Chapter-2

LITERATURE REVIEW

Total quality management (TQM) is the system of activities directed at achieving

delighted customers, empowered employees, higher revenues, and reduced costs
(Juran, 1995). A recently published study (Bou-Llusar et al., 2009) reviews the
variety of definitions of TQM available in the literature (Oakland, 2000; Dale, 2003;
Eriksson and Garvare, 2005) and concludes that it is a management approach which
prescribes guidelines for organizations to operate and achieve high performance. The
literature suggests that organisational excellence is a key stage on the TQM journey.
Furthermore, it is often applied to TQM enabling actions as an effectiveness measure
(McAdam, 2000). To practice the guidelines in a systematic way many quality awards
and excellence models like, Deming Prize, Malcolm Baldrige National Quality Award
(MBNQA) and Excellence Model by the European Foundation for Quality
Management (EFQM) have been evolved. The scope of TQM and models of
performance excellence has not been restricted to any particular region or a particular
sector of industries. To further study the TQM approach and its application in the
health care industry of India and Iran, the theme of the present research, previous
studies have been reviewed and presented in this chapter.

2.1 Factors of Total Quality Management and Organisational Performance

Based on an extensive literature review of conceptual as well as empirical studies
(Flynn et al., 1994; Powell, 1995; Ahire et al., 1996; Black and Porter, 1996; Zeitz et
al., 1997), Motwani (2001) has identified seven factors critical to TQM
implementation and 45 measures of TQM performance. The seven factors include top
management commitment; quality measurement and benchmarking; process
management; product design; employee training and empowerment; vendor quality
management; and customer involvement and satisfaction. The factors are briefly
explained below in the form of excerpts from the work by Motwani (2001).

(i) Top management commitment: The degree of visibility and support that
management takes in implementing a total quality environment is critical to the
30
success of TQM implementation. Four distinctive ways that management can support
TQM implementation: allocating budgets and resources; control through visibility;
monitoring progress; and planning for change. There should be a focus on transferring
management support to the shop floor. Management should plan to reduce
traditionally structured operational levels and urmecessary positions. Simplifying the
organization will lead to the establishment of an infrastructure of integrated business
functions participating as a team and supporting the strategic vision of the company.

(ii) Quality measurement and benchmarking: A company must embrace strong

acceptance and maintenance of a total quality measurement and benchmarking plan.
Quality programs should measure the percentage or the number of parts that deviate
from the acceptable in order to prevent the recurrence of a defect. The cost of quality
could include relevant changes in market share, warranty costs, and inspection,
reworks, and scrap costs. The cost of nonconforming raw materials could include lost
revenue or productivity costs and would aid in vendor selection and certification.

(iii) Process management: This factor emphasizes adding value to processes,

increasing quality levels, and raising productivity per employee. However, there were
varied tactics emphasized to accomplish this factor. The list contains: improving work
center methods and installing operator-controlled processes that lead to a lower unit
cost, embracing kaizen (continuous improvement) philosophies, reducing the operator
material handling duties, promoting a design for a manufacturing program, and
achieving a compact process flow.

(iv) Product design: Design practices provide an ideal starting point for the study of
quality performance. A wide range of possible choices exist till designs are finalized.
Organizations should consider the factors when plaiming for the product design
processes: understand fully the customer product and service requirements; emphasize
fitness of use, clarity of specifications and producibility; involve all affected
departments in the design reviews; and avoid frequent redesigns.

(v) Employee training and empowerment: Employees must be oriented to a

company's philosophy of commitment to never-ending improvement, be informed of
company goals, and be made to feel a part of the team. Proper training includes
31
explanation of overall company operations and product quality specifications.
Specific measures for evaluating training include: the time and money spent by
organizations in training employees and management in quality principles, problem
solving skills, and teamwork. On the other hand, specific measures of employee
empowerment include: the degree to which cross-departmental and work teams are
used, the extent of employee autonomy in decision making, the extent of employee
interaction with customers, and the extent to which employee suggestion systems are
being used.

