International Journal of Health Care Quality AssuranceEmerald Article: Obstacles to TQM success in health care systemsAli Mohammad Mosadeghrad

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To cite this document: Ali Mohammad Mosadeghrad, (2013),"Obstacles to TQM success in health care systems", International Journal of Health Care Quality Assurance, Vol. 26 Iss: 2 pp. 147 - 173

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Obstacles to TQM success inhealth care systems

Ali Mohammad MosadeghradSchool of Management and Medical Informatics,

Tehran University of Medical Sciences, Tehran, Iran

Abstract

Purpose – Many healthcare organisations have found it difficult to implement total qualitymanagement (TQM) successfully. The aim of this paper is to explore the barriers to TQM successfulimplementation in the healthcare sector.

Design/methodology/approach – This paper reports a literature review exploring the majorreasons for the failure of TQM programmes in healthcare organisations.

Findings – TQM implementation and its impact depend heavily on the ability of managers to adoptand adapt its values and concepts in professional healthcare organisations. Unsuccessful TQM effortsin healthcare organisations can be attributed to the strongly departmentalised, bureaucratic andhierarchical structure, professional autonomy, tensions between managers and professionals and thedifficulties involved in evaluating healthcare processes and outcomes. Other obstacles to TQM successinclude lack of consistent managers’ and employees’ commitment to and involvement in TQMimplementation, poor leadership and management, lack of a quality-oriented culture, insufficienttraining, and inadequate resources. The review was limited to empirical articles written in the Englishlanguage during the past 30 years (1980-2010).

Practical implications – The findings of this article provide policy makers and managers with apractical understanding of the factors that are likely to obstruct TQM implementation in thehealthcare sector.

Originality/value – Understanding the factors that obstruct TQM implementation would enablemanagers to develop more effective strategies for implementing TQM successfully in healthcareorganisations.

Keywords Total quality management, Failure, Obstacles, Successful implementation, Health care

Paper type Literature review

IntroductionHealthcare organisations face a number of serious challenges, particularly concerningeffectiveness, efficiency and quality. Therefore, there is a pressing need for a new approachin managing healthcare organisations to become more cost-effective in the delivery of highquality healthcare services. Quality management constitutes an appropriate response tothese challenges. It is a potential way to improve systems and procedures as effectively aspossible by using scientific methods to achieve an optimum outcome. Total qualitymanagement as a quality management strategy aims to enhance customer satisfaction andsubsequently organisational performance by providing high quality products and servicesthrough the participation and collaboration of all stakeholders, teamwork, customer drivenquality and continuously improving the performance of inputs and processes by applyingquality management techniques and tools.

Total quality management (TQM) became one of the competitive strategies ofchoice during the 1990s. It has been widely implemented in various firms throughout

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Obstacles toTQM success

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Received 17 March 2011Revised 1 June 2011

Accepted 1 July 2011

International Journal of Health CareQuality AssuranceVol. 26 No. 2, 2013

pp. 147-173q Emerald Group Publishing Limited

0952-6862DOI 10.1108/09526861311297352

the world for achieving greater profitability (Mosadeghrad, 2005). There is awidespread consensus that a successful TQM implementation is related to economicand performance success (Brah et al., 2002; Hansson and Eriksson, 2002; Hendricks andSinghal, 2001; and Kaynak, 2003). The success of TQM in industry has encouragedmany healthcare managers to examine whether it works in the healthcare sector. As aresult, in the last 30 years, many healthcare organisations increasingly adopted theTQM principles to improve the quality of outcomes and efficiency of healthcareservices delivery. An effective TQM implementation enables healthcare organisationsto identify clients’ requirements to deliver appropriate care, benchmark for bestpractices and improve processes to reduce the frequency and severity of medical errors.These activities lead tohigh quality healthcare services, patient satisfaction, andincreased productivity and profitability (Alexander et al., 2006; Macinati, 2008).

Nevertheless, the application of TQM in practice involves many difficulties. Manyhealthcare organisations have found difficulties in implementing TQM successfully(Bringelson and Basappa, 1998; Ennis and Harrington, 1999; Huq and Martin, 2000;Zabada et al., 1998). Although some quality improvement projects were successful(Chattopadhyay and Szydlowski, 1999; Francois et al., 2003; Jackson, 2001; Klein et al.,1998; Motwani et al., 1996), most of these have been limited to a small number ofhealthcare organisations or a few departments in a healthcare organisation or a narrowaspect of organisational performance.

Total quality management has its roots in manufacturing sector. There arequestions regarding its applicability to the healthcare sector (Atchison, 1992; Zabadaet al., 1998). The concept of TQM consists of two components: values, concepts andprinciples (i.e. management support, employee involvement, and teamwork), andtechniques and tools (e.g. statistical process control tools). TQM techniques and toolsmay be applicable everywhere. However, its values and principles need to be adaptedto strong professional healthcare settings. Simply adopting TQM principles will notguarantee its success. An application of hard factors of TQM without updatingorganisational structure and improving its soft factors leads to an insignificantimprovement in organisational performance and early abandonment of this strategy. Asuperficial implementation of TQM results in low or even no productivityimprovement. This causes a negative psychological effect on employees.Subsequently, employees lose interest in TQM implementation.

Instances of failed TQM initiatives have led researchers to focus more directly onthe shortcomings and difficulties associated with TQM (Amar and MohdZain, 2002;Bhat and Rajashekhar, 2009; Jun et al., 2004; Ljungstrom and Klefsjo, 2002; Salegnaand Fazel, 2000). However, obstacles to implementing TQM successfully in healthcareorganisations have not been fully addressed.

AimsThis study aims to identify factors underlying failures in TQM implementation inhealthcare sector. The aim is to get a better understanding of why such TQMimplementations fail so frequently. In addition, the study has endeavoured to presentreasons for their occurrence and to make recommendations that help healthcaremanagers to develop more effective strategies that will enhance the chances ofachieving business excellence.

