You are on page 1of 14

Sci.int.

(Lahore),26(5),2603-2616,2014

ISSN 1013-5316; CODEN: SINTE 8

2603

IDENTIFICATION OF CRITICAL SUCCESS FACTORS OF TQM


IMPLEMENTATION IN HEALTH CARE SECTOR OF PAKISTAN USING
PARETO ANALYSIS APPROACH
1,2

S.M. Irfan, 2Daisy Mui Hung Kee, 1Rashid Waheed Qureshi, 3Rashid Hussain

Department of Management Sciences, COMSATS Institute of Information Technology, Lahore Pakistan


2
School of Management, Universiti Sains Malaysia, Malaysia
3
Leading Edge Human Capital Solutions, Inc., Canada
Irfansyed36@gmail.com

ABSTRACT: Due to the rising costs of health care, complexities in diseases and in its diagnostics, huge equipment and
treatment costs, high customer expectations for quality, has built a tremendous pressure on health care institutions in
almost all the developed and developing economies to transform their old fad working system to cost effective, patient
focus, efficient and high quality services. Thus to deliver high quality of health care services, to gain patient and their
families satisfaction, quality has taken a central position. To ensure quality, patient safety, preventive measures to
control infections, and gain patient and their families satisfaction, there is a growing trends among the health care
institutions to implement quality standard and systems. Majority of the well know hospitals around the globe has
adopted or adapted quality management systems to address the above issues. Total Quality Management (TQM) is a
well proven strategic management system in all sectors of industry to achieve excellence in business by focusing on
customer needs and wants for superior quality and cost effective services or products. This study aimed to identify the
critical success factors (CSFs) of TQM for the successful implementation of TQM in health care sector of Pakistan.
After a careful and comprehensive review of 135 studies on TQM and also considering the importance of contextual
factors of hospital settings in Pakistan, this study proposed 9 CSFs of TQM for health care sector: top management
commitment and leadership role, human resource focus, process management, supplier quality management, quality
data and reporting, strategic quality management, patient focus, continuous quality improvement, and services focus.
Descriptive statistics and Pareto analysis were employed to identify the core CSFs of TQM for health care. Suggested
CSFs of TQM can be employed in order to achieve excellence in health care services.
Keywords: TQM, critical success factors (CSFs), health care in Pakistan, Pareto Analysis
1. INTRODUCTION
The rising costs of healthcare, complexities in diseases and
in its diagnostics, huge equipment and treatment costs and
high customer expectations for quality, has built a
tremendous pressure on health care institution in the
developed and developing countries to transform their old
conventional
working system with efficient quality
management systems. Rapid developments in medicines and
medical field, advancement of technologies for patient
diagnostics and treatment, cost effective, specialized and
high quality healthcare services have created a competitive
environment in the healthcare market. The increasing
demand for better quality of health care services, and patient
safety issues has put an immense pressure on health care
institution to develop a positive consumer culture, increased
efficiency, flexibility, and improved quality of healthcare
services [1, 2]. Thus old models of assuring quality through
self-defined quality standards by healthcare provider are no
longer sufficient to solve quality problems in the healthcare
sector. Thus, Health care institutions require immediate
reforms to address the quality and patient safety issues [3]
Some of the hospitals has adapted or adopted quality
management systems, standards, and also have been
accredited by quality and health care quality accreditation
agencies but still a large number of hospitals are providing
lower level of required health care services to the patient.
This issue has been of a major concern for health care
managers and they need to redesign strategies by focusing
on patient requirement for high quality of services at
affordable costs [4]. According to health care industry in

United States and Canada has also been passing through


transformational phase due to ever-increasing healthcare
costs and increased demands from dissatisfied patients and
third party payers and TQM is particularly useful to deliver
best quality of health care service through continuous
improvement at all levels in the hospitals [5]. TQM practices
in health care institutions provide a better way to resolve the
quality related issues more efficiently and are one of the best
ways to gain patient satisfaction [6, 7].
Numerous empirical studies are witnessed that effective
implementation of TQM helps to boost organizational
performance[8-10] , increased employees performance [11],
efficiency and rapid delivery [12], increased productivity
and cost reduction [13, 14]. Due to the domination of
research from engineering and operations disciplines [15],
most of the TQM literature has been evolved from
manufacturing sector [16, 17]. TQM adoptability in service
firms is slower [18-20] and still slow in terms of strategic
commitment towards TQM as compare to manufacturing
sector [21]. However, it is widely believed that TQM
concepts and practices are equally relevant for service
organizations [22] but services firms have to apply TQM
selectively as compare to manufacturing firms [23].
Wardhani [24] reported that there are only 14 articles out of
533 published between 1992 to 2006 in which a limited set
of TQM practices has been considered in health care setup.
Talib, Rahman, and Qureshi [25] also reported the similar
results and identified only 15 studies out of 585 studies
where, a very limited set of TQM practices were discussed

2604

ISSN 1013-5316; CODEN: SINTE 8

in a healthcare setup. However, there are some


commonalties in reporting of studies which brings to an
average of 14 studies from these two review articles.
Therefore, there is a need to conduct a comprehensive study
to identify the CSFs of TQM that are best suitable for public
hospitals in Pakistan by keeping in view the importance of
contextual factors in Pakistani hospital settings. There is a
substantial lack of detailed, up to date and comparative
research regarding CSFs of TQM in health care setting. In
addition, there are substantial variations in reported research
between different countries. Present study attempts to bridge
the gap between the national and international literature in
healthcare by introducing appropriate CSFs of TQM for
hospital setting. The paper is structured as follows. First we
briefly
review
prior
research
regarding
TQM
implementation in various setting such as manufacturing,
services, and healthcare. We then suggest CSFs of TQM that
are best suitable in healthcare settings and its
implementation will leads to achieve excellence in health
care services for public and private hospitals, healthcare
bodies, professionals, academicians and make a significant
contribution in national as well as in international literature.
2. LITERATURE REVIEW
TQM has become the most comprehensive approach with
multiple characteristics and dimensions and is termed as a
philosophy, a systematic approach, a management approach
and now it is understood as a management innovation, if not
management revolution[26]. TQM implementation has
progressed through three different ways; by adopting quality
management system i.e. ISO-9001 series of standards [27],
quality awards criteria [28], and TQM practices, tools and
techniques or sometimes termed as CSFs of TQM [29, 30].
Successful implementation of TQM requires to identify
CSFs that are most suitable for continuous improvement in
all areas to increase the success rate of TQM implementation
by supporting prevention methods and cost reduction
techniques [31]. CSFs are set of enablers or variables that
ensure the success for organization as well as managers in
those critical areas of the organization that must require
special and continual attention to gain high performance
[32]. CSFs are those areas in the organizations that needs
attention and need to be addressed to ensure satisfactory
results and competitive organizational performance [33] and
also to gain greatest competitive influence [34]. Wali,
Deshmukh, and Gupta [35] concluded that it can be said
that the CSFs are the selected few primary requirements that
must be present in an organization to attain its vision, and to
be guided towards its vision and success depends on
customer program, stakeholders, people and process.
Saraph, Benson, and Schroeder [36] were the first who
introduced eight TQM practices. Later, numerous studies has
been conducted to examine what constitute TQM, what are
the common barriers for implementing TQM and what
factors are critical for the successful implementation of
TQM [37, 38]. Although these studies have reported
inconsistency in results. However, TQM practices or CSFs
of TQM are not industry specific and it is equally important
for manufacturing as well as for services [39], but there is no
universally accepted TQM framework [38]. TQM and

