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Development and validation of a

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measurement instrument for assessing
quality management practices in
hospitals: an exploratory study
ab a b a
Jingjing Xiong , Zhen He , Ben Ke & Min Zhang
a
College of Management and Economics, Tianjin University,
Tianjin, People's Republic of China
b
School of Humanities & Management, Wenzhou Medical
University, Wenzhou, People's Republic of China
Published online: 23 Feb 2015.

To cite this article: Jingjing Xiong, Zhen He, Ben Ke & Min Zhang (2015): Development
and validation of a measurement instrument for assessing quality management practices
in hospitals: an exploratory study, Total Quality Management & Business Excellence, DOI:
10.1080/14783363.2015.1012059

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 Total Quality Management, 2015
http://dx.doi.org/10.1080/14783363.2015.1012059

Development and validation of a measurement instrument for

assessing quality management practices in hospitals: an exploratory
study
∗
Jingjing Xionga,b, Zhen Hea, Ben Keb and Min Zhanga
a
College of Management and Economics, Tianjin University, Tianjin, People’s Republic of
China; bSchool of Humanities & Management, Wenzhou Medical University, Wenzhou, People’s
Republic of China

To face the profound changes from both inside and outside, health-care sectors have
begun to implement effective quality management (QM) practices following
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manufacturing and other service industries. However, there is relatively little

literature on the development of reliable and valid measurement instruments to
assess the implementation of QM practices in hospitals. Based on the high-class QM
practices of manufacturing and other service industries, the paper extends the
previous empirical research to the health-care sectors and creates a nine-construct
measurement instrument. For validation purposes, a cross-sectional survey involving
204 quality managers and directors of large public hospitals was carried out between
April and October 2013 in China. We explore the reliability, detailed item analysis
and validity of the instrument by applying psychometric methods. Empirical results
support the claim that the instrument developed in this study is reliable and valid. It
could be an aid for hospitals to assess their QM status and identify the most
important areas for quality improvement.
Keywords: quality management practices; hospital; measurement instrument; quality
improvement

1. Introduction
Health care is a service every person needs. It has become one of the fastest growing indus-
tries in the service organisation in recent years (Lee, 2012). Meanwhile, health-care organ-
isations are facing profound changes from both inside and outside. The changes inside
health-care sectors include increasing management commitment to health-care quality,
reducing patients’ complaints and cost of poor quality, streamlining health-care processes,
etc. And the changes outside include pressure from government, customers and other sta-
keholders demanding improvement in the quality of care (Kunst & Lemmink, 2000). In
light of this, quality management (QM) has become the principal means by which
changes in a health-care organisation can be facilitated and expressed (Dahlgaard, Petter-
sen, & Dahlgaard-Park, 2011; Sangüesa, Mateo, & Ilzarbe, 2007). QM can be character-
ised by its principles, practices and techniques (Ebrahimi & Sadeghi, 2013). Hospitals are
learning QM theories and practices such as total quality management (TQM), six sigma
management, lean and zero defect borrowed from business sectors not only to improve
the quality of health care, but also to reduce costs and promote marketability (Eggli &
Halfon, 2003; Short, 1995).

∗
Corresponding author. Email: zhangmin792002@tju.edu.cn

# 2015 Taylor & Francis

 2 J. Xiong et al.

Whatever QM practices hospitals may choose, hospital managers expect successful

implementation. It is necessary to have an instrument which incorporates a set of
constructs of QM practices to measure or evaluate the performance of QM practices
(Hietschold, Reinhardt, & Gurtner, 2014). Unfortunately studies on QM practices in the
health-care sectors are sparse as a whole (Talib, Rahman, & Azam, 2011). In contrast
to business sectors, there are currently no well-established measurement instruments
(defined as psychometrically validated surveys, self-assessment manuals or other
measurement tools) to assess the strengths and opportunities of QM practices in hospitals
(Groene, Botje, Suñol, Lopez, & Wagner, 2013).
For this reason, this study aims to shed further light on the development and validation
of a measurement instrument for assessing organisation-wide QM practices in hospitals.
The remainder of the paper is structured as follows. The next section presents a literature
review and the theoretical framework of the research. Afterwards, the paper addresses the
instrument design and development of hospital QM practices. Subsequently, the impli-
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cation of the results are discussed. The last section draws conclusions and lists some sug-
gestions for future research.

