International Journal of Health Care Quality Assurance Why TQM does not work in Iranian healthcare organisations Ali Mohammad Mosadeghrad

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Article information: To cite this document: Ali Mohammad Mosadeghrad , (2014),"Why TQM does not work in Iranian healthcare organisations", International Journal of Health Care Quality Assurance, Vol. 27 Iss 4 pp. 320 - 335 Permanent link to this document: http://dx.doi.org/10.1108/IJHCQA-11-2012-0110 Downloaded on: 30 January 2016, At: 13:10 (PT) References: this document contains references to 36 other documents. To copy this document: [email protected] The fulltext of this document has been downloaded 310 times since 2014*

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IJHCQA 27,4

Why TQM does not work in Iranian healthcare organisations Ali Mohammad Mosadeghrad Health Management and Economics Research Centre, School of Health Management and Information Sciences, Tehran University of Medical Sciences, Tehran, Iran

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320 Received 10 November 2012 Revised 13 April 2013 Accepted 30 August 2013

Abstract Purpose – Despite the potential benefits of total quality management (TQM), many healthcare organisations encountered difficulties in its implementation. The purpose of this paper is to explore the barriers to successful implementation of TQM in healthcare organisations of Iran. Design/methodology/approach – This study involved a mixed research design. In-depth interviews were conducted with TQM practitioners to explore TQM implementation obstacles in Iranian healthcare organisations. In addition, this study involved survey-based research on the obstacles associated with successful TQM transformation. Findings – TQM implementation and its impact depend on the ability of managers to adopt and adapt its values and concepts in professional healthcare organisations. Unsuccessful TQM efforts in Iranian healthcare organisations can be attributed to the non-holistic approach adopted in its implementation, inadequate knowledge of managers’ about TQM implementation, frequent top management turnover, poor planning, vague and short-termed improvement goals, lack of consistent managers’ and employees’ commitment to and involvement in TQM implementation, lack of a corporate quality culture, lack of team orientation, lack of continuous education and training and lack of customer focus. Human resource problems, cultural and strategic problems were the most important obstacles to TQM successful implementation, respectively. Practical implications – Understanding the factors that are likely to obstruct TQM implementation would enable managers to develop more viable strategies for achieving business excellence. Originality/value – Understanding the factors that are likely to obstruct TQM implementation will help organisations in planning better TQM models. Keywords Total quality management, Quality management Paper type Research paper

International Journal of Health Care Quality Assurance Vol. 27 No. 4, 2014 pp. 320-335 r Emerald Group Publishing Limited 0952-6862 DOI 10.1108/IJHCQA-11-2012-0110

Introduction Total quality management (TQM) is a strategy to enhance customer satisfaction and organisational performance by providing high-quality products and services by involving stakeholders, encouraging teamwork, customer-driven quality and continuously improving structures and processes by applying quality management techniques and tools. Iranian policy makers and managers were encouraged to use this strategy to improve health services. Managers and researchers implemented TQM using the Deming FOCUS-PDCA quality-improvement approach, while the ISO 9001:2000 quality management system (QMS) was used as a TQM implementation and evaluation model. Although TQM implementation resulted in some improvements in Iranian healthcare organisations (Aghlmand et al., 2008; Hamidi and Tabibi, 2004; Mohammadi et al., 2007), it did not sustain health service quality, customer satisfaction and productivity (Behshid, 2003; Dargahi, 2003; Nouri, 2001). Some authors even suggested that Iranian healthcare organisations were not yet ready to adopt TQM Sincere appreciation is expressed to all the interviewees and survey participants.