(vi) Vendor quality management: Many companies now support, at least in theory,
the need to work more closely with their suppliers. Partnerships with suppliers have
the greatest appeal to most companies due to the shared risks associated with the
development of new products. Vendor partnerships should be based on a quality
program and accepted docimientation of progress towards continuous improvement in
quality.

(vii) Customer involvement and satisfaction: Customer service should be addressed

from two main areas: internal customer service and external customer assurance.
Components of an internal customer service plan should include providing timely and
dependable deliveries, presenting improvements or cost saving suggestions to
management and authorizing employees to self-implement solutions, cross-training
employees for mastery of more than one job and providing adequate technical
training. An external customer service program should include providing customers
with timely information and quick responsiveness to complaints, and maintaining a
corporate goal to reduce the quantity of questions or complaints while recognizing all
successful efforts by employees in providing outstanding service. Measures need to be
those which show where improvement has been made and where improvement is
possible, rather than merely monitoring people's work.

Factors which are critical to success or failure of TQM may be classified as soft and
hard. Nofal et al. (2005) explains the soft factors as those which are intangible and
difficult to measure. Such factors are related to leadership and employee involvement
and include commitment and involvement of senior executives; comprehensive policy
development and effective deployment of goals; entire workforce commitment to
32
quality goals of the organisation; supervisors, unit heads and divisional managers
assume active new roles; empowerment; effective communication; internal customer-
supplier concept; teamwork; system for recognition and appreciation of quality
efforts; and training and education. On the other hand, systems and quality tools and
techniques are referred to as the hard factors of quality. Benchmarking, performance
measurement, quality control tools, cost of quality, supplier and customer
management, and quality management systems are included in the hard category of
factors. Combining various soft and hard factors, Al-Nofal et al. (2005) have
proposed 19 elements of TQM. The elements include leadership; employee
involvement and empowerment; middle management role; training and education;
rewards and recognition; teamwork; role of employee unions; policy and strategy;
resources management; communicating management; managing suppliers; accredited
quality management system; organizing for quality; managing by process;
benchmarking; self-assessment; cost of quality; quality control techniques; and
measuring customer wants and satisfaction. They have examined the impact of such
factors on the success of TQM implementation in different geographical contexts.
They have found that top management commitment, maximising employee
commitment; involvement and empowerment, managing by customer-driven systems
and processes, and continuous improvement, are most essential and ftmdamental to
effective and successful implementation of TQM.

Seetharaman et al. (2006) have investigated why TQM fails in many organizations
despite the proven fact that it is an approach which leads to improvement in various
dimensions of organisaional performance. The research points out that, though most
organizations start TQM efforts for their success, they are frequently exposed to the
factors which may cause their TQM efforts to delay or even fail. TQM is a sure bet to
reverse poor performance, but when it did not yield the expected results, it was
deemed a failure. The review has been done to identify the common problems that
lead to the failure of TQM implementation in the organization and has pointed out the
critical success factors of TQM. Nevertheless, the overall results of this research
imply that the imderstanding of the elements that cause failure to the TQM
implementation can provide needed help for companies involved in long-term
continuous improvement efforts. If the advanced TQM approach is properly followed,
it will help the companies to achieve organizational excellence.
33
Literature on critical success factors (CSFs) of TQM has recently been reviewed and
documented by Karuppusami and Gandhinathan (2006) using Pareto analysis. They
have examined various empirical studies on TQM (e.g. Saraph et al., 1989; Anderson
et al, 1995; Ahire, et al, 1996; Wilson and Collier, 2000; Wall et al, 2003) and have
identified 56 critical success factors. Out of which, 14 CSFs have been found
accounting for 80 per cent and accordingly have been labeled as vital few. The
remaining 42 factors, accounting for 20 per cent of occurrences frequency, constitute
the useful many category. The role of management leadership and quality policy,
supplier quality management, process management, and customer focus and training
has been among the vital few CSFs.