2. Literature review
QM has become an all-pervasive management philosophy, finding its way into most
sectors of today’s business society (Sousa & Voss, 2002). In general, there are three frame-
works to construct or evaluate the model of QM practices in hospitals from the extant lit-
erature. The first framework, such as the structure – process – outcome model proposed by
Donabedian (1980), is designed to take into consideration the characteristics of the health-
care industry. Its language is clearly understood by health-care specialists (Donahue &
Vanostenberg, 2000). However, it may concern the quality of medical care rather than
that of organisation-wide QM practices (Kunkel, Rosenqvist, & Westerling, 2009).
The second refers to quality award models such as Malcolm Baldrige National Quality
Award (MBNQA) and European Foundation Quality Management (EFQM) (Lee, Lee, &
Olson, 2013; Meyer & Collier, 2001). These models are used by health-care organisations
as a guide to quality implementation to enhance their international reputation. The quality
award models, especially the ‘Malcolm Baldrige Health Care Criteria’ provide excellent
tools to examine all parts of the management system for health-care organisations. The
purpose of the criteria is to empower a health-care organisation to reach its goals,
improve its results and become more competitive by aligning its plans, processes,
decisions, people, actions and results. The Baldrige criteria focus on the results of health
care and processes, customers, workforce, leadership and governance, and finance and
markets. However, the purpose of this study is to develop a structure used to assess
strengths and opportunities of QM practices in hospitals. QM practices are a set of interact-
ing activities, methods and procedures used to achieve quality improvement goals (Boyer,
Gardner, & Schweikhar, 2012). Considering the above slight differences in the purpose of
quality award models and our study, we continue to find the third framework.
The third is based on empirical studies on hospital QM, as shown in Table 1
(Alolayyan, Ali, & Idris, 2011; Arasli & Ahmadeva, 2004; Cohen et al., 2008; Macinati,
2008; Miller, Sumner, & Deane, 2009; Rad, 2005; Sutherasan, Aungsuroch, Prachusilapa,
& Fisher, 2007; Wagner et al., 2014; Wagner, De Bakker, & Groenewegen, 1999). In
general, these studies first defined the domains of QM based on wide-ranging literature,
created a list of constructs and used the health-care managers and quality experts’ opinions
to revise the final framework of QM practices. Afterwards, the researchers used surveys
 Table 1. Constructs of QM practices identified in empirical studies on hospital QM.
QM practices
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Quality Product/
Top Quality Employee Process Customer Supplier information and Quality service
Author(s) management policy relations management focus QM analysis structure design Training
p p p p
Wagner et al.
(1999) p p p
Arasli and
Ahmadeva
(2004) p p p p p p
Rad (2005) p p p p
Sutherasan
et al. (2007) p p p p p p
Cohen et al.
(2008) p p p p p p p
Macinati
(2008) pa p p p p p p
Miller et al.

Total Quality Management

(2009) p p p p p p p
Alolayyan et al.
(2011) p p p p p p
Wagner et al.
(2014) pb p p p p p p p
Saraph et al
(1989)
a
Miller et al. (2009) used the framework of Saraph et al. (1989) and in their paper the construct of management leadership included the items of quality policy.
b
Saraph et al. (1989) considered the role of top management and quality policy as one construct.

3
 4 J. Xiong et al.

and interviews to identify appropriate practices. A close examination of the constructs of