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MethodA meta-analysis of TQM empirical implementation barriers studies in healthcareorganisations was undertaken. A total of 15 electronic databases were searched in thissystematic and meta-analysis literature review. These include PubMed, AcademicJournals Database, Directory of Open Access Journals, Ebsco research databases, Elsevierscience, Emerald, Google Scholar, JournalSeek, JSTOR, ScienceDirect, Social ScienceCitation Index, SpringerLink, Social Science Research Network, Web of Knowledge, andWorldWideScience. Keywords to search the literature included total quality management,implementation, healthcare organisations, failure, barriers, and obstacles.

In addition, journals such as TQM Journal, Total Quality Management and BusinessExcellence, Quality Progress, International Journal of Quality & Reliability Management,International Journal for Quality in Healthcare, International Journal of Applied QualityManagement, International Journal of Healthcare Quality Assurance, Journal of QualityManagement in Healthcare, Journal of Quality and Safety in Healthcare, Journal ofOperations Management, and Journal of Managing Service Quality were searched forarticles not yet indexed in the databases. Furthermore, the reference lists of the retrievedarticles were evaluated to identify additional relevant research articles. The final stepwas a general internet search using Google, and Yahoo search engines to find furtherinformation relating to TQM failure and implementation obstacles in healthcare sector.

The selection was restricted primarily to the following studies (see the Appendix):. published between 1980 and 2010;. those written in English;. examined TQM implementation in healthcare organisations using an empirical

approach (quantitative or qualitative); and. identified reasons for TQM failure.

After manually screening and evaluation of the related literature, a total of 16 empiricalstudies reporting TQM implementation obstacles in healthcare organisations wereselected for this systematic and meta-analysis. The empirical studies were conducted innine countries. A total of ten studies were reported in developed countries and six indeveloping countries. A questionnaire survey was used for data collection in 11 studies.The rest of studies (five) used case study approach and interviews for collecting data.

Both qualitative and quantitative analyses were used in this study. Content analysiswas used to describe and explain the reasons for the failure of TQM programmes inhealthcare organisations. NVivo software (version 7) was used for qualitative dataanalysis and retrieval. In addition, SPSS software (version 11.5) was used to providedescriptive statistics such as frequency and percentage. Regression analysis was usedto determine which obstacles were perceived as significant in TQM failure.

ResultsThe reasons for TQM failure addressed in the literature can be categorised into threegroups:

(1) ineffective or inappropriate TQM model;

(2) ineffective or inappropriate TQM implementation method; and

(3) inappropriate environment for TQM implementation.

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Ineffective or inappropriate TQM modelSuccessful TQM implementation requires a clear understanding of the concept andprinciples of TQM. However, TQM does not provide an explicit theory. While it iswidely practiced, there is little agreement on what it is and what its essential featuresare. TQM is a diffuse concept and an abstract term, with many vague descriptions, andno generally accepted definition or agreed content. Mosadeghrad (2011) in an attemptto define TQM found 73 different definitions of TQM in the literature. TQM has beenvariously defined as an “Approach” (Flynn et al., 1994), a “Culture” (Kanji and Yui,1997), a “Philosophy” (Joyce et al., 2006), a “System” (Hellsten and Klefsjo, 2000), a“Strategy” (Harvey and Brown, 2001), a “Programme” (Joss and Kogan, 1995), a“Process” (Almaraz, 1994), a “Technology” (Camison, 1996), and a “Technique” (Wonget al., 2010). Consequently, TQM is used interchangeably with other terms such ascontinuous quality improvement, quality assurance and total quality control.

Total quality management suffers from both theoretical problems and practicaldifficulties (Mosadeghrad, 2012). TQM is partially developed (Singh and Smith, 2006;Vouzas and Psychogios, 2007). Some complementary management theories must beintegrated with TQM to refine and develop it further to achieve competitive advantage.An intensive knowledge of sociology, psychology and change management helpsintroduce, institutionalise and manage the TQM change successfully. There is a needfor an empirically sound and comprehensive model of TQM to assist managers inplanning and executing TQM practices, and monitoring and improving the quality ofhealthcare services. Nowadays, three major quality management frameworks –standards-based approaches (e.g. ISO 9001); quality award models; and individualdeveloped models – are accepted as guides to TQM implementation.

The ISO 9001: 2000 offers a system of quality assurance to healthcare organisations.It gives them a degree of standardisation and procedural control. ISO 9001 directsmanagers to re-examine all their processes and identify any discrepancies betweenwhat employees are actually doing and what the documentation asks to be done. Itfocuses on processes rather than outcomes (Ozturk and Swiss, 2008). ISO 9001encourages employees to demonstrate compliance with the procedures, rather than tostrive for continuous improvement. ISO focuses on doing things right, not necessarilydoing the right things right from a customer point-of-view. ISO 9001 only ensures thata quality management system exists. It cannot guarantee its functionality. It is not aguarantee of quality or better performance (Curkovic and Pagell, 1999; Martınez-Costaet al., 2009). It is possible to have an ISO 9000 system and still manufacture/deliverpoor quality products/services. ISO 9001 also leads to an increased bureaucracy withinan already complex and highly bureaucratic healthcare system. It results in additionalpaperwork related to new protocols and procedures (Poksinska et al., 2006; Singelset al., 2001). ISO provides a generic guideline that comes from industry experience anddoes not specifically address all areas relevant to healthcare. Therefore, qualityimprovement is mainly limited to supportive and administrative functions, rather thanclinical and patient care activities. Simply implementing ISO alone does not appear tobe comprehensive enough to gain competitive advantages (Corbett et al., 2005; Najmiand Kehoe, 2000; Sun et al., 2004; Terziovski et al., 2003). Therefore, healthcareorganisations should not solely rely on the ISO quality management system. ISO 9001,through offering a set of policies and guidelines for quality management provides afoundation to TQM. It could be a starting point for TQM implementation.