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practices (Amerion, 2003; Mosadeghrad et al., 2006; Raiesi and Madani, 2002). TQM is a western management concept, which originally evolved from Japanese industrial management. Hence, it may not integrate well into other contexts (e.g. Iran) or sectors (i.e. healthcare). Differences in structures, cultures, working relationships, payment systems, provider attitudes and client expectations, all play significant roles in TQM implementation and its outcomes (Mosadeghrad, 2013a, b). Simply adopting TQM principles will not guarantee its success. Literature review Despite TQM’s promise, in reality, many healthcare managers had difficulty implementing TQM (Buciuniene et al., 2006; Huq and Martin, 2000; Lee et al., 2002; Theodorakioglou and Tsiotras, 2000). Some authors doubted that applying this strategy in healthcare organisations was appropriate (Atchison, 1992; McConnell, 1992). The most frequently mentioned reasons for TQM failure in healthcare include incompatible organisational structure, weak quality-oriented culture, inconsistent top management support, poor planning and insufficient training (Mosadeghrad, 2013a). Hierarchical structure in healthcare exemplifies bureaucratic and authoritative cultures that are not conducive towards employee empowerment, which is crucial to TQM’s success (Abd-Manaf, 2005; Mosadeghrad, 2012a; Zabada et al., 1998). Significant autonomy among some staff in such a hierarchical and departmentalised structure enhances their ability to resist change (Francois et al., 2003; McNulty and Ferlie, 2002). Such a structure makes it difficult to achieve horizontal coordination and vertical integration, which are necessary for effective TQM. Other obstacles to successful TQM include insufficient clinical staff involvement, inadequate resources, poor communication, inappropriate recognition and reward system, weak partnerships, short-term thinking and unrealistic expectations (Alexander et al., 2007; Kozak et al., 2007; Mosadeghrad, 2005; Wardhani et al., 2009; Withanachchi et al., 2007). While the difficulties associated with TQM in healthcare have been studied, TQM obstacles in Iranian health sector have not been fully addressed. Hence, this study aims to identify the factors underlying TQM failures in the Iranian health sector. The author presents reasons for their occurrence and recommends suitable TQM implementation plans. Method In-depth interviews and a questionnaire survey were used to collect data. The mixed methods approach enhanced the study’s validity and reliability. Qualitative study results – barriers to TQM implementation in the Iranian health sector A purposeful sample was selected from those healthcare organisations that implementedTQM in Isfahan province. In total, 20 participants involved in Deming PDCA’s application to healthcare organisations and 30 participants working in three ISO certified hospitals were interviewed (total 50 persons). The interviews were recorded digitally and transcribed. The NVivo software was used for data analysis and retrieval. Transcript content was grouped using 23 codes allocated to five themes (Table I). Management turnover and managers’ poor commitment emerged as the main barriers to effective TQM implementation. No justification for TQM The demand for TQM within Iranian healthcare was not problem led. The decision to implement ISO in hospitals was made by top managers at Isfahan University of Medical

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Strategic

Human resources

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Contextual Structural Procedural Table I. Barriers to implementing TQM in the Iranian healthcare sector

No justification for TQM Weak management involvement and support Management instability Competing management priorities Poor planning Staff shortage Less qualified and competent employees Insufficient quality related education and training Employee resistance to change Weak employee commitment and involvement Clinical scepticism Weak change-agent acceptance Poor recognition and reward programme Weak quality oriented culture Insufficient teamwork and cooperation Weak quality improvement structure Resource constraint The nature of healthcare processes Inappropriate organisational change Weak customer focus Weak evaluation and self-assessment system Difficulties in evaluating healthcare processes Bureaucracy

Sciences (IUMS) or Social Security Organisation. If top managers adopt TQM because staff in other organisations have or because it is currently popular then TQM understanding will be low. Managers should tell employees why TQM is a good organisational strategy: [y] if my personnel do not know why they should do the job [Quality improvement], they just do it reluctantly. If I explain it and convince them of it, they do it better. If they see that it benefits them, their motivation increases (P48).

Those more interested in research than action led most FOCUS-PDCA projects. Researchers selected some measurable processes, established a team, collected data, implemented changes and then measured the improvement: A few processes were selected and were improved. The number of improvement projects was more important than the employees’ commitment and involvement. The person who was the owner of the process [employee] had no motivation for improvement. Employees were not convinced that TQM would benefit them. Quality improvement was superficial and did not root deeply in employee’s activities (P2).

Weak management involvement and support Several participants identified manager commitment as crucial for sustaining TQM. Managers must constantly demonstrate visible support for quality improvement (QI) transformations. Employees look to manager involvement for an example that things are changing: “We cannot expect staff to improve the quality [of services] if top managers do not believe in ISO implementation” (P33). Top manager commitment is the most important factor in quality initiative success or failure. The former secretary for QI at IUMS explained: When I was in the health network, I did not face any problem [with implementing FOCUSPDCA]. The problems started when I moved to the University to work in the quality improvement committee. I, as the manager, trained employees by myself in the health

network. We worked well on quality improvement projects. I did not succeed in the University because top managers did not believe in it (P15).

Poor TQM-knowledge could be a reason for manager apathy towards its implementation. If TQM understanding is low, commitment will also be low, which will lead TQM to be abandoned early:

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It was very hard to get top managers’ commitment and support. Top managers in this hospital do not know too much about ISO principles. They promised to support us but it was just verbally. ISO is more successful in Hospital “C” than here. There, hospital managers understood it well and believe in it. Therefore, they are more involved in ISO implementation (P32).

Management instability Manager turnover is another reason for their low commitment to TQM. In a highly centralised organisation, in which top managers are the main decision makers, any change in their composition affects TQM sustainability. A participant explained: “Strategies are person- [y] rather than [y] system-oriented. Once the person leaves the organisation, the strategy goes as well” (P3). Participants provided TQM failure examples owing to top manager turnover: TQM was halted because the health minister had been changed. When Dr “X” (the minister) left the Ministry of Health, he took TQM with him! (P3). It took a lot of time to get the support of [Isfahan] University chancellor for TQM. After he left, TQM has been halted as well (P4).