Al-Khalifa and Aspinwall (2008) have developed and validated a survey instrument to
measure CSFs of TQM in the United Kingdom. The empirical results indicate that the
manufacturing sectors in UK are embarked towards quality excellence.

An extensive literature survey of 28 different models of TQM available in the context

of manufacturing sector e has been carried out by Sharma and Kodali (2008). Based
on this, the authors have proposed a list of TQM implementation elements which,
they claim, will direct an organization towards manufacturing excellence, as well as
ensuring that the elements withstand the test of time, pace of technology, market and
customer changes. They have categorised the various frameworks into the following
three broad categories.

(a) Award based: Although award-based frameworks are meant mainly for
organizations seeking to be recognized as leaders in the quality management field. In
this paper, Sharma and Kodali (2008) take the view that the award-based irameworks
are more suitable for self-assessment as well as to gain recognition of a company's
effort towards applying for an award. Award-based models are but one of the tools
within the spectrum of quality initiatives to be employed when an organization has
reached a mature level of TQM implementation. Some of the frameworks included in
their study are Malcolm Baldrige National Quality Award, European Foundation for
Quality Management, and Deming Prize Model for TQM (Stading and Vokurka,

34
2003); Japan Quality Award (Ueda, 2001); Rajiv Gandhi National Quality Award
(Tan and Khoo, 2002); and Iran National Quality Award (ISIRI, 2010).

(b) Researcher/academic-based: Academic-based frameworks are those developed

by academics and researchers mainly through their own research and experience in
the field. The reviewed academic-based frameworks include Critical factors and
performance measures of TQM (Motwani, 2001), Kano's basics for TQM model
(Sharma, 2004), and Components of successful total quality management (Tari,
2005).

(c) Consultant based: Basically, consultant-based frameworks are those derived

from personal opinion and judgment through experience in providing consultancy to
organizations embarking on the TQM journey.

Generally consulting companies either have developed their own frameworks or

follow some other well-known framework to help them in their work. However, the
focus of this paper is the award-based and academic-based frameworks.

The authors (Sharma and Kodali, 2008) have identified 36 frameworks of TQM and
conducted a comparative analysis with an objective to develop a new framework that
can guide organizations towards achieving TQM excellence. This, they consider, to be
the starting point for an organization's journey towards manufacturing excellence.

The main TQM elements as proposed by Sharma and Kodali (2008) are supplier
focus/management, leadership, people/change management, process management,
knowledge management, societal impact/responsibility, continuous improvement,
performance measures, and customer satisfaction/focus.

There are plenty of evidences available in the literature, a few have already been
presented above, to the effect that TQM and performance improvement have a
positive relationship (Brah et al, 2000; Prajogo and Brown, 2004; Hermann et al.,
2006; Soltani and Lai, 2007; Motwani, 2001; Montes et al., 2003; Brah and Lim,
2006; Demirbag et al., 2006; Kapuge and Smith, 2007; Sila, 2007). The Malcolm
Badrige quality award criteria too confirms such relationship between quality
35
management practices and business results (Evans and Jack, 2003). There are,
however, some researchers who found that the implementation of TQM did not
improve performance. For example, Dow et al. (1999); Singles et al. (2001); Samat et
al. (2006).

Zakuan et al. (2010) have developed a model of TQM implementation in relation with
organizational performance. Eight constructs of TQM, namely, quality leadership,
customer focus and satisfaction, quality information and analysis, human resource
development, strategic plaiming management, supplier quality management, quality
results, and quality assurance have been identified by them. Satisfaction level and
business results measure the organizational performance in their study. The study
shows a positive impact of TQM effectiveness on organizational performance.

2.2 Cultural Differences and TQM

Several other researchers have examined the relationship of TQM and its
effectiveness with cultural differences at national and organizational levels. A few are
presented below.