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Quality award models provide a framework of essential quality managementpractices for organisations to implement TQM programmes, benchmark best practicesand perform self-assessments against established criteria to identify their strengthsand weaknesses (Ghobadian and Woo, 1996). There are many quality award models allover the world. Some of them are regional awards (e.g. Minnesota Quality Award) andothers are national (e.g. Malcolm Baldrige award) or international (e.g. EuropeanFoundation Quality Management Award in Europe). These TQM frameworks areextensively used in healthcare organisations for self-assessment and performanceimprovement purposes (Foster et al., 2007; Nabitz et al., 2000; Vernero et al., 2007).However, they have foundation in industry and have not been developed specificallyfor the healthcare sector. Incorporating clinical standards in these quality awardmodels provides the potential to deliver high quality healthcare services. It encourageshealthcare organisations to improve clinical procedures, rather than being limited toadministrative activities.

Many quality gurus and researchers developed various TQM models (Baidoun andZairi, 2003; Hansson and Klefsjo, 2003; Kakkar and Narag, 2007; Srdoc et al., 2005;Sureschchandler et al., 2001; Thiagaragan et al., 2000; Venkatraman, 2007). Theireffectiveness depends on how effectively they are developed and incorporated intoorganisational policies and practices. Most of these TQM models are general guidelinesand do not specifically address all areas relevant to the healthcare system. Hence, thereis a need for a suitable TQM framework for the healthcare sector.

Ineffective or inappropriate TQM implementation methodMany of the failures of TQM are attributed to the methods of implementation (Bayazit,2003; Hansson and Klefsjo, 2003; Seetharaman et al., 2006). The implementation ofTQM principles and practices (i.e. management commitment, teamwork, focus oncustomers and continuous improvement) must be supported by techniques and tools toachieve business excellence. There is no standard method for implementing TQM coreprinciples in an organisation to achieve good outcomes. This is left to the interpretationof quality practitioners. Consequently, the same TQM programme may result indifferent outcomes in different organisations.

There are three main reasons for an in-effective TQM implementation method,i.e. over use, under use and misuse of quality management practices, techniques andtools. Overuse occurs when managers apply sophisticated techniques and tools that arebeyond the understanding of the employees. Therefore, they cannot implement themethods completely and properly. Under use occurs when organisations do not fullyimplement all of the key values and principles of TQM. Most failures with TQM resultfrom partial implementations of its principles and practices. Misuse occurs whenmanagers implement practices, techniques and tools, which are not compatible withthe organisation’s cultures and operations (e.g. using participatory managementtechniques in an organisation with authoritative leadership style and individualisticculture).

Inappropriate environment for TQM implementationTotal quality management programmes will not succeed unless rooted in a supportiveenvironment (supportive leadership, quality culture and appropriate structure).Overall, 39 barriers to implementing TQM successfully in healthcare organisations

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were identified in the reviewed empirical studies. These barriers were categorised intofive groups:

(1) Strategic barriers:. poor management and leadership;. lack of top management support;. management turnover;. middle-management resistance to change;. inappropriate planning;. placing a poor priority on quality improvement; and. unlimited demand for healthcare services.

(2) Human recourses barriers:. lack of employees’ interest in TQM;. lack of employees’ motivation and satisfaction;. lack of employees’ commitment and involvement;. physicians’ indifference towards TQM;. professional autonomy;. incompetent employees;. employees’ resistance to change;. lack of good human resource management;. inadequate empowerment at all levels;. employee shortage, and increased work load;. poor education and training;. lack of recognition and reward for success; and. lack of union co-operation.

(3) Contextual barriers:. inappropriate organisational culture;. inter-departmental barriers;. difficulties in changing organisational culture;. lack of team orientation;. poor communication; and. mindset barriers.

(4) Procedural barriers:. lack of process focus;. lack of focus on patient satisfaction;. lack of customer awareness;. complexity of processes;. fragmentation of activities;

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. bureaucracy and paperwork;

. lack of measurement, evaluation and self-assessment; and

. difficulties in measuring quality.

(5) Structural barriers:. inappropriate organisational structure;. lack of physical resources;. lack of information systems;. lack of financial support; and. time shortage.

Table I shows the ten most frequently mentioned environment-related reasons for TQMfailures in literature. Lack of employees’ and managers’ consistent commitment to andinvolvement in TQM activities were the most cited barriers to TQM implementation inhealthcare organisations. Regression analysis showed that management turnover,middle management resistance, lack of resources, inappropriate culture and short-termthinking was the major barriers to implementing TQM in healthcare organisations.

Poor leadership, inappropriate organisational culture, lack of employeeinvolvement, lack of top management support, and lack of training were the mostmentioned barriers to successful TQM implementation in developed countries. Incontrast, lack of management support, lack of employee involvement, poor leadership,lack of training, inappropriate organisational culture, lack of recognition and rewardfor success, and hierarchical and authoritative organisational structure were the mostcited barriers to successful TQM implementation in developing countries.

According to Easton (1993), the moderate results of implementing TQMprogrammes in some American companies were attributed to deficient leadership.The importance of visionary leadership, including philosophy, style and behaviour inTQM implementation was in fact addressed in the previous studies (Alexander et al.,2007; Berwick et al., 2003; Maguerez et al., 2001; Mosadeghrad, 2005; Wardhani et al.,2009). Top-down authoritative leadership style must be replaced with a moresupportive, democratic, charismatic and participative style that allows employees’involvement in TQM activities.

