TQM and industry 4.

0: Elevating the Opportunity to Achieve a high level of

quality of health care services in a Developing Country like Jordan

Introduction

Jordan is a low-middle-income nation with few natural assets, hence the kingdom has considered the

improvement of its human capital one of its most precious assets and strategic foundations. (Ajlouni,

2015). One of the Middle East's most advanced healthcare systems is found in Jordan. The complicated

interplay of Jordan's three main sectors—public, private, and campaign contributors up its health system.

(Dawani et al., 2014) The public sector consists of two major public programs that finance as well as

deliver care: the Ministry of Health (MOH) and Royal Medical Services (RMS). Other smaller public

programs include several university-based programs, such as Jordan University Hospital (JUH) in

Amman and King Abdullah Hospital (KAH) in Irbid. Due to Jordan's virtually complete lack of natural

resources, the health sector's primary significance is in its ability to provide high-quality services (Abu-

Rumman et al., 2021). Nowadays, the ability to compete in a market with other firms in the same

industries has grown to be an essential component of enterprises, differentiating service delivery through

a variety of difficulties and factors. In general, services are mostly created in response to consumer needs

(Saeed et al., 2013) sustainability in healthcare has drawn substantial attention in terms of service quality,

investment, technology, market size, patient safety, and governmental laws. (Swarnakar et al., 2022), and

Alongside the rapid advancement of medical devices, clinical research, data analytics, and information

technology, there has been an increase in interest in engineering approaches to the delivery of healthcare

globally (Li & Carayon, 2021) (Al-Shdaifat, 2015). It is becoming increasingly clear that information

technology, systems engineering tools, and innovation strategy are essential for addressing the

interconnected quality and productivity crises that healthcare systems worldwide are currently

experiencing (Cassel & Saunders, 2014) and (Kaplan et al., 2013). Constructing hospitals that can meet

the concept of health as a whole and well-being necessitates using sustainable building techniques. Such
complex realities function as a single, integrated organism that can only be strong and effective if every

component is of satisfactory quality. Sustainability must be considered a fundamental necessity and a

quality concern(Capolongo et al., 2015). In response, procedures, organization, and management of

healthcare departments must be improved (Naser Alolayyan et al., 2011), and as a result, healthcare

leaders have looked more at the digital transformation of healthcare institutions, the trend toward

digitization and data interchange in industry, enabled by contemporary digital technologies like the

Internet of Things (IoT), Cloud Computing, Machine Learning, and Big Data, is referred to as the Fourth

Industrial Revolution, or Industry 4.0 (I4.0) (Lasi et al., 2014) and (Mustapha et al., 2021). Patients

provide accurate information (feedback) that reflects the success of health institutions, and therefore

measuring the quality of healthcare services from their point of view is an important element in

evaluating the performance of the sector. (Zaid et al., 2020). In developing countries, where many people

lack access to quality services, improving the quality of healthcare services has become a concern not

only for patients, but also for governments, managers, professionals, and hospitals. Patients require more

healthcare services, and they compare their experiences with those in countries where services are of

higher quality (Ovretveit & Al Serouri, 2006). Managers have been compelled to implement sustainable

quality improvement strategies including Total Quality Management to improve service processes, safety,

delivery, and risk. (Leite, 2021).

Up to this, researchers had each offered a theoretical foundation for how TQM and I4.0

technologies might affect the quality of healthcare services. (Lhotska, 2020) shuva and abrar

(Mustapha et al., 2021) (Mwanza et al., 2023). Yet, no single study has empirically combined

these two strategies for health care services quality. Because of this, no single study has looked

at the moderating effect of TQM on I4.0 and healthcare service quality, particularly in

developing nations like Jordan. As a result, to fill up such research gaps, the current study will attempt

to address the below research questions:

RQ1: To what extent do TQM and I4.0 have distinct impacts of TQM and I4.0 on the quality of health

care services?

RQ2: Does TQM act as a mediator between I4.0 and the quality of health care services?

RQ3: What is the impact of I4.0 technologies on TQM implementation?