Al-Nofal et al. (2010), have discussed TQM factors in Kuwait and compared the
findings with their similar studies conducted in Malaysia, Palestine and Saudi Arabia .
This comparative study has suggested that culture has big impacts on successful TQM
implementation. Previously, Camison (1998) has suggested that TQM initiatives in an
organization lead to changes in the organizational culture. The author analyses a
system of values key to TQM programme, the available methods for the change, some
essential supports in the process of introduction of TQM programme, and the
conditions to assure the success of any initiative of this kind. Noronha (2003), using a
sample of total quality management (TQM) companies operating in mainland China,
Hong Kong, and Taiwan, has tested a TQM model explaining the influence of
Chinese cuhural values on TQM. The results indicated that the proposed model
demonstrated satisfactory goodness of fit. The underlying Chinese values of
abasement, adaptiveness, harmony with people, harmony with the universe,
interdependence, and respect for authority were found to have important influences on
four quality dimensions, namely climate, processes, methods, and results. A case
study conducted by Boggs (2004) on TQM applications in a church reveals that TQM
36
implementation can lead to a balanced framework of competing values of an
organisation. He has also found that both TQM principles and managerial ideology of
TQM implementation can influence changes in the cultural profile. Rad (2006) has
determined the impact of cultural values on the success of TQM implementation with
reference to the Isfahan University hospitals in Iran. His findings include that TQM
had the most effect on process management, focus on customers and leadership and
management and less effect on focus on suppliers, performance results, strategic
planning and focus on material resources. Human resource problems, performance
appraisal and strategic problems were the most important obstacles to TQM success
respectively. Also, the success of TQM in hospitals with organic organizational
structure and mediimi organizational culture was found higher than mechanistic and
bureaucratic hospitals with weak organizational culture. A comparative study of
cultural differences and quality practices in Korea, USA, Mexico, and Taiwan (Yoo et
ai, 2006) suggests that collectivistic cultures, not power distance cultures, make a
significant difference in employee empowerment which plays an important role in
enhancing quality results. However, employee empowerment practices have not been
uniform across the countries in question.

2.3 TQM Frameworks in Health Care

Health care organizations are peculiar in their nature of operations and customers.
Good health is genuinely a common need for all and customers (patients) can not be
segmented on the basis of social or economical factors unlike in case of other
industries. The health care services are directed to individuals who belong to a wide
range of income and need a variety of medical treatments. Service providers are
expected to focus on moral and ethical aspects of business. TQM implementation and
its effectiveness in health care has, therefore, been a separate subject of research in
service sector. Researches in this area have been addressing the issues like
development of survey instrument, framework of service quality, barriers and
challenges, and adaptation of various TQM models like MBNQA and EFQM
Excellence model (Vallejo etal., 2006; Bou-Llusaret al., 2009).

Good health is a vital necessity of human beings and poor quality of health care is
crucial for their lives. Rising costs, technological advancements, aging population,
37
competitiveness, and commercialization of health services at the cost of business
ethics have drawn attention of academicians, professionals and the governing bodies
towards the management of health care performance.

Healthcare systems have made various efforts to manage their problems. The latest of
the efforts has been the deployment of performance measurement, monitoring and
improvement initiatives. Umbrella organizations such as the World Health
Organization (WHO) and the Organisation for Economic Co-operation and
Development (OECD) have taken an international lead in encouraging health system
performance measurement (WHO, 2000; Smith, 2002; OECD, 2004^ OECD 2004^).

Many industrialized countries are seeking to measure and raise the productivity of
their health systems through performance measurement. A number of countries have
sought to manage this proliferation through the creation of theoretical frameworks
through which measures can be organized and prioritized. The performance of health
care systems in these theoretical frameworks has been classified by certain
performance attributes, among them are the quality of care, access to care and the cost
of care (Kelley and Hurst, 2006).

Quality of care can be defined as "the degree to which health services for individuals
and populations increase the likelihood of desired health outcomes and are consistent
with current professional knowledge" (lOM, 1990; OECD, 2004*').