QM practices and their frequency of occurrence in Table 1 shows that the most frequently
covered QM constructs in the literature are top management and quality policy, employee
relations, process management, customer (patient) focus, quality information and analysis.
Besides, the constructs of QM practices identified by Saraph, Benson, and Schroeder
(1989) are also provided in Table 1. It should be noted that important practices such as
supplier QM, the role of the quality department and training recommended by Saraph
et al. (1989) have not been paid enough attention in other studies. In this paper, the
model of Saraph et al. (1989) is adopted based on several considerations. First, Saraph
et al. (1989) proposed the operational measures of overall organisational QM practices.
The instrument can be used individually or in concert to produce a profile of organis-
ation-wide QM practices. Second, the constructs of Saraph et al. (1989) represent the
most comprehensive instrument to measure QM (Wilson & Collier, 2000) and have
been widely recognised and empirically tested (Macinati, 2008; Miller et al., 2009;
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Talib, Rahman, & Qureshi, 2013). In addition, the framework of Saraph et al. (1989) is
applicable to both manufacturing and service sectors (Claver, Tari, & Molina, 2003).
On one hand health-care providers can use it as a benchmarking tool to evaluate
various QM practices compared with other competing hospitals. On the other hand, the
model opens health-care sectors to new methods, ideas and tools to improve their effec-
tiveness and helps them to learn best QM practices from other businesses.
Moreover, the majority of studies in Table 1 focus on assessing the links between QM
practices and organisation performance (e.g. Alolayyan et al., 2011; Macinati, 2008) rather
than the development process of reliable and valid instruments for measuring QM prac-
tices. As Flynn, Schroeder, and Sakakibara (1994) pointed out, it is necessary to
develop reliable and valid instruments for measuring QM (cause), as well as quality per-
formance (effect). The development of a reliable and valid instrument for assessing QM
practices in hospitals is a prerequisite for examining some hypotheses concerning QM,
for example the relationship between QM practices and hospital performance.
Therefore, in this study, we adopt the framework of QM practices provided by Saraph
et al. (1989) for QM construction. Meanwhile, considering the characteristics of health-
care sectors and covering more recent QM topics, we incorporate supplementary
changes based on other QM models (Macinati, 2008; Miller et al., 2009). Seven of
eight constructs of QM practices identified by Saraph et al. (1989) are included. They
are top management and quality policy, the role of the quality department, training,
process management, quality data and reporting, employee relations and supplier QM.
The product/service design construct is omitted because it is unsuitable for the health-
care sector (Macinati, 2008; Miller et al., 2009). We add one construct ‘customer focus’
because health-care market competition is becoming fierce, and hospitals are increasingly
focusing on patients. Existing empirical studies (Alolayyan et al., 2011; Arasli & Ahma-
deva, 2004; Miller et al., 2009; Rad, 2005; Wagner et al., 1999, 2014) also point out that
the construct ‘customer satisfaction’ is the key to QM in health-care sectors. Table 2 illus-
trates our eight constructs of QM practices and related descriptions.

3. Method
3.1. Design of the measurement instrument
Data for this study were collected using a questionnaire survey. A set of items was devel-
oped based on the studies described above (Macinati, 2008; Miller et al., 2009; Saraph
et al., 1989). Originally, the measurement instrument contained 8 constructs with 56
 Total Quality Management 5

Table 2. Constructs of QM practices in hospitals.

Constructs Related categories Descriptions
Top management Leadership; top management To describe the crucial role of top
and quality support; hospital commitment to managers in driving hospital-wide
policy quality improvement; strategic QM efforts and to examine how a
quality planning; policy planning hospital develops and implements its
and documents quality strategy and goals
Role of the quality Quality structure To describe the visibility and autonomy
department of the quality department, the
coordination between the quality
department and other departments.
Effectiveness of the quality
department
Training Training and education Provision of quality-related training
including quality concepts and
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statistical techniques for managers

and employees
Process Process control based on standards To emphasise conformance to patient
management (customer) requirements by means of
managing, evaluating and improving
hospital key processes. Clarity of
process ownership, boundaries and
steps
Customer focus Patient involvement; patient To describe the extent to which patients
satisfaction; patient relations (customers) are satisfied and to which
a health-care organisation evaluates
the feedback from its patients
(customers) to improve quality
Employee relations Human resources management; A general component that encompasses
employee participation and a variety of human resource
development; focus on employee; management practices for the success
employee management of QM, such as employee
involvement, empowerment,
recognition and so on
Quality Information and data for quality Use of quality data. To describe how
information and improvement; quality data and hospital mangers ensure the
analysis reporting availability of reliable, adequate,
timely and relevant data and
information for all key users to
improve quality of health care
Supplier QM Supplier involvement; supplier To encourage an effective and long-
partnerships term cooperation with fewer
dependable suppliers to improve
quality. Purchasing policy
emphasising quality rather than price

items. Responses to these questions are measured using a five-point Likert scale, with a
value of 1 indicating ‘Strongly disagree’ and a value of 5 indicating ‘Strongly agree’.
To ensure the reliability of the questionnaire, the English version was first developed,
then translated into Chinese by a senior professor of QM from China and checked by
several quality managers from Chinese hospitals. The Chinese version was then translated
back into English by a professor of hospital management from Wenzhou Medical Univer-
sity. The back-translated English version was compared with the original English version
to improve the accuracy of the translation.
 6 J. Xiong et al.