Total quality management and healthcare quality services

TQM is a managerial strategy that helps an organization become world-class by guaranteeing

that its goods and services fulfill consumers' needs and expectations (S. Sader et al., 2019) .total

quality management is a management system consisting of tools, techniques, and objectives to

focus on continuous improvement (Abbas, 2020). The main goals of TQM are to improve the

quality of products and services and customer satisfaction by integrating all operational

processes to provide a dynamic output (Yue et al., 2011), It is a shift in focus that the company

manages, with the focus of the organization's energies on the continuous improvement of all

processes and systems and, above all, the many stages of work, as quality is nothing more than

understanding customer desires and transforming them into specifications to meet the customer's

needs, as quality is nothing more than knowledge The client’s desires and transforming them into

specifications that meet the client’s needs (Anil & Satish, 2019). The ultimate goal of total

quality management is to improve customer satisfaction by improving product and service

quality while using the least possible resources (Qasrawi et al., 2017) regardless of their

management status to provide consumers with the value of quality by doing the right job the first

time. And permanently, the goal of improvements in the functions and processes of an

organization is to provide consumers with the value of quality by doing the right job the first
time and that is, the goal of improvements in the functions and processes of the organization is to

provide consumers with the value of quality through performance (Rebelo & Gomes, 2017 ).

TQM integration necessitates a culture change in the frequency of operation commitment,

administrative modifications, a customer-focused approach, and numerous training programs

(Dubey & Gunasekaran, 2015)

The purpose was to benefit business stakeholders by having all employees at the firm work

together with business processes to generate products and services that are affordable and meet

or surpass customers' expectations. (Wang et al., 2017). Through applying the TQM approach,

numerous hospitals have seen significant improvements in the administration's performance,

customer happiness, service quality, and other areas. To operate more effectively (Yang, 2003),

on the other hand, The adoption and implementation of TQM's values and concepts by managers

inside professional healthcare organizations will have a significant impact on the program's

implementation. The heavily departmentalized, bureaucratic, and hierarchical structure,

professional autonomy, conflicts between managers and professionals, and challenges in

measuring healthcare processes and outcomes are all reasons why TQM attempts in healthcare

organizations have been unsuccessful (Mosadeghrad, 2013)

According to ISO 9000, the purpose of TQM is to promote quality standards or create demand

for quality throughout the supply chain. (Chaturvedi, 2020). a fundamental idea that ensures

excellent quality inside a company, may be used through technology since it enables strong

leadership, ongoing development, and employee involvement (Tortorella et al., 2022), the

relationship between TQM and healthcare 4.0 is covered next.

(Schreiber & Paulin, 1992) showed that several different quality factors are present in health

care, all of which are significant. Doctors, hospitals, nursing homes, clinics, and other healthcare
providers are the sellers of medical services because they provide these services for a set fee. The

customer or patient who purchases these medical services at the agreed-upon cost is known as

the buyer. It could also include aspects of performance that are directly tied to and closely

associated with healthcare, such as the quality of the staff's attitudes, housing, the safety and

security of patients, and other issues that relate to hospitals and nursing homes.

(Yusuf et al., 2007) has been made clear that TQM refers to an organization's efforts to

accomplish quality development, quality assurance, and quality maintenance at various levels to

please customers. If the business gets involved in helping the area in which it operates and

contributes to social welfare and environmental issues, the company's reputation will improve.

Industries still confront difficulties when implementing TQM and I4.0 in their organizations,

even though doing so can improve economic sustainability.(Lucianetti et al., 2018).

Industry (4.0) and quality of healthcare services

As part of the German government's contemporary manufacturing strategy, Industry 4.0, which was first

conceptualized in 2011 at the Hannover Fair, entails increased interconnection between people, machines,

and systems through real-time data sharing (Germano et al., 2021). For the domains of operations

management and supply chain management, I4.0 brings up a whole new universe of possibilities. (Lasi et

al., 2014). Blockchain, big data, cloud computing, and IoTs are just a few of the emerging technologies

that make it possible to track patients' medical records. That makes it easier for medical experts to

comprehend the patient's history and respond appropriately.(Mustapha et al., 2021). In addition, I4.0

applications aim to address current issues such as increased personalization, global competition,
unpredictable economic conditions, and needs, as well as quicker invention and throughput times (Müller

et al., 2018). Strategic alignment, mechanization, and digitization can be made possible by I4.0

technologies, which could lead to advancements in a variety of domains, including transportation,

production, and procurement.(Li & Carayon, 2021).

