Question:

The section will be part of the literature review chapter, not all of it:
– write about the literature on TQM in healthcare. you need to find out how much literature has already been published on this topic and how the research has been conducted (their design and methodology)
You firstly write up a section based upon your findings from the following key word searches:
* “TQM” and “hospitals”
* “TQM” and “healthcare”
* “quality management” and (“hospitals” or “healthcare”)
When writing this up do fully comment on how much literature there is on this topic, what country it is in and how it is conducted.
Secondly focus on writing up a section based upon the international dimension from the following key words searches:
* “TQM” and “Saudi Arabia”
* “TQM” and “Middle East”
* “TQM” and “national culture” etc
*please use only academic articles as sources or references dated from 2007 and above.
* you can use the attachment as a guide

Answer:

Title: Total quality management implementation in Saudi Arabia: A study of benefits, barriers and enablers of TQM in public hospitals

Introduction

The issue of Total Quality Management is not new to the healthcare sector. Like in other fields of professional specialty, TQM continues to generate profound interest among many stakeholders in the healthcare sector. From an international perspective, there is abundant literature on the issue of Total Quality Management (TQM) in hospitals (Menachemi 2010, p. 56). This literature focuses on a wide range of issues, ranging from the logic of TQM implementation to different dimensions of TQM in healthcare (Menachemi 2010, p. 56). In other areas, focus is on public hospitals, where emphasis tends to be directed at TQM practices in specific countries (Hikmet & Bhattacherjee 2009, p. 6. Other than implementation, there is also abundant literature on best practices and the relationship between TQM and the six sigma model.

Trends in TQM literature: An international perspective

One of the areas of TQM study frequently covered in literature is that of the adoption and implementation of TQM in hospitals (Salaheldin & Mukhalalati 2009, p. 8, Pongpirul 2006, p. 1141, Talib 2011, p. 41). In such a study, Kennedy (2009, p. 897) focused on the way implementation decisions relating to TQM are made in US hospitals. Kennedy used the institutional theory to investigate the way social and economic factors come into play when adoption decisions are being made. The study entailed reference to research on organizational decision-making to determine whether adoption decisions are viewed as threats or as opportunities. Kennedy (2009, p. 904) found out that motivations for the appearance of legitimacy exist side by side with motivations for the realization of improvement in economic performance. Moreover, issue perception appeared to impact significantly on the degree of TQM implementation in practice.

While Kennedy (2009, p. 904) discussed the subject of issue perception, Duggirala (2008, p. 694), in an earlier study, had addressed provider-perceived dimensions in the provision of total quality management within the healthcare sector. The country of focus in Duggirala’s (2008) study was India. The research paper also assessed the impact that different dimensions of this provider-perceived TQM have on hospital performance. The research design of the study entailed designing a questionnaire on the basis of extensive literature review on quality of healthcare as well as a pilot survey that was carried out among medical professionals. The impact of the various dimensions was assessed with the use of multiple regression analysis. Some 14 distinct dimensions were identified in relation to provider-perceived TQM (Duggirala (2008, p. 712). However, despite their distinctiveness, close relationships were found to exist among these dimensions (Duggirala (2008, p. 714).

India was also the country of focus for the study by Manjunath (2007, p. 131). In this case, though, Manjunath (2007, p. 131) dwelt on a specific aspect of TQM, known as the Malcolm Baldrige National Quality Award Criteria (MBNQA). The MBNQA criteria testing were done in a 300-bed hospital situated in the Southern part of the country. In terms of methodology, the MBNQA criterion was the basis of in-depth interviews that were conducted with the hospital’s heads of department. The data obtained was analyzed and compared with the points obtained in the MBNQA criteria. On this basis, the hospital was found to be operating on a higher level of quality performance. However, the researcher found out that the hospital still had many opportunities for improving the MBNQA criteria even further, particularly in the areas of analysis and knowledge management (Manjunath 2007, p. 137).

