Total Quality Management & Business Excellence

ISSN: 1478-3363 (Print) 1478-3371 (Online) Journal homepage: http://www.tandfonline.com/loi/ctqm20

Development culture and TQM in Turkish

healthcare: importance of employee
empowerment and top management leadership

İzlem Gözükara, Nurdan Çolakoğlu & Ömer Faruk Şimşek

To cite this article: İzlem Gözükara, Nurdan Çolakoğlu & Ömer Faruk Şimşek (2018):
Development culture and TQM in Turkish healthcare: importance of employee empowerment
and top management leadership, Total Quality Management & Business Excellence, DOI:
10.1080/14783363.2017.1366266

To link to this article: https://doi.org/10.1080/14783363.2017.1366266

Published online: 08 Jan 2018.

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Total Quality Management, 2018
https://doi.org/10.1080/14783363.2017.1366266

Development culture and TQM in Turkish healthcare: importance

of employee empowerment and top management leadership
∗
İzlem Gözükara a , Nurdan Çolakoğlu a and Ömer Faruk Şimşek b
a
Department of Business Administration, Istanbul Arel University, İstanbul, Turkey;
b
Department of Psychology, Istanbul Arel University, İstanbul, Turkey

Total quality management (TQM) is directed at quality consciousness throughout all

organisational processes. A successful TQM practice requires a culture that can
adapt to changes and promote innovation. Development culture focuses especially
on improvement, flexibility and external environment, concerning with growth,
innovation and adaptation. From this perspective, the present study aims to examine
the link between development culture and TQM in Turkish healthcare organisations
and to explore the mediating roles of top management leadership and employee
empowerment. Data were collected by using survey method and analysed by using
structural equation modelling while being controlled for common method bias. The
findings revealed that while development culture has a positive influence TQM, it is
the top management leadership which mediates this relationship, not the employee
empowerment. The results are discussed considering the difference in these
mediating effects and organisational implications of the findings are provided.
Keywords: total quality management; TQM; development culture; top management
leadership; employee empowerment; healthcare organisations

1. Introduction
TQM is a quality approach that refers to a participatory management strategy combined
with teamwork, leading to the manufacture of defect-free products and customer satisfac-
tion. TQM implementation requires proactivity for realising TQM values such as the per-
formance of the appropriate action in the appropriate manner as well as maintenance of
task performance to the necessary extent (Rahman & Laosirihongthrong, 2008). This
brings the need for a cultural match in the organisation because the success or failure of
TQM is substantially determined by the culture of the organisation (Shokshok, Rahman,
Wahab, & Ismail, 2011). The available literature reports that flexible and human-oriented
cultures empowering and valuing employees are likely to contribute more to the success of
TQM (e.g. Tata & Prasad, 1998). Accordingly, a development culture, a cultural orien-
tation based on flexibility values with change and adaptability, may facilitate the TQM
success. A flexibility and autonomy-focused culture with participative support may also
contribute to employee empowerment, which enables employees to be internally motiv-
ated to have the confidence of performing ability (Spreitzer, 2007). TQM success, in
addition to culture and empowerment, also depends on the commitment and support of
top management as top management leadership is considered as a key factor for a success-
ful TQM practice (Ahire & Ravichandran, 2001).
Despite the extensive literature on TQM, empirical research on its implementation is
limited especially in developing countries. There is also a lack of TQM framework specific

∗
Corresponding author. Email: izlemg@arel.edu.tr

# 2018 Informa UK Limited, trading as Taylor & Francis Group

2 I. Gözükara et al.

to the healthcare industry. TQM is of critical importance in this industry as healthcare

organisations face a challenge of both providing improved services and making no conces-
sions on quality. In Turkey, healthcare organisations now need more to adapt to innovation
and provide high-quality healthcare services due to the significant transformation with the
growing private hospital sector over the last decade. In the healthcare context, it is not easy
to establish or predict the outcomes as they are related to health. Therefore, some research-
ers (e.g. Yang, 2003) argue that the healthcare industry still suffers from a lack of a com-
monly agreed-upon framework for quality measurement. However, it is known that
achieving success in TQM largely depends on the top management’s adoption of TQM
(Demirbilek & Çolak, 2008).
Therefore, we assumed that Turkish healthcare organisations with a development
culture geared towards innovation, improvement and flexibility would implement a suc-
cessful TQM practice. Moreover, in the light of the literature presented below, we
assumed that two critical variables among others mediate the effects of a development
culture on TQM; employee empowerment and top management leadership. Top manage-
ment leadership is believed to be the driving force behind TQM success (e.g. Ahire & Ravi-
chandran, 2001). Employee empowerment, on the other hand, is considered essential to
improved organisational performance (e.g. Karim & Rehman, 2012). Consequently, we
provided a review of literature to support the assumption that a development culture contrib-
utes to the impact of these factors, which in turn contributes to the success levels of TQM.