Instability may also force managers to avoid organisational changes: “Managers do not have job security. They know if their strategy fails, they will be dismissed. Fear of failure makes managers not to accept the risk of trying something new” (P17). Consequently, managers cannot plan for the long-term and have to emphasise shortterm plans: “The management life of managers is short. Therefore, solving daily problems is more important for them than improvement”, said a health network’s CEO. Competing management priorities TQM was not treated as a key strategic issue on the management agenda in Iranian healthcare organisations. Therefore, organisational goals and priorities change with a change in top management team: “When managers change, the plans and priorities change as well” (P8). Now, cost containment and responding to customers’ increasing demand tended to dominate the management agenda. “When, the Minister of Health changed, the strategic priorities also changed. Other issues like infectious or communicable diseases are more important now” (P11). Poor planning Participants believe that planning for quality; i.e. setting goals, objectives, policies, tactics, while also defining roles and responsibilities, is crucial for TQM success: “Lack of long or short term plans was an important reason for ISO failure. Objectives were not defined or were unclear” (P13). However, they found planning difficult owing to uncertainty and insufficient financial resources: There are many factors affecting a plan. Some [y] are unpredictable and out of the control of managers. Managers write a plan but cannot implement it. They do not know how much budget they will get from the government (P2).

Some participants argued that if TQM is to be successfully implemented in an organisation then quality goals need to be incorporated into the organisational plans: “Instead of having

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something separate like FOCOUS-PDCA for process improvement, it is better to incorporate quality objectives in the organisation’s plan” (P6). It is also important to allow the change agent to identify and meet stakeholders’ needs, so that the process does not stop owing to their resistance: Change agent should identify and recognise all the change stakeholders and their needs. Then, she/he should plan in a way that the benefits of the change would be more than the losses for the stakeholders (P4).

Interviewees also said that involving middle managers in the planning process was important. Their knowledge about employees’ potentials will help to implement TQM effectively: Middle managers should be involved in planning. Unfortunately, their participation is very superficial. Thus, they will not cooperate in the execution of plans, as they do not believe in it. If they were involved in the planning process, they would have more motivation for its implementation (P13).

Staff shortage Participants felt staff shortage was a serious barrier to TQM implementation; they believed that ISO system implementation would take too much time from their typical day-to-day activities: If ISO has to be implemented in a hospital [successfully], further staff and resources should also be committed (P25). We should have enough staff to allocate at least one hour a day to think about the quality of our work and doing quality control (P15).

Less qualified and competent employees Participants identified the human factor as a fundamentally important TQM implementation aspect in their organisations. They argued that managing change requires competent and committed employees: “Appointment of the right people in the right position results in hospital productivity. We need capable, motivated and committed employees who believe in ISO” (P31). However, public hospital managers have less power for managing human resources: A manager cannot recruit or dismiss employees easily. It should be done through the social security organisation. I might find a competent person outside the hospital, but I cannot recruit him/her as my consultant (P31).

Therefore, participants demanded a change in the current recruitment policies to help managers identify and recruit the most appropriate personnel to provide quality services: The process of employee recruitment, retention and evaluation is inappropriate. It is based on testing people’s general information. Employees are not competent enough and do not have motivation for work. This has to be changed (P13).

Insufficient quality-related education and training TQM requires employees to have QI skills. However, health professionals were not trained sufficiently in quality management: An employee who starts his/her work does not know about TQM. Quality improvement should be taught in universities. The person who is working in an organisation is not familiar

with this term. A physician has been trained almost seven years in a university but is not familiar with the TQM concept. Nobody told him about it (P2).

Education and training are significant stimulating factors for changing organisational culture and achieving TQM’s benefits. The education supervisor in a health network argued that:

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Developing a quality culture requires the development of employees’ KAP [Knowledge, Attitude and Practice]. Employees’ knowledge, attitude and practice should be changed. When this happens, whether the top manager [change agent] is present or not, the programme will continue. For TQM to be successful, people should believe in it (P3).

Participants believe that training and education help them understand TQM and secure commitment towards its implementation; e.g. one ISO certified hospital education supervisor said: At first, I thought that ISO9001:2000 is not suitable for the hospital. I attended many ISO and quality auditing workshops. Then, I had a better feeling about it. I believe that there is nothing wrong with the ISO itself. The problem is in its implementation. We did not understand it well (P33).

However, interviewees expected that training should be provided by TQM experts: For a model to survive, it should be taught by an expert to help people to understand it. TQM was a new paradigm. We had many questions about it. When we asked the lecturers our questions, their answers were not convincing. They were more theoretical. They were not very helpful in practice (P3). I could not understand the [quality] discussion in the training workshops. They were not practical. I even doubt that they [lecturers] understood it well (P44).

Employee resistance to change Some people resist change because it is unfamiliar and they perceive it as a threat. Many individuals dislike change. While they see that it may benefit the organisation, change to them simply means additional work: ISO resolves managers’ problems, not those of the employees. ISO gives order to the work that is of interest to managers. The result is not tangible for employees. My work increased. Nevertheless, my revenue did not change (P40).

It seems that TQM requires employees to work harder for no rewards. A hospital quality manager explained: When employees see that ISO involves extra work for them and that there is no benefit for them, they started to complain and resisted it (P22).