Sci.int.(Lahore),26(5),2603-2616,2014

business excellence models are widely accepted TQM


framework.
2.1 TQM IN MANUFACTURING
TQM evolution and its success is manufacturing dominant
as its success is recognized by the Japanese manufacturing
industry and later admired by USA in 1980s. Early work on
TQM is developed by quality gurus [40, 41]. Saraph,
Benson, and Schroeder [36] considered as a major
contributor by presenting the eight CSFs of TQM after a
comprehensive review of teachings of quality gurus which
are; role of management, leadership and quality policy, role
of quality department, training, product/service design,
supplier quality management, process management, quality
data and reporting, and employees relations. Thus these
authors laid the foundation of empirical studied in TQM and
further development of literature and this field.
Flynn, Schroeder, and Sakakibara [42] also made a
comprehensive review of literature and came up with 11
CSFs for manufacturing that includes; quality leadership,
quality improvement rewards, process control, feedback,
cleanliness and organization, new product quality, interfunctional design process, selection for teamwork
management, teamwork, customer interaction. Motwani,
Mahmoud, and Rice [43] and Badri, Davis, and Davis [44]
tested Saraph, Benson, and Schroeder [30] instrument in
India and UAE respectively. Powell [45] presented 12 CSFs
based on literature that are; top management leadership,
empowerment, quality policies, quality measurement
system, training, statistical quality control, supplier quality
management, role of quality department, teamwork,
customer satisfaction, communication of information, and
benchmarking. Black, and Porter [46] included Malcom
Baldrige award criteria in their study after comprehensive
review of literature and came up with 10 CSFs i.e. strategic
quality management, customer satisfaction orientation,
people and customer management, communication of
improvement information, external interface management,
improvement measurement systems, corporate quality
culture, supplier partnerships, operational quality
management, teamwork structures for process improvement.
Meanwhile, Ahire, Golhar, and Waller [47] proposed an
instrument considering 12 TQM practices: top management
commitment, supplier quality management, supplier
performance, customer focus, SPC usage, employee
involvement, benchmarking, employee training, product
quality,
employee
empowerment,
design
quality
management, and internal quality information usage. Madu,
Kuei, and Jacob [48], first provided a conceptual model for
CSFs of TQM and organizational performance verified
empirically in manufacturing and services firms. However,
results of their studies present some irrelevance between
manufacturing and service firms about the values of quality
management
activities.
Joseph,
Rajendran,
and
Kamalanabhan [49] developed a measurement using 9
critical dimensions of TQM to evaluate the level of TQM in
Indian organizations and these dimensions are:
organizational commitment, role of the quality department,
product design, training, supplier quality management,

Sci.int.(Lahore),26(5),2603-2616,2014

ISSN 1013-5316; CODEN: SINTE 8

process management, quality data and reporting, human


resource management.
Later studies on TQM have established its linkage with
performance and a vast amount of literature has been
reported on it. Samson, and Terziovski [10] developed an
instrument based on MBNQA criteria and empirically tested
the reliability and validity of the constructs and further
investigated the relationship between these constructs and
operational performance in Australian and New Zealand
manufacturing companies. Zhang, Waszink, and Wijngaard
[50] identified 11 TQM constructs to implement TQM in
Chinese manufacturing companies and determined that this
framework can be implemented in any of the manufacturing
industry and also suggested that researcher can used this
instrument for TQM theory development. Sila, and
Ebrahimpour [51] made an review of TQM studies from
1989 to 2000, and identified 25 TQM construct. Similarly,
many empirical studies have been conducted to establish a
relationship among CSFs of TQM or TQM practices and
various performance measures that provides positive results
[52-54].
2.2 TQM IN SERVICE SECTOR
During the last decade a tremendous growth has been
observed in services sector and service sector is contributing
63.6% GDP of world economy according to international
Monetary Fund (IMF) World Economic Outlook database,
2012 [55]. Majority of the TQM literature is related to
manufacturing sector [56, 57] and later studies verified that
TQM approach is equally relevant to service organizations.
Silvestro [58] made an attempt to transform the
manufacturing dimensions of TQM for service organizations
and reported that majority of these TQM practices for
manufacturing are useful in services. Brah, Wong, and Rao
[59] developed a TQM and performance framework and
include 11 constructs and tested in Singapore service sector.
Sureshchandar, Rajendran, and Anantharaman [39] has
propose a holistic model for Total Quality in Services (TQS)
with 12 dimensions and tested these constructs in Indian
banking industry and analyzed a positive impact on
performance and these dimensions includes; top
management commitment and visionary leadership, human
resource management, technical system, information and
analysis system, benchmarking, continuous improvement,
customer focus, employee satisfaction, union intervention,
social responsibility, servicescapes, service culture.
Later, Saravanan, and Rao [60], and Al-Marri, Ahmed, and
Zairi [61] tested TQS and identified a positive relationship
among TQS and performance measure. Tsang, and Antony
[62] studied service organizations of UK and selected 11
CSFs of TQM identified that customer focus is the most
important whereas, supplier partnership is among the least
important factor. Fotopoulos and Psomas [63] conducted
studies in Greek companies by dividing CSFs of TQM into
soft (quality management principles) and hard (quality tools
and techniques) that provides a significant and positive
relationship among TQM and performance. The relationship
among critical dimensions of TQM and organizational
performance in services have been empirically tested and

2605

validated that CSFs of TQM contribute in enhancing


organizational performance [61, 64].
2.3 TQM IN HEALTH CARE
Like the other sectors of service economy importance of
quality has been recognized quite late in health care sector. It
may be due to the complexity and nature of the services
deliver by the health care institutions. However, quality has
been an integral part of health care service since its
evolution as services here are linked with the life of the
patient. Lin, and Clousing [65] made an exploratory studies
on effectiveness of TQM program in US State of Northern
Louisiana hospitals and explored that hospitals recognize the
importance of TQM but are still in some phase of
implementation of quality management systems. Aly, and
Mark [66] has emphasized that leadership vision,
competency of quality leaders, quality council, physicians
involvement, a clear quality vision and strategy, customer
focus, timely and adequately management training,
education and awareness of all employees, define analyze
and improve processes, and integration of management
system must be in a sequence that are essential critical
dimensions of TQM in hospitals. Klein, Motwani, and Cole
[67] used TQM tools, PDCA approach and continuous
quality improvement at emergency care of Saint Mary
hospital USA and reported that these approaches are
essential in gaining customer satisfaction, time and cost
effectiveness, and employees satisfaction. Yang [7]
identified that there is an urgency for implementation of ISO
series of standards, quality management practices, tools and
techniques, healthcare quality improvement circles, and
continuous quality improvement of process and system at all
level to address the rising issues of healthcare quality.
Mosadegh Rad [68] has examined CSFs of TQM in Iranian
health care settings and Dilber [69] has tested TQM and
performance in Turkish health care settings. Later, Hazilah
[70] empirically tested five TQM practices in Malaysian
hospital settings, and Arasli, and Ahmadeva [71] introduced
10 dimensions for the Cyprus hospitals but they did not
include any TQM practices. Raja, Deshmukh, and Wadhwa
[72],
Manjunath, Metri, and Ramachandran [6] tested
quality awards and Business Excellence Models (BEM)
criteria respectively to measure the performance of health
care institution. Sang, DonHee, and Chang-Yuil [73] tested
high-performance work systems (HPWS) as an instrument to
measure the effects of HPWS on service quality, employee
attitude, customer satisfaction and customer loyalty in
healthcare (public and private hospitals) settings of Korea.
Lee-DonHee [74] identified that quality of healthcare
services is critical for the healthcare institutions and
implementation of quality programs based on quality
standards ISO 9001-2008, Malcolm Baldrige Healthcare
Criteria for Performance (MBHCP), European Foundation
for Quality Management (EFQM), and Joint Commission
Model of Accreditation (JCI) helps hospitals to gain patient
satisfaction and safety and also a source to enter in the
international market to attract the international healthcare
tourism. It is further claimed by the author that quality
control and TQM are most widely used quality programs in
healthcare institutions. In a recent study, Lee, Lee, and