1.1. Development culture and total quality management

Organisational culture is among the most effective constructs within an organisation, as it
has an impact on the beliefs and performance of employees. It is considered to be signifi-
cantly influential on a successful working environment and crucial for management due to
its influence on organisational effectiveness, adoption of new strategies and organisational
change (Van Den Bosch, Volberda, & De Boer, 1999).
Development culture is a type of organisational culture that fosters employee motiv-
ation, especially regarding learning processes (Scott, Mannion, Marshall, & Davies,
2003). The important factors in this culture include growth, encouragement, creativity
and diversification. Development culture involves and empowers significant values and
attitudes directly related with the work of employees (Akkoç, Çalışkan, & Turunç,
2012). Thus, it provides more focus and stability in terms of identifying and setting
ground for such values. It also enables flexibility with a focus on external environment.
The orientation of this culture is towards improvement, innovation and continuous adap-
tation to changing environment. Therefore, organisations with a development culture are
likely to strive for meeting their customers’ expectations through constant innovative
activities (Elfaituri, 2012).
Prior research has demonstrated that the culture of an organisation is significantly
involved in successful implementation of TQM (e.g. Beer, 2003; Detert, Schroeder, &
Mauriel, 2000). TQM is a philosophy of management regarding employees and oper-
ational processes with focus on satisfaction of customers and improvement of organis-
ational performance. It is a broadly recognised approach to continuous improvement of
organisational processes in order to achieve maximum customer value and satisfy custo-
mer needs, resulting in higher levels of productivity and profitability (Wang, Chen, &
Chen, 2012).
In managerial perspective, TQM emerges when all managers and employees within an
organisation are involved, embracing the idea that quality is a continuous and integral part
 Total Quality Management 3

of the business (Adair, 2004). TQM incorporates scientific management elements by

focusing on processes, measurement, assessment, management and problem-solving tech-
niques, while simultaneously containing a social management system through its emphasis
on leadership, employees, communication and work design (Ghobadian, Gallear, Woo, &
Liu, 1998).
Several studies have reported that there is a reciprocal association between the culture
of an organisation and TQM. According to Kujala and Lillrank (2004), the success of
TQM largely depends on the compatibility of the organisation’s culture with the main
TQM values. The literature review by Tata and Prasad (1998) concluded that flexi-
bility-focused cultures have greater potential for successful TQM implementation than
control-focused cultures. The study by Elfaituri (2012), likewise, established that group
and development cultures are positively related with all factors of TQM implementation.
Al-Khalifa and Aspinwall (2000) also reported group and development cultures as the best
organisational cultures for TQM. In the light of this theoretical background, we propose
the following hypothesis:
H1: Development culture has a positive effect on TQM.

1.2. Top management leadership and employee empowerment as mediators

In this section, we provide a supporting literature review on the possible mediator roles of
top management leadership and employee empowerment. We provided, accordingly, an
empirical and theoretical literature background concerning the link of development
culture with both top management leadership and employee empowerment and how
these two mediators could contribute to total quality management practices.
Top management bears greater significance for a successful management theory to
accomplish goals in the long term, and top management should act as a role model and
actively participate in the implementation of decisions. The significant role of top manage-
ment was particularly emphasised by Deming (1982) for accessing necessary resources,
empowerment of all organisational members, commitment to organisational systems and
achieving total quality objectives. Hence, the degree of top management commitment is
regarded as an initial point towards TQM implementation and performance within an organ-
isation (Ahire & Ravichandran, 2001). Unless top management strongly provides support, it
is not possible to adopt TQM and fine-tune its performance (Flynn, Schroeder, & Sakaki-
bara, 1995). A successful TQM practice requires quality commitment and support for
which top management bears the major responsibility, which renders top management
become the most vital element for a successful TQM practice (Lewis & Smith, 1994).
The leadership of top management can be influenced by the culture of an organisation.
As reported by Schein (2004), differences in culture are associated with either positive or
negative impact on leadership. As the core and shared value system of an organisation,
culture strongly influences behaviours of all-level employees including top management.
The culture of an organisation manifests itself in its management actions and policies
(Khan, 2006). Therefore, in order to achieve success in TQM, the organisational culture
has to allow change and adaptability so that the top management will be able to
embrace and support such organisation-wide change required by TQM.
Employee empowerment is a symbolic explanation for employees’ individual state,
which is described by meaningfulness, ability of effective performance and autonomy
of action (Menon, 2001). According to Spreitzer (2007), the empowerment experienced
by employees is psychological, which internally motivates employees to have the
4 I. Gözükara et al.