Changing employees’ long-standing habits was another reason for their resistance. Established employees have more difficulty adjusting to change: Hospital “D” is an old hospital. People there worked on the processes for a long time in that way. When a new system asks them to alter it and do it in another way, they resist. In contrast, employees in hospitals “B” and “C” did not work for long time. They can change their working habits easily (P14).

Weak employee commitment and involvement Successful TQM is highly dependent on employee commitment to quality management’s goals. “Lack of belief in quality is the main barrier to successful implementation of

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TQM” (P33). Interviewees believed that employee commitment to and involvement in QI activities were important reasons for TQM failure: Those people were not motivated for quality improvement. Employees did not believe that quality improvement would benefit them (P2).

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Managers’ support can lead to higher employees’ organisational commitment, which, in turn, may lead to their involvement in quality management activities. When top managers support TQM, they send strong signals to employees about QI’s importance. An interviewee in a health network said: Resistance to TQM is a typical resistance to any change. When we started it [TQM programme], some people thought it is another fashion. They did not cooperate initially. However, when they saw that top management supports it and that everywhere people were talking about it, even a simple health worker in a rural health house, they decided to be in line with the others (P3).

Clinical scepticism Physicians play supplier and customer roles within the healthcare organisations. Nevertheless, physician participation in TQM remained a challenge in ISO certified hospitals: “Physicians are the most influential group in the hospital. Getting them involved in quality management is very difficult” (P14). Some physicians believe that ISO cannot be applied to physicians’ work. “ISO is for managers as it defines the functions [processes]” (P34). “Standards [ISO] cannot be applied in medicine. Each doctor practices with his or her own guideline. There is no necessity that they must have a consensus on a specific guideline” (P32). Physicians feel that ISO is a fantasy and there are issues that are more important to work on than ISO: They [managers] conduct [training] workshops on hospital waste management, while the monitor does not work in the CCU [Coronary Care Unit]. For me the monitor is more important. For about ten years, they collected hospital waste in this way and nothing happened. I think ISO is a fantasy. Some basic facilities and prerequisites should be provided before going for ISO (P47).

Time constraint was the main reason for physicians’ limited participation. “Physicians are very busy. Most of them have to work in several places. They have to work in the out-patient department, visit in-patients and perform surgeries” (P34). “I have to work 175 hours a month. Sometimes I have to work 18 hours continuously. I even do not have enough time for study” (P46). Lack of accepting the change agent Employees accepting the change agent also affect TQM success. Managers must appoint the right person to direct the TQM implementation programme. Whenever the change agent was a medical doctor, s/he enjoyed more power and acceptance by staff. In contrast, when this person had a nursing background, there was strong resistance from the employees, particularly nurses. The change agent should be both respected by other staff and equipped with enough knowledge and experience in TQM implementation: If you want to implement a change [programme], appoint the best person who is respected by his or her colleagues and has good knowledge and interpersonal relations. In this case, 50% of problems would be resolved itself (P37).

Poor recognition and reward programme The employee evaluation and reward system was not changed during ISO implementation in Isfahan hospitals. There were no rewards for staff who embraced ISO. There is a need for a fair reward and recognition system for sustaining TQM programmes. It is easier to begin TQM than to sustain its continuity. Tangible incentives are needed to sustain TQM. A quality manager noted that:

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Staff did not want it [ISO]. They think it is just extra work. There was no reward for them after the hospital attained ISO certification. Some people have been recognised who did not contribute too much towards ISO activities (P22).

Weak quality-oriented culture Culture change is an essential element for TQM’s successful implementation: “If the organisational culture does not change, we cannot expect a successful ISO implementation” (P14). To succeed, TQM needs a collaborative culture characterized by trust, cooperation and accountability: A culture of quality management should be developed to sustain quality management in the organisation. Managers should trust employees and employees should be responsible for the quality of their work (P2).

Insufficient teamwork and cooperation Interviewees also agree that TQM requires teamwork and employee cooperation. “Employees should improve the quality through teamwork and cooperation with other members of the organisation” (P2). However, participants found teamwork a big challenge; they think Iranians prefer to work individually in ordinary situations: We have not been successful in teamwork except in the revolution [Islamic Revolution of Iran in 1979]. We get the best [sport] medals in world wrestling and power-lifting champions, but we are not successful in football. We should learn to work together (P5).

Weak quality-improvement structure TQM requires a suitable quality structure to be implemented successfully. However, some participants argued that TQM structures and systems were not established in their organisation: “The structure is not ready for ISO implementation. Hospitals have been forced to get ISO, but there is no organisational position for a quality improvement officer” (P13 and P42). Resource constraints According to some interviewees, resource shortage hindered TQM implementation, leading to its eventual failure: “FOCUS PDCA was very simple itself and we had no problem in its implementation. The problem was in its continuity. Employee shortage and financial problems were significant barriers to TQM implementation” said the health network’s CEO. Consequently, managers were reluctant to fully implement TQM. Sufficient high-quality resources must be available to speed up TQM implementation. Managers should allocate a specific budget for TQM and a quality manager argued that committing financial resources to TQM through cost savings decreases motivation and eventually service quality: The hospital manager tries to fund the ISO project by just saving money in other areas. It leads to a decrease in the quality of services in those areas. I have to be very careful to do the [ISO related] job in the lowest possible cost. A manager must find external resources to fund ISO (P22).