TQM failure reasonsFrequency of

occurrencePrioritised

rank

Lack of employees particularly physicians’ involvement 10 1Lack of consistent top management support 10 2Poor leadership and management 9 3Lack of a quality-oriented culture 8 4Insufficient education and training 8 5Inadequate resources 5 6Lack of a robust monitoring and measurement system 5 7Employee shortage 5 8Lack of a plan for change 4 9Poor communication 4 10

Table I.Prioritisation of barriersto TQM implementation

in healthcare

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Just as managers can support TQM, they can also obstruct it. Juran (1988) believed thatmost of the problems associated with quality are attributed to management. Mostobstacles to TQM implementation such as lack of a vision, lack of a strategic plan, poororganisational culture, poor communication, lack of employee empowerment, inadequateresources, and employee resistance to change are linked to how effectively the TQMprogramme is managed. The implementation of quality management itself requires“management quality”. TQM implementation and its impact depend on the ability ofmanagers to adopt and adapt its values and basic principles in professional healthcareorganisations. It requires a change in management thought, attitude, behaviour and roles.Managers must discard outdated management methods and accept the philosophy ofcontinuous quality improvement. The success of TQM depends largely on managementability to create a vision, plan for, and lead the organisational change required for TQMsuccess. Top management needs to ensure that all facets of the organisation (i.e. theorganisational structure, leadership styles, incentive schemes, trainings, communications,procedures and processes) reflect TQM values and principles.

As healthcare organisations are growing in number and complexity, there is agrowing need for professional managers and leaders who are accountable forcontinuously improving corporate (clinical, operational and financial) performance.The introduction of professional management into the healthcare system increasesmanagerial control of services and promotes organisational productivity. Healthcareorganisations can be managed better by having well-trained managers supporting andleading the teams that manage the processes to deliver the best possible services forpatients. Managerial knowledge and skills are key success factors for the effectivemanagement of healthcare organisations.

Lack of top management involvement in and commitment to TQM change is thecommon reason for TQM failure (Hamidi and Zamanparvar, 2008; Kozak et al., 2007;Mosadeghrad, 2005). Low management commitment and involvement can lead to failurein as many as 80 per cent of organisations (Jaehn, 2000). Juran and Gryna (1993) attributethe failure of the quality management initiatives in the West in the 1970s and 1980s tolack of top management involvement in quality management. Top management shouldbe very committed to and fully involved in continuous quality improvement. The degreeto which employees adopt TQM strategy will be contingent upon the degree to which topmanagers are involved in, and committed to the TQM principles. A lack of TQMknowledge, frequent top management turnover, avoiding taking risks and ineffectivecommunication between managers and employees are the main reasons for the lowmanagement commitment to TQM programmes (Deming, 1986; Mosadeghrad, 2005;Soltani et al., 2005; and Psychogios and Priporas, 2007). Therefore, there is a need formanagement transformation. Continuous education and training help managers tounderstand the philosophy of TQM and implement it properly.

Management turnover is one of the most important obstacles to successful TQMimplementation. Management turnover increases the chance of subjectivemanagement, leading to unfavourable outcomes. Managers may avoid taking risksand making radical changes because they are afraid that it may cost them their jobs(Soltani et al., 2005). Therefore, managers cannot plan for the long term and have tomaintain the status quo. The job security of managers encourages long-term planningand their commitment to pursuing long-term objectives. Mobility of management wasin fact, considered a deadly disease for business by Deming (1986).

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According to Manz and Sims (1993), middle managers are the biggest obstacle tosuccessful TQM implementation. Without middle manager’s support, the TQMprogramme would be halted. Middle managers may see that the transition towardsTQM cost them in status, power and recognition. Lack of involving middle managersin TQM initiative makes them resist the TQM change programme and react withsuspicion and uncertainty (Balding, 2005; Jacobsen, 2008; Harrington and Williams,2004). Top management should clarify middle managers’ roles in relation to TQMimplementation, provide necessary education and training and empower them tocommunicate the TQM message to employees (Dale and Cooper, 1994).

A successful TQM implementation needs a long-term strategic plan. According toNewall and Dale (1991), lack of detailed planning prior to the introduction of TQM inorganisations is a key reason for its future difficulties there. Many TQMimplementation problems can be overcome by proper planning. Qualitymanagement programmes will fail if quality objectives are not incorporated into theorganisation’s strategic planning process. Strategic quality planning is essential forTQM initiatives to be successful (Chan and Ho, 1997; Francois et al., 2003; Hamidi andZamanparvar, 2008). Strategic quality planning is necessary for integrating qualityobjectives, requirements and targets into organisational operations and activities.

Poor education and training are also major obstacles to the development andimplementation of TQM initiatives. Training and education are key components in theTQM programme, and have an important role in establishing a common language ofquality, and securing commitment and behaviour change towards continuous qualityimprovement. The review of literature corroborates the importance of appropriateeducation and training in the process of TQM implementation (Chow-Chua and Goh,2002; Huq and Martin, 2000; Maguerez et al., 2001). Education and training enhanceemployees’ job-related skills, communication and teamwork, and help to overcomeemployees’ resistance to TQM change (Kaynak and Hartley, 2008). Education andtraining can result in a more satisfied workforce and an environment for innovationand creativity. Healthcare managers should develop the technical capabilities ofemployees and enable them to improve the quality of services continuously. Educationand training provide the necessary knowledge, skills and abilities for employees to dotheir job effectively, diagnose and correct their daily problems.