confidence of performing ability. Empowered employees possess the ability to deal with
issues or people by means of their knowledge and skills (Conger & Kanungo, 1988),
exhibit superior performance and show greater commitment (Chen, Kirkman, Kanfer,
Allen, & Rosen, 2007). Employee empowerment aims to enhance authority, responsibility
and commitment to minimise the management – employee gap (Spreitzer, 1995), and
therefore, it is utilised by several organisations for increased motivation, improved knowl-
edge and capabilities required by the changing market. This makes employee empower-
ment an essential practice that should be used by managers for better organisational
performance (Karim & Rehman, 2012).
Empowerment can be strongly influenced by the organisational culture as the culture
of an organisation identifies how contextual factors and work behaviours of employees are
related (Spreitzer, 1995). Several scholars (e.g. Johnson, 2009; Spreitzer, 1995) suggest
that it is more likely for empowerment to be successful in the presence of a suitable organ-
isational culture. From this perspective, a flexibility- and autonomy-oriented culture that
supports participation may foster employee empowerment. In this context, Shakibaei,
Khalkhali, and Nezgad (2012) reported a significant relationship between organisational
culture types and employee empowerment, and more applicable employee empowerment
activities in the organisations with a more change-oriented culture. Likewise, Jung, Chow,
and Wu (2003) suggested that employee empowerment would be successful in the organ-
isations where employees can easily realise their innovative ideas.
Employee empowerment is also considered as a key factor for TQM practices since a
successful TQM practice depends greatly on changing employee attitudes and behaviours.
TQM focuses on a quality climate that requires involvement of all employees and their
contributions to improve work performance (Lawler, 1992). Thus, it can be argued
from a managerial perspective that empowered employees are essential to a successful
TQM practice. Supporting this, Ueno (2010) emphasised the significant role of empower-
ment in achieving and increasing quality, while Boon, Arumugam, Safa, and Bakar (2007)
suggested that employee empowerment is critically important in TQM, which has a sig-
nificant impact on job involvement. Based on this theoretical background, we propose
the following hypotheses:
H2: Development culture has a positive effect on top management leadership.
H3: Development culture has a positive effect on employee empowerment.
H4: Top management leadership has a positive effect on TQM.
H5: Employee empowerment has a positive effect on TQM.

1.3. Top management leadership vs. employee empowerment in TQM

A successful TQM practice requires involvement and commitment of all parties within an
organisation. Almost all TQM studies up to date suggest top management leadership’s
commitment and employee empowerment as the vital components of a successful TQM
implementation (e.g. Deming, 1982; Ugboro & Obeng, 2000).
Top management leadership reflects the extent to which top management determines the
quality management goals, supplies and distributes necessary resources, actively supports
quality improvement and evaluates the QM implementation and performance (Saraph,
Benson, & Schroeder, 1989). For an effective TQM practice, first, top management should
strongly embrace the concept and undertake the responsibility. Since TQM involves a top-
down change in all organisational procedures and processes, the top management is respon-
sible to communicate all relevant information on TQM principles and values to the
 Total Quality Management 5

employees and make them be involved (Ahire & Ravichandran, 2001). The support and
involvement of employees can be achieved only by such commitment of the top manage-
ment. Therefore, TQM implementation requires a top management leadership committed
to create an organisational environment that empowers employees (Mandava & Bach, 2015).
Top management leadership is also essential to the empowerment of employees, the
other key component of TQM. Through empowerment, employees are granted necessary
resources and autonomy to react against quality-related issues (Ugboro & Obeng, 2000).
As a result, employees are likely to acquire new knowledge and skills by being involved in
TQM, which in turn encourages them to change their attitudes and behaviours towards
improved quality (Hanson, Porterfield, Ames, Adsit, & Lewis, 1995). In this sense,
employee empowerment cannot be realised unless there is an active involvement and
support of top management due to the power sharing nature of empowerment (Ugboro
& Obeng, 2000). In the light of this theoretical background, we develop the following
hypothesis:
H6: Top management leadership has a greater mediating effect on the development culture–
TQM relationship than employee empowerment.
Based on the literature and hypotheses presented above, the present study investigates the
mediator roles of employee empowerment and top management leadership in the relation-
ship between development culture and total quality management. The model tested con-
cerning these relationships is presented in Figure 1.

2. Method
2.1. Strategy of analyses
The model proposed by the present study was tested using structural equation modelling.
LISREL 8.80 (Jöreskog & Sörbom, 2001) was used in the analyses with the Maximum
Likelihood estimation method. Since the structural equations in the model were estimated
by taking common method variance (CMV) into account, the paths from CMV to all
observed variables of the latent constructs were added, while the covariance of CMV
with all latent constructs was constrained to be zero (Johnson, Rosen, & Djurdjevic,
2011; Williams & Anderson, 1994). Additionally, the variance of CMV was set to 1.00
in order to achieve identification. The measurement model was tested twice, with and
without the control variable, to identify its effect on the relationships between the latent
constructs used in the model.