Extracted from various studies (Arab, et al. 2003; WHO, 2000; AHRQ, 2004;
Donabedian, 2003; National Patient Safety Foundation, 2000; Juran and Godfrey,
2000), Kelley and Hurst (2006) have identified and described the following three
major components of health care performance.

• Effectiveness: The degree of achieving desirable outcomes, given the correct

provision of evidence-based healthcare services to all who could benefit, but
not to those who would not benefit. Effectiveness is the extent to which
attainable improvements in health are attained. Juran and other authors cite

38
 effectiveness as the degree to which processes result in desired outcomes, free
from error.
• Safety: The degree to which health care processes avoid, prevent, and
ameliorate adverse outcomes or injuries that stem from the processes of health
care itself Safety is a dimension that is closely related to effectiveness,
although distinct from it in its emphasis on the prevention of unintentional
adverse events for patients.
• Responsiveness or patient-centeredness: Refers to how a system treats
people to meet their legitimate non-health expectations. Patient centeredness is
the degree to which a system actually functions by placing the patient/user at
the center of its delivery of healthcare and is often assessed in terms of
patient's experience of their health care.

Huq (1996) has developed a framework consisting of 18 measurable TQM

dimensions and validated the instrument through its application in six mid-western
US hospitals. The study suggests that like any other business, health care
organizations too must build distinctive competences to be successful in the market.
For hospitals, such competences may mean quality care at reasonable cost, service
features that are not easy to duplicate, or focusing on the provider-customer
connections.

The survey (Huq, 1996) was able to identify the basic health of TQM programmes at
the hospitals studied without consideration of the unique circumstances that prevail in
these hospitals. These hospitals identified the need to adopt total quality management
to survive in the rapidly changing health care environment. Most of these hospitals are
currently two to four years into the implementation of TQM. During that time, a
quality definition has been developed, quality management has been identified as a
strategic directive, education of managerial personnel has taken place and teams have
begun to operate with some of them having completed their work. Senior
management in these hospitals made a major commitment to provide direction for the
rollout of TQM. AccountabiUties related to TQM were included in performance
appraisals for senior and middle management. Efforts are being undertaken to identify
projects in departments which previously have not participated.

39
Examining the applicability of TQM to health care in the USA and UK, Zairi and
Feeney (1996) have explained the process of quality health care and its measurement.
At that time the conclusion was that in the USA, TQM has already ingrained itself in
the healthcare sector as a result of soaring health care cost, heightened participation of
American patients in health care purchasing, increased competitiveness among
hospitals, and rising malpractice litigation costs. In the UK, the concept of TQM was
in its infancy stage but was expected to gain prominence as internal and external
pressures mount. The recent changes in the UK health service have emphasized the
importance of increased customer choice and patient satisfaction, making their
arguments against TQM imtenable.

Bandyopadhyay (2008) surveyed hospitals in the Michigan city of the USA to explore
the quality management policies and practices. The findings include that 90 Percent of
the hospitals reported that they had focused on quality in their strategic plans, 80
Percent of the hospitals reported that they have a quality policy manual, 80 Percent of
the hospitals reported that they have a quality standards, 85 Percent of the hospitals
reported that they have a quality assurance department, and 85 Percent of the
hospitals reported that they have at least one quality manager. The authors conclude
that Majority of these hospitals have embraced Feigenbaum's comprehensive
approach to quality management commonly known as Total Quality Management
(TQM) which encourages continuous improvement of Quality of health care services
for achieving highest level of customers safety and satisfaction. Michigan hospitals
are continuously upgrading their equipment through lease/purchase, and improving
their nursing and other health care services through rigorous training, and upgrading
their patient billing and recording services using state of the art information
technology to become one of the finest hospitals in the USA.

Ghahramani (2000) has proposed a TQM model based on systems engineering

approach. The author claimed that the model can significantly and objectively
increase efficiency, productivity and profit margins of care providers in the health
care industry. The model is customer driven and results oriented rather than based on
individual employee performance. This model is an evolutionary and objective

40
approach to an industry that is in urgent need of improvements and is currently too
costly to operate.