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The nature of healthcare processes Some participants believe that various healthcare processes make it difficult to apply QI owing to the employee shortage: We have many units and processes. It is very difficult to implement quality management in about 150 units. In a manufacturing company, there are a limited number of processes. Here, we have about 500 processes. This makes quality improvement so difficult (P6).

Inappropriate organisational change QI projects were mainly limited to administrative and support processes owing to TQM implementation difficulties in clinical areas. One participant said: “In ISO and FOCUS-PDCA, less work [process improvement] has been done in clinical areas. ISO stopped at the door of physicians. The main area, treatment, was overlooked” (P8). Furthermore, hospital processes were designed for staff not patients’ convenience. A hospital quality manager provided an example: We chose outpatients’ waiting time as a quality indicator. Receptionists did not accurately record the [patient waiting] time. The records were not reliable. We changed the indicator to the doctor’s on-time practice. We asked the receptionist to record doctors clocking in and out times to make sure they are coming and leaving on time (P22).

In healthcare organisations where FOCUS-PDCA was used, a few QI teams were established to work on measurable processes. Employees defined process objectives, measured the processes, found the problems and applied solutions. QI projects were fragmented, isolated and inconsistent. Further, they were limited to a few departments and with narrow measurable outcomes: What we have done was mostly piecemeal quality improvement not continuous quality improvement. It stalled at the Check phase of the PDCA cycle. Nobody supported the team [process owners] after improving the process (P2).

Some participants complained about QI techniques and tools: “For quality improvement, we just focused on FOCUS-PDCA and did not use other techniques. We have been trained in just this technique. Therefore, everybody knows TQM with FOCUS PDCA” (P2). Employees were demanding more flexibility in using QI methods: I do not agree that we should follow a standard method for quality improvement. We have been told to write an opportunity statement to explain the problem in a structured way. It was difficult for me to write it. The implementation phase was easier for me than this paper work. I personally like to get the job done first and then document it (P4).

Lack of customer focus Iranian public healthcare staff are overwhelmed with their patients as healthcare demand increases. Therefore, public healthcare providers may not justify the cost of improving the system with such a robust market. The hospital quality manager stated: Patients have to come to the public hospitals. We are not dependent on customers. They are dependent on us. Thus, patient satisfaction may not be very important for providers. Satisfying patients is very important in private hospitals. Private hospitals have to improve the quality of services to attract more patients (P32).

The public healthcare culture in Iran is not customer-oriented. Rarely, during the interviews did participants talk about customers and their involvement in TQM programmes. A quality manager stated: “FOCUS-PDCA asked for the process

owners’ involvement. Other stakeholders like patients were not invited for the process improvement decisions”. Difficulties in evaluating healthcare processes It is difficult to evaluate healthcare processes. Owing to outcome probabilities, it is difficult to measure healthcare QI’s impact:

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Non-conformance and lack of quality cannot be identified easily in healthcare. Outcomes are probable in healthcare. For two different patients with the same disease you cannot expect the same results by giving them the same medicine (P41).

Weak evaluation and self-assessment system Internal audits were conducted before certification audits in all three ISO certified hospitals. Employees in ISO certified hospitals perceived ISO as controlling rather than empowering: There was a resistance from the employees with regard to monitoring non-conformance services. They feared that an internal audit is a means of finding their mistakes and reporting them to the management. It caused much tension among employees (P33).

Therefore, internal quality-auditing objectives should be explained to employees. Internal auditing must focus on processes not employees. Audit and control requires active employee participation. However, owing to problems, some employees did not take internal auditing seriously. A hospital quality manager argued: When we go [to departments] for an internal audit, employees do not listen to our recommendations and do not take them seriously to resolve their quality problems. As a result, external auditors regarded them [those problems] as non-conformances (P32).

Bureaucracy Implementing ISO 9001 led to increased bureaucracy in an already complex and highly administrative system. Many participants were upset by the ISO related documentation – a barrier to doing their jobs effectively, which caused dissatisfaction: “I used to call the maintenance department for fixing equipment directly. Now, I have to fill in a form and it takes more time” (P37). “I used to write the request for the laboratory test on a form and send it with the sample to the laboratory [department]. Now, I have to record it in the nursing file, in the computer and on the form. My work has been multiplied” (P30). Some participants viewed much paperwork was unnecessary: “Documentation affects our principal work [patient care]. They [external auditors] just look at the reports. If I wrote them well, that is fine. They do not evaluate my practice. Hospital X is not an ISO certified hospital. However, their nursing processes are better. We just fill out the forms” (P25). Documentation tended to reduce employee motivation among those who did not see its value: The external auditors asked us to attach the equipment operating manual on it. Everybody knows how to switch on a PC. There is no need for an operating manual for that (P22).