Figure 1. The proposed model concerning the relationships among study variables.
6 I. Gözükara et al.

Finally, the structural model with CMV was estimated in order to evaluate whether the
model fits well to the data. An alternative structural equation model was also tested to rule
out the possibility that the fit of the proposed model is simply the result of a statistical
coincidence. The alternative model assumed that employee empowerment and top man-
agement leadership contribute to the levels of development culture which, in turn, contrib-
utes to total quality management. The structural model was tested by using a full latent
variable structural equation modelling, and by switching to an all-Y model specification,
as suggested by Williams and Anderson (1994). The significance of indirect effects in the
model was evaluated by the estimates produced by LISREL.

2.2. Sample and data collection

This study included 510 employees from healthcare facilities (hospitals) in Istanbul and
the data were collected using a questionnaire form. Participation was on a voluntary
basis, the questionnaire forms were completed through interviews and there were no
missing data. The questionnaire includes five items regarding demographic characteristics
of the participants. Demographic details are presented in Table 1.
Twenty-two outliers were detected and eliminated from the data before the analyses. In
the study, 66.5% of the participants were female and 33.5% were male. Of the participants,
32.0% were in the age range of 20– 30, 48.4% were 31– 40 and 19.6% were 41– 57. Based
on the educational level, 21.2% of the participants were secondary school graduate, 69.9%
were undergraduate and 8.9% were graduate. Among the participants, middle-level execu-
tives were on the first rank with 61.0%, followed by lower level executives with 32.1%.
Based on the term of duty in the institution, 45.5% had been working in their institutions
from one to five years, 25% from 6 to 10 years and 14.5% had been working less than one
year.

Table 1. Demographic characteristics of participants.

f %
Gender
Female 324 66.5
Male 164 33.5
Age
20–30 157 32.0
31–40 235 48.4
41–57 96 19.6
Educational level
Secondary school 104 21.2
Undergraduate 341 69.9
Graduate 43 8.9
Position
Top executives 34 6.9
Middle-level executives 298 61.0
Lower level executives 156 32.1
Term of Duty
,1 year 72 14.5
1–5 years 231 45.5
6–10 years 127 25.0
11–15 years 41 8
16–20 years 22 4.3
.20 years 14 2.7
 Total Quality Management 7

2.3. Measures
TQM was measured by using a 16-item instrument adapted from prior research (Coyle-
Shapiro, 2002; Zeitz, Johannesson, & Ritchie, 1997). The instrument includes four dimen-
sions (top management support, employee involvement, continuous improvement and cus-
tomer focus) with four items each. Sample items include ‘Top managers in my department
set clear goals for quality improvement’, ‘People in this organisation have a relatively high
level of authority over their work-related decisions’, ‘People in this organisation are con-
stantly improving their business process’ and ‘This company refers customer needs to
develop their business strategies’, respectively. The items were responded on a five-
point Likert scale ranging from 1 (‘strongly disagree’) to 5 (‘strongly agree’). The Cron-
bach’s alpha of the instrument varied between 0.73 and 0.84.
Development culture was measured by using an 8-item instrument developed by Tseng
and Lee (2009). The items were responded on a five-point Likert scale ranging from 1
(‘strongly disagree’) to 5 (‘strongly agree’). Sample items include ‘Our company empha-
sises on creativity for the new productivity and service’ and ‘Our company flexibly gets
the new challenge’. The Cronbach’s alpha of the instrument was 0.73.
Employee empowerment was measured by using a 9-item instrument developed by
Ugboro and Obeng (2000) based on Conger and Kanungo’s (1988) empowerment defi-
nition. The instrument contains four items for the delegation of decision-making authority,
four items for the involvement in decision-making process and one item for the access to
information. Sample items include ‘Employees have the needed authority to resolve cus-
tomers’ quality-related problem’, ‘As a result of TQM, processes that bring multiple per-
spectives to bear on quality are now in place’ and ‘Information about job requirement is
made available to employees’, respectively. The items were responded on a five-point
Likert scale ranging from 1 (‘strongly disagree’) to 5 (‘strongly agree’). The composite
Cronbach’s alpha of the instrument was 0.77.
Top management leadership was measured by using a 9-item instrument developed by
Ugboro and Obeng (2000). The instrument contains five items for evaluating leadership
roles, two items for top management commitment and involvement, and two items for
resource allocation. Sample items include ‘Top management has assumed the responsibil-
ity for initiating and maintaining total quality goals and culture’, ‘Top management is
involved in reviewing progress towards total quality’ and ‘Top management provides
necessary funds to train employees on the essential TQM techniques’, respectively. The
items were responded on a five-point Likert scale ranging from 1 (‘strongly disagree’)
to 5 (‘strongly agree’). The Cronbach’s alpha of the instrument was 0.71.

