Total quality management in the health-care context: integrating the literature and directing future research

Figures & data

Figure 1 Consort flow chart of systematic review method.

Abbreviation: TQM, total quality management.

Table 1 Matrix of the reviewed literature

Study number	Authors	Study design	Study respondents	TQM predictors	Findings
1	Alaraki (2014)^Citation41	Cross-sectional design	400 clinical staff (Saudi)	Leadership, information analysis, continuous improvement, supplier management, employee management, process management, customer focus, and education and training	TQM practices have significant positive effect on performance
2	Al-Shdaifat (2015)^Citation42	Cross-sectional design	332 nurses (Jordanian hospitals)	Continuous improvement, training, education, customer focus, teamwork and top management commitment	Of all the TQM practices, continuous improvement is the most important factor
3	Irfan et al (2012)^Citation24	Cross-sectional design	239 doctors (Pakistani public hospitals)	1. HR focus: training, empowerment, reward, recognition and employees’ involvement 2. Management structure: key information to all employees, leadership role and culture 3. Quality tools: quality goals and planning, measuring key results and statistical process control	The selected TQM practices have significant positive impact on TQM implementation and also on operational performance
4	Mrayyan and Al-Faouri (2008)^Citation25	Cross-sectional design	640 registered nurses (Jordanian hospitals)	Leadership, interpersonal relations/communications, critical care, planning/evaluation, professional development and collaboration	The selected six TQM practices have a relationship with nurses’ job performance
5	Danial (2009)^Citation26	Quasi-experimental design	80 nurses (Iranian hospitals)	Management commitment, customerism, education, continuous improvement, cooperation and participation, and evaluation and decision-making	TQM parameters required for the provision of heath care were significantly different
6	Duggirala et al (2008)^Citation44	Pilot survey	Patients (Indian hospitals)	Infrastructure, personnel quality, quality of communication, process of clinical care, administrative procedures, safety indicators, overall, experience of medical care received and social responsibility	The seven TQS practices have positive relationships with patient satisfaction
7	Naser Alolayyan et al (2011)^Citation45	Cross-sectional design	400 nurses (Jordanian hospitals and medical center)	Training, employee management, process management, leadership, supplier management, customer focus, continuous improvement and information analysis	TQM practices in Jordanian hospitals have significant impact on the intensity of the operational flexibility of nurses
8	Sweis et al (2013)^Citation46	Cross-sectional design	320 employees (Saudi hospital)	Teamwork, continuous improvement, training, customer satisfaction and top management support	TQM practices have positive influence on staff empowerment
9	Awases et al (2013)^Citation27	Cross-sectional design	180 nurses (Namibian hospitals)	Knowledge and skills, organizational mission and objectives, staffing and schedule of duty, performance appraisal, nursing management, commitment and satisfaction, remuneration, benefits, reward and recognition, workspace and environment, leadership and management style, and staff development	Four of TQM practices (absence of recognition of staff with excellent performance, lack of performance appraisal indicators, poor condition of work, quality performance outcomes) have negative effect on nurse performance; other practices have positive effect on nurse performance
10	Al-Ahmadi (2009)^Citation28	Cross-sectional design	1834 nurses (Saudi hospitals)	Commitment, job satisfaction, personal and professional variables, and commitment	Commitment, personal and professional variables, and job satisfaction have positive effect on job performance
11	AbuAlRub and Al-Zaru (2008)^Citation30	Cross-sectional design	206 nurses (Jordanian hospitals)	Intention to stay at work, recognition and stress	Job stress and recognition have negative relationship with nurse performance
12	Güleryüz et al (2008)^Citation31	Cross-sectional design	5550 nurses (Turkish hospitals)	Nurse commitment	Nurse commitment has positive effect on job satisfaction
13	Kumar et al (2016)^Citation47	Quasi-experimental design	138 workers (experimental group), 137 workers (control group) (Pakistani hospitals)	TQM intervention program: training	The result showed a significant difference in the scores of the control group (62%) and the intervention group (87%) (p<0.001) with regards to TQM intervention (training)
14	Lashgari et al (2015)^Citation32	Quasi