-term strategies through a strategic
quality planning process. The strategic quality planning construct examines how
managers sets strategic directions, establishes a long-term vision, develops the values
required for long-term success, sets strategic goals and objectives, incorporates quality
in the strategic goals and objectives and implements these via appropriate strategies,
policies and action plans. Thus, I propose:
P2. Strategic quality planning is positively and significantly related to
organisational performance.
Quality culture
TQM requires changes in managers’ and employees’ believes, attitudes and behaviours
to focus on continuous improvement. Successful implementation of TQM requires a
significant commitment to a culture emphasising trust, empowerment, entrepreneurship,
teamwork, cooperation, risk taking and continuous improvement (Kaluarachchi, 2010;
Mosadeghrad, 2006; Wardhani et al., 2009). TQM programmes are more likely to succeed
if the prevailing organisational culture is compatible with the values and basic
 assumptions proposed by the TQM discipline (Kujala and Lillrank, 2004). The quality Developing
culture construct examines how managers develops a nurturing organisational culture and validating
that supports quality. Hence, the following proposition is proposed:
a TQM model
P3. Quality culture is positively and significantly related to organisational
performance.
Education and training 547
Continuous and widespread education and training provide a good foundation for
cultural change required for TQM implementation. Education and training help develop
employees’ capabilities on a continuous basis. The review of literature corroborates the
importance of appropriate education and training in the process of TQM implementation
(Goetsch and Davis, 2010; Palo and Padhi, 2003; Yusof and Aspinwall, 2000). The
education and training construct examines how managers recognises and nurtures
the development of employees’ abilities, skills and knowledge. Accordingly, I propose:
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P4. Education and training are positively and significantly related to organisational
performance.
Employee management
Employee empowerment, commitment and involvement in quality management are
key factors in successful implementation of TQM and were indeed included in previous
TQM studies (Lee and Quazi, 2001; Metri, 2005; Soltani et al., 2003). The employee
management construct examines how managers develop and manage the capabilities
of people at individual, team-based and organisational levels, promote fairness and
equality, involve, encourage and enable people to contribute to the achievement of
the organisational goals and recognise their achievements. I propose then:
P5. Employees management is positively and significantly related to organisational
performance.
Customer management
Many quality gurus and writers considered customer-driven quality a major success
factor of the TQM effort (Crosby, 1992; Deming, 1986; Oakland, 2003). Systems and
processes must be in place to identify customer needs, translate these needs into
appropriate organisational requirements and satisfy them. The customer management
construct examines how the organisation builds relationships with customers,
determines customers’ requirements and expectations and measures their satisfaction,
and uses the feedback of customers in improving quality of services. Thus, the
following proposition is offered:
P6. Customer management has a positive influence on organisational performance.
Supplier management
On an average, 40 per cent of production cost is due to purchased materials (Besterfield,
1994). On the other hand, purchased materials are often a major source of quality
problems (Zhang et al., 2000). Thus, supplier management is an important aspect of
TQM. An effective supplier management reduces procurement costs and enhances the
quality of purchased products (Slaight, 1999). The supplier management construct
examines how the organisation manages suppliers effectively and efficiently to support
key organisation processes, policies, strategies and action plans. Therefore, I expect:
P7. Suppliers management has a positive influence on organisational performance.
 TQM Resource management
27,5 Quality improvement requires additional investments in time, capital and resources to
develop an appropriate infrastructure for quality. Allocation of resources (i.e. human,
equipment and material) is necessary for delivering desired healthcare services to meet
customer needs. Managers are responsible to provide appropriate resources to make
the implementation of TQM successful. An effective resource management system
548 enhances efficiencies, improves safety and reduces errors. The resources management
construct examines how the organisation manages its internal physical resources
effectively and efficiently to support key organisation processes. The following
proposition is therefore proposed:
P8. Resource management has a positive influence on organisational performance.
Information management
Fundamental to TQM is collecting accurate, timely, reliable and relevant data and
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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. Several studies reported that a lack of good
information system and information required for quality managemnet influenced the
success of quality improvement (Lee et al., 2002; Shortell et al., 1998). Thus, it is
hypothesised that:
P9. Information management has a positive influence on organisational performance.
Process management
TQM focuses on studying, understanding and improving the processes. Process
management concerns the value adding system and involves the policies, procedures
and practices that are required to control the process. Many TQM writers have pointed
out the importance of focusing on the effective management of processes (Beskese and
Cebeci, 2001; Flynn et al., 1994; Oakland, 2003). The process management construct
examines how key processes are designed, implemented, managed and improved to
support the organisation’s strategy and action plans, fully satisfy customers and other
stakeholders and achieve better performance. Therefore, I propose:
P10. Process management has a positive influence on performance results.