3. Results
3.1. Test of the measurement model
Measurement model was defined by using sub-factors of Total Quality Management (top
management support, employee involvement, continuous improvement and customer
focus) and two parcels for other measures of development culture, employee empower-
ment and top management leadership. Item parcelling was used since these three measures
have no sub-factors. Given that the total quality management measure has a sub-scale of
top management support which is very similar to the construct of top management leader-
ship, this indicator was eliminated from the measurement model to decrease the overlap
between the constructs. The means, standard deviations and intercorrelations between
the indicators are presented in Table 2.
8 I. Gözükara et al.

To examine the effects of CMV, two measurement models were tested. The first model
included CMV, while the second did not. The measurement model in which CMV was not
included resulted in an acceptable fit to the data with the following statistics: x2(21, N ¼
488) ¼ 72.31, p , .05; GFI ¼ 0.97; CFI ¼ 0.99; RMSEA ¼ 0.071 (90% confidence
interval for RMSEA ¼ 0.053 – 0.089). On the other hand, the test of the measurement
model with CMV resulted in better goodness-of-fit statistics: x2(20, N ¼ 488) ¼ 64.00,
p , .05; GFI ¼ 0.97; CFI ¼ 0.99; RMSEA ¼ 0.067 (90% confidence interval for
RMSEA ¼ 0.049 – 0.086), which is indicated by the chi-square difference test (D2 ¼
8.31, df: 1, p , .01). These results suggested that the method effects influenced the
measurement of the latent variables, which was also evidently observed from the low
factor loadings in general (see Table 3), as well as the lower correlations between the con-
structs (see Table 4) when the method effects were included in the structural equation.
CMV was influential on all indicators in the measurement model. The largest effects of
CMV were on the customer focus, an indicator of total quality management, and one of the
parcels of the employee empowerment.
As a result of the effects of method variables on the indicators, the correlations between
the variables decreased by nearly 10%. The largest decrease was observed for the correlations
of the total quality management with employee empowerment and development culture
while the weakest was between total quality management and employee empowerment.

3.2. Test of the structural model

A test of the structural model resulted in an acceptable fit to the data with the following
statistics: x2(21, N ¼ 488) ¼ 68.37, p , .05; GFI ¼ 0.97; CFI ¼ 0.99; RMSEA ¼
0.068 (90% confidence interval for RMSEA ¼ 0.050 – 0.086). However, the path coeffi-
cient (b ¼ 2.02) from employee empowerment to total quality management was found
to be non-significant (t ¼ 0.09, p . .05) and eliminated from the model. Elimination of
this path from the model did not affect the model fit as indicated by the chi-square differ-
ence test (D2 ¼ 0.061, df: 1, p . .01). The standardised parameter estimates for the final
model were shown in Figure 2.
An alternative structural equation model was also tested to rule out the possibility that
the fit of the proposed model is simply the result of a statistical coincidence. The alternative
model proposed that top management leadership and employee empowerment contribute to
total quality management by the mediatory role of development culture. Structural equation
model results showed that this model deteriorated the model fit as indicated by the follow-
ing goodness-of-fit statistics: x2(23, N ¼ 488) ¼ 121.26, p , .05; GFI ¼ 0.95; CFI ¼
0.97; RMSEA ¼ 0.094 (90% confidence interval for RMSEA ¼ 0.078–0.11). These
results indicated the superiority of the proposed model over the alternative one.
The estimates produced by LISREL program showed a significant indirect effect (0.41,
SE ¼ .06, t ¼ 7.17, p , .01) from development culture to total quality management as
indicated by the proposed model. Indeed, the path coefficient from development culture
to total quality management decreased from .55 to .24 when the mediators were included
into the model.
Although these results suggested that the relationship between development culture
and total quality management was mediated by top management leadership and employee
empowerment, it is unclear whether both of the mediator variables contribute to this indir-
ect effect. To test the independent contributions of the mediator variables, a nested models
strategy was used. Two nested models could be depicted from the proposed model: first,
the model in which the path from top management leadership to total quality management
Table 2. Means, standard deviations and intercorrelations among the observed variables.
Variables M SD TMS EI CI CF DC1 DC2 TML1 TML2 EE1
TQM
TMS 14.19 3.47 –
EI 13.85 3.58 .77∗∗ –
CI 14.55 3.01 .71∗∗ .72∗∗ –
CF 14.98 2.96 .39∗∗ .34∗∗ .45∗∗ –
DC
DC1 13.38 3.74 .58∗∗ .53∗∗ .51∗∗ .41∗∗ –
DC2 13.50 3.74 .61∗∗ .55∗∗ .54∗∗ .41∗∗ .90 –
TML
TML1 17.66 3.93 .57∗∗ .61∗∗ .57∗∗ .44∗∗ .65∗∗ .66∗∗ –
TML2 13.84 3.38 .56∗∗ .62∗∗ .56∗∗ .40∗∗ .69∗∗ .69∗∗ .86∗∗ –
EE