Organisational culture is one of the most important influencing factors in theimplementation of TQM in healthcare sector. Cultural variables are found responsiblefor more than 50 per cent of the variance in TQM implementation (Mosadeghrad, 2006;Wakefield et al., 2001). The most difficult obstacles to the application of TQM in healthsector are cultural (Huq and Martin, 2000; Zabada et al., 1998). Creating a supportiveculture is one of the most frequently mentioned difficulties to TQM implementation inhealthcare sector. Therefore, organisational culture is the most often ignoredcomponent of TQM during the course of TQM implementation. There are powerfulsub-cultures such as physicians, nurses and paramedics who have their own interests.They define quality differently and follow specific ways to achieve it. Consequently,healthcare managers have little control over TQM implementation (Natarajan, 2006;Piligrimiene and Buciniene, 2008; Zabada et al., 1998). Therefore, cultural changes arerequired to implement TQM successfully. A “corporate culture of quality” should bedeveloped. This involves building and enhancing trust, motivation, empowerment,co-operation, risk taking, innovation, and continuous improvement through job

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security, teamwork, support and equitable compensation (Mosadeghrad, 2006;Wardhani et al., 2009). To create a quality culture, a change in organisationalfactors, both soft (i.e. shared vision, values and believes) and hard (i.e. systems andstructures) is needed. Strong and inspirational leadership has a key role in changingthe organisational culture. Continuous and widespread education and training providea good foundation for cultural change required for TQM implementation. However, itneeds to be supplemented by appropriate supportive systems to encourage effectivecommunication and people involvement in TQM projects.

The success of TQM also depends on its fit with organisational structure. Structurehas to follow the strategy. The very complexity of the healthcare system and itsbureaucratic and highly departmentalised structure can pose a significant obstacle tothe implementation of TQM and decrease its effectiveness (Adinolfi, 2003; Badrick andPreston, 2001; Jabnoun, 2005; Lim and Tang, 2000; Naveh and Stern, 2005).Mechanistic, bureaucratic and authoritative structures, risk aversion, and complexityimpede successful TQM implementation. McLaughlin and Kaluzny (1990) and Shortand Rahim (1995), argue that the complex, bureaucratic and highly departmentalisedstructure, and the multiple layers of authority are the most difficult barriers toimplement TQM in healthcare organisations. The traditional hierarchical structure ofhealthcare organisations exemplifies bureaucratic and authoritative cultures that arenot conducive towards employee empowerment and commitment, which are crucial tothe successful implementation of TQM (Abd-Manaf, 2005; Shortell et al., 1995; Zabadaet al., 1998). Moreover, healthcare settings are structured in departments withsignificant autonomy of action, which further enhances their ability to resist change(Francois et al., 2003; McNulty and Ferlie, 2002). Such a structure makes it difficult toachieve horizontal coordination and vertical integration, which are necessary foreffective TQM implementation.

Specialised accountability combined with professional autonomy segment the workprocesses. As a result, efforts to improve the quality of healthcare services arestratified hierarchically. Physicians take responsibility for one aspect, nurses foranother and managers for still another. No single group is held accountable for the totalhealth care delivery process (Kaluzny et al., 1992; Moss and Garside, 1995). Theprofessional bureaucracy and paternalism (e.g. physician power), and work on humanbeings limit hierarchical authority and make it difficult for managers to use scientificquality management principles.

Institutionalisation of TQM in healthcare requires building a supportiveinfrastructure to enhance the effectiveness of implementing its practices. It is verydifficult to implement TQM in a rigid mechanistic and bureaucratic structure. Organicstructures with low centralisation and formalisation are more conducive to the successof TQM implementation ( Jabnoun, 2005; Moreno-Lozon and Peris, 1998; Tata andPrasad, 1998). Decentralisation improves employees’ involvement and participation inTQM activities and reduces power distance within healthcare organisations(Mosadeghrad, 2006). A quality management infrastructure should be established toimplement and manage a TQM programme. This should consist of a qualitymanagement council, a quality management department, a quality steering committee,functional and cross-functional quality improvement teams, and quality audit teams.

Total quality management should be implemented by the frontline employees. Theymust take the responsibility for delivering high quality healthcare services. Employee

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empowerment, commitment and involvement are key factors in the successfulimplementation of TQM and, were indeed included in previous TQM studies. Variousstudies have shown that human resources problems such as lack of employees’motivation and involvement in TQM activities, their low knowledge and experienceabout TQM implementation, changing employees’ work habits, lack of teamorientation, lack of linkages between employees’ compensation and their performanceand lack of time are human resource barriers in implementing TQM successfully inhealthcare organisations (Alexander et al., 2007; Francois et al., 2003, Huq and Martin,2000; Kozak et al., 2007; Mosadeghrad, 2005; Ozturk and Swiss, 2008; Withanachchiet al., 2007).

Effective, frequent and immediate recognition and reward improves employeemorale, self-esteem, and interest in TQM (Brashier et al., 1996). When employees feelthat they are not recognised for their efforts, they become resistant to the TQMprogramme. This acts as a barrier to the success of the TQM initiative. TQM must beresult-oriented in order for employees to believe in it. The TQM implementation shouldlead to an increase in employee satisfaction and motivation. Financial incentivesincrease employees’ motivation and involvement in quality management activities.Incurring too much work without providing tangible benefits is the most significantreason for employees’ apathy.

Physicians play an important role in facilitating or impeding TQM implementation.However, getting them involved in TQM programmes is a challenge for managers.Potter et al. (1994) believe that without physicians’ involvement, quality improvementwould be limited to issues marginal to the central problems of health careorganisations. Physicians have remained divided from managers. They believe thatTQM adds unnecessary bureaucracy and is used mainly for cost control and it is,therefore, applicable only to administrative and support functions (Ennis andHarrington, 1999; Moeller, 2001; Zabada et al., 1998). As a result, physicians do not feelthat TQM activities are part of their responsibilities. Subsequently, they are less likelyto participate in TQM activities, less likely to receive education and training in qualityimprovement methods and to use quality improvement methods in their daily work(Cohen et al., 2008). Physicians are not likely to be distracted from their patients in afee-for-service payment system towards a quality management system that expectsthem to be more transparent, more responsible, more customer-oriented, and to followmanagerial rules and standards.