(Karatas et al., 2022) shared that occupies a significant position among the technologies offered by

Industry 4.0 in the healthcare industry. It aids in the domain's design, advancement, analysis, assessment,

and optimization of operations. The medical device sector will undoubtedly go through a transitional

period as I4.0 is implemented because maintaining compliance and demonstrating quality processes are

so crucial. The purpose of this study is to highlight the current state of research and potential future

advances for each industry 4.0 application area(Kute et al., 2022). Because of the technologies and

services affected by industry 4.0, healthcare has considerably improved. (Mustapha et al., 2021) results

indicate

that industry 4.0 is greatly raising healthcare standards. Blockchain, big data, cloud computing, and IoTs

are just a few of the emerging technologies that make it possible to track patients' medical records. This

makes it easier for medical practitioners to comprehend the patient's history and treat them appropriately.

adopt the incorporation of industry 4.0 technology to maintain creativity and strengthen doctor-patient

connections. The public's readiness to adopt such technologies, and their integration into the healthcare

sector(Pr Ep Rin t n Ot Pe Er Re Vie We Pr Ep Rin t n Ot Pe Er, n.d.).

Industry 4.0 in TQM implementation

The manner quality is controlled inside the business must also adapt to these changes, for

example, by carefully utilizing all available technology to maximize quality. These adjustments

are necessary to maintain the TQM approach's alignment with I4.0 (de Sousa Jabbour et al.,

2018).

Interconnectivity allowed organizations the ability to use network technology more effectively,

proactive maintenance warnings are quicker to foresee issues, and assets are dispersed efficiently
and effectively—all of which provided a strong foundation for corporate success. (S. Sader et al.,

2019). I4.0 has the power to influence the best methods for putting concepts from Total Quality

Management into practice. A corporate organization should concentrate on creating the

integration of working individuals with I4.0 and utilizing real-time control approaches to have a

successful TQM principles implementation. (Asif, 2020). (Ali & Johl, 2021) found that top

management commitment, customer focus, training and learning, and quality of big data and

analysis are the four soft factors that make up an effective Quality 4.0 implementation in

business. Process management, continuous improvement, and product/service design are three

more hard dimensions that demonstrated the successful adoption of Quality 4.0. Using Industry

4.0 will elevate employees' roles in Quality Assurance from normal tasks to greater levels of

regulation and control for the production process, depending on the situation and context-

sensitive targets. (S. S. A. Sader et al., 2017)

The ideal methods for putting the principles of Total Quality Management into reality can be

influenced by Industry 4.0. According to the International Organization for Standardization

(2015), TQM methods are known to be similar to the ISO 9001:2015 model, which emphasizes

customer focus, leadership, engagement of people, process approach, improvement, and

evidence-based decision-making.

Identified Gaps in the Literature Review:

The results of the literature review revealed that it makes sense to translate the idea of industry 4.0 into

health 4.0. Healthcare has numerous, non-standardized processes. Process automation is influenced by

several variables, including the hospital's management style and type. The automated component in the

majority of hospitals is the EHR (electronic health records). Once more, the shape and structure of this are

not conventional.(Pillai & ManikKadam, 2020)

References

Abu-Rumman, A., Mhasnah, A., & Al-Zyout, T. (2021). Direct and indirect effects of TQM on the

patients’ satisfaction and loyalty in the Jordanian health care sector. Management Science Letters,

11, 493–502. https://doi.org/10.5267/j.msl.2020.9.018

Ajlouni, M. T. (2015). Prepared by : Dr . Musa Ajlouni. April.

https://doi.org/10.13140/RG.2.1.1107.4086

Al-Shdaifat, E. A. (2015). Implementation of total quality management in hospitals. Journal of Taibah

University Medical Sciences, 10(4), 461–466. https://doi.org/10.1016/j.jtumed.2015.05.004

Ali, K., & Johl, S. K. (2021). Soft and hard TQM practices : future research agenda for industry 4 . 0.

Total Quality Management, 0(0), 1–31. https://doi.org/10.1080/14783363.2021.1985448

Asif, M. (2020). Are QM models aligned with Industry 4.0? A perspective on current practices. Journal

of Cleaner Production, 258, 120820. https://doi.org/https://doi.org/10.1016/j.jclepro.2020.120820

Capolongo, S., Bottero, M. C., & Lettieri, E. (2015). Chapter 1 Healthcare Sustainability Challenge.