Methodology
Purpose
The purpose of this study was to explore the impact of TQM in Iranian healthcare
organisations. In addition, this study sought to identify critical success factors of TQM
implementation.

Method
The data for this research were drawn from a cross-sectional questionnaire survey
collected from healthcare organisations that implemented TQM initiatives.

Settings and participants

Managers or quality managers of healthcare organisations (e.g. hospitals and health
centres) in both public and private sectors in Isfahan province, Iran were asked to
 participate in this survey. Healthcare organisations were categorised into three Developing
groups: small (with less than 100 employees), medium (with 101-500 employees) and and validating
large sized (with more than 500 employees).
a TQM model
Questionnaire development
The survey questionnaire was divided into two sections. The first section sought general
information about the healthcare organisations and demographic information of the 549
respondents. In the second section of the survey, the degree of TQM implementation
in each organisation was measured. Three different types of validity were tested in
this study (i.e. content validity, construct validity and criterion-related validity). In this
research, 15 TQM constructs have content validity since they were derived from an
extensive review of the literature, and detailed evaluations by academics and
practitioners who have worked in the area of TQM in Iran.
The construct validity of each TQM construct was evaluated separately by factor
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analysing the items corresponding to the construct to ensure that items in each
construct reflected sufficiently the scope of each construct. Based on factor analysis,
the initial 52 variables in TQM success questionnaire are factored on to 15 TQM
element constructs. All the constructs were uni-factorial; and the item loading range for
each extracted factor was high. Each factor accounted for more than 70 per cent of the
variance of the respective item sets. Results of the factor analysis indicate a high level
of construct validity of the measure. Table I lists the correlation matrix for the 15 scales
of the TQM implementation practices.
TQM constructs can have criterion-relation validity if the collective measure of the
TQM practices is highly and positively correlated with a measure of quality
performance. In this study, the ten TQM practices (enablers) are the predictors and the
five performance measures are the relevant criteria. The correlation coefficient obtained
was more than 70 per cent. These correlations were statistically significant at p o 0.001,
indicating strong criterion-related validity. In addition, the questionnaire was
administered to three ISO certified hospitals. It was found that on all the questions
in the final draft of the questionnaire, a high total score was obtained by the ISO
certified hospitals. This was indicative of the criterion validity of the instrument.

Item numbers
Scales 1 2 3 4 5

Leadership and management 0.717 0.777 0.764 0.703 –

Strategic quality planning 0.743 0.851 0.872 – –
Quality culture 0.798 0.707 0.712 – –
Education and training 0.786 0.703 0.772 – –
Employee management 0.781 0.716 0.812 0.798 0.816
Customer management 0.764 0.710 0.727 0.754 0.791
Supplier management 0.716 0.722 0.733 – –
Resource management 0.872 0.848 0.798 – –
Information management 0.771 0.737 0.785 – –
Process management 0.733 0.796 0.800 0.824 0.712
Employee results 0.841 0.734 0.711 – –
Customer results 0.830 0.733 0.715 – – Table I.
Supplier results 0.820 0.809 0.771 – – Item to scale
Society results 0.817 0.764 0.753 – – correlation matrix
Organisation results 0.760 0.720 0.780 – – (Pearson correlation)
 TQM Cronbach’s α was computed separately for the items of each scale. As shown in
27,5 Table II, Cronbach’s α values of the 15 TQM constructs all exceed the 0.70 standard of
reliability for survey instrument. Accordingly, the instrument has been proven to be an
acceptable and reliable instrument through this test.
A five-point response scale was used for these items (from 1 ¼ very little extent
to 5 ¼ very large extent). The possible justified scores for TQM success were
550 varied between 1 and 5. Scores of 2 or lower on the total scale indicate very low,
scores between 2 and 2.75 indicate low, scores between 2.76 and 3.50 indicate moderate,
scores between 3.51 and 4.25 indicate high and scores of 4.26 or higher indicate very
high TQM success.

Data analysis
The data were analysed using the Statistical Package for the Social Sciences (SPSS 11).
Descriptive statistics such as means and standard deviations were computed for each of
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the questionnaire items. Independent-samples t-test and analysis of variance were

performed to determine the significance of the difference among means of the considered
groups. Regression analysis was used to identify the most important predictor domains
in overall TQM success. A confirmatory factor analysis using AMOS software was used
to test the TQM model.