Apart from the issue of dimensions of adoption and perception, the issue of accreditation has also been covered fairly well in recent TQM literature (Aldaqal & Alghamdi 2012, p. 52, Wardhani 2009, p. 219, Serour 2006, p. 74, Badri, Attia, & Ustadi 2009, p. 18, Albejaidi 2010, p. 158). An example of such literature is the study by Sutherasan (2008, p. 315), which was carried out on hospitals in Thailand. As a background to the study, Sutherasan (2008, p. 316) observed that there was lack of sufficient literature on TQM activities in all accredited hospitals in Thailand. For Sutherasan, emphasis was on the lack of analysis of relationships between the time that had elapsed since the accreditation of the hospitals and the frequency of TQM-related obstacles. It was against this backdrop that the study focused on the activity level and barriers encountered in TQM activities.

The research design in Sutherasan’s (2008, p. 317), study involved a TQM assessment scale based on the Malcolm Baldrige Framework, which consisted of 80 items. This scale was used to determine the level of adoption of TQM principles in Thai accredited hospitals. Questionnaire surveys were sent to 52 quality managers at the accredited hospitals, and the response rate was 79%.

Sutherasan (2008, p. 320) found the level of TQM activity to be 3.82 on the five-point scale, that is, within the range of ‘neutral’ and ‘agree’. The highest score was recorded on ‘Senior Executive Leadership’ at 4.09. Second in the performance rank was ‘Information and Analysis’ (3.90). Interestingly, no significant differences were recorded in the TQM performances of the hospitals. Moreover, statistical significance was observed on the relationship between the length of time of accreditation and TQM activity. The dimensions of TQM activity appeared most influential included human resource management, quality management, strategic quality planning, senior executive leadership, and customer satisfaction.

Moreover, Sutherasan (2008, p. 320) observed that the factors that contributed most significantly to the TQM activities of accredited Thai hospitals included employee participation, continuous surveys, and commitment of the management team. The factors that hindered TQM activities most significantly included a high turnover rate and employee fatigue.

Iran is another country where several studies on TQM in hospitals have been carried out. In one of these studies, Askarian (2010, p. 2321) investigated the TQM approach in the management of healthcare waste at Namazi hospital. Askarian’s (2010, p. 2321) study was influenced by the need to address the worldwide issue of the 10-25% of the medical waste that is considered hazardous and a threat to patients, healthcare workers, the general population, and the environment.

The study design entailed selection of Namazi Hospital as the site of the study and then determining whether there was a decrease in the level of infectious waste upon application of a TQM method. This entailed weighing all the waste obtained from 29 admission wards during a one-month period. The results of the study showed a 26% reduction in the amount of infectious waste after intervention through the TQM method (Askarian 2010, p. 2322). The new waste management approach, therefore, was considered highly effective. Askarian also concluded that the waste management approach should be accompanied by clear definitions and employee training in order to bring about waste reduction and a consequent decrease in expenditure on healthcare waste management.

Raeissi (2009, p. 109) also focuses on Iran in his study, which involves evaluating the performance of the TQM model known as ISO 9001:2000. This evaluation was carried out on all Tehran Province hospitals affiliated to Social Security Organizations. From the outset, though, Raeissi concedes that the effectiveness of different quality management models has in recent times been questioned in various forums. It is for this reason that the researcher feels the need to evaluate the performance of the ISO 9001:2000 model in the context of Iran.

Raeissi’s study was based on a descriptive and cross-sectional design which was adopted using an applied approach. Quality experts and managers came together to form a brainstorming committee. Inferential statistics were used to analyze the data obtained. In all the elements evaluated, improvement in performance levels was recorded. These elements included marketing processes, finance, administrative activities, customer satisfaction, and human resource affairs; and the rate of improvement was as follows: 45.8%, 50.31%, 57.91%, 60.41%, and 61.24% respectively (Raeissi (2009, p. 118). Although the level of improvement was found to be significant, it was viewed to be still far from the ideal standards, hence the need to focus on continuous improvement within healthcare organizations.

In Rad’s (2007, p. 15) study, focus is on the barriers to successful TQM implementation in healthcare settings in Iran. This study employed cross-sectional and descriptive research, complemented by the use of two questionnaires that were handed to 90 healthcare managers. The findings showed that the main barriers existed in the form of human resource, structural, and strategic problems.