Total Quality Management

EE1 16.64 4.10 .49∗∗ .52∗∗ .47∗∗ .36∗∗ .63∗∗ .62∗∗ .69∗∗ .77∗∗ –
EE2 14.32 2.91 .44∗∗ .52∗∗ .50∗∗ .38∗∗ .56∗∗ .56∗∗ .69∗∗ .71∗∗ .78∗∗
Notes: N ¼ 488; TQM: Total quality management; DC: Development culture; TML: Top management leadership; EE: Employee empowerment; TMS: Top management support; EI:
Employee involvement; CI: Continuous improvement; CF: Customer focus; DC1-2: Two parcels for development culture; TML1-2: Two parcels for top management leadership;
EE1-2: Two parcels for employee empowerment ∗∗ p,0.01.

9
10 I. Gözükara et al.

Table 3. Standardised factor loadings for the measurement model with Common Method Variance
(CMV).
Variable TQM DC TML ED CMV
EI .78∗∗ (.85∗∗ ) .45∗∗
CI .63∗∗ (.85∗∗ ) .55∗∗
CF .42∗∗ (.52∗∗ ) .56∗∗
DC1 .82∗∗ (.93∗∗ ) .44∗∗
DC2 .85∗∗ (.96∗∗ ) .45∗∗
TML1 .78∗∗ (.90∗∗ ) .43∗∗
TML2 .83∗∗ (.95∗∗ ) .49∗∗
EE1 .82∗∗ (.90∗∗ ) .41∗∗
EE2 .66∗∗ (.86∗∗ ) .56∗∗
Notes: N ¼ 488; TQM: Total quality management; DC: Development culture; TML: Top management
leadership; EE: Employee empowerment; EI: Employee involvement; CI: Continuous improvement; CF:
Customer focus; DC1-2: Two parcels for development culture; TML1-2: Two parcels for top management
leadership; EE1-2: Two parcels for employee empowerment; the values in parentheses are loadings before
method effects were included in the model ∗∗ p,0.01.

Table 4. Correlations of the Latent Constructs with (above diagonal) and without (below diagonal)
common method bias.
Variable TQM DC TML EE
∗∗ ∗∗
TQM – .70 .76 .69∗∗
DC .55∗∗ – .79∗∗ .74∗∗
TML .64∗∗ .72∗∗ – .89∗∗
EE .53∗∗ .63∗∗ .84∗∗ –
Notes: N ¼ 488; TQM: Total quality management; DC: Development culture; TML: Top management
leadership; EE: Employee empowerment ∗∗ p,0.01.

was set to zero (Model A), the second in which the path from employee empowerment to
total quality management was set to zero (Model B).
The chi-square difference test (D2 ¼ 18.68, df: 1, p , .01) indicated that Model A was
worse than the proposed model in which the path was freely estimated. To set the path
from employee empowerment to total quality management (Model B), however, resulted
in non-significant chi-square difference (D2 ¼ 0.061, df: 1, p . .01), showing that this
path did not contribute to the fit of the model and could be omitted. All these results pro-
vided support for the structural model, indicating that top management leadership, but not
employee empowerment, mediated the relationship between development culture and total
quality management.
All these results showed that all of our hypotheses were supported, except Hypothesis
5. The parameter estimates produced by LISREL indicated a partially mediated model in
which the relationship between development culture and total quality management was
mediated by top management leadership.

4. Discussion
This study investigated the effect of development culture on TQM and the degree to which
top management leadership and employee empowerment mediate such effect in Turkish
healthcare organisations. The results demonstrated that development culture has a positive
 Total Quality Management
Figure 2. Standardised parameter estimates for the proposed model with common method bias.
Notes: N ¼ 488; EI ¼ Employee involvement, CI ¼ Continuous improvement, CF ¼ Customer focus, DC1-2 ¼ Two parcels for development culture,
TML1-2 ¼ Two parcels for top management leadership, EE1-2 ¼ Two parcels for employee empowerment.