Hypothesis development
A test value of 3.50 was decided based on the Likert scale coding method of the
questionnaire. Hypothesis can be written in a statistical equation as follows:
H1. µ⩾3.50 (TQM is successful)

Results
Out of 90 questionnaires sent to the healthcare organisations, 55 questionnaires were
returned and were analysed (61 per cent). In total, 33 organisations were hospitals and
the rest were health centres. In total, 41 (74.5 per cent) of healthcare organisations were

TQM constructs Item numbers Number of items Cronbach’s α

Leadership and management 1-4 4 0.82

Strategic quality planning 5-7 3 0.87
Quality culture 8-10 3 0.83
Education and training 11-13 3 0.89
Employee management 14-18 5 0.83
Customer management 19-23 5 0.83
Supplier management 24-26 3 0.75
Resource management 27-29 3 0.89
Information management 30-32 3 0.82
Process management 33-37 5 0.88
Employee results 38-40 3 0.73
Customer results 41-43 3 0.78
Supplier results 44-46 3 0.85
Table II. Society results 47-49 3 0.82
Internal consistency Organisation results 50-52 3 0.81
analysis Overall TQM success 1-52 52 0.96
 public organisations. Of the total, 7.3, 78.2 and 14.5 per cent of healthcare organisations Developing
were small-, medium- and large-sized organisations. Three hospitals were successful in and validating
obtaining ISO 9001:2000 certificates.
The majority of respondents were in their 30s and held either a bachelor or a master
a TQM model
degree. Totally, 67.3 per cent of respondents had taken part in TQM, 40 per cent in ISO
9000 series, 38.2 per cent in productivity management, 25.5 per cent in human resource
management, 18.1 per cent in statistical quality control tools, 14.5 per cent in quality 551
costing, 9.1 per cent in six sigma and 7.2 per cent in EFQM-training programmes.
The mean score of TQM success in healthcare organisations was 3.41 (medium) from
five credits compared with the possible range of 2.06-4.17 (Table III). It can be seen that the
sample mean of 3.41 is lower than the hypothesised value of 3.50. A p-value of 0.180 was
determined which suggests that the null hypothesis is accepted (one-sample t-test). Hence,
it can be concluded that TQM was not successful in Iranian healthcare organisations.
The overall mean is below 4.0 on all of the TQM constructs, indicating that these
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aspects of implementation are not well executed in any of these healthcare organisations.
TQM practices (enablers) and results (performance) received mean ratings of 3.44 and
3.34, respectively. Of the 15 TQM constructs in Table II, customer management received
the highest mean score of 3.69 and 70.9 per cent of the organisations achieved a high
score for this construct. Supplier management was rated lowest.
Private healthcare organisations were more successful in their TQM programme
than their public counterparts (3.53 compared to 3.38). However, the difference was
not statistically significant ( p ¼ 0.292). Although statistically insignificant ( p ¼ 0.257),
it was observed that the TQM implementation score was lower as the size of the
organisation increases, indicating that smaller organisations tend to implement TQM
more successfully than larger ones.
The mean score of TQM success in healthcare organisations, in which their top
managers were strongly committed to quality management, was higher than other
organisations with lower top management commitment (3.47±0.39 in comparison with
3.09±0.76). The differences between the values were statistically significant ( p ¼ 0.04).

% distribution of mean scores

TQM constructs Mean score SD Low (o2.75) Medium (2.75-3.50) High (3.51-5)