In a different study, Gorgi (2011, p. 2) compared the TQM processes employed in the Iranian healthcare system with those used in the Indian healthcare system. Just like the study by Manjunath (2007, p. 131), which was also done in India, the Baldrige healthcare criteria was used. In this research design, reference was also made to the guidelines that were proposed by the American Hospitals Association. Data collection was done in cities in India and Iran, and the ANOVAs tool was used to compare three groups in terms of performance and quality planning.

The study found out that differences exist in the performance of different hospitals in India and Iran (Gorgi (2011, p. 4). However, in all the groups, no hospital was found to be close to the benchmarks in terms of performance scores. These findings indicated the need for healthcare service providers to focus more on efforts to improve the level of performance through higher quality of management practices Gorgi (2011, p. 5).

The other country where several studies on TQM in hospitals are available is Turkey. Dilber (2008, p. 221) did a study on the country, and his aim was to evaluate the effect that TQM has on performance in the country’s healthcare industry. Dilber was interested in what he called ‘critical factors’ and their influence on the business performance of Turkish small- and medium-size hospitals.

In terms of research methodology, a canonical correlation analysis was used to identify the critical factors and to establish their relationship to TQM within the hospital industry (Dilber 2008, p. 225). Thirty items were identified and then used to measure 8 dimensions of TQM using the 5-point Likert scale. For performance measurement, subjective measures were used, whereby the perceptions of hospital administrators were sought regarding the performance of their organizations in relation to market competition. The analysis of data showed that there was a positive correlation between hospital performance and all the four critical factors of TQM in the Turkish healthcare industry (Dilber 2008, p. 231).

            In another study that also drew on the Turkish experience, Kozak (2007, p. 202) explored the issue of implementation of TQM in the country’s hospitals. The study, though, focused only on hospitals operating in the public sector, with employees’ perceptions being critically analyzed. The research findings implied that employees’ perceptions have a far-reaching impact on the success of TQM activities.

The subject of Six Sigma has also been widely explored in recent TQM literature (Lindenauer 2007, p. 491, Walston & Al-Harbi 2008, p. 247). Black (2007, p. 261), for instance, used a descriptive research design to analyze trends in the use of the Six Sigma approach in the healthcare industry. Black’s findings showed that although TQM recorded early success in hospitals, it has in recent times failed largely because of difficulties in assigning financial benefits to TQM activities.

These difficulties definitely underscore the existence challenges that appear the initial gains that had been achieved in TQM (Natarajan 2007, p. 574). Natarajan (2007, p. 574) came to this conclusion after undertaking a descriptive study on various approaches for ensuring improvement in safety, quality, and productivity in healthcare.

Employees, no doubt, play a key role in the success of TQM activities in hospitals. There are many studies that focused on employees’ wellbeing in relation to TQM (Lindberg 2007, p. 371). In a four-year case study, Lindberg found out that downsizing as a result of limited resources tends to have a negative impact on TQM implementation.

Total quality management implementation in Saudi Arabia

Several studies have been carried out on TQM implementation in the Saudi Arabian context. Whereas some studies dwell on implementation, others focus on patient satisfaction as an indicator of success of TQM activities. One of these studies was done by Al Awa, Al Mazrooa, Habib, & Rayes (2010, p. 321) and it entailed an assessment of the impact of accreditation on the quality of care and patient safety at King Abdul-Aziz University Hospital.

In this study, the research design of choice was cross-sectional surveys, which were conducted both before and after accreditation. Some 870 registered nurses from 22 different hospital units participated in the surveys, which were electronically accessed. The study design also had a component of the 5-point Likert scale, after which pre- and post-survey results were recorded and analyzed with the use of the McNemar test. In total 721 nurses participated in the survey questionnaire, with 675 meeting the survey criteria. In the end, post-accreditation was seen to improve perception regarding practices on patient care quality and safety.