Sharing experiences from the European health care, 0vretveit (2000) finds that some
hospitals have applied TQM ideas and have been successful to improve quality, given
certain conditions. However, improving patient satisfaction and reducing costs have
been least important reasons for using TQM methods.

In the context of Iran, Lameei (2005) has conducted a survey of 34 hospitals

associated with medical colleges to assess their readiness for TQM implementation. In
the Islamic Republic of Iran the health care system is completely integrated into its
medical education system. Every university/school of medical sciences (USMS) is
responsible for providing both education and health care services. In 2001, TQM was
informally introduced in this integrated system of medical education and health care
services. The findings revealed that 48% had 50 to 59% readiness, 26% were found
60 to 70% ready for TQM implementation, and the remaining 26% were more than
70% ready. Another finding was that, there was a discrepancy between top
management teams, understanding of TQM and their actual actions in taking steps
regarding its implementation. In conclusion, although the universities/ schools of
medical sciences are taking steps toward setting the stage for TQM implementation,
each one with its own pace, but the top management team must take more active role
than the past in preparation for and implementation of TQM.

Rad (2005) has studied barriers to successful implementation of TQM in Irani health
care organizations. Using two questionnaires- one each to study success factors and
barriers, the survey was conducted in health care service organizations in the Isfahan
province. The findings suggest that process management and focus on employees had
a positive and the greatest effect on TQM success. Whereas, strategic and structural
problems were the most important obstacles to successful implementation of TQM.

Two articles have recently been published from Iran which lead to comparative
analysis of different hospitals, within and outside the country, on TQM
implementation and organizational excellence. Maleki and Izadi (2008) have studied
two ISO 9001 certified hospitals, Alborz and Panzdah-e-Khorad, situated in the
41
capital city Tehran. The data gathering tool consisted of an EFQM questionnaire filled
in during group working sessions, interview with hospital managers, and also the
available documents kept at different wards. Data were collected on four criteria of
results- performance, customer, society, and people in the hospitals. The findings
showed that Panzdah-e-Khordad hospital achieved a higher score (236.lout of a total
of 500 points) compared to Alborz hospital with 212.2 points. The authors conclude
that the health care area is one of the best fields for application of the model towards
the performance excellence and gaining better organizational results and hence, it
seem that the model has a high potential in responding to problems commonly seen in
health sector. Hamidi and Zamanparvar (2008) examined hospitals from Asia, Africa,
North and South America, and Europe to study the appropriateness of various models
and approaches of TQM. The authors found that the main purposes for which quality
is promoted in the sample hospitals include improvement in service efficiency,
delivery, quality of work life, and change in organizational culture. Regarding the
approaches and models of quality management, the authors reported that cultural
change, quality assurance, and ISO 9000 have been the major focus of the hospitals in
question. The major problems revealed in establishing the quality management were
resistance against the change, lack of commitment from the senior management, lack
of strategic planning and lack of resources.

In Indian context, three recent articles have been found very relevant to the theme of
the present research. In 2007, Manjunath et al. studied a 300-bed hospital in the
southern part of the country to evaluate its performance and compare it with the
MBNQA criteria. The case study illustrates the measurement of quality performance
through MBNQA to the health care administrators that is the first step for managing
and improving quality in health care organisations. It provides lessons for those
hospitals that have already started quality initiatives. The results identify the strengths
and opportunities for improvement through MBNQA criteria. The total points scored
are 753 out of 1,000 points. This reveals that quality performance of case hospital is
of higher level. However among all the seven criteria, the hospital has still more
opportunity to improve the quality in the fourth criterion -measure, analysis and
knowledge management (Manjunath et al, 2007).