Then the instrument was pilot tested in three hospitals to confirm that the measurement
items are clear and unambiguous. Each pilot consisted of structured interviews with rel-
evant quality managers to collect feedback. Six questions were deleted based on the
pilot tests. The final instrument has 8 constructs with 50 items (Please see Appendix for
details).

3.2. Sample and participants

China is one of the most populous countries in the world. Health-care providers in China
are divided into 3 levels and 10 classes according to certain indicators such as size,
medical quality, facilities, history and social impact. Level III hospitals play an important
role in the Chinese National Health Service system as they provide a wide variety of ser-
vices and usually have the highest level of medical quality. Because large hospitals are
complex organisations with a significant and sustained interest in developing and imple-
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menting various QM practices, we selected large hospitals in China (level III hospitals)
as the target population.
As our study is exploratory in nature, and for reasons of practicality and convenience,
we chose a representative province, Zhejiang, as our target sample. Zhejiang Province is
located in southeast China and has a total population of 54.77 million people. It is a typical
Chinese province in terms of economic development and marketisation. Facing great chal-
lenges, large hospitals in Zhejiang Province have carried out various QM initiatives such
as ISO 9000, TQM and six sigma management.
There were 122 large hospitals (level III hospitals) in Zhejiang Province by the end of
March 2013. In these hospitals there are many alumni of Wenzhou Medical University
located in the south of Zhejiang Province. The university alumni association helped us
contact the alumni who could assist with carrying out the survey. The objectives and
requirements of our survey were fully communicated between our research group and
the relevant alumni. Meanwhile, the selected alumni were trained ahead of time. The
alumni aided us in finding the appropriate respondents of the questionnaire, introducing
the purpose of the study, informing respondents of the anonymity of the survey and
giving explanations for specific items. Most questionnaires were distributed and collected
by post and some were sent by email for reasons of convenience. To encourage partici-
pation, we promised a free report based on the results of our study. Forty of the 122
approached hospitals were involved in the survey.
From April to October in 2013, 400 questionnaires for 40 hospitals were sent to differ-
ent levels of managers with sufficient knowledge and experience who were familiar with
the QM practices followed in their respective hospitals. These respondents typically
carried the title of vice president of quality, quality manager, director of medical depart-
ment, head of the nursing department, head of the outpatient department, physician-
manager, nurse-manager and so on. A total of 229 completed questionnaires were
returned. After screening, we discarded 25 of the 229 questionnaires that were not com-
pleted properly, leaving 204 valid responses (51% valid response rate).

4. Results
4.1. Reliability
Using the reliability analysis programme in SPSS 22.0, we performed an internal consist-
ency analysis for each construct. Cronbach’s alphas range from 0.86 to 0.92 (greater than
the recommended value of 0.70), showing that the instrument is reliable (Nunnally, 1978).
 Total Quality Management 7

4.2. Detailed item analysis

To evaluate the assignment of items to constructs, we use the correlation analysis in
SPSS 22.0 and attain the correlation between each item and each construct. The corre-
lation is used to determine whether an item belongs to the assigned construct or
another, or whether the item should be eliminated. Table 3 shows the correlation
matrix between the eight constructs and the measurement items. For example, item 1
(our hospital’s top management supports a long-term quality improvement process
and provides the necessary and continuous resources for quality improvement) has cor-
relation coefficients of 0.661, 0.354, 0.433, 0.478, 0.338, 0.402, 0.390 and 0.327 with
the eight constructs. For item 1, construct 1 (top management leadership and quality
policy) is the average of items 2 – 11, so the high correlation between construct 1
and item 1 is to be expected. Because item 1 has relatively small correlations with
other constructs, it can be concluded that it has been correctly assigned to construct 1.
All other items are similarly examined in Table 3. It is found that all items
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have higher correlations with the originally assigned constructs than with the other
constructs.