11
12 I. Gözükara et al.

effect on TQM. Besides, top management leadership was found to mediate such effect of
development culture on TQM. Nevertheless, employee empowerment did not exhibit any
mediating effect on the development culture –TQM relationship in the present study.
Based on these findings, we believe that this study contributes to the limited literature
regarding a TQM framework specific to healthcare organisations, especially in developing
countries such as Turkey. Furthermore, this study advances the available literature on the
organisational culture – TQM link by demonstrating how development culture determines
the success of TQM. Furthermore, this study is different from similar studies on this topic
due to its inclusion of two mediator variables in the analysis process while advanced stat-
istical techniques were used to control for the common method bias. Thus, we believe that
the present study enhances the relevant literature by bringing a new perspective to the
topic.
First, our study established that development culture positively affects TQM. TQM is
an inclusive approach, which primarily aims at improving the quality about the outcomes
for both employees and customers. Several factors are involved in a successful TQM
implementation. Among others, organisational culture is known to have a significant
role in the success of TQM (e.g. Beer, 2003; Detert et al., 2000). This suggests that the
type of organisational culture should be taken into consideration during an attempt to
determine the factors with influence on TQM success. In other words, TQM success is
likely to depend on the culture of the organisation. Accordingly, it can be argued that
the characteristics of the organisational culture should be in accord with the values and
principles of TQM so that the TQM practice can achieve success. As demonstrated by
our study, development culture, which mainly focuses on growth, creativity, and inno-
vation, and aims to adapt to the external environment (Quinn & Spreitzer, 1991), exerts
such positive effect on TQM. This finding suggests that the characteristics of development
culture enable a TQM programme to be successful, especially in healthcare organisations.
In this regard, our finding is in line with the study by Salaheldin and Mukhalalati (2009)
that reported that both creativity and innovation have a positive and significant impact on
critical TQM success factors in Jordanian healthcare sector. Thus, the present study may
help healthcare organisations create a culture matching with the TQM concept and facili-
tate its success based on the characteristics of a development culture.
As we assumed in Hypothesis 2, development culture was found to have a positive
impact on top management leadership. The culture of an organisation can be considered
as its basic structure with a powerful influence on how all members work and interact.
A culture that best fits the objectives of the organisation is likely to be largely adopted
by its members. When a quality approach is to be implemented, one of the most important
factors is the fit and readiness of the culture in order to achieve success (Khan, 2006). Top
management leadership, in turn, is usually considered as the key starting point towards a
successful TQM practice (Ahire & Ravichandran, 2001). From this perspective, it is more
likely for the top management leadership to be effective and successful in the organis-
ations, which have a culture supporting change. In this sense, our finding suggested that
organisations with a development culture positively influence the top management
leadership.
When a global change such as TQM is to be adopted within an organisation, it is not
likely to be successful unless the top management is strongly involved. The key role of top
management primarily involves embracing TQM values and principles and then convey-
ing such knowledge to the employees so that all employees become active in the TQM
practice. The significance of top management leadership has been demonstrated in
several studies. For instance, the study by Zehir and Sadıkoğlu (2012) suggests that
 Total Quality Management 13

TQM practices are likely to fail without top management leadership and support. Like-
wise, Minjoon, Shaohan, and Hojung (2006) reported that the commitment of top manage-
ment to the implementation of TQM improves teamwork, training satisfaction and
empowerment of employees. Our study also found that top management leadership,
which involved employee involvement, continuous improvement and customer focus,
has a positive effect on TQM. This finding suggests that TQM achieves success when
top management grants employees the authority to make work-related decisions, and
when works actively to improve organisational processes and satisfies the needs of custo-
mers. We believe that these two findings will advance the extant literature on the top man-
agement leadership in TQM practices as well as provide a new perspective for the
development culture – top management leadership research.
Another finding of this study showed that development culture is positively related with
employee empowerment. Employee empowerment is a crucial construct constituting the
basis of the theory of TQM due to its relation with customer satisfaction (Ugboro &
Obeng, 2000). Empowerment builds a bond between employee’s strengths and skills,
and supportive and proactive responses to changes (Thamizhmanii & Hasan, 2010). This
makes it especially important during TQM implementation because TQM requires all
members to be actively involved in improving quality (Ueno, 2010). Employees can be suc-
cessfully empowered only in the presence of an organisational culture that enables and sup-
ports such process (Fernandez & Moldogaziev, 2013). Similarly, the study by Shakibaei
et al. (2012) reported that empowerment is more applicable in the organisations which
have a more change-oriented culture. In this regard, our finding indicates that organisations
with a development culture are more likely to empower their employees.
Empowerment also considerably influences employee satisfaction and motivation,
which results in a successful TQM practice (Kappelman & Prybutok, 1995). Based on
our finding, empowered employees positively contribute to the successful TQM
implementation. As a systematic approach to quality, the success of TQM is strongly
associated with changing employee attitudes and actions. Besides, innovation and
change can take place when all parties collaborate, which results best from employee
empowerment (Kennedy & Scleifer, 2006). Accordingly, our study established that
employee empowerment is positively related to TQM.
The last finding of our study indicated that top management leadership mediates the
effect of development culture on TQM, whereas employee empowerment exhibited no
such effect. Although TQM is an organisation-wide approach that requires involvement
of all members, our finding clearly highlighted the critical role of top management.
More specifically, top management leadership is essential for the positive relationship
between development culture and TQM. In other words, development culture exerts its
positive impact on TQM only when top management fully adopts and supports TQM.
On the other hand, it can be argued that development culture does not require employee
empowerment to positively affect TQM, as the present research did not reveal any mediat-
ing effect of empowerment. This means that the positive relationship between development
culture and TQM does not emerge through employee empowerment. In conclusion, this
study suggests that the healthcare organisations which have a development culture and a
supportive and committed top management would successfully implement a TQM practice.