Leadership and management 3.59 0.53 12.7 27.3 60.0

Strategic quality planning 3.24 0.68 20.0 38.2 41.8
Quality culture 3.46 0.49 9.1 36.4 54.5
Education and training 3.43 0.59 18.2 30.9 50.9
Employee management 3.56 0.58 9.1 27.3 63.6
Customer management 3.69 0.56 5.5 23.6 70.9
Supplier management 3.12 0.64 27.3 41.8 30.9
Resource management 3.18 0.72 25.5 32.7 41.8
Information management 3.38 0.54 18.2 32.7 49.1
Process management 3.45 0.59 10.9 43.6 45.5
Employee results 3.35 0.56 18.2 34.5 47.3 Table III.
Customer results 3.39 0.54 16.4 32.7 50.9 The mean score
Supplier results 3.20 0.66 23.6 38.2 38.2 of TQM principles’
Society results 3.41 0.58 10.9 43.6 45.5 success in Isfahan
Organisation results 3.37 0.57 16.4 32.7 50.9 healthcare
Overall TQM success 3.41 0.47 12.7 30.9 56.4 organisations
 TQM The Pearson correlation matrix shows that top management support is significantly
27,5 correlated with both TQM practices (r ¼ 0.714, po0.0001) and organisational performance
(r ¼ 0.626, po0.0001). Top management commitment has been significantly correlated
with other TQM constructs such as strategic quality planning (r ¼ 0.727), employee
management (r ¼ 0.664), education and training (r ¼ 0.570) and quality culture (r ¼ 0.537).
This shows that top management plays a critical role in promoting TQM implementation
552 in the organisation.
There are associations between TQM success and the manager’s education in
quality management techniques. The more knowledge managers had about TQM, the
greater was their commitment to quality (r ¼ 0.303, p ¼ 0.041). Employee involvement
and commitment was also related to management commitment (r ¼ 0.369, p ¼ 0.006).
Organisations with the greatest emphasis on employee empowerment achieved a
higher implementation score (3.62) than those with medium (3.26) and low degrees of
empowerment (2.42). The differences between values of TQM implementation were
statistically significant ( p o 0.001).
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The mean score of TQM success in ISO 9000 certified organisations was 3.95±0.24
while in non-ISO 9000 certified organisations was 3.38±0.47. Significant differences
were observed between values ( p ¼ 0.04). The ISO certified organisations mean
scores are higher on all TQM constructs, and significantly higher on five constructs
(Table IV).
A majority of the respondents (80 per cent) were found to have adopted participative
management techniques in their organisations. The second highest degree of practice
was business process reengineering (27.3 per cent). Total productive maintenance
(TPM) was the least preferred and implemented technique in the healthcare organisations
(10.9 per cent). Quality management systems (e.g. ISO 9001:2000) was found to be the
most useful activity in TQM success. Managers who incorporated and used a number of
techniques and tools achieved more success from their TQM programme. For example,
the success of TQM in organisations that used one, two, three, four, five, six and eight
different managerial techniques was 3.13, 3.29, 3.44, 3.60, 3.71, 3.80 and 4.17 on a five
scale, respectively.

TQM constructs ISO 9000 certified Non-ISO 9000 certified p-value Results

Leadership and management 3.67 3.58 0.79 Not sig.

Strategic quality planning 3.25 3.23 0.97 Not sig.
Corporate quality culture 3.56 3.46 0.73 Not sig.
Education and training 4.44 3.37 0.002 Sig.
Employees management 4.13 3.52 0.08 Not sig.
Customer management 3.80 3.68 0.74 Not sig.
Supplier management 3.67 3.08 0.13 Not sig.
Resource management 3.89 3.13 0.08 Not sig.
Information management 4.11 3.34 0.015 Sig.
Process management 4.73 3.38 0.001 Sig.
Employee results 3.67 3.33 0.32 Not sig.
Customer results 3.89 3.37 0.10 Not sig.
Supplier results 3.78 3.17 0.12 Not sig.
Table IV. Society results 4.11 3.37 0.030 Sig.
Results of quality Organisation results 4.11 3.33 0.020 Sig.
management Overall TQM success 3.95 3.38 0.04 Sig.
practices Note: Comparison between ISO 9000 certified against non-ISO 9000 certified healthcare organisation
 In this study, 15 constructs of TQM were investigated, of which ten were enablers Developing
and five were results. Table V shows the correlation coefficients for TQM constructs. and validating
All the correlations among the TQM constructs were found to be positive and
statistically significant at p o 0.01. The correlations among the TQM constructs
a TQM model
provide an indication of the extent to which they reinforce one another in the TQM
effort. Therefore, an integrated approach should be taken to improve the
TQM constructs. 553
Leadership has shown to have a direct impact on strategic planning and significant
indirect effects on process management and organisation results. The impact of
strategic quality planning on process management and overall performance has been
validated through indirect effects. Quality culture has demonstrated to have a strong
influence on employee, customer and supplier management and indirect effects on
process management. Teamwork and a participatory culture were positively related to
employee empowerment and involvement in quality improvement activities (r ¼ 0.446,
p ¼ 0.001). Process management was observed to be related to customer satisfaction
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(r ¼ 0.310, p ¼ 0.02). The TQM implementation had a strong impact on quality