4.3. Validity
After verifying the reliability of the constructs, several approaches to assessing the
validity are considered: (1) content validity, (2) criterion-related validity and (3) construct
validity.
The eight constructs of hospital QM practices developed in this study have good
content validity due to the selection process of the measurement items. Measurement
items are selected based on an extensive literature review and detailed evaluations by aca-
demicians and hospital managers. Furthermore, the pilot test indicates that the content of
each construct is well represented by the measurement items employed.
Criterion-related validity is a measure of how closely constructs representing the
various QM practices are related to measures of quality performance. Two measures of
quality performance were obtained from the sample of hospital managers. Managers
were asked to rate (from 1 to 5) the medical quality performance of their hospitals and cus-
tomer satisfaction over the past three years. This subjective measure is chosen over an
objective measure because of the difficulty in obtaining objective data (Saraph et al.,
1989). Schneider, Parkington, and Buxton (1980) and Kunst and Lemmink (2000)
claimed that the perceptions of managers could be a reliable proxy of the actual perceived
service quality of customers. Cohen et al. (2008) proved the external validity of managers’
assessment of hospital quality and believed that the bias is not serious in this way. We use
canonical correlation in SPSS 22.0 to study the interrelationships between two variable
sets: the performance measures (the criterion set) and the constructs (the QM set). The cor-
relation coefficient of the quality performance measures and the eight measures of QM is
0.6. This shows that the eight constructs have a relatively high degree of criterion-related
validity when taken together.
Construct validity can be assessed by factor analysis. Items 20, 22, 45 and 50 are elimi-
nated, because those items have factor loadings of less than 0.4 on the intended construct
or cross-loading problems. Table 4 presents the factor loadings in the final model and we
can find that the constructs of QM practices have increased from eight to nine according to
the results. Nine constructs emerged from 46 items, accounting for 69.6% of the total var-
iance. The recalculated Cronbach’s alphas are all greater than 0.70.
 8 J. Xiong et al.

Table 3. Item to construct correlation matrix for QM practices.