2606

ISSN 1013-5316; CODEN: SINTE 8

Olson [75] used MBHCP criteria as CSFs of TQM in data


analysis of 254 South Korean hospitals and observed that the
seven categories has strong and positive association with
each other.
2.4 QUALITY MANAGEMENT STANDARDS AND
AWARDS
Quality management standards like ISO-9000-2008 series of
standards are among the largest implemented standards
around the globe in almost all the industry. It can be
considered as a first step towards TQM implementation
[76].These quality management standards focuses on
management development and development of operating
procedures to ensure consistency in production/operations
that ultimately helps to ensure the services and product
delivery that meet and exceed customer stated and implied
requirements [77]. Colton [78] stated that healthcare
managers observed that quality management standards help
to improve the operational efficiency, services delivery and
cooperation among the departments as. Eight quality
management principles includes: customer focus, leadership,
involvement of people, process approach, system approach
to management, continual improvement, factual approach to
decision making, mutually beneficial supplier relationships.
TQM and BEMs are widely used quality management
framework to increase performance and excellence in
business. Numerous studies had empirically verified that
enablers of this model significantly contribute in achieving
quality and performance results [53]. Curkovic [79], also
agreed that MBNQA successfully addresses the major
dimensions of TQM envisioned by the quality Gurus. An
MBNQA [80] criterion for performance excellence consists
of seven items: leadership, strategic planning, customer
focus, measurement analysis and knowledge management,
workforce focus, operational focus, and results (products and
process, customer focus, workforce focused, leadership and
governance, financial and market results).
European Foundation for Quality Management (EFQM) was
established in 1991 and EFQM is also used as a framework
for quality performance measurement and this models has
been adopted in many countries around the globe [81]. This
model is considered as a valid representation of TQM in
European context [82, 83] and can be considered as
framework for TQM implementation [81]. The main
criterion according to European Foundation for Quality
Management (EFQM) [84] consists of nine performance
indicators from which five enablers and four result
indicators: leadership, strategy, people , partnerships &
resources, processes, products & services, result indicators
(customer, people, society, and business results).
JCI was established in 1997 in order to measure the standard
based evaluation of healthcare institution around the world
to improve patient quality of healthcare services, and patient
safety related issues. JCI standards are based on consensus
based standards in order to assess the operations and
management in all aspects of hospitals [85]. JCI (2008)
accreditation standards for hospitals are divided into two
broad categories as: patient-centered standards ( access to
care and continuity of care, patient and family rights,
assessment of patients, care of patients, anesthesia and

Sci.int.(Lahore),26(5),2603-2616,2014

surgical care, medication management and use), health care


organization
and
management
standards
(quality
improvement and patient safety, prevention and control of
infections, governance, leadership, and direction, facility
management and safety, staff qualifications and education,
and management of communication and information).
Like the quality models, MBNQA, EFQM, JCI, and ISO
series of standards, Malcolm Baldrige Healthcare Criteria
for Performance (MBHCP) is specifically used to measure
the information and data available at hospital, and quality
results based on providing healthcare services to patients
through quality management activities provided by
organizational support [86]. MBHCP was introduced in
USA in 1995 based on MBNQA as a pilot program to
measure the quality and performance of the healthcare
institution. MBHCP is evaluated and updated every year by
keeping in view the changing global environment [75].
MBHCP award is considered to be the most prestigious
awards for organizational performance of healthcare around
the globe [87]. It also follows the MBNQA criteria for
assessment.
Thus keeping in view the above discussed review on
literature, this study analyzes that CSFs of TQM are not
industry specific and it may be implemented across any type
of services sector. However, core CSFs of TQM can easily
be identified from the above review of literature, which are
the integral part of all studies either it is in manufacturing,
services, healthcare or quality awards or models and ISO
series of standards and these are CSFs includes; top
management commitment and leadership role, human
resource focus, customer focus, improvement of processes
by adopting best techniques it may involve benchmarking,
improvement in product and service design, develop to
record, maintain, analyzes data using statistical methods and
then utilizes these results to make improvement at all levels,
development of suppliers, and finally achieve organizational
goals and objectives through a continual improvement
process at all levels.
2.5 HEALTH CARE SYSTEM IN PAKISTAN
With the rapid growth in Pakistan population exceeding by
184.2 million people and indeed it is a great challenge for
government to make reasonable efforts and concurrent
planning for the development of healthcare system for its
citizen. According to Economic Survey of Pakistan (20122013), government allocates only 0.35 percent of its entire
GDP on health care expenditures. At present there are 1,207
hospital, 5,382 dispensaries, 5,404 basic healthcare units,
and 696 maternity and child care units in the country.
Majority of the public and private hospitals are located in
urban areas and especially, in main cities of Pakistan.
Therefore, the people living in rural areas are deprived off to
avail the normal healthcare facilities and have to travel long
distances to avail the healthcare facilities. In short, the
available healthcare system is inadequate, inefficient, and
underfunded. More efforts by government need to be done in
order to enhance the health indicator in the country. Table 1
provides a snapshot of shortage healthcare workers and
facilities in Pakistan for 184.4 million people of Pakistan.
The statistics of these recent four years also suggest that due

Sci.int.(Lahore),26(5),2603-2616,2014

2607

ISSN 1013-5316; CODEN: SINTE 8

to rapid growth in population, the demand for both


healthcare workers and the facilities (e.g., the number of
person per bed/doctor/nurse) is also increasing each year.
Still no significant efforts or planning at government level is
visible for further development of healthcare sector
especially public hospitals.
These authors further conclude that healthcare reforms
require quick initiative and immediate attention to address of
various domains of healthcare system [88]. This include:
health financing imperatives, governance imperatives,
service delivery imperatives, human resources imperatives,
health information imperatives, medicines and technology
imperatives, and information communication technology
imperatives.

this a total of 593 articles were downloaded and after a


careful selection only 134 articles were selected and a
check sheet was developed to record the TQM practices
used in selected articles. This study has identified
application of TQM in all sectors of economy, 71 selected
articles were from manufacturing sector, 28 from service
sector, 20 studies from health care, and 16 studies tested
TQM in both manufacturing and service sector as given in
the Figure 3.

Figure 3: TQM Practices across Industry

Nishtar [88] provided a snapshot of current healthcare


system in Pakistan and it is shown in the Figure 1.