Quantitative study results – TQM implementation barriers A questionnaire survey was conducted to determine TQM implementation barriers in Iranian healthcare organisations. The questionnaire contained five six-item components rated on a five-point Likert-type scale: 1 ¼ very little extent to 5 ¼ very

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Table II. Item to scale (Pearson) correlation matrix

large extent. Construct validity was evaluated by factor analysis (Table II). Questionnaire test-retest reliability was evaluated using the Cronbach’s a coefficient (Table III). In total, 90 questionnaires were sent to healthcare staff in organisations that implemented TQM in the Isfahan province, 55 questionnaires were returned and analysed (61 per cent). In total, 60 per cent were from hospitals and the remaining from health centres. Almost three-quarters were public organisations. Three hospitals had the ISO 9001:2000 certification. The TQM implementation mean score in healthcare organisations was 3.14 (medium) on a five-point scale. Personnel and contextual problems were the most important obstacles to TQM implementation (Table IV). Staff in public organisations experienced more problems in TQM implementation than private ones ( p ¼ 0.002). Staff in large healthcare organisations reported more TQM obstacles than smaller organisations ( po0.001). The top three major obstacles to the successful TQM implementation were related to employees. Respondents perceived “insufficient salaries and wages” (item 14) as the most significant barrier to TQM implementation. About three-quarters (70 per cent) reported this being a significant barrier, receiving the highest mean rating (4.02). Receiving the second highest mean rating (3.67) was “lack of qualified and competent

Scales problems

1

2

Strategic Contextual Human resources Procedural Structural

0.703 0.740 0.799 0.710 0.798

0.734 0.714 0.803 0.786 0.735

TQM constructs

Table III. Internal consistency

Strategic barriers Contextual barriers Human resource barriers Procedural barriers Structural barriers Overall TQM barriers

TQM barriers

Table IV. TQM implementation problems

Human resource problems Contextual problems Strategic problems Structural problems Procedural problems Total

Item numbers 3 4 0.816 0.751 0.718 0.724 0.803

0.713 0.725 0.805 0.809 0.778

5

6

0.765 0.729 0.0806 0.744 0.712

0.807 0.719 0.757 0.765 0.758

Item numbers

Number of items

Cronbach’s a

1-6 7-12 13-18 19-24 25-30 1-30

6 6 6 6 6 30

0.82 0.83 0.86 0.82 0.73 0.94

Mean score

SD

Low o2.75

% distribution mean scores Medium 2.75-3.50

3.39 3.21 3.07 3.01 3.03 3.14

0.68 0.69 0.72 0.59 0.71 0.60

21.8 27.3 30.9 34.5 40.0 27.3

29.1 40.0 45.5 50.9 38.2 43.6

High 3.51-5 49.1 32.7 23.6 14.6 21.8 29.1

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employees” (item 13). Approximately 60 per cent reported this as being a significant barrier to TQM implementation. The third item, “lack of effective motivation mechanisms” (item 15) received a 3.45 mean rating. Fewer financial resources were also perceived as a major obstacle for 49 per cent. Staff shortage was reported as an impediment in 34.5 per cent of healthcare organisations. Low employee commitment and involvement in quality activities was reported by 47.3 per cent as a considerable barrier. Frequent manager-turnover was found to be related to poor strategic planning and insufficient employee involvement in TQM ( po0.05). In a correlation analysis between TQM barriers and its problems, personnel, contextual and strategic problems had most effect, while structural and procedural problems had less effect. Table V shows that these relationships were statistically significant in all cases ( po0.01). Stepwise regression analysis indicates that contextual problems had the largest variance in TQM implementation problems (92 per cent).

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Discussion Applying ISO in Iranian healthcare organisations was top-down; therefore, it did not secure the employee commitment and remained at training and quality awareness level. Bottom-up TQM initiatives (e.g. FOCUS-PDCA), on the other hand, were started by interested individuals (e.g. researchers) without enough top manager support. Such initiatives were narrowed to a few processes and faded as soon as the researchers left the organisation. Hence, a “top-led” and “bottom-fed” TQM initiative provides better sustainable outcomes. Organisational change is more effective when brought about by volunteer participants, supported fully by top managers who should be committed to and involved in TQM (Mosadeghrad et al., 2013). However, numerous barriers, including manager turnover, weak knowledge about TQM and inadequate resources made management efforts to improve quality difficult (Mosadeghrad, 2012b). This study revealed that TQM knowledge was superficial. It resulted in inconsistency, shallow implementation and lower commitment, resulting in its failure and early abandonment. Continuous education and training help managers to understand TQM philosophy and implement it properly. TQM and its impact depend on managers’ ability to adopt and adapt its values and concepts in professional healthcare-based settings. It requires a change in management thought, behaviour and roles. The degree to which employees adopt TQM strategy will be contingent upon the degree to which top managers support TQM. Manager turnover was the most important obstacle to successful TQM implementation in Iranian healthcare organisations. A possible explanation for this might be that turnover increases subjective management, leading to unfavourable outcomes. Managers cannot plan for the long term and have to maintain the status quo. Job security encourages long-term