Construct
Item
Construct number 1 2 3 4 5 6 7 8
1. Top management 1 0.661 0.354 0.433 0.478 0.338 0.402 0.390 0.327
and quality policy 2 0.683 0.382 0.528 0.509 0.397 0.399 0.438 0.295
3 0.627 0.332 0.460 0.447 0.333 0.346 0.352 0.245
4 0.735 0.359 0.537 0.535 0.383 0.400 0.459 0.260
5 0.784 0.390 0.524 0.509 0.372 0.415 0.439 0.304
6 0.703 0.353 0.496 0.499 0.325 0.467 0.434 0.409
7 0.737 0.425 0.524 0.558 0.403 0.507 0.476 0.443
8 0.596 0.405 0.497 0.455 0.370 0.594 0.466 0.500
9 0.618 0.444 0.501 0.469 0.428 0.492 0.492 0.455
10 0.587 0.476 0.474 0.405 0.325 0.361 0.457 0.284
11 0.650 0.465 0.516 0.537 0.465 0.509 0.575 0.481
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2. Role of the quality 12 0.494 0.685 0.516 0.429 0.351 0.432 0.492 0.412
department 13 0.444 0.702 0.487 0.448 0.358 0.466 0.524 0.477
14 0.482 0.686 0.567 0.430 0.391 0.431 0.516 0.375
15 0.404 0.738 0.492 0.412 0.385 0.441 0.521 0.416
3. Training 16 0.569 0.470 0.649 0.562 0.495 0.442 0.504 0.392
17 0.636 0.457 0.686 0.544 0.431 0.483 0.507 0.382
18 0.468 0.540 0.678 0.508 0.504 0.603 0.585 0.570
19 0.501 0.426 0.716 0.506 0.448 0.529 0.600 0.423
20 0.540 0.579 0.712 0.602 0.496 0.675 0.644 0.618
4. Process 21 0.572 0.482 0.634 0.716 0.614 0.500 0.604 0.456
management 22 0.470 0.311 0.489 0.610 0.512 0.462 0.519 0.453
23 0.530 0.405 0.527 0.684 0.474 0.460 0.519 0.446
24 0.572 0.457 0.569 0.696 0.549 0.612 0.648 0.549
25 0.559 0.468 0.538 0.692 0.543 0.544 0.561 0.469
5. Customer focus 26 0.413 0.302 0.452 0.550 0.690 0.402 0.483 0.397
27 0.482 0.364 0.547 0.649 0.811 0.503 0.586 0.501
28 0.408 0.323 0.501 0.495 0.753 0.441 0.453 0.409
29 0.490 0.444 0.600 0.647 0.748 0.549 0.604 0.565
30 0.364 0.372 0.385 0.470 0.635 0.386 0.428 0.489
6. Employee relations 31 0.400 0.425 0.438 0.431 0.430 0.613 0.422 0.434
32 0.443 0.476 0.487 0.500 0.502 0.684 0.503 0.543
33 0.426 0.432 0.482 0.496 0.455 0.639 0.488 0.538
34 0.551 0.429 0.549 0.555 0.441 0.709 0.561 0.552
35 0.476 0.479 0.566 0.466 0.477 0.638 0.587 0.537
36 0.424 0.330 0.482 0.448 0.325 0.617 0.414 0.496
37 0.433 0.325 0.454 0.414 0.298 0.660 0.505 0.478
38 0.471 0.371 0.566 0.519 0.385 0.696 0.577 0.568
7. Quality information 39 0.479 0.387 0.528 0.472 0.456 0.479 0.668 0.466
and analysis 40 0.480 0.436 0.536 0.543 0.553 0.527 0.739 0.536
41 0.521 0.512 0.600 0.587 0.555 0.555 0.772 0.611
42 0.519 0.555 0.613 0.631 0.521 0.634 0.814 0.611
43 0.539 0.576 0.602 0.629 0.531 0.556 0.816 0.620
44 0.501 0.513 0.613 0.612 0.445 0.552 0.755 0.532
45 0.457 0.434 0.486 0.565 0.412 0.495 0.584 0.523
8. Supplier QM 46 0.417 0.438 0.484 0.485 0.472 0.526 0.562 0.678
47 0.446 0.406 0.479 0.496 0.370 0.562 0.562 0.717
48 0.350 0.432 0.441 0.398 0.339 0.456 0.487 0.603
49 0.368 0.449 0.473 0.441 0.525 0.570 0.602 0.714
50 0.349 0.377 0.417 0.466 0.543 0.596 0.516 0.632
Note: Bold values are significant at the 0.01 level.
 Total Quality Management 9

Table 4. Factor loadings and Cronbach’s alphas for QM practices.

Cronbach’s Item Factor loadings on
Construct (number of items) alpha number primary scale
1. Top management leadership (4) 0.87 1 0.777
2 0.768
3 0.738
4 0.599
2. Quality policy (7) 0.88 5 0.687
6 0.708
7 0.705
8 0.588
9 0.516
10 0.621
11 0.446
3. Role of the quality department (4) 0.86 12 0.698
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13 0.743
14 0.672
15 0.795
4. Training (4) 0.85 16 0.598
17 0.652
18 0.516
19 0.600
5. Process management (4) 0.86 21 0.565
23 0.688
24 0.461
25 0.587
6. Customer focus (5) 0.87 26 0.705
27 0.742
28 0.771
29 0.646
30 0.696
7. Employee relations (8) 0.89 31 0.710
32 0.721
33 0.680
34 0.523
35 0.479
36 0.512
37 0.532
38 0.514
8. Quality information and analysis (6) 0.92 39 0.676
40 0.749
41 0.700
42 0.680
43 0.638
44 0.602
9. Supplier QM (4) 0.85 46 0.747
47 0.723
48 0.702
49 0.557
Notes: Extraction method: principal component analysis. Rotation method: varimax with Kaiser normalisation.
Items 20, 22, 45 and 50 in Appendix were eliminated due to the loading problems and the item numbers here are
consistent with those in Appendix.
 10 J. Xiong et al.