3 RESEARCH METHODOLOGY
Main aim of this study is to identify the CSFs of TQM in
health care keeping in view, the contextual factors of
Pakistani working environment, organizational structures,
and organizational culture. First step is to identify the
appropriate research articles for this study, we used
academic journals and databases like; Science Direct and
Scopus, Taylor Francis, EBSCO Host, Emerald, Willey on
line library, and Google Scholars. For specific articles we
used phrases, Critical Success Factors for TQM, TQM
implementation, Instrument for TQM implementation,
CSFs
of
TQM,
TQM
in
health
care/manufacturing/services, and TQM practices. After
a detailed review of articles only those articles were
selected where, TQM CSFs or TQM practices were
discussed and tested either theoretical or empirically and
selection process is given in the Figure 2.
To avoid duplication of the selected articles, researchers
import references into reference manager Endnote X7. For

Selection of the construct under relevant category was


another complex task because majority of the TQM
construct were used with different captions and there was a
slight difference in some items of these constructs but core
concept was almost same. Therefore, researchers of this
study have selected the relevant construct under one
caption and details of some of the major constructs are
given in the Table 2.
The data recorded for this study identify more than 100
CSFs of TQM and majority of the practices are the
subcategories of some main categories meaning that with
different captions but presenting the core concept of the
major construct as discussed in the Table 1, and therefore
this study includes 35 CSFs of TQM representing the
broader categories of CSFs of TQM. However, the
construct which were rarely used and not representing the
TQM philosophy were rejected. The total frequency of
occurrence was 876 [89] and final list of these 35 TQM
practices with frequency, percent frequency, and percent
cumulative frequency of each of the TQM practices are
shown in the Table 3.
Frequency of occurrence of each TQM practices is
presented in the Figure 4.
Researchers also made industry specific analysis of CSFs
of TQM as given in Figure 5.
Pareto analysis is one of the important quality tools that
helps us in decision making and is employed to identify the
vital few and useful many items. It ranks the data
classification in descending order by placing the highest
frequency of occurrence to lowest frequency of occurrence
and the total frequency is considered to be 100%. It works
on famous Pareto principle (80/20) i.e. vital few items are
representing the 80% of cumulative frequency of the data
and useful many items occupy the remaining 20%

2608

ISSN 1013-5316; CODEN: SINTE 8

Labels
Top Management
Commitment and
Leadership role
Human Resource
Focus
Quality Data and
Reporting

Customer Focus

Process management

Supplier Quality
Management
Product /Service
quality Design
Continuous quality
improvement
Strategic quality
planning
Benchmarking
Quality management
system

Sci.int.(Lahore),26(5),2603-2616,2014

Table 2: TQM Practices with Different Captions


Captions
top management commitment and visionary leadership, role of top management, visionary leadership, leadership
and policy, top management implication, executive commitment, quality leadership, top management leadership,
top executive support, top management philosophy, senior executive involvement, leadership and support from top
management, top management commitment
employee relations, workforce management, human resource management, human resource focus, hiring and
selection, employees empowerment and involvement, rewards and recognition, training, teamwork, quality teams,
workforce management, employee participation, quality circles, employee focus, employee satisfaction
quality data, quality data and reporting, process measurement, quality measurement, information and analysis,
measurement and feedback, quality improvement measurement systems, quality information availability, and
quality information usage, quality measurement, quality improvement measurement systems, work information
sharing, measurement analysis and knowledge
customer focus, customer focus and satisfaction, customer analysis, close cooperation with customers, customer
service, customer orientation, customer satisfaction orientation, customer feedback, customer and market focus,
customer relationship, customer satisfaction orientation, customer involvement, closeness to customers
process management, management of process quality, quality of product, process and service, processes, internal
process management, external process management, systems and processes, process improvement, process
assurance system, process control management, process improvement, process control management, process
control, process quality management, process quality, management process
supplier quality management, supplier relationship, supplier quality involvement, supplier quality, supplier
management, supplier relationship management, supplier satisfaction, supplier involvement, supplier performance,
suppliers cooperation, supplier quality assurance
product design, service design, design management, design and development of new products, product or service
design process
continuous improvement, continuous support, continuous process improvement
quality strategy, strategy and innovation, strategic quality planning, strategic integration, policy and strategy,
strategy for TQM, operational quality planning, strategic quality management, and quality goals and policy
benchmarking, competitive benchmarking, benchmarking on quality and service, benchmarking and quality
measurement
quality systems, role of quality department, quality assurance, quality control, quality councils, quality monitoring,
quality policy, mission statement, quality focus

Figure 4: Most Frequently used TQM Practices

Fig. 5

Sci.int.(Lahore),26(5),2603-2616,2014

Labels

1.
2.
3.
4.
5.

TMC
HRF
QDR
CSF
PRM

6.

SQM

7.

CIM

8.
9.
10.
11.

SDG
SQP
BEN
QCL

12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.

QMS
COM
SPC
SRP
CUL
RCM
JIT
SER
TCM
CQL
TSY
ZDF
FLX
COP
OPQ
OBH
QCR
IPT

30.
31.
32.
33.

EIM
DCM
DSI
SRM

34. OPS
35. STF

ISSN 1013-5316; CODEN: SINTE 8

2609

Table 3: TQM Practices in Manufacturing, Services and Healthcare


TQM Practices
Frequency
%
%Cumulative Frequency
Frequency
Top Management
Commitment
127
14.481
14.481
Human Resource Focus
129
14.709
29.19
Quality Data and Reporting
94
12.657
41.847
Customer Focus
111
10.718
52.566
Process Management
84
9.578
62.144
Supplier Quality
Management
66
7.526
69.669
Continuous Quality
Improvement
39
4.561
74.23
Product /Service Quality
Design
36
4.105
78.335
Strategic Quality Planning
35
3.991
82.326
Benchmarking
30
3.535
85.861
Quality Culture
13
3.421
89.282
Quality Management
System
31
1.482
90.764
Communication
9
1.026
91.79
SPC Usage
9
1.026
92.816
Social Responsibility
8
0.912
93.729
Cultural Change
6
0.684
94.413
Resource Management
6
0.684
95.097
Just In Time
5
0.570
95.667
Servicescapes
3
0.456
96.123
Technical Competencies
4
0.456
96.579
Cost Of Quality
4
0.342
96.921
Technical System
3
0.342
97.263
Zero Defect
3
0.342
97.605
Flexibility
3
0.342
97.948
Cooperation
2
0.342
98.29
Operational QM
2
0.228
98.518
Organizational Behavior
2
0.228
98.746
Quality Circles
2
0.228
98.974
Improvement Tools
2
0.228
99.202
External Interface
Management
3
0.228
99.43
Design Of Conformance
1
0.114
99.544
Design Instrument
1
0.114
99.658
Service Marketing
1
0.114
99.772
Operational Support
System
1
0.114
99.886
Stakeholder Focus
1
0.114
100

cumulative frequency of the data. Results of Pareto analysis


and their descriptions are reported in Figure 6.
4. RESULTS AND DISCUSSION
Results of the analysis shows that top management
commitment, human resource focus, quality data and
reporting, customer focus, process management, supplier
quality management, continuous improvement, product or
service design, strategic quality planning, quality
management system, and benchmarking are most
frequently used in the literature. Thus these practices may
be considered as core practices, and applicable and
acceptable in all type of industry. As there is no exhaustive
research work in health care due to its late acceptance in
health care like the other service sectors. There seems to
dearth to develop a holistic model for TQM from
management perspective particularly in hospital settings.
Thus this studies proposed 9 CSFs of TQM mainly based
on literature derived from [59, 30, 39]. For this study, we

included 9 CSFs of TQM for healthcare; top management


commitment and leadership role, human resource focus,
supplier quality management, strategic quality planning,
patient focus, process management, quality data and
reporting, continuous improvement, and servicescapes.
Reliability and validity of the proposed constructs has been
empirically verified in various studies. It has also been
observed in the literature that all these factors significantly
contributes in increasing financial as well as non-financial
performance of the organizations.
5. DISCUSSION AND CONCLUSION
In this paper, we have addressed the identification of the
critical dimensions of TQM in healthcare sector. To explore
this issue in depth, we have further investigated TQM in
manufacturing, service and healthcare settings. Key
dimensions of TQM in healthcare specifically for public
and private hospitals in Pakistan has been identified after a