improvement (r ¼ 0.739, p o 0.001).
All quality management practices (enablers) were positively associated with TQM
success. The results of the stepwise regression analysis indicate that employee
management has the largest amount of variance in TQM success (81 per cent), followed
by information management, customer management, process management, leadership,
resource management, training, strategic quality planning and supplier management.
The most important contributing factors to successful TQM implementation in
healthcare organisations were considering customer needs in process improvement
activities, improving relationships between employees and managers, encouraging
innovation and creativity, developing a participatory culture, customer relationship
management, pursuing long-term organisational goals and policies, identifying and
defining processes, management involvement in quality improvement activities
and having an information management system.
Higher levels of TQM practices implementation were found to be associated with
higher organisational performance (r ¼ 0.914, p o 0.001). TQM enablers were
categorised into primary (initial) enablers (i.e. employee, customer, supplier, resource,
information and process management) and secondary (supportive) enablers
(i.e. leadership, strategic quality planning, quality culture and education and training).
Both initial and supportive enablers of TQM were inter-correlated and both jointly
enhanced performance. There was significant correlation between organisational
performance and initial enablers (r ¼ 0.811) and supportive enablers (r ¼ 0.609).
The results of the stepwise regression model indicate that 83 per cent of the variance
in overall organisational performance is explained by employee management,
information management, customer management and process management. The
variables – considering customer needs in process improvement activities, developing
mission and vision according to customer needs, having an information management
system, continuous quality improvement and human resource development – are the
most influential TQM dimensions for improving organisational performance.
Figure 2 shows the relationships among TQM practices and overall organisational
performance. The results of the stepwise regression model indicate that 53 per cent of
the variance in employee results is explained by Employee management and Leadership.
Customer results are related to Process management, Education and training and
Customer management and the corresponding value of R2 is 55 per cent.
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27,5

554
TQM

matrix of
Table V.

independent

factor scores
and dependent
variable construct
Bivariate correlation
TQM constructs 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17

1. Overall TQM success –

2. Leadership and management 0.827 –
3. Strategic quality planning 0.813 0.785 –
4. Quality culture 0.763 0.740 0.760 –
5. Education and training 0.799 0.600 0.644 0.624 –
6. Employees management 0.902 0.722 0.782 0.712 0.720 –
7. Customer management 0.810 0.692 0.656 0.653 0.518 0.707 –
8. Supplier management 0.712 0.616 0.546 0.578 0.591 0.640 0.668 –
9. Resource management 0.634 0.450 0.434 0.526 0.546 0.608 0.516 0.629 –
10. Information management 0.766 0.625 0.580 0.471 0.660 0.611 0.535 0.515 0.506 –
11. Process management 0.837 0.606 0.572 0.527 0.736 0.498 0.750 0.683 0.614 0.710 –
12. Employee results 0.730 0.548 0.591 0.571 0.513 0.701 0.617 0.681 0.464 0.414 0.558 –
13. Customer results 0.797 0.713 0.684 0.479 0.621 0.652 0.646 0.589 0.499 0.624 0.651 0.512 –
14. Supplier results 0.666 0.683 0.627 0.557 0.688 0.632 0.675 0.642 0.578 0.714 0.624 0.576 0.761 –
15. Society results 0.689 0.491 0.423 0.384 0.523 0.560 0.630 0.567 0.446 0.548 0.527 0.440 0.575 0.624 –
16. Organisation results 0.626 0.645 0.551 0.591 0.622 0.679 0.618 0.611 0.603 0.737 0.772 0.558 0.626 0.645 0.559 –
17. TQM practices 0.993 0.841 0.827 0.796 0.809 0.916 0.803 0.820 0.719 0.755 0.836 0.704 0.757 0.835 0.636 0.807 –
18. Overall performance 0.894 0.645 0.554 0.409 0.613 0.734 0.674 0.572 0.591 0.602 0.738 0.669 0.818 0.681 0.658 0.793 0.914
 Strategic quality Employee Employee Developing
planning management results
and validating
a TQM model
Supplier Supplier
management results

555
Leadership and Customer Customer
management management results

Education and Process

training management Figure 2.
Resource Society
management results Path analysis of the
links between the
TQM practices and
Information Organisation the results
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Quality culture
management results

The dependent variable of supplier results is related to Supplier management, Process

management and Strategic planning, with an R2 of 71 per cent. Society results are
related to Customer management and Information management with an R2 of 44 per cent.
Organisation results are related to Process management, Resource management and
Information management with an R2 of 0.718 which indicates that 71 per cent of the
variance of organisation results is explained by these three enablers. All dependent
variables are predicted by a significant regression ( po0.001).