A related study was conducted by Alaloola & Albedaiwi (2007, p. 632), in which focus was on patient satisfaction. Just like in the study by Mazrooa, Habib, & Rayes (2010, p. 321) the healthcare organization chosen was King Abdul-Aziz Medical Center. In both cases, an underlying belief entailed knowing the service perspective of the patients as an indicator of core service quality.

The methodology used in the study by Alaloola & Albedaiwi (2007, p. 632) required a cross-sectional survey, in which 1983 outpatient, inpatient, and emergency care unit patients were required to fill in a patient satisfaction questionnaire. The main areas where satisfaction was expressed included room comfort, room temperature, respectful staff, and room cleanliness. These findings bring into perspective the importance of the seemingly trivial aspects of TQM. The main weakness of this study, though, is failure to zero in on specific themes relating to TQM (Alaloola & Albedaiwi, 2007, p. 634).

A similar weakness is inherent in the analysis that Walston & Al-Harbi (2008, p. 245) provide regarding the changing trends in the Saudi Arabian healthcare system. Rather than talk about TQM, the researchers restrict themselves to the limited scope of limited quality of care offered to the Saudi Arabian citizens. The others issues addressed include restructuring of the healthcare system, privatization of public hospitals, and the introduction of insurance coverage for both citizens and foreign workers. An interesting finding, though, is that of reliance on the private sector to meet the quality standards expected by the country’s rapidly growing population. Another key finding is that whereas the quality of healthcare has been deteriorating, the costs have been rising.

Al-Ahmadi & Roland (2007, p. 335) adopt a similar approach in their review of Saudi Arabia’s primary healthcare quality. The researchers focus only on quality of primary healthcare instead of looking at the issue from the wider perspective of TQM. The study used a systematic search strategy, in which published literature was used to obtain data on the country’s primary care services and the barriers to the achievement of high-quality care. 128 studies were identified, 31 of which met the review’s inclusion criteria. These studies showed methodological diversity. On the one hand, satisfactory access to care was reported in the case of maternal healthcare, and immunization. On the other hand, poor access was reported in the case of prescribing patterns, disease management programs, and referral patterns (Al-Ahmadi & Roland 2007, p. 341).

The range of issues addressed in TQM-related studies in the context of Saudi Arabia appears limited. This is not surprising considering that there is not much literature on TQM activities in Saudi hospitals in the first place. This lack of thematic focus is reflected even in those studies that appear to closely examine the issue of TQM implementation closely. One such study was done by Abdi-Aziz (2011, p. 21), in which case focus was on Jeddah City.

Abdi-Aziz (2011, p. 21) sought to evaluate how TQM in Jeddah’s hospitals that are run by the Ministry of Health contributes to continuous improvement of the quality of healthcare services. The research paper adopted a descriptive design. The main issues under analysis included the commitment of the lead team, changes in organizational culture, costs of quality, and human resource management. The main finding of the study was rather controversial Abdi-Aziz (2011, p. 52) concluded that the TQM tools applied in Jeddah City public hospitals make no contribution to the quality of the city’s healthcare system. However, Abdi-Aziz (2011, p. 57) admitted that there is need for further studies on quality costs in relation to TQM in the healthcare sector. Abdi-Aziz also pointed out the need for an in-depth analysis of other dependent variables relating to the commitment of top management.

The issue of quality of health care appears to draw more attention than that of TQM in Saudi Arabia. In many studies, the areas that researchers choose to investigate relate to various aspects of quality healthcare. For instance, Al-Arfaj (2007, p. 134) explores the quality of care given to diabetes patients at Armed Forces Hospital, which is situated to the south of the country. In this study, the research design entailed a random selection of diabetic patients who were seeking treatment at the hospital. An interview questionnaire was complemented with a data sheet in gathering research data from the respondents. Most patients expressed satisfaction with the nature of interaction with their doctors. However, only 41.5 expressed satisfaction with regard to access to diabetes treatment. Al-Arfaj (2007, p. 134) concluded that the quality of health services offered at the hospital’s Diabetes Center is low. Whereas the level of satisfaction among diabetic patients was high, a low level of satisfaction was recorded with regard to access to health professionals as well as treatment. This research paper has far-reaching implications on satisfaction as a key dimension in determining the success of TQM activities.