International Academic Conference, 6(3), 0–9. https://doi.org/10.1007/978-3-319-14036-0

Cassel, C. K., & Saunders, R. S. (2014). Engineering a Better Health Care System: A Report From the

President’s Council of Advisors on Science and Technology. JAMA, 312(8), 787–788.

https://doi.org/10.1001/jama.2014.8906

Chaturvedi, A. (2020). Implementation of TQM in Commercial Banks: Employees Perception. SSRN

Electronic Journal, IX(V), 2989–2997. https://doi.org/10.2139/ssrn.3619738

Dawani, H. A., Hamdan-Mansour, A. M., & Ajlouni, M. T. (2014). Users’ Perception and Satisfaction of

Current Situation of Home Health Care Services in Jordan. Health, 06(07), 549–558.

https://doi.org/10.4236/health.2014.67074
de Sousa Jabbour, A. B. L., Jabbour, C. J. C., Foropon, C., & Godinho Filho, M. (2018). When titans

meet – Can industry 4.0 revolutionise the environmentally-sustainable manufacturing wave? The

role of critical success factors. Technological Forecasting and Social Change, 132, 18–25.

https://doi.org/https://doi.org/10.1016/j.techfore.2018.01.017

Dubey, R., & Gunasekaran, A. (2015). Exploring soft TQM dimensions and their impact on firm

performance: some exploratory empirical results. International Journal of Production Research,

53(2), 371–382. https://doi.org/10.1080/00207543.2014.933909

Germano, A. X. dos S., Mello, J. A. V. B., & Motta, W. H. (2021). Contribution of industry 4.0

technologies to sustainability: a systematic review/Contribuicao das tecnologias da industria 4.0

para a sustentabilidade: uma revisao sistematica. Palabra clave, 11, NA.

Kaplan, G., Bo-Linn, G., Carayon, P., Pronovost, P., Rouse, W., Reid, P., & Saunders, R. (2013).

Bringing a Systems Approach to Health. NAM Perspectives, 3(7). https://doi.org/10.31478/201307a

Karatas, M., Eriskin, L., Deveci, M., Pamucar, D., & Garg, H. (2022). Big Data for Healthcare Industry

4.0: Applications, challenges and future perspectives. Expert Systems with Applications, 200,

116912. https://doi.org/https://doi.org/10.1016/j.eswa.2022.116912

Kute, S. S., Tyagi, A. K., & Aswathy, S. U. (2022). Industry 4.0 Challenges in e-Healthcare Applications

and Emerging Technologies BT - Intelligent Interactive Multimedia Systems for e-Healthcare

Applications (A. K. Tyagi, A. Abraham, & A. Kaklauskas (Eds.); pp. 265–290). Springer Singapore.

https://doi.org/10.1007/978-981-16-6542-4_14

Lasi, H., Fettke, P., Kemper, H. G., Feld, T., & Hoffmann, M. (2014). Industry 4.0. Business and

Information Systems Engineering, 6(4), 239–242. https://doi.org/10.1007/s12599-014-0334-4

Leite, H. (2021). The impact of non-urgent patients in emergency departments’ operations. International

Journal of Quality & Reliability Management, 38(4), 932–954. https://doi.org/10.1108/IJQRM-01-

2020-0016

Lhotska, L. (2020). Application of industry 4.0 concept to health care. Studies in Health Technology and

Informatics, 273, 23–37. https://doi.org/10.3233/SHTI200613

Li, J., & Carayon, P. (2021). Health Care 4.0: A vision for smart and connected health care. IISE

Transactions on Healthcare Systems Engineering, 11(3), 171–180.

https://doi.org/10.1080/24725579.2021.1884627

Lucianetti, L., Chiappetta Jabbour, C. J., Gunasekaran, A., & Latan, H. (2018). Contingency factors and

complementary effects of adopting advanced manufacturing tools and managerial practices: Effects

on organizational measurement systems and firms’ performance. International Journal of

Production Economics, 200, 318–328. https://doi.org/10.1016/j.ijpe.2018.04.005

Mosadeghrad, A. M. (2013). Obstacles to TQM success in health care systems. International Journal of

Health Care Quality Assurance, 26(2), 147–173. https://doi.org/10.1108/09526861311297352

Müller, J. M., Kiel, D., & Voigt, K. I. (2018). What drives the implementation of Industry 4.0? The role

of opportunities and challenges in the context of sustainability. Sustainability (Switzerland), 10(1).