2610

ISSN 1013-5316; CODEN: SINTE 8

Fig. 2

Fig. 6
comprehensive review of literature and these dimensions
are best fit in the context of Pakistani public as well as
private hospitals. The model developed in this paper
provides a promising theoretical perspective to explore
CSFs of TQM in Pakistani health care sector. We have
attempted to tie various literature reviews and research
regarding on TQM and CSFs together to identify the CSFs
in healthcare setting. Ultimately, we believe that nine CSFs
which are considered as core CSFs of TQM and provides a
guarantee for its success provided the barriers and obstacles
discussed in literature should be addressed first.
5.1 Top Management Commitment and Leadership
Role
Role of top management is the foremost important and
considered as a fist enabler in TQM implementation in any
organization. The key challenge for the top management is
to effectively manage the relationships among companys
vision, mission, strategies, quality values, and to make a
clear understanding among the employee. Any strategic

Sci.int.(Lahore),26(5),2603-2616,2014

movement is likely to be fail without positive commitment


of the top management [90]. Top management has to
perform certain roles, provision of resources, developing
quality policy, setting quality goals, quality trainings, and
motivation for improvement efforts [91]. In healthcare
setup, top management role is more crucial as compare to
the other service environment and is responsible for quality
of care and overall hospital system [86, 92]. TQM
practitioners and researchers have recognized the
importance of top management role in driving
companywide quality management efforts and also a major
factor for successful achievement of quality performance
[40, 93, 94]. Leadership at all levels in the organization has
to set quality goals, develop system that guide and pursuit
for organizational performance through a continuous
quality improvement process [95, 63]. Physician, surgeons,
pharmacists, and other healthcare professionals in a
leading role are effective in implementation process and
also have to encourage their subordinates to contributes in
its success [72, 96].
5.2 HUMAN RESOURCE FOCUS
Core concept of TQM is strictly focuses on employee
participation, empowerment, training and education,
teamwork, and reward and recognition as advocated by all
the quality gurus [like; 97, 40]. Thus employees are now
recognized as valuable asset and effective management of a
human resources leads to gain sustainable competitive
advantage. A strong linkage between these practices and
organizational performance outcome has been verified in
numerous studies. Instead of looking at the impact of single
HR practice, our model suggests that the HR practices
needed to be bundle into meaning group of practices. This
study propose that it is not practice per se that make the
different but the degree to which they align with each other
to create meaningful of bundle of practice [98]. This study
assumes that the presence of strong HRM system may bring
a better impact on TQM success. HRM may be additive
and synergistic whereas, single HRM practice may not
deliver the similar effect. Thus this study includes; training
and education, employee involvement and empowerment,
rewards and recognition system has been considered in this
construct. All these practices are representing the soft
dimensions of TQM and TQM cannot be achieved by
proper addressing the soft aspects of TQM [99, 100].
5.3 PATIENT FOCUS
Major reasons to implement best strategies and deliver high
quality of product or services is to gain customer
satisfaction. the key component that should be properly
address to get success in the market, gain financial benefits,
competitive edge and better market orientation. Customer
focus can be defined as the degree to which an organization
understand the needs and wants of the customer proactively
and gain their satisfaction through continuous quality
improvement of the product/service deliver to them [39,
101]. Deming [40] argued that organizations must
understand customer needs and current and future wishes,
so that designed product or services meet customer
satisfaction level. Successful companies always put
customer needs first before any decision making [102].

Sci.int.(Lahore),26(5),2603-2616,2014

ISSN 1013-5316; CODEN: SINTE 8

Flynn, Schroeder, and Sakakibara [103] suggested that


customer should be involved at all level in designing phase
and process development which will help to reduce error
level when full production begins. Timely response to
customer requirements is the major factor to gain
competitiveness [104] and employee quick response to
customer complaints causes to improve service quality
[105]. In healthcare setup customers are patients and
majority of them have a sound knowledge and information
before availing any healthcare services and to avail best
services they are ready to travel long distances [106]
because every patient needs sound diagnostics, consultation
of best doctor and best specialized treatment and care [72].
In many countries, healthcare sector have become an
industry and healthcare institutions has developed their
systems to offer specialized healthcare services to attract
the healthcare tourist and local patient and start addressing
patient needs while designing their healthcare facilities.
5.4 CONTINUOUS IMPROVEMENT
Development of TQM field is incremental not exhaustive,
and it has developed over a time starting from inspection to
TQM and continuously developed using continuous quality
improvement as an important driver and contributes in
business excellence [107]. Continuous improvement is also
among the core concept of TQM as advocated by all the
quality gurus. It is most important enabler to increase
productivity [108] and there exist a positive relationship
between continuous improvement and productivity [109].
Continuous improvement is not one time activity but it is
an ongoing process. In hospitals, due to complexities of
diseases and changing pattern of diseases, it requires most
advance equipment, technical system, methods that helps in
right diagnostics and also continuously updating the
knowledge and skill of all involved human resource. It is a
consider as a dynamic process that focuses on improvement
and it build relationship with other elements and also
effects the organization environment [110]. Therefore,
hospitals needs to have continuously monitor and upgrade
knowledge base of its people as well as infrastructure for
delivering quality of healthcare services to the patients to
gain their delight.
5.5 QUALITY DATA AND REPORTING
Quality data and reporting is as a part of information and
analysis system and in TQM literature these terms are used
alternatively. It involves costs of poor quality because of
scarps, reworks, and due to warranty costs and this
information is further analyze using quality tools control
charts to identify the potential and minor problems and it
also provides us feedback on possible improvement [111,
112]. Quality of data is most crucial element in effective
decision making and designing customer focused services.
It contains customer feedback for improvement, detailed
information about services delivered and also influence the
firm performance throughout the product/service life cycle
and has a positive effect on product or service design,
process management and supplier quality management
[113].
Proper reporting and storing data helps to measure the
supplier performance and work as a data base in the

2611

organization. It is also important that it must be accessible


to the assigned managers or staff that provides them an
opportunity to make best decision and also a tool to
increase material quality, reduction in costs, identification
key problematic areas and also helpful in supplier
development [114]. Therefore, availability of accurate data
and maintaining a databases can accurately identify the
different measurements like; percent part rejection, process
capability ratios, amount of scrap, cost of warranties and
reliability [115]. Monitoring the material and all inputs and
throughputs can be easily measured and monitored. In
hospital context this factor requires more importance as
investigation in right diagnostics; doctors need accurate
data regarding lab reports, previous medical examinations,
reports, and patient history. It also allows us to record and
report errors, cost of quality, defects in order to improve the
quality of services.
5.6 PROCESS MANAGEMENT
Process management is a systematic approach of managing
all the organizational resources efficiently and effective in a
systematic way to achieve organizational performance
objectives [116, 117]. Elusive management of all the major
business processes is essential for the successful
implementation of TQM to improve quality and
performance in the organization [39]. In health care setup it
is of more critical in nature due to the health care service
environment because hospitals are delivering both the
tangible and intangible services. Service delivery processes
should be comprehensive in order to deliver error free
services to the customers [39]. Thus key aspect of this
construct requires carefully focus on service design and
benchmark best practices, processes, and system that helps
the hospitals to deliver best quality, error free, focuses on
patient safety, efficient methods of hospital waste disposal,
and a healthy, hygienic environment to the patient and their
families. Thus process management addresses and meeting
the patient perceptions and expectations during a treatment
process and final outcome of the treatment process [118].
5.7 SUPPLIER QUALITY MANAGEMENT
Supplier quality improvement, supplier development and a
comprehensive measurement and evaluation system is an
integral part of quality implementation and over all service
improvement. In health care set up suppliers includes, the
equipment manufacturers, pharmaceutical companies and
the medical universities providing valuable human
resources to the hospitals. Thus, in health care setup
hospitals and health care agencies needs to look this issue
more critically as it is linked with the human life. Thus
strategies should be developed and communicate to the
suppliers and comprehensive system is required to measure
their performance at regular intervals.
5.8 STRATEGIC QUALITY PLANNING
All quality improvement efforts in the organizations are
strongly depending upon the organizational strategic
quality plans. Thus it requires a strong commitment of
management and leadership at all levels for its future
quality vision and initiatives taken towards internal and
external
customer
satisfaction,
supplier
quality
improvement efforts, and its benefits to the community.