Discussion
The findings suggest that TQM has not been fully successful in the healthcare
organisations of Iran. This seems to be in agreement with other research findings on
the application of TQM/CQI in healthcare (Huq and Martin, 2000; Lee et al., 2002;
Theodorakioglou and Tsiotras, 2000). Implementing TQM in healthcare organisations
requires an understanding of the particular nature of the sector, which influences the
applicability of TQM practices. Due to the distinctive nature of healthcare services,
there are incompatibilities between the TQM philosophy and the practices on which
the management of healthcare organisations is currently based. The very complexity
of the healthcare system and its bureaucratic, and highly departmentalised and
hierarchical structure can pose a significant obstacle to the implementation of TQM
and decrease its effectiveness (Adinolfi, 2003; Lim and Tang, 2000; Mosadeghrad,
2012a; Naveh and Stern, 2005).
The TQM constructs were also found to be highly interrelated. The interdependent
nature of TQM constructs explains why TQM has not produced maximum benefits for
Iranian healthcare organisations. Both primary and supportive TQM enablers
(constructs) jointly enhance results (organisational performance). Therefore, it is
necessary for all the TQM constructs to be present to ensure its success in an
organisation. Higher levels of organisational performance were significantly correlated
with great utilisation of TQM practices in Iranian healthcare organisations. These
findings are consistent with those of Douglas and Judge (2001), who found that
healthcare organisations with a greater degree of implementation of TQM practices
have a greater probability of improving their organisational performance.
 TQM The finding showed that “primary” TQM elements have a more significant and
27,5 positive impact on organisational performance, when compared to “secondary” TQM
elements. This is not suggesting that “secondary” TQM constructs are not useful, but
their direct contribution is less than that of “initial” TQM constructs. Secondary’ TQM
elements are significant to support the “primary” TQM elements. Employee management,
information management, customer management, process management and leadership
556 were the strongest significant predictors of organisational performance. Therefore, the
effective implementation of these practices is likely to result in improved performance. This
finding is supported by Samson and Terziovski (1999), who argue that categories of
leadership, people management and customer focus are the strongest significant predictors
of organisational performance. Sila and Ebrahimpour (2005) also found that leadership, and
information and analysis carry strong implications in terms of a company’s business results.
A strong relationship between leadership and the success of TQM has been reported
in this study. The findings also revealed that leadership has positive effects on
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organisational performance by influencing other TQM practices. The high correlation