5. Implications and limitations

The present study offers influential implications for organisations, especially in the health-
care industry regarding a TQM strategy. Healthcare organisations utilise TQM to better
14 I. Gözükara et al.

satisfy patient expectations and needs, and a TQM practice may not be as effortless as it is
in other service industries (Yang, 2003). Satisfaction of patients has become highly crucial
for the success of hospitals. Therefore, TQM may offer a solution to the problems experi-
enced in the healthcare organisations in developing countries such as Turkey.
TQM practices involve a cultural change in organisations. Our findings suggest that
healthcare organisations may invest in creating a culture that would support creativity,
innovation and flexibility, referring to a development culture. Since we determined that
development culture has a positive impact on TQM and top management leadership
enhances this impact, we recommend healthcare organisations to create a flexible
culture supporting employees to be creative, take initiatives and participate in decision-
making processes while adopting a TQM practice. By establishing a development
culture and achieving the full commitment of the top management that is actively
engaged in such culture, healthcare organisations will enhance the performance and invol-
vement of their staff, leading to a successful TQM practice.
It is a well-known fact that the involvement and commitment of all organisational
members are essential to TQM success; however, top managers are the primary com-
ponents related to organisational climate and value formation. As indicated by Ugboro
and Obeng (2000), top management should be active and determined to best develop an
organisational climate encouraging total quality. Therefore, we recommend that top man-
agers adopt a total quality-based mindset, gain knowledge about TQM criteria, train their
employees about total quality, establish clear and reasonable performance goals, and
provide regular feedback. Top management is the construct that can both shape the
values of the organisation and set a managerial ground towards an organisation-wide
change. We also recommend organisations to be familiar with the positive impact of
development culture on top management leadership, which in turn positively influences
TQM, and to train their top managers accordingly. In this context, top managers may
also provide their employees with opportunities of involvement and responsibility in
order to enhance employee empowerment. Through empowerment, employees are more
likely to express their ideas and act in the case of quality-related problems, leading to
enhanced autonomy and more effective decision-makers. Through empowerment,
employees improve the quality of processes within their responsibility zone, and act in
accordance with the total quality goals set by the top management.
Although this is not the first study conducted on TQM in Turkish hospitals, it has a
distinguishing feature, as it includes a multiple mediation model. Furthermore, our
research showed that top management leadership is of greater importance than employee
empowerment in successful TQM implementations in the healthcare organisations with a
development culture. Employee empowerment is required for the success of TQM, as all
organisational members should be actively engaged in such process; however, our finding
emphasises that healthcare organisations are not likely to achieve a successful TQM
implementation unless their top management provides full support and commitment,
regardless of the extent to which they empower their employees. This finding may
greatly contribute to the establishment of a TQM framework in healthcare settings, as
maintaining a continuous, high-quality service is critical for these organisations. Health-
care organisations must place greater emphasis on quality than those in other fields due
to the nature of the service provided. Quality is paramount, as it involves both human
health and continuous changes. Therefore, an incompatibility between the departments,
managers and employees within a healthcare organisation would cause serious problems.
This makes TQM even more important in the healthcare setting, as it may solve such pro-
blems by creating a quality-focused and an organisation-wide strategy involving all
 Total Quality Management 15

members. For this purpose, healthcare organisations should create an innovative and
empowering culture in order both to compete with others and to deal with the changing
environment. This culture should favour skills and the free flow of information,
accompanied by the active role modelling of top management.
Based on our findings, we believe that a more expansive research may be conducted to
determine the factors influencing the commitment of top management to TQM in health-
care organisations. Another approach may include the comparison of other service organ-
isations to reveal the differences in TQM adoption and practices. Additionally, future
studies may involve other parties such as medical staff and administrative members of
organisations to discover their perceptions of TQM and the quality of the services pro-
vided. Finally, a longitudinal study may be conducted with a healthcare organisation
that has recently adopted a TQM strategy and in which the transition process can be
observed in terms of critical success factors. Longitudinal studies may also be used to
provide better insight into patient outcomes and management perspectives.

Disclosure statement
No potential conflict of interest was reported by the authors.

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