5. Discussion
The article aims to develop an instrument suitable for measuring QM practices in hospitals
based on the studies by Saraph et al. (1989) and others. This instrument included eight con-
structs of QM practices originally. They are top management and quality policy, the role of
the quality department, training, process management, customer focus, employee
relations, quality information and analysis and supplier QM. They are identified as key
constructs of QM practices.
According to the findings of factor analysis, the top management and quality policy
construct is split and listed as two separate constructs. As shown in Table 4, items 1 – 4
constitute a construct named ‘top management leadership’ that relates to strong commit-
ment and support from top management. Items 5 – 11 form the other construct named
‘quality policy’, which can be interpreted as the specificity and decomposition of
quality goals to achieve excellence in performance. Some researchers (Cohen et al.,
2008; Macinati, 2008; Rad, 2005; Wagner et al., 2014) are in favour of dividing the top
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management leadership and quality policy construct into two separate constructs to
emphasise their respective importance.
It also finds support for applying supplier QM, the role of the quality department and
training as important practices in QM implementation. Regarding supplier-related prac-
tices, suppliers of goods and services play as critical a role in the delivery of services in
hospitals as they do in the making of products for manufacturing organisations. Good prac-
tices for supplier QM include fostering a purchasing policy that emphasises quality rather
than price, a strong interdependence between hospitals and suppliers and reliance on sup-
plier process control. Many researchers have stressed the importance of effective supplier
QM in the health-care sector (Alolayyan et al., 2011; Lee, Lee, & Schniederjans, 2011;
Macinati, 2008; Rad, 2005).
Regarding the role of the quality department construct, we identify it as another impor-
tant QM practice for hospitals. Some studies highlight that this construct is an important
underlying factor of the QM systems adopted by health-care providers (Macinati, 2008;
Miller et al., 2009). When a quality department is established and supported with fulltime
QM staff and budget allocation for QM, it is a sign to hospital employees that top manage-
ment is commitment to quality improvement and the commitment favours their acceptance
of responsibility for quality.
For training-related practices, insufficient education and training are major obstacles to
the implementation of QM initiatives (Mosadeghrad, 2013). Education and training can
result in a more satisfied workforce and help employees to overcome their resistance to
continuous quality improvement. Some studies corroborate the importance of appropriate
training in hospital QM (Alolayyan et al., 2011; Cohen et al., 2008; Miller et al., 2009;
Sutherasan et al., 2007; Wagner et al., 2014). Hospitals should develop suitable training
programmes to help managers and direct doctors and nurses to enhance the quality-
related skills, communications and teamwork.
The other four constructs of QM practices including process management, customer
focus, employee relations, quality information and analysis have been discussed deeply
in previous studies of hospital QM. For lack of space, we do not go into detail on these
four constructs.

6. Conclusions and limitations

Compared with earlier studies on hospital QM, this study presents a set of QM practices
based on the framework proposed by Saraph et al. (1989) and other scholars. The empirical
 Total Quality Management 11

results of this study show that the instrument is a reliable and valid measure to assess
organisational-wide QM practices in hospitals. The instrument can help hospital managers
to obtain a better understanding of QM practices and to identify the most important areas
for quality improvement. It can be used to compare the development of QM in different
hospitals to prioritise quality improvement efforts. Furthermore, the instrument contrib-
utes to promoting the learning of the best QM practices from the manufacturing and
other service industries. Academic researchers can use the instrument to measure
quality practices in the health-care sectors and to examine hypotheses concerning QM,
such as the relationship between QM and hospital performance.
This study has certain limitations and opens directions for future study. First, the
instrument developed in this research has not included organisational culture though it
is reported as a construct of QM in some studies. Because organisational culture penetrates
into many aspects of QM such as leadership style, process management, strategy planning
and decision-making of organisations, it may be difficult to make it a separate construct.
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We think of organisational culture as a prerequisite for quality improvement implemen-

tation rather than as a separate construct of QM practices. Second, due to the limitations
of research conditions, the survey data used in this study were collected from level III hos-
pitals in Zhejiang Province, China. Hospitals of different categories are quite different in
terms of service quality, and level III hospitals are generally regarded as better ones. Thus
the generalisability of the instrument to hospitals of other levels should be further studied.
Further, this instrument was developed and tested in China, thus limiting its appropriate-
ness for studies in other countries. Thus, future research in this area should continue to
improve the reliability of the constructs. We hope that this study will draw more attention
to the study of QM in the health-care sector and contribute to hospital QM theory and
practice.