between leadership and management and each of the other constructs suggests that the
former played an important role in driving the latter. Leadership and management had
the most effect on strategic quality planning, quality culture, employee management
and customer management. Sustainable top management involvement in TQM is
vital for the success of TQM initiatives. The results have shown that for healthcare
organisations in which managers were committed more to TQM, its success was
greater than in other organisations with a less management commitment. This finding
is consistent with the TQM literature (Balding, 2005; Mosadeghrad, 2005). Top
management must be totally committed to TQM in both words and actions to sustain a
long-term effort to improve performance.
Achieving and sustaining quality requires a long-term commitment to quality
management. Quality should be recognised as an organisation’s strategic goal and
should be reflected in the organisation’s corporate vision and mission. The current study
shows that strategic quality planning had the most effect on quality culture, employee
management and customer satisfaction. However, Iranian healthcare organisations use
strategic quality planning to a lower extent. Managers should develop plans to
implement quality management changes and control their effects. A strategic quality
plan ensures the availability of resources for TQM implementation. It helps identify
customers’ and other stakeholders’ requirements and then design strategies and action
plans to achieve the goals and objectives. Without the integration of quality management
with strategic and operational plans, it becomes yet another initiative.
Organisational culture influences the thoughts, feelings and interaction among
people in an organisation (Boon et al., 2007). It acts as a force for cohesion in an
organisation and therefore can support or inhibit the process of change towards the
application of TQM (Sinclair and Collins, 1994; Tata and Prasad, 1998). Organisational
culture must be congruent with TQM or TQM initiatives need to be modified to fit the
Iranian (or other) culture and healthcare systems. Although quality culture had the
most effect on organisation, employee and customer results, TQM implementation had
the least effect on organisational culture of Iranian healthcare organisations.
Organisational culture is difficult to change due to its deep-rooted nature. Therefore,
some managers may invest less on developing a quality culture before implementing
their TQM initiatives to avoid the employees’ resistance.
Insufficient training on quality was found to impede successful TQM implementation
in Iranian healthcare organisations. The results have shown that education and training
 were directly related to quality culture, employee management, process management, Developing
customer management and supplier management. A positive relationship between and validating
quality-related knowledge and managers’ involvement in and commitment to TQM was
also found in this study. Therefore, it is necessary to ensure employees actually
a TQM model
understand the values and principles of TQM, and are equipped with skills and
knowledge required to improve the quality of their work. Education and training can
result in a more satisfied workforce and an environment for innovation and creativity. 557
The findings of this study indicate that employee management is arguably the most
important factor affecting the TQM programme. This finding is consistent with other
studies claiming that employees have an important role in quality management success in
service organisations (Agus, 2005; Dilber et al., 2005). Employees are the driving force of
TQM success. Their active involvement in quality improvement activities plays critical role
in TQM success. Findings of this study indicated that Employee management had the most
effect on customer management, process management, resource management, employee
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results, society results, customer results and organisation results. The findings also suggest
that those healthcare organisations emphasising employee empowerment are more likely to
be successful in their implementation efforts. Financial incentives and non-monetary reward
systems increase the effectiveness of TQM programmes. Employees should be rewarded
for their efforts and successes at quality improvement. Managers should implement policies
and programmes that link performance to the accomplishment of quality objectives at the
organisational, group and individual levels (Allen and Kilmann, 2001).
TQM cannot exist without a strong customer focus. Customer focus is the foundation
of the TQM philosophy. In fact, quality management cannot exist without a strong
customer focus. The finding revealed that Customer management had the most effect on
process management, customer results, and organisation results. These findings
concurred with the assertions of other studies that concluded that effective customer
management activities and focus on customers’ requirements could contribute towards
the level of customer satisfaction (Mosadeghrad, 2012b; Terziovski, 2006).
Top management should establish effective information systems and encourage
employees to use objective data in their decision processes. Information management
had the most effect on process management, employee results, organisation results,
customer results and supplier results in this study. The results also confirmed the
empirical findings of several previous studies that suggest a positive link between
information and analysis and customer satisfaction (Min et al. 2002; Ooi et al., 2011).
Allocating necessary resources are essential for TQM programmes to be continued
effectively. Resource management had the most effect on process management,
organisation results, supplier results and customer results. Supplier management
emerged as an important construct of TQM, positively affecting process management,
resource management, supplier results, organisation results and customer results.
However, it was ranked as the least practiced by healthcare organisations. This
indicates that a much greater emphasis must be given on supplier management in
future quality improvement programmes. If organisations do not manage their
suppliers properly, the chances of getting high quality materials and services will be
lower and can result in lower quality healthcare services and higher total quality costs.
In TQM, the emphasis is on studying processes and improving them to provide
customers with desired products and services. Process management, was found to have
a positive significant impact on organisation results, customer results, employee results
and supplier results in this study. Similarly, Kumar et al. (2008) found that process
management is a critical driving force of customer satisfaction.
 TQM Another point worth mentioning here is that ISO certified hospitals have better quality
27,5 management practices and enjoy better quality results. A quality management system such
as ISO 9001:2000 could be a good first step towards TQM implementation, mainly because
of raising awareness of quality among employees and improving processes through the
development of work procedures (Gotzamani and Tsiotras, 2001; Martínez-Costa and
Lorente, 2004). Therefore, implementing ISO 9000 and TQM jointly has more impact on
558 organisational performance. However, there is still a long journey from ISO to TQM.