https://doi.org/10.3390/su10010247

Mustapha, I. Bin, Khan, N., Qureshi, M. I., & Harasis, A. (2021). Impact of Industry 4.0 on Healthcare: A

Systematic Literature Review (SLR) from the Last Decade Sustainablity View project Sea freight

for SME View project. Article in International Journal of Interactive Mobile Technologies, 1, 116–

128. https://doi.org/10.3991/ijim.v15i18.25531

Mwanza, J., Telukdarie, A., & Igusa, T. (2023). Impact of industry 4.0 on healthcare systems of low- and

middle- income countries: a systematic review. Health and Technology, 35–52.

https://doi.org/10.1007/s12553-022-00714-2

Naser Alolayyan, M., Anuar Mohd Ali, K., & Idris, F. (2011). The influence of total quality management

(TQM) on operational flexibility in Jordanian hospitals. Asian Journal on Quality, 12(2), 204–222.

https://doi.org/10.1108/15982681111158751

Ovretveit, J., & Al Serouri, A. (2006). Hospital quality management system in a low income Arabic

country: an evaluation. International Journal of Health Care Quality Assurance Incorporating

Leadership in Health Services, 19(6–7), 516–532. https://doi.org/10.1108/09526860610686999

Pillai, S., & ManikKadam. (2020). The Impact of Industry 4.0 on Healthcare 4.0. ResearchGate.
Pr ep rin t n ot pe er re vie we Pr ep rin t n ot pe er. (n.d.).

Sader, S., Husti, I., & Daróczi, M. (2019). Industry 4.0 as a key enabler toward successful implementation

of total quality management practices. Periodica Polytechnica Social and Management Sciences,

27(2), 131–140. https://doi.org/10.3311/PPso.12675

Sader, S. S. A., Istv, S., Management, E., Engineering, M., & Istv, S. (2017). SUGGESTED

INDICATORS TO MEASURE THE IMPACT OF INDUSTRY 4 . 0 ON TOTAL QUALITY

MANAGEMENT. 301(6), 298–301.

Saeed, R., Ghafoor, M. O., Sarwar, B., Lodhi, R. N., Arshad, H. M., & Ahmad, M. (2013). Factors

Affecting Customer Satisfaction in Health Care Servicesin Pakistan.

Schreiber, M. H., & Paulin, S. (1992). Total quality management in healthcare. Investigative Radiology,

27(1), 101–102. https://doi.org/10.1097/00004424-199201000-00024

Swarnakar, V., Bagherian, A., & Singh, A. R. (2022). Prioritization of critical success factors for

sustainable Lean Six Sigma implementation in Indian healthcare organizations using best-worst-

method. TQM Journal, September. https://doi.org/10.1108/TQM-07-2021-0199

Tortorella, G. L., Fogliatto, F. S., Sunder M, V., Cawley Vergara, A. Mac, & Vassolo, R. (2022).

Assessment and prioritisation of Healthcare 4.0 implementation in hospitals using Quality Function

Deployment. International Journal of Production Research, 60(10), 3147–3169.

https://doi.org/10.1080/00207543.2021.1912429

Wang, L., He, J., & Xu, S. (2017). The application of industry 4.0 in customized furniture manufacturing

industry. MATEC Web of Conferences, 100, 2–5. https://doi.org/10.1051/matecconf/201710003022

Yang, C. (2003). The establishment of a TQM system for the health care industry. The TQM Magazine,

15(2), 93–98. https://doi.org/10.1108/09544780310461107

Yue, J.-W., Ooi, K.-B., & Keong, C. C. (2011). The relationship between people-related total quality

management (TQM) practices, job satisfaction and turnover intention: A literature review and

proposed conceptual model. African Journal of Business Management, 5(15), 6632–6639.

https://doi.org/10.5897/AJBM10.435
Yusuf, Y., Gunasekaran, A., & Dan, G. (2007). Implementation of TQM in China and organisation

performance: An empirical investigation. Total Quality Management and Business Excellence,

18(5), 509–530. https://doi.org/10.1080/14783360701239982

Zaid, A. A., Arqawi, S., Al Shobaki, M. J., Arqawi, S. M., Mwais, R. M. A., & Abu-Naser, S. S. (2020).

The Impact of Total Quality Management and Perceived Service Quality on Patient Satisfaction and

Behavior Intention in Palestinian Healthcare Organizations. Trku, 62(03), 221–232.

https://www.researchgate.net/publication/341043587