Overall problems Structural problems Procedural problems Strategic problems Contextual problems Human resource problems

Overall problems

Structural problems

Process problems

Strategic problems

Contextual problems

– 0.862 0.851 0.895 0.930

– 0.707 0.723 0.727

– 0.692 0.692

– 0.805



0.917

0.726

0.694

0.757

0.909

Table V. Inter-correlations between TQM implementation problems and its dimensions

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planning and managers’ commitment to pursuing long-term objectives (Mosadeghrad et al., 2013). Qualitative and quantitative data showed that personnel problems were significant barriers to the successful TQM implementation: consistent with other research, which found that employee shortage, demotivation, low involvement in quality management activities, insufficient time and low wages and salaries are barriers to implementing TQM in healthcare organisations (Amar and MohdZain, 2002; Francois et al., 2003). Incurring too much work without having tangible benefits is the most significant reason for employee apathy. Financial incentives increase employee motivation and involvement in quality management activities. Physicians play an important role in facilitating or impeding TQM implementation (McNulty and Ferlie, 2002; Ransom et al., 2005). However, involving them in TQM projects is challenging. Physicians are not likely to be distracted from their patients in a fee-for-service payment system towards a QMS that expects them to be more transparent, responsible, accountable and customer-oriented, and to follow managerial rules and standards. Physicians perceived Iranian healthcare TQM as another passing managerial fad. They will be more involved in TQM activities if they realise its benefits. Managers must develop systems to encourage and reward physician commitment and participation though training and financial incentives. Top managers need to ensure that all organisational facets (i.e. the organisational structure, leadership style, incentive schemes, training, communications and processes) reflect TQM values and principles. The organisational structure and culture must be able to sustain and nurture TQM (Mosadeghrad, 2006). Iran’s healthcare system is highly centralised. The top management team (Minister and deputies) are key players in determining goals, policies, strategies and resource allocation. Any substantial change in the team composition can change strategic priorities. After the Iran presidential election in 2006 and following ministerial change, quality management was not the Ministry of Health’s top priority. Access, equity and cost containment were substituted as priorities. Consequently, TQM has not been fully institutionalised in Iranian healthcare organisations. A successful TQM programme requires long-term commitment (Cohen and Brand, 1993). However, manager turnover in the Iranian public health sector can compromise this commitment. QI should be considered in the Iranian national plan for economic, social and cultural development. This involves considering quality as a key government priority, formulating national quality management policies, defining an organisational structure for quality management in the public sector, allocating resources and clarifying responsibilities. TQM should be a strategic issue in the agenda for change. A Quality Act should be established to oblige healthcare managers to set up a QMS to ensure high-quality services. A National Quality Board should be formed to ensure overall quality-system alignment. This involves the Minister’s direct involvement and support, setting the national quality goals, formulating quality management policies and assuming the responsibility for driving the quality agenda. Additionally, a quality management institute should be formed in the Ministry of Health to oversee QI. This involves creating a QI QMS, performance assessment, setting quality standards, providing incentives for its introduction and implementation, training healthcare professionals on quality management and supporting staff to improve their services. Such a structure should be also established in healthcare organisations. Support (physical, financial and staff) should be provided to sustain this structure and the QI activities. Continuous QI

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should be understood as the organisation’s strategic objective and must be an integral part of employees’ daily jobs. A QMS should be designed to capitalise on quality management techniques such as FOCUS-PDCA. Such a system provides a framework for managing, improving and controlling processes. Study participants agreed that ISO 9001 was helpful to manage processes through developing work procedures and instructions. However, substantial difficulties were reported during ISO 9001 planning and implementation. The most critical problems were limited applicability to healthcare, paperwork, management knowledge about ISO 9001, insufficient resources, insufficient commitment and little emphasis on continuous improvement. Consequently, ISO registration did not improve hospital performance, probably because ISO initiation in Iranian healthcare organisations was driven by external pressures than by internal management need or pressure from customers and payers to improve quality. Getting the ISO quality management certificate was perceived as the end rather than as a means to an end. It is also useful to invite consultants with TQM expertise and healthcare knowledge. They may be more acceptable to healthcare employees, who tend to resist “nonhealthcare professionals”. Their experience in successful TQM implementation can assure staff that the programme can work. There is also a need for a full-time quality manager to help facilitate the change process. The findings suggest that physicians can act as effective change agents. Incorporating well-respected and knowledgeable physicians into quality management roles also helps facilitate clinicians’ involvement in TQM programmes (Glickman et al., 2007). A corporate quality culture should be developed to sustain QI activities. This involves building and enhancing trust, motivation and cooperation through job security, team working and equitable compensation. A change in organisational factors, both soft (i.e. shared vision and values) and hard (i.e. systems and structures) is needed to create a quality culture. Staff in every organisation must adjust their culture, structures, systems, plans, working relationships and leadership styles to successfully implement TQM (Singh and Smith, 2006). Indeed, many theories in western developed countries may need to be reassessed in developing countries such as Iran. Each region or nation may require different approaches to successfully implement TQM initiatives. Emphasis should be placed on improving the processes rather than blaming employees during TQM implementation. Processes should be defined and designed to meet functional requirements and customer expectations. Process complexity, poor quality audits and performance measurement systems were the main procedural barriers to TQM success in Iranian healthcare organisations. Conclusion and implications TQM has been applied by enthusiastic managers and practitioners in the Iranian health sector. Applying TQM’s hard factors (i.e. FOCUS-PDCA) without updating the structure and improving its soft factors (i.e. leadership, culture, power distribution, etc.) resulted in its early abandonment and no significant improvement in organisational performance. Unsuccessful TQM efforts were attributed to the non-holistic approach adopted in its implementation, top-manager turnover, weak management support, poor planning for TQM deployment, inadequate training, employee belief in TQM’s effectiveness, limited resources available to implement TQM, limited time for TQM implementation, physician-oriented healthcare systems and inadequate focus on customer. Strong clinical and managerial leadership, emphasising planning, training, developing a quality structure and culture help overcome these barriers. This study was

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conducted in a limited geographic region, so an additional sample with participants from healthcare organisations in other countries would give a better view of the TQM implementation barriers in healthcare organisations. References Abd-Manaf, N.H. (2005), “Quality management in Malaysian public health care”, International Journal of Health Care Quality Assurance, Vol. 18 No. 3, pp. 204-216. Aghlmand, S., Akbari, F., Lameei, A., Mohammad, K. and Arab, M. (2008), “Developing evidencebased maternity care in Iran: a quality improvement study”, BMC Pregnancy Childbirth, Vol. 8, p. 20. Alexander, J.A., Weiner, B.J., Shortell, S.M. and Baker, L.C. (2007), “Does quality improvement implementation affect hospital quality of care?”, Hospital Topics, Vol. 85 No. 2, pp. 3-12. Amar, K. and MohdZain, Z. (2002), “Barriers to implementing TQM in Indonesian manufacturing organisations”, The TQM Magazine, Vol. 14 No. 6, pp. 367-372. Amerion, A. (2003), “A survey of TQM applicability in a teaching hospital”, Proceedings of the 2nd Congress of Quality Improvement in Health Care Services, Ministry of Health, Tehran. Atchison, T.A. (1992), “TQM: the questionable movement?”, Healthcare Financial Management, Vol. 46 No. 3, pp. 15-19. Behshid, M. (2003), “Reasons for TQM failure”, Proceedings of the 2nd Congress of Quality Improvement in Health Care Services, Tehran. Buciuniene, I., Malciankina, S., Lydeka, Z. and Kazlauskaite, R. (2006), “Managerial attitude to the implementation of quality management systems in Lithuanian support treatment and nursing hospitals”, BMC Health Services Research, Vol. 6, p. 120. Cohen, S. and Brand, R. (1993), Total Quality Management in Government: A Practical Guide for the Real World, The Jossey-Bass Public Administration Series, San Francisco, CA. Dargahi, H. (2003), “Factors affecting TQM failure in healthcare organisations”, Teb and tazkieh, Vol. 50, pp. 49-61. Francois, P., Peyrin, J.C. and Touboul, M. (2003), “Evaluating implementation of quality management system in a teaching hospital’s clinical department”, International Journal for Quality in Health Care, Vol. 15 No. 1, pp. 47-55. Glickman, S.W., Baggett, K.A., Krubert, C.G. and Peterson, E.D. (2007), “Promoting quality: the health-care organization from a management perspective”, International Journal for Quality in Health Care, Vol. 19 No. 6, pp. 341-348. Hamidi, Y. and Tabibi, J. (2004), “A survey of TQM implementation in Hamadan healthcare organisations”, Journal of Hamadan University of Medical Sciences, Vol. 11 No. 1, pp. 37-43. Huq, Z. and Martin, T.N. (2000), “Workforce cultural factors in TQM/CQI implementation in hospitals”, Healthcare Management Review, Vol. 25 No. 3, pp. 80-93. Kozak, M., Asunakutlu, T. and Safran, B. (2007), “TQM implementation at public hospitals: a study in Turkey”, International Journal of Productivity and Quality Management, Vol. 2 No. 2, pp. 193-207. Lee, S.C.K., Kang, H.Y., Cho, W. and Chae, Y.M. (2002), “Assessing the factors influencing continuous quality improvement implementation: experience in Korean hospitals”, International Journal for Quality in Health Care, Vol. 14 No. 5, pp. 383-391. McConnell, C.R. (1992), “Quality: a watchword for the 1990s or the same old song?”, Health Care Manager, Vol. 10 No. 4, pp. 75-82. McNulty, T. and Ferlie, E. (2002), Reengineering Health Care: The Complexities of Organisational Transformation, Oxford University Press, Oxford.

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Why TQM does not work in Iranian healthcare organisations.

Despite the potential benefits of total quality management (TQM), many healthcare organisations encountered difficulties in its implementation. The pu...
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