Lack of time is the main barrier for physicians’ low participation in TQM activities.They are more devoted to patient treatment than to TQM. They perceive a conflictbetween allocating time for treating patients and performing TQM activities(Maguerez et al., 2001; Valenstein et al., 2004). Physicians by tradition expect moreautonomy and do not accept changes that might limit their power (McLaughlin andKaluzny, 1990; Ruiz and Simon, 2004). Hence, perceived loss of autonomy is anotherreason for the high resistance among physicians. They think the standardisationconcept in TQM may limit their freedom to diagnose and prescribe freely. Physicians’relative inexperience and unwillingness to work as team members are alsocontributing to their apathy to TQM (Zabada et al., 1998).

Managers must develop systems to encourage and reward physicians’ commitmentand participation though training and financial incentives. Physicians would be moreinvolved in TQM activities if they realised its benefits to them. The active involvement

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of top management can also encourage physician participation in TQM projects. It isnot necessary to include every physician in all TQM activities. Incorporatingwell-respected and knowledgeable physicians into quality management rolesfacilitates physicians’ involvement in TQM programmes (Glickman et al., 2007; andWakefield and Wakefield, 1993). They then act as models, mentors and motivators forother physicians.

People’s resistance to change is the primary barrier to implementing TQM in anorganisation. TQM can be a source of fear and anxiety (Matherly and Lasater, 1992).The reasons for employees’ resistance to a TQM programme may include fear of losingjobs or related benefits, personal uncertainty, group pressure, perceived loss of control,a lack of knowledge of the nature and the impact of the proposed change, and a lack ofadequate planning (Alas, 2007; Carter, 2008; Harrington and Williams, 2004; Self andSchraeder, 2009). Many TQM programmes fail because too little attention is paid to thehuman factor. The implementation of TQM results in more demands on employees andmore work pressure. This is often caused by standardisation, increased bureaucracy,new responsibilities and increased accountability to managers (Parker and Slaughter,1993; Senge, 2006; Walston et al., 2000). Human resource systems must support theTQM programme through the development of the necessary motivation, attitudes andthe competencies.

Managers must minimise the sense of ambiguity among employees using effectivecommunication and planning. Managers must justify TQM implementation in theorganisation. They should persuade employees that they are serious about TQM.Communication is needed to clarify the future state for employees. Managers must letemployees know what would happen and how they would be affected by the TQMprogramme (Abraham and Crawford, 1997). Managers should create the belief amongemployees that the appropriate training and education will be provided. Hence,employees will be able to perform well and take advantage of opportunities that mayarise from implementation of the TQM initiative (Self and Schraeder, 2009).

According to Sewell (1997), serious problems in TQM implementation are likely tooccur if there is any attempt to achieve quality without a full understanding of thecustomers’ needs and requirements. However, the paternalistic attitude among manyhealthcare professionals that only they can define quality attributes limits theapplication of customer-driven TQM programmes (Milakovich, 2005). Customer focusin TQM requires that customers are identifiable and can define and recognise quality.However, it is difficult to identify customers and satisfy their needs in healthcaresector. Unlike in most other industries, purchasing decisions, payment and receipt ofhealthcare service are separate. The patient is not necessarily the ultimate “external”customer in healthcare. Other external groups such as the government, employers andthird party payers affect patient expectations and this makes it difficult to anticipatepatient needs. Patients, in general, lack the ability to judge the technical aspects ofhealthcare services (Cheng and Chung, 2002; Naveh and Stern, 2005). Many patients donot even know their own healthcare needs (Berwick et al., 1992) or even their rights inhealthcare organisations (Mosadeghrad and Esna-ashary, 2004). Therefore, healthcareorganisations tend to focus on their internal quality requirements rather thancustomers’ needs (Yang, 2003).

Failure to provide adequate resources to support quality improvement programmesis another cause for the failure of TQM (Alexander et al., 2007; Lee et al., 2002; Moeller,

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2001). Allocating necessary resources are essential for TQM programmes to becontinued effectively. Those healthcare organisations struggling financially will not beable to sustain the benefits of TQM programmes. Purchased materials are often amajor source of quality problems (Flynn et al., 1994; Zhang et al., 2000). An effectivesupplier relationship management system reduces procurement costs, enhances thequality of purchased products and provides differentiated and customized services forhealthcare organisations (Rao et al., 1999; Slaight, 1999).

Several studies reported that a lack of good information system and informationrequired for quality management, influenced the success of quality improvement(Hamidi and Zamanparvar, 2008; Lee et al., 2002; Moeller, 2001). Fundamental to TQMis collecting timely, reliable and relevant data and information from both inside andoutside the organisation for assessing, improving and evaluating purposes ( Joss andKogan, 1995; O’Brien et al., 1995). Such information is necessary for the appropriateusage of resources, identification of customer requirements, evaluating theeffectiveness and efficiency of the operations and determining the cause of qualityproblems. Using a quality-oriented information system helps in studying the processesand identifying and then prioritising quality problems. It allows the sharing of bestpractices among departments and across organisations, and enables the widespreadautomated collection of data to support quality improvement efforts (Dewhurst et al.,2003; Ransom et al., 2005). Using information technology supports TQMimplementation (Rivers and Bae, 1999).

Total quality management focuses on studying, understanding and improving theprocesses. Many TQM writers have pointed out the importance of focusing on theeffective management of processes (Huq and Martin, 2000; Mosadeghrad, 2005; andRaja et al., 2007). Quality should be incorporated in the organisation’s processes andpractices. The prevalent processes, procedures and practices in healthcare can promoteor hinder efforts to improve performance. Major procedural problems that healthcareorganisations may encounter during the TQM implementation tend to be as follows:complexity of processes, bureaucracy, and difficulties in measuring and controllinghealthcare outcomes (Buciuniene et al., 2006; Huq, 2005; Mosadeghrad, 2005;Seetharaman et al., 2006).