Interestingly, the Saudi healthcare sector has been highlighted as one of the sectors that implement TQM principles (Al-Qahtani 2011, p. 31). Al-Qahtani used a descriptive research method to elaborate on the TQM application process that the Ministry of Health of Saudi Arabia underwent in ensuring compliance to the laid-out TQM standards.

The Saudi Arabian Ministry of health operates in an environment where there is no rich history of TQM activities in other sectors. However, this has not held back the desire of stakeholders in the country’s health sector to apply for TQM compliance. This is because of the underlying government mission to ensure that the quality of healthcare offered to citizens is improved.

There are many studies that indicate that the main unit of TQM implementation in the Ministry of Health is hospitals. It is on this basis that the Saudi ministry of health has been developing a program for measuring the effectiveness of various TQM activities. The assumption has been that through this measurement, policymakers can determine the benefits, barriers, and enablers of various TQM activities undertaken in public hospitals.

One TQM activity that is considered particularly beneficial in Saudi public hospitals entails the use of training seminars. These seminars are normally conducted under the stewardship of both and international training specialists. The people who are normally involved in the TQM application are the ones who can best appreciate the value of training seminars in the country’s public hospitals. A further assessment of the success of this training program is normally undertaken by the control department, which also oversees issues of quality of healthcare. In recent times, a new development has entailed transferring the TQM application role to public hospitals instead of centralization at the ministry level. Although this process has been going on at a rather slow pace, there is hope that it will be completed in near future (Al-Qahtani 2011, p. 31). However, it will definitely take some time before its effectiveness is measured and determined. This will call for further studies on the barriers to TQM implementation in the Saudi public hospitals.

It is rather unfortunate that Al-Qahtani’s 2011, p. 31) paper did not address cost issues. However, this is not surprising, mainly because issues of cost-effectiveness tend to be overlooked in public sector issues. This is an unfortunate omission, though, because cost issues constitute an integral component upon which TQM principles are founded. As pointed out by many scholars, cost issues should be addressed in all TQM discussions (Alaloola & Albedaiwi 2007, p. 637, Al Awa, Al Mazrooa, Habib, & Rayes 2010, p. 322, Bloom & Propper 2010, p. 12)

Saeed (2009, p. 61) is one of the scholars who have addressed the cost issues in their studies. He notes that among Saudi healthcare managers in the public sector, perceptions have a significant influence on the issue of cost whenever quality improvement initiatives are being undertaken. In his study, Saeed (2009, p. 61) sought to address the healthcare managers’ perceptions of the influence of cost on quality management initiatives. The research was designed in such a way that data would be obtained through a self-administered questionnaire distributed in the Western region of the country. In total, some 236 public-hospital healthcare managers participated. Saeed found out that less than 50% of the managers expressed satisfaction with the TQM activities of their hospitals. These managers identified ‘cost of malpractice lawsuits’ as the most influential issue in TQM implementation. In terms of the least influence, the issue of ‘data on cost allocation’ was singled out.

The issue of managerial challenge had also been previously addressed by Rose (2009, p. 148), although instead of tying it to cost issues, she chose to dwell on public hospital service quality. The issue of perception, however, did arise, only that this time it was in relation to hospital service quality. Rose (2009, p. 151) uses a descriptive research design, where six different quality dimensions are discussed. Though the cost factor was not one of the research issues in Rose’s study, it emerged as a key factor in the perception of customers in Saudi public hospitals.  Khoja 2011, p. 164) points out, the issue of quality assurance programs is not new in the Saudi healthcare sector.

The other issues that have been explored in literature on TQM implementation in the Saudi public hospitals include physicians’ behavior (Shehri & Alhaqwi 2008, p. 941, Neyaz 2011, p. 23), primary care (Khoja 2011, p. 165), doctor-management interaction (Al-Shehri 2009, p. 942), TQM implementation criteria (Qureshi 2009, p. 1587) and the use of electronic health recording system (Bah 2011, p. 118)

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