42
Duggirala et al. (2008) have proposed a questionnaire for hospitals to examine the
quality of care being delivered by them to the patients. The questionnaire was
administered to the respondents in government and private hospitals located in major
cities in the states of Tamil Nadu and Gujarat in India. The respondents included
medical, nursing, and paramedical and support staff of the hospitals surveyed. A total
of 100 responses have been obtained after sending out 300 questionnaires to different
hospitals across India. This yielded a response rate of 33 percent. Hospitals with 50
beds and above have been chosen to be part of the study. The questionnaire is a seven
point Likert scale (from 1 indicating very low to 7 indicating very high). The findings
highlight 14 distinct dimensions of provider-perceived TQM and the relationships
among them. Positive and significant relationships among the dimensions and hospital
performance have been found using multiple regression analysis. The following are
the critical factors of provider-perceived TQM in hospitals that have been identified in
this paper- Top management commitment and leadership. Human resource
management in the hospital. Process management. Hospital facilities and
infi"astructure. Patient focus. Employee focus. Measurement of hospital performance,
Hospital information system. Errors, safety and risk management. Service culture,
Continuous improvement, Benchmarking, Union influence, and Governance and
social responsibility. The authors have also examined the impact of the 14 provider-
perceived dimensions of TQM in healthcare on hospital performance. The level of
hospital performance is operationalized in terms of seven dependent variables: patient
satisfaction with overall quality of healthcare provided by the hospital to the patients
over the last 1 year , satisfaction of doctors with respect to overall hospital
functioning , satisfaction of nurses with respect to overall hospital functioning ,
satisfaction of paramedical and support staff with respect to overall hospital
fiinctioning, level of overall financial performance of the hospital , level of medico-
legal cases against the hospital, and level of recognition of the hospital in society.

Extending the framework proposed by Duggirala et al. (2008), Padma et al. (2009)
have developed a more comprehensive conceptual survey instrument to determine the
quality of health care in India from the viewpoints of patients as well as their
attendants. The eight dimensions of their framework of service quality in the context
of health care include infi-astructure, personnel quality, process of clinical care,
administrative procedures, safety indicators, corporate image, social responsibility,
43
and trustworthiness of the hospital. The authors mention that items in every factor
from the existing Hterature on healthcare services, related services, Malcolm Baldrige
National Quality Award and Joint Commission International frameworks have formed
the basis of their framework. Thus the study claims that the proposed model goes
beyond the SERVQUAL dimensions and their items and can be used by hospital
administrators and managers to measure the level of service delivered by them. A
seven-point Likert scale (ranging from 1 indicating "very low" level of service to 7
indicating "very high" level of service) has been suggested to measure the perceptions
of services offered.

2.4 Conclusions from the Chapter

Studies have suggested quite a large number of
factors/elements/constructs/dimensions of TQM implementation. Many of them have
appeared more frequently than others. TQM and performance improvement have a
positive relationship, particularly, the Malcolm Badrige quality award criteria
confirms such relationship between quality management practices and business
results.

A study by Salaheldin (2009) indicates that there are many empirical studies which
examine TQM practices-performance relationships in large firms but the small and
medium firms still need a little more attention of researchers.

Culture, national as well as organizational, too has a big impact on TQM

implementation and its effectiveness. The literature suggests both ways- TQM
changes organisational culture and culture contributes significantly in effectiveness of
TQM plans.

Service sector as such is found lagging behind in effectively implementing the TQM
practices (Yasin et al, 2004; Samat et al, 2006) for various reasons. The situation
worsens further when we look at the services, like health care, that are directed at
customers (Khamalah and Lingaraj, 2003). While the literature concerning service
quality dimensions in the healthcare industry is replete with studies from the
developed world, researchers from developing countries have been exploring the
applicability of the related models and frameworks in their specific context. In Indian
44
context, there is a dearth of an independent model of service quaHty as almost all the
existing studies applied SERVQUAL framework, except that of Duggirala et al.
(2008) (Padma et al., 2009). Iran too does not seem to have any established
framework for measuring quality efforts and performance of its health care industry.

Zakuan et al. (2010) suggest that despite the number of publications and quantity of
research on TQM, there is actually little empirical work that has been carried out in
developing countries, particularly in the ASEAN region.

45