2612

ISSN 1013-5316; CODEN: SINTE 8

Thus strategic quality planning process should be


embedded with the quality planning of all processes [119].
5.9 SERVICES FOCUS
Service quality is quite complex phenomenon as majority of
the services are intangible in nature. Customer has to buy the
services first and then he is able to percieve its quality. In
health care setup, customer (patient) are receiving both
intagible (diagnostics) and tangibles (surgical procedures)
services. Thus hosptials have to focus on tangibles as well
intangibles at the same time. In service sector physical
enviornment is of most importance because it influences the
behaviors and also create an image of the organization [39].
Thus in hospitals tangibles includes machinery and
equipment, hygene conditions in the hospital as well as in
the wards, sitting areas, standarized laboartories,
pharmacies, canteens, well equiped operation theators etc.
Other than this, highly qualified surgions, phycians, and
other supporting staff also influences the patient behaviors
as it creat assurance among them. Johnston [120] suggested
that service organizations must deliver promised services,
provides persoanl touch, proactive approach to resolve
customer issues and problems, and try to provides comfort in
service beyond their expectation is a way to gain customer
delight. Thus a careful addresses these factors leads to gian
excellence in healh care services.
In conclusion, these CSFs of TQM we have suggested
provides an underlying mechanism to boost the operational
and organizations performance of health care sector and thus
leading to excellence in health care services in Pakistan.
More broadly, CSFs of TQM discussed in this paper will
direct future research towards the development of TQM and
performance model for the health care sector in Pakistan to
deepen our understanding of TQM.

7.

8.

9.

10.

11.

12.

13.
14.

15.

16.

17.
REFERENCES
1. Lee, A.W. Ng, and K. Zhang, The quest to improve
Chinese healthcare: some fundamental issues.
International Journal of Health Care Quality
Assurance. 20(5): p. 416-428, 2007.
2. Mosadegh Rad, A survey of total quality management
in Iran: barriers to successful implementation in health
care organizations. Leadership in Health Services.
18(3): p. 12-34, 2005.
3. Koeck, C. and V. Kazandjian, Doing better: a global
medical interest. The Effectiveness of CQI in Health
Care: Stories from a Global Perspective, ASQC
Quality Press, Milwaukee, WI. 1997.
4. Mosadegh Rad, The impact of organizational culture
on the successful implementation of total quality
management. The TQM Magazine. 18 (6): p. 606-625,
2006.
5. Short, P. and Rahim, Total quality management in
hospitals. Total Quality Management. 6(3): p. 255-264,
1995.
6. Manjunath, U., B.A. Metri, and S. Ramachandran,
Quality management in a healthcare organisation: a
case of South Indian hospital. The TQM Magazine.
19(2): p. 129-139, 2007.

18.

19.

20.

21.

22.

23.

Sci.int.(Lahore),26(5),2603-2616,2014

Yang, The establishment of a TQM system for the


health care industry. The TQM Magazine. 15(2): p. 93
98, 2003.
Prajogo and Sohal, TQM and innovation: a literature
review and research framework. Technovation. 21(9):
p. 539-558, 2001.
Psychogios, A.G. and C.V. Priporas, Understanding
total quality management in context: qualitative
research on managers awareness of TQM aspects in
the Greek service industry. The Qualitative Report.
12(1): p. 40-66, 2007.
Samson and Terziovski, The relationship between total
quality management practices and operational
performance. Journal of operations management.
17(4): p. 393-409, 1999.
Ooi, K.B., et al., Does TQM influence employees' job
satisfaction? An empirical case analysis. International
Journal of Quality & Reliability Management. 24(1): p.
62-77, 2007.
Palo, S. and N. Padhi, Measuring effectiveness of
TQM training: an Indian study. International Journal
of Training and Development. 7(3): p. 203-216, 2003.
Garvin, D.A., What does product quality really mean?.
Sloan Management. 1984.
Lam, S.S.K., Quality management and job satisfaction:
an empirical study. International Journal of Quality &
Reliability Management. 12(4): p. 72-78, 1995.
Redman, T. and B.P. Mathews, Service quality and
human resource management: A review and research
agenda. Personnel Review. 27(1): p. 57-77, 1998.
Agus, Reducing the effects of multicollinearity through
principle component analysis: a study on TQM
practices. Malaysian Management Review. 35(1): p.
43-50, 2000.
Ljungstrom, M. and B. Klefsjo, Implementation
obstacles for a work-development-oriented TQM
strategy. Total Quality Management. 13(5): p. 621-634,
2002.
Brah, S.A., J.L. Wong, and B.M. Rao, TQM and
business performance in the service sector: a Singapore
study. International Journal of Operations &
Production Management. 20(11): p. 1293-1312, 2000.
Huq, Z., Managing change: a barrier to TQM
implementation in service industries. Managing
Service Quality. 15(5): p. 452-469, 2005.
Shortell, S.M., et al., Assessing the impact of
continuous
quality
improvement/total
quality
management: concept versus implementation. Health
services research. 30(2): p. 377, 1995.
Yasin, M.M., et al., TQM practices in service
organizations: an exploratory study into the
implementation, outcome and effectiveness. Managing
Service Quality. 14(5): p. 377-389, 2004.
Samat, Ramayah, and N.M. Saad, TQM practices,
service quality, and market orientation: Some empirical
evidence from a developing country. Management
Research News. 29(11): p. 713-728, 2006.
Huq and Stolen, Total quality management contrasts in
manufacturing and service industries. International

Sci.int.(Lahore),26(5),2603-2616,2014

24.

25.

26.

27.

28.

29.

30.

31.

32.

33.

34.

35.

36.

37.

38.

ISSN 1013-5316; CODEN: SINTE 8

Journal of Quality & Reliability Management. 15(2): p.


138-161, 1998.
Wardhani, V., et al., Determinants of quality
management systems implementation in hospitals.
Health Policy. 89(3): p. 239-251, 2009.
Talib, Rahman, and Qureshi, Assessing the awareness
of total quality management in Indian service
industries: An empirical investigation. Asian Journal
on Quality. 12(3): p. 228-243, 2011.
Dahlgaard-Park, S.M., et al., Diagnosing and
prognosticating the quality movementa review on the
25 years quality literature (19872011). Total Quality
Management & Business Excellence. 24(1-2): p. 1-18,
2013.
Dasarathan Thandapani, et al., Quality models in
industrial and engineering educational scenarios: a
view from literature. The TQM Journal. 24(2): p. 155166, 2012.
Dimara, E., et al., Strategic orientation and financial
performance of firms implementing ISO 9000.
International Journal of Quality & Reliability
Management. 21(1): p. 72-89, 2004.
Salaheldin, Critical success factors for TQM
implementation and their impact on performance of
SMEs. International journal of productivity and
performance management. 58(3): p. 215-237, 2009.
Saraph, J.V., P.G. Benson, and R.G. Schroeder, An
instrument for measuring the critical factors of quality
management. decision Sciences. 20(4): p. 810-829,
1989.
Nwabueze, U., Chief executives hear themselves:
leadership requirements for 5-S/TQM implementation
in healthcare. Managerial Auditing Journal. 16(7): p.
406-410, 2001.
Boynton, A. and R. Zmud, An assessment of critical
success factors. Sloan Management Review (pre-1986).
25(4): p. 17-27, 1984.
Joyce, P., R. Green, and G. Winch, A new construct for
visualising and designing e-fulfilment systems for
quality healthcare delivery. The TQM Magazine. 18(6):
p. 638-651, 2006.
Horng, C. and F. Huarng, TQM adoption by hospitals
in Taiwan. Total Quality Management. 13(4): p. 441463, 2002.
Wali, A.A., S. Deshmukh, and A. Gupta, Critical
success factors of TQM: a select study of Indian
organizations. Production Planning & Control. 14(1):
p. 3-14, 2003.
Saraph, Benson, and Schroeder, An instrument for
measuring the critical factors of quality management.
decision Sciences. 20(4): p. 810-829, 1989.
Sila, Examining the effects of contextual factors on
TQM and performance through the lens of
organizational theories: an empirical study. Journal of
operations management. 25(1): p. 83-109, 2007.
Yusof, S.R.M. and E.M. Aspinwall, Critical success
factors in small and medium enterprises: survey results.
Total Quality Management. 11(4-6): p. 448-462, 2000.