Implementing TQM in healthcare organisations requires an understanding of theparticular nature of the sector, which influences the applicability of TQM practices.Healthcare systems are among the most complex systems serving humans. Delivery ofhealthcare services represents a complex collection of diagnostic, therapeutic andlogistic processes, all of which must be highly coordinated to ensure the delivery ofquality healthcare services. The professional dominance environment of healthcare,the complex nature of healthcare practices and ethical considerations add to thecomplexity (Kimberly and Minvielle, 2000). The complexity in health care is anobstacle to systems thinking, which is critical in successful TQM implementation.

Appropriate measurement of processes and outputs/outcomes is key element ofTQM success. However, it is difficult to define, measure and control outcomes inhealthcare due to the intangibility of healthcare services (Morrison and Heineke, 1992).Every patient is different. Patients cannot be treated like manufactured products. It isdifficult to establish a link between the inputs and the outcomes in the health sector asit is done in manufacturing sector. Many variables affect the outcomes in healthcare.The outcomes are also dependent on the compliance and co-operation of patients

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themselves. Appropriate models should be used to measure quality healthcareservices. A clinical governance system should be incorporated in such models fordefining clinical standards and monitoring performance against standards.

Healthcare problems also tend to be more complex and require a high degree ofcustomised solutions (Abd-Manaf, 2005). This aspect of healthcare is in contradictionwith the concept of variation control and standardisation in TQM. Furthermore,customers in health sector are powerless to alter healthcare providers’ behaviourthrough market transactions (Zabada et al., 1998). Patients depend on physicians andnurses. Cultural and socio-demographic factors such as age and gender, severity ofillness, and psychosocial factors such as patient fears and dependence on thehealthcare providers prevent the expression of dissatisfaction (Arnetz and Arnetz,1996; Fung and Cohen, 1998; and Satia and Dohlie, 1999).

Total quality management should be institutionalised in healthcare organisations.The Ministry of Health should incorporate TQM concepts as a strategic issue in itsagenda for change. A Quality Act should be established at the Ministry of Health level tooblige all healthcare organisations to set up a quality management system (QMS) basedon customer focus and continuous quality improvement to ensure high qualityhealthcare services. A National Quality Board should be formed to ensure the overallalignment of the quality management system. This involves the direct involvement andsupport of the minister, considering quality as a key national health priority, setting thenational quality goals, formulating national quality management policies, allocatingresources and clarifying responsibilities. A quality management institute should beformed in the Ministry of Health to oversee quality improvement of healthcare servicesdelivered by healthcare organisations. This involves creating a quality managementsystem for quality improvement and performance assessment, setting quality standards,providing incentives for the introduction and implementation of quality managementprogrammes, training healthcare professionals in quality management concepts, andsupporting healthcare organisations to improve their services. Such a structure shouldalso be established formally in healthcare organisations. To sustain this structure and,consequently, the quality improvement activities, support (physical, financial andhuman resources) should be provided.

The challenges to adopting TQM in healthcare organisations suggest thatmanagers should take a cautious and an incremental approach in its implementation.Radical transformation of processes has been found to have negative and detrimentaleffects on many organisations (Singh and Smith, 2006). TQM does not produce resultsin the short term. It does not offer quick answers to all organisational problems(Hendricks and Singhal, 1997; and Huq, 1996). Implementation of TQM is acomprehensive and long-term process. It can take an organisation years to put TQMfundamental principles, procedures and systems into place, create an organisationalstructure and culture which is conducive to continuous improvement and change thevalues and attitudes of its people to adopt the new behaviour as a consistent way ofworking (Dale et al., 1997). The process of adapting and institutionalising TQM is adifficult, long-term, comprehensive and continuous process that needs patience,constant top management support and commitment. It may take five years or longer toimplement and institutionalise TQM properly throughout an organisation to achievethe benefits (Satia and Dohlie, 1999; and Saravanan and Rao, 2007). Organisationsshould be patient and realistic about what to expect from TQM.

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DiscussionManagers should minimise five gaps to maximise the benefits of a TQM programme(Figure 1). These gaps include: information-related gap, plan-related gap,implementation-related gap, perception-related gap, and expectation-related gap.Gap 1 is the gap between management perception of the TQM model and the actualspecification of the TQM model. It shows the distance between what the TQM modelcontains and what managers think the model is. Proper education and training help tonarrow this gap. Gap 2, shows the gap between management perception of the TQMmodel and the plan designed to implement the model. Despite careful planning, a TQMinitiative can still fail. Gap 3, plan-implementation gap, shows the gap between whatthe plan says for implementing the TQM model and what actually has beenimplemented. Gap 4, perceived results- manager’s expected results, is the gap betweenperceived results of implementing the TQM model and managers’ expected resultsfrom its implementation. Finally, Gap 5 is the gap between perceived results ofimplementing the TQM model and the expected results of the actual TQM model.

The model proposed in Figure 2 helps explain why TQM initiatives fail in practice(Gap 3). Many of the obstacles identified in this study that hinder TQM efforts areleadership factors, or strongly influenced by leadership. Top management involvementand continuous support through setting goals, training, creating a quality culture, andallocating resources improve employees’ satisfaction, which leads to their commitmentto quality improvement.

Theoretical implicationsFrom the theoretical point-of-view, this study contributes to the literature in terms ofidentifying and ranking obstacles to TQM implementation in healthcare organisations.TQM does deliver better performance when an appropriate model of TQM isappropriately implemented in a supportive environment (i.e. supportive infrastructure,appropriate leadership and quality culture).