Acknowledgements
The authors would like to acknowledge the contributions of the alumni of Wenzhou Medical Uni-
versity who provided significant assistance in distributing and collecting the questionnaires. The
authors are grateful to the editor and anonymous referees for their valuable comments that have
improved this paper.

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

Funding
This work was supported by the National Natural Science Foundation of China [grant number
71225006]; Zhejiang Provincial Natural Science Foundation of China [grant number
LY14G030024].

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Appendix

Measurement instrument: selected from the Hospital Quality Management Practices Survey
questionnaire
Note: This appendix contains 50 items in the research instrument after pilot tests. The items
noted by an asterisk (∗ ) were eventually dropped to improve the construct validity of the instrument.
Responses to these questions are measured using a five-point Liker scale: l ¼ Strongly disagree;
2 ¼ Somewhat disagree; 3 ¼ Medium; 4 ¼ Somewhat agree; 5 ¼ Strongly agree. In every case, a
higher score indicates the better quality management practices.

1) Our hospital’s top management supports a long-term quality improvement process and pro-
vides the necessary and continuous resources for quality improvement.
2) Our hospital’s top management participates in quality improvement activities.
3) Quality is considered as a strategic priority by top management.
4) Our hospital’s top management makes strategic quality planning based on customers’
requirements.
5) Quality objectives are assigned to clinical departments.
6) Quality objectives are assigned to administrative departments.
7) Quality objectives are assigned to medical technical departments.
8) Quality goals and policy are understood within the hospital.
9) Major department heads within our hospital are involved in quality planning.
10) Our hospital’s top management considers quality improvement as a way to ameliorate
financial performance.
11) Our hospital’s top management and major department heads are evaluated based on quality
performance.
12) Visibility and autonomy of the quality department.
13) Good coordination between the quality department and other departments.
14) Effectiveness of the quality department in improving quality.
15) Interaction between top management and the quality department.
16) Commitment of the hospital’s top management to employee training and availability of
resources for employee training in the organization.
17) Quality-related training given to managers and supervisors throughout the organization.
18) Quality-related training given to employees throughout the organization.
 14 J. Xiong et al.

19) Training in quality concepts and statistical techniques throughout the organization.
∗
20) Effectiveness of employee quality training programs.
21) Processes in our hospital are designed/improved based on customers’ requirements.
∗
22) Use of inspection to ensure quality services in our hospital.
23) Use of preventive controls to ensure quality services in our hospital.
24) Our hospital makes extensive use of statistical techniques to reduce variation in processes.
25) Our hospital has good plans for emergency to ensure operations not to be interrupted.
26) Our hospital is in close contact with patients and other customers.
27) Our customers give us feedback on quality and delivery performance.
28) Our hospital regularly carries out external customers’ satisfation survey.
29) We use customer requirements and expectations as the basis for quality.
30) Our employees know who our customers are.
31) Quality improvement teams are utilized throughout the hospital.
32) Effectiveness of employee involvement in quality programs.
33) Our employees participate in quality improvement decisions.
34) Our employees are held responsible for their quality performance.
35) Our hospital gives feedback to employees on their quality performance.
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36) On-going employees are aware of the importance of clinical service quality.
37) Our employees are recognized with monetary incentives for superior quality performance.
38) Our employees are recognized with non-monetary incentives for superior quality
performance.
39) Quality data (error rates, defect rates, cost of quality, etc) are available in our hospital.
40) Quality data are available to managers and supervisors.
41) Quality data are shared among the employees.
42) Quality data is timely.
43) Quality data are used as tools to manage quality.
44) Quality data are used to improve clinical and operational performance.
∗
45) Quality data are used to evaluate department heads and managerial performance.
46) Suppliers are selected based on quality rather than price.
47) Our hospital has a thorough supplier rating system.
48) Our hospital strives to establish long-term relationships with few dependable suppliers.
49) Our suppliers are involved in our quality improvement process.
∗
50) We provide quality training and education for our suppliers.