One encouraging finding from this study was that, where TQM was used with other
management initiatives and strategies, these organisations were likely to have a
greater appreciation of the benefits of TQM and a higher level of performance. The
finding is supported by the earlier studies which show that using an integrated quality
management model and applying several quality management practices in a
complementary way is usually more effective than single practices (Dey and Hariharan,
2006; Revere and Black, 2003; Sun et al., 2004). Managers can use a number of quality
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management strategies and techniques and enjoy the synergistic impact of them on
each other. Quality management systems should be chosen based on the needs of the
organisation. One system is not a perfect fit for any organisation. However, pulling the
best of each quality management system may be of better benefit to an organisation.
TPM and 5S have always been the least favoured quality activities adopted in Iranian
healthcare settings. It is important for managers to use these two techniques as well in
order to develop and sustain a quality culture.
Quality management requires the cooperation and collaboration of all those people
involved in the delivery of healthcare services. The results have shown that TQM had
better effects on performance in organisations using participative management.
Nevertheless, the use of suggestion scheme did not lead to good results, though quality
circles and autonomous groups had more synergistic effects. It seems that healthcare
managers do not use the suggestion system appropriately and systematically.
Therefore, employees are not interested in this participative management technique
and prefer to do quality efforts together in quality teams. Managers should give
employees more autonomy to do their own works.
The findings of this study showed that smaller healthcare organisations tend to
implement TQM more successfully than larger ones. There is a debate in the literature
about the influence of the size of a firm on TQM implementation. While Ghobadian and
Gallear (1996) and Taylor and Wright (2003) did not find operational differences in
TQM implementation attributable to firm size, other studies found a significant
difference between TQM success and the size of the firm (Eng and Yusof, 2003;
Hendricks and Singhal, 2001).
Private Iranian healthcare organisations experienced higher success in their TQM
programme than public ones. Despite the potential benefits, several scholars suggest
difficulties in adopting the principles of TQM in the public sector. A short-term
perspective due to frequent political changeovers, a highly centralised structure, a lack
of management autonomy, inter-organisational politics, complex inter and intra-
organisational relationships, financial pressures, an emphasis on due process over
efficiency, lack of market incentives, external constraints, resistance to change, little
incentive to innovate and reduce costs in the public sector and rising demand for public
services contribute to the difficulty of adopting and implementing TQM in the public
sector (Bowman and Hellein, 1998; Morgan and Murgatroyd, 1994).
TQM must be modified substantially to fit the public sector’s unique
characteristics. The public sector will also need to change many of its attitudes,
 behaviours and even its culture to be compatible with the principles underpinning Developing
the TQM approach. It requires long-term commitment, changes in organisational and validating
goals and performance indicators, changes in management roles and practices, and
major work and organisational redesign. It requires accountability by professional
a TQM model
managers and leaders, an emphasis on results rather than on procedures, explicit
standards and performance measures, an emphasis on competition and performance-
oriented reward schemes to improve productivity and more enlightened financial 559
management that uses resources efficiently rather than “spending up a given annual
budget” (Brysland and Curry, 2001; Scharitzer and Korunka, 2000).
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).
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Conclusions
The findings indicated that TQM was less successful in Iranian health sector due to lack
of a quality management system, low employees participation in quality management
activities and inappropriate strategies for managing quality. The research suggests that
TQM implementation practices could result in better organisational performance. The
findings revealed that the primary constructs of TQM were the strongest predictors of
organisational performance. The most important contributing factors to successful TQM
implementation in the Iranian health sector were Employee management, Information
management, Customer management, Process management and Leadership.
Furthermore, using a combination of quality management techniques has “synergistic”
effect on TQM success.
TQM demonstrates some potential for successful implementation in Iranian
healthcare organisations as far as its principles and practices can be adapted
in an ethnocentric manner tailored to the Iranian context and culture. Successful
implementation of TQM depends on a number of factors such as, top management
commitment and involvement, strategic quality planning, focus on customers
(both internal and external), quality awareness training, employee commitment and
continuous improvement.
The findings of this study contribute to the quality management and healthcare
literature in several ways. First, a valid and reliable instrument was developed and
used to assess TQM practices in the Iranian health sector. Second, this research
documented the extent to which Iranian healthcare organisations utilised TQM. As
noted earlier, there is very little information in the current literature on the extent of
quality management implementation in the healthcare organisations of this country.
This study contributed to theory about the nature of quality management practices in
Iranian healthcare organisations.
From a practical point of view, the findings provide managers and researchers with
a practical understanding of the critical success factors of TQM implementation in
healthcare organisations. The results will help managers in planning more effective
TQM designs. They will be able to re-allocate more resources to those constructs of
TQM that have the most significant impact on organisational performance. The
findings will provide decision makers with quantifiable benchmarks on TQM
implementation in Iranian healthcare organisations. Managers and researchers can
employ the survey instrument to evaluate TQM implementation initiatives and identify
problem areas requiring improvement.
 TQM This study may serve as a foundation for future research in different countries and
27,5 diverse cultural settings. Researchers will be able to use the findings for developing
quality management theory and constructing a suitable model of TQM. The results of
such studies can be very helpful for developing a model of TQM that can be
implemented successfully in a cross-cultural context.

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Further reading
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Care Research and Review, Vol. 53 No. 4, pp. 397-416.

Corresponding author
Dr Ali Mohammad Mosadeghrad can be contacted at: mosadeghrad@gmail.com

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