Figure 1.A gap model for TQM

implementation

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Managerial implicationsFrom a practical point-of-view, the findings of this paper provide policy makers andmanagers with a practical understanding of the factors that are likely to obstruct TQMimplementation. A thorough understanding of these factors increases the probabilityof TQM success by predicting and avoiding those barriers during TQMimplementation. Consequently, this provides direction and guidance in developingstrategies for an effective and efficient TQM transformation. Health care managers willbe able to plan better TQM strategies that will avoid some of the problems identifiedby this article into the implementation of successful TQM initiatives.

ConclusionThis paper uncovers the main impeders to successful TQM implementation inhealthcare organisations. The limited success of TQM efforts in healthcareorganisations are due to a lack of consistent managers’ and employees’ commitmentto and involvement in TQM implementation, poor leadership and management, a lackof a quality-oriented culture, insufficient training in TQM principles and methods, poorplanning for TQM deployment, inadequate resources to implement the TQM initiative,limited time to devote to TQM implementation and improper evaluation. Inflexibleorganisational structure, departmentalised, bureaucratic and hierarchical structure,

Figure 2.Factors inhibiting TQMsuccessful implementation

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physician-oriented healthcare systems, inadequate focus on patients and clients andthe difficulties involved in evaluating healthcare processes and outcomes are alsobarriers to successful TQM implementation in healthcare organisations. Theseperceived barriers could be overcome by healthcare managers’ and providers’willingness to change, and a strong clinical and managerial leadership emphasisingplanning, training, and developing a quality structure and culture. The study suggestsa need for a model of TQM to serve as a guide for the holistic implementation of TQMin healthcare organisations. Such a quality management system should not involveextra work for employees, but should rather be incorporated into the existing workschedules.

Limitations and implications for future researchThis literature review has examined the last 30 years of quality management systemsimplementation literature. One reviewer carried out this literature search, and this mayhave introduced bias into the search process. The review was limited to articles writtenin the English languages. Relevant information from books, journals and websiteswritten in other languages would provide additional valuable information.

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Appendix

Author/s Country TQM obstacles

Abd-Manaf (2005) Malaysia Lack of management knowledge to successfullyimplement quality managementTime-consuming quality improvement effortsDifficulties in implementing quality improvementeffortsMindset barriers

Alexander et al. (2007) USA Lack of sustained leadershipLack of extensive training and supportLack of robust measurement and data systemsLack of incentives and human resources practicesLack of supportive context

Brashier et al. (1996) USA Lack of management commitmentLack of employee interestLack of good plansPhysician indifference towards TQMLack of focus on the processFinancial constraints

Chan and Ho (1997) USA and Canada Insufficient quality improvement skillsPoor planningPlacing a poor priority on continuous qualityimprovementLack of employee participation

Ennis and Harrington (1999) Ireland Organisational resistance to culture changeLack of financial resourcesEmployee resistance to changeLack of human resourcesMiddle management resistance to changeInter-departmental barriersDifficulties in measuring qualityUnlimited demand for healthcare servicesQuality not seen as an issue by staffLack of top management commitmentLack of union co-operationLack of enthusiasm

Huq and Martin (2000) USA Lack of planningLack of a conducive and supportive cultureLack of physicians and nurses involvementLack of employee empowermentPoor education and trainingInadequate methods to measure the cost of qualityAn emphasis on quality of care outcomes ratherthan both outcomes and the process of care services

Joss and Kogan (1995) UK Lack of leadershipLack of senior management commitmentLack of adequate planningProfessionalism/turf battlesLack of education and training

(continued )

Table AI.TQM implementation

obstacles in healthcareorganisations

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Author/s Country TQM obstacles

Kozak et al. (2007) Turkey Lack of support of top managementLack of employees’ participationLack of a measurement systemLack of a reward system

Lin and Clousing (1995) USA Lack of top management involvement andcommitmentLack of employee involvementLack of focus on patient satisfaction

Matherly and Lasater (1992) USA Lack of managers’ participationOverlapping of responsibilities of leadershipLimited resourcesFear of changeWork overloads

Mosadeghrad (2005) Iran Lack of qualified and competent employeesLack of employees’ involvement in qualitymanagement activitiesEmployees’ shortageLack of top management commitmentLack of a strategic plan for changeFrequent top management turnoverLack of a quality cultureIneffective communicationComplexity of processesLack of a quality audit systemLack of financial resources

Nwabueze (2001) UK Poor communicationEmployee shortageLack of up-to-date facilitiesLack of customer awarenessLack of effective leadershipFragmentation of activitiesPoor scheduling

Ozturk and Swiss (2008) Turkey Lack of outcome measuresLack of participative decision-makingDistorted incentive systemsRewarding the wrong peopleRewarding the wrong thingsLimited managerial, financial and organisationalautonomyLack of doctors’ participation in qualityimprovement efforts

Potter et al. (1994) UK Involving only particular individuals or groups inquality improvement projectsInadequate team-briefing approachesLack of staff knowledge of quality managementapproachesCommunications barriersLack of customer focusAuthoritarianismLack of medical staff active involvementIncorporating quality approaches in managerialtasksLack of involvement of middle managers

(continued )Table AI.

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About the authorAli Mohammad Mosadeghrad, BSc, MSc, PhD, is Assistant Professor, School of Managementand Medical Informatics, Tehran University of Medical Sciences, Tehran, Iran. Ali MohammadMosadeghrad can be contacted at: mosadeghrad@yahoo.com

Author/s Country TQM obstacles

Withanachchi et al. (2007) Sri Lanka Lack of leadershipLack of top management supportLack of continuous monitoring and measurementInadequacy of knowledge and training about TQMLack of employee specially doctors’ involvementDifficulty in allocating time for activitiesWork load of preparing TQM related documentsLack of financial and other resourcesDifficulty of changing work habits

Yang (2003) Taiwan Functional, bureaucratic and hierarchical structureAuthoritarian cultureLeadership styleProfessional autonomyLack of consensus for TQM adoption amongphysiciansInternal requirement dominationManpower shortfall Table AI.

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