2613

39. Sureshchandar, Rajendran, and Anantharaman, A


holistic model for total quality service. International
Journal of Service Industry Management. 12(4): p.
378-412, 2001.
40. Deming, W.E., Out of the crisis, Massachusetts
Institute of Technology. Center for Advanced
Engineering Study, Cambridge, MA. p. 510, 1986.
41. Juran, Universal Approach to Managing for Quallity:
The Quality Trilogy. 1986.
42. Flynn, B.B., R.G. Schroeder, and S. Sakakibara, A
framework for quality management research and an
associated measurement instrument. Journal of
Operations Management. 11(4): p. 339-366, 1994.
43. Motwani, E. Mahmoud, and G. Rice, Quality Practices
of Indian Organizations:: An Empirical Analysis.
International Journal of Quality & Reliability
Management. 11(1): p. 38-52, 1994.
44. Badri, M.A., D. Davis, and D. Davis, A study of
measuring the critical factors of quality management.
International Journal of Quality & Reliability
Management. 12(2): p. 36-53, 1995.
45. Powell, T.C., Total quality management as competitive
advantage: a review and empirical study. Strategic
management journal. 16(1): p. 15-37, 1995.
46. Black, S.A. and L.J. Porter, Identification of the
Critical Factors of TQM*. decision Sciences. 27(1): p.
1-21, 1996.
47. Ahire, Golhar, and Waller, Development and validation
of TQM implementation constructs. decision Sciences.
27(1): p. 23-56, 1996.
48. Madu, Kuei, and Jacob, An empirical assessment of the
influence of quality dimensions on organizational
performance. International Journal of Production
Research. 34(7): p. 1943-1962, 1996.
49. Joseph, Rajendran, and Kamalanabhan, An instrument
for
measuring
total
quality
management
implementation in manufacturing-based business units
in India. International Journal of Production Research.
37(10): p. 2201-2215, 1999.
50. Zhang, Waszink, and Wijngaard, An instrument for
measuring TQM implementation for Chinese
manufacturing companies. International Journal of
Quality & Reliability Management. 17(7): p. 730-755,
2000.
51. Sila and Ebrahimpour, An investigation of the total
quality management survey based research published
between 1989 and 2000: A literature review.
International Journal of Quality & Reliability
Management. 19(7): p. 902-970, 2002.
52. Hendricks and Singhal, Firm characteristics, total
quality management, and financial performance.
Journal of operations management. 19(3): p. 269-285,
2001.
53. Prajogo and Hong, The effect of TQM on performance
in R&D environments: A perspective from South
Korean firms. Technovation. 28(12): p. 855-863, 2008.
54. Rahman, A comparative study of TQM practice and
organisational performance of SMEs with and without
ISO 9000 certification. International Journal of

2614

55.

56.

57.

58.

59.

60.

61.

62.

63.

64.

65.

66.

67.

68.
69.

ISSN 1013-5316; CODEN: SINTE 8

Quality & Reliability Management. 18(1): p. 35-49,


2001.
Irfan and Kee, Critical Success Factors of TQM and its
Impact on Increased Service Quality: A Case from
Service Sector of Pakistan. Middle-East Journal of
Scientific Research. 15(1): p. 61-74, 2013.
Agus and Abdullah, The mediating effect of customer
satisfaction on TQM practices and financial
performance. Singapore Management Review. 22(2): p.
55-73, 2000.
Ljungstrom and Klefsjo, Implementation obstacles for
a work-development-oriented TQM strategy. Total
Quality Management. 13(5): p. 621-634, 2002.
Silvestro, R., The manufacturing TQM and service
quality literatures: synergistic or conflicting
paradigms? International Journal of Quality &
Reliability Management. 15(3): p. 303-328, 1998.
Brah, Wong, and Rao, TQM and business performance
in the service sector: a Singapore study. International
Journal of Operations & Production Management.
20(11): p. 1293-1312, 2000.
Saravanan, R. and K. Rao, The impact of total quality
service age on quality and operational performance: an
empirical study. The TQM Magazine. 19(3): p. 197205, 2007.
Al-Marri, Ahmed, and Zairi, Excellence in service: an
empirical study of the UAE banking sector.
International Journal of Quality & Reliability
Management. 24(2): p. 164-176, 2007.
Tsang and Antony, Total quality management in UK
service organisations: some key findings from a
survey. Managing Service Quality. 11(2): p. 132-141,
2001.
Fotopoulos, C.V. and E.L. Psomas, The structural
relationships between TQM factors and organizational
performance. The TQM Journal. 22(5): p. 539-552,
2010.
Sureshchandar, Rajendran, and Anantharaman,
Customer perceptions of service quality in the banking
sector of a developing economy: a critical analysis.
International Journal of Bank Marketing. 21(5): p.
233-242, 2003.
Lin and J. Clousing, Total quality management in
health care: a survey of current practices. Total Quality
Management. 6(1): p. 69-78, 1995.
Aly, N.A. and R. Mark, TQM implementation in
hospitals. Computers & industrial engineering. 25(1):
p. 299-302, 1993.
Klein, D., J. Motwani, and B. Cole, Quality
improvement efforts at St Marys Hospital: a case
study. Managing Service Quality. 8(4): p. 235-240,
1998.
Mosadegh Rad, The Principles of Health Care
Administration. 2003: Dibagran Tehran,Tehran.
Dilber, M., et al., Critical factors of total quality
management and its effect on performance in health
care industry: a Turkish experience. Problems and
Perspectives in Management. 4: p. 220-234, 2005.

Sci.int.(Lahore),26(5),2603-2616,2014

70. Hazilah, N., Practice follows structure: QM in


Malaysian public hospitals. Measuring Business
Excellence. 13(1): p. 23-33, 2009.
71. Arasli and Ahmadeva, No more tears! A local TQM
formula for health promotion. International Journal of
Health Care Quality Assurance. 17(3): p. 135-145,
2004.
72. Raja, M.P.N., S. Deshmukh, and S. Wadhwa, Quality
award dimensions: a strategic instrument for measuring
health service quality. International Journal of Health
Care Quality Assurance. 20(5): p. 363-378, 2007.
73. Sang, DonHee, and Chang-Yuil, The impact of highperformance work systems in the health-care industry:
employee reactions, service quality, customer
satisfaction, and customer loyalty. The Service
Industries Journal. 32(1): p. 17-36, 2012.
74. Lee-DonHee, Implementation of quality programs in
health care organizations. Service Business. 6(3): p.
387-404, 2012.
75. Lee, D. Lee, and D.L. Olson, Health-care quality
management using the MBHCP excellence model.
Total Quality Management & Business Excellence.
24(1-2): p. 119-137, 2013.
76. Irfan, et al., Improving Operational Performance of
Public Hospital in Pakistan: A TQM Based Approach.
World Applied Sciences Journal. 19(6): p. 904-913,
2012.
77. Evans and Lindsay, Managing for quality and
performance excellence. 2009: South-Western Cengage
Learning, Mason.
78. Colton, D., Quality improvement in health care:
conceptual and historical foundations. Eval Health
Prof. 23(1): p. 7-42, 2000.
79. Curkovic, S., et al., Validating the Malcolm Baldrige
National Quality Award framework through structural
equation modelling. International Journal of
Production Research. 38(4): p. 765-791, 2000.
80. MBNQA. 2013-2014.
81. Bou-Llusar, J.C., et al., An empirical assessment of the
EFQM Excellence Model: Evaluation as a TQM
framework relative to the MBNQA Model. Journal of
Operations Management. 27(1): p. 1-22, 2009.
82. Eskildsen, J.K., Identifying the vital few using the
European Foundation for Quality Management Model.
1998.
83. Westlund, A.H., Measuring environmental impact on
society in the EFQM system. Total Quality
Management. 12(1): p. 125-135, 2001.
84. European Foundation for Quality Management
(EFQM). European Foundation for Quality
Management. 2013.
85. JCI, Improving quality and patient safety around the
globe., Joint Commission International, Oakbrook
Terrace, 2008.
86. Meyer, S.M. and D.A. Collier, An empirical test of the
causal relationships in the Baldrige Health Care Pilot
Criteria. Journal of Operations Management. 19(4): p.
403-426, 2001.

Sci.int.(Lahore),26(5),2603-2616,2014

ISSN 1013-5316; CODEN: SINTE 8

87. Evans, Organisational learning for performance


excellence: A study of Branch-Smith Printing Division.
Total Quality Management. 21(3): p. 225-243, 2010.
88. Nishtar, S., et al., Pakistan's health system:
performance and prospects after the 18th Constitutional
Amendment. The Lancet. 2013.
89. Irfan and Kee. Critical Success Factors of TQM in
Pakistan healthcare Services: A Literature Review. in
10th Asian Academy of Management International
Conference 2013. 2013. Penang, Malaysia: Asian
Academy of Management, Universiti Sains Malaysisa.
90. Kanji, Business excellence: make it happen. Total
Quality Management. 13(8): p. 1115-1124, 2002.
91. Juran and Gryna, Quality Planning and Analisys.
Printed by MvGraw-Hill. 31993.
92. Talib, Rahman, and Azam, Best Practices of Total
Quality Management Implementation in Health Care
Settings. Health Marketing Quarterly. 28(3): p. 232252, 2011.
93. Flynn, Schroeder, and Sakakibara, The impact of
quality management practices on performance and
competitive advantage. Decision Sciences. 26(5): p.
659-691, 1995.
94. Juran, The Quality Trilogy: A Universal Approach to
Managing for Quality, in ASQC 40th Annual Quality
Congress in Anaheim, California, 1986.
95. Demirbag, M., et al., An analysis of the relationship
between TQM implementation and organizational
performance: evidence from Turkish SMEs. Journal of
Manufacturing Technology Management. 17(6): p.
829-847, 2006.
96. Wakefield, et al., Organizational culture, continuous
quality improvement, and medication administration
error reporting. American Journal of Medical Quality.
16(4): p. 128-134, 2001.
97. Crosby, P.B., Quality is free: The art of making quality
certain. Vol. 94. 1979: McGraw-Hill New York.
98. Huselid, M.A., S.E. Jackson, and R.S. Schuler,
TECHNICAL
AND
STRATEGIC
HUMAN
RESOURCES MANAGEMENT EFFECTIVENESS
AS DETERMINANTS OF FIRM PERFORMANCE.
Academy of Management Journal. 40(1): p. 171-188,
1997.
99. Ho, Duffy, and Shih, Total quality management: an
empirical test for mediation effect. International
Journal of Production Research. 39(3): p. 529-548,
2001.
100. Rahman and Bullock, Soft TQM, hard TQM, and
organisational performance relationships: an empirical
investigation. Omega. 33(1): p. 73-83, 2005.
101. Zhang, Z., Developing an instrument for measuring
TQM implementation in a Chinese context. 1999:
University of Groningen.
102. Philips, Q., Philips QualityLet's Make Things Better.
Corporate Quality Bureau, Philips Electronics NV,
Eindhoven. 1995.

2615

103. Flynn, Schroeder, and Sakakibara, A framework for


quality management research and an associated
measurement instrument. Journal of Operations
Management. 11(4): p. 339-366, 1994.
104. Zairi and Youssef, Competing through modern quality
principles: a forward management approach.
International Journal of Technology Management.
16(4): p. 291-304, 1998.
105. Bitner, M.J., Servicescapes: the impact of physical
surroundings on customers and employees. The
Journal of Marketing. p. 57-71, 1992.
106. Irfan and Ijaz, Comparison of service quality between
private and public hospitals: empirical evidences from
Pakistan. Journal of Quality and Technology
Management. VII(II): p. 91-114, 2011.
107. Oakland, J.S., Total quality management: The route to
improving performance. 1993, London: Butterworth
Heinemann.
108. Terziovski, M., Quality management practices and
their relationship with customer satisfaction and
productivity improvement. Management Research
News. 29(7): p. 414-424, 2006.
109. Lakhal, L., F. Pasin, and M. Limam, Quality
management practices and their impact on
performance. International Journal of Quality &
Reliability Management. 23(6): p. 625-646, 2006.
110. Nilsson, Antoni, and Dahlgaard, Continuous
improvement in product development: improvement
programs and quality principles. International Journal
of Quality & Reliability Management. 22(8): p. 753768, 2005.
111. Choi, T., Conceptualizing continuous improvement:
Implications for organizational change. Omega. 23(6):
p. 607-624, 1995.
112. Ho, Duffy, and Shih, An empirical analysis of effective
TQM implementation in the Hong Kong electronics
manufacturing industry. Human Factors and
Ergonomics in Manufacturing & Service Industries.
9(1): p. 1-25, 1999.
113. Kaynak, H., The relationship between total quality
management practices and their effects on firm
performance. Journal of operations management.
21(4): p. 405-435, 2003.
114. Krause, D.R., R.B. Handfield, and T.V. Scannell, An
empirical investigation of supplier development:
reactive and strategic processes. Journal of Operations
Management. 17(1): p. 39-58, 1998.
115. Forza, C. and R. Filippini, TQM impact on quality
conformance and customer satisfaction: a causal
model. International Journal of Production Economics.
55(1): p. 1-20, 1998.
116. Talib and Rahman, Critical success factors of TQM in
service organizations: a proposed model. Services
Marketing Quarterly. 31(3): p. 363-380, 2010.
117. Zairi, M., Business process management: a boundary
less approach to modern competitiveness. Business
Process Management Journal,. 3(1): p. 64-80, 1997.

2616

ISSN 1013-5316; CODEN: SINTE 8

118. Talib, Z. Rahman, and M. Azam, Best Practices of


Total Quality Management Implementation in Health
Care Settings. Health Marketing Quarterly. 28(3): p.
232-252, 2011.
119. Garvin, Managing quality: The strategic and
competitive edge. 1988: Simon and Schuster.

Sci.int.(Lahore),26(5),2603-2616,2014

120. Johnston, R., Towards a better understanding of service


excellence. Managing Service Quality. 14(2/3): p. 129133, 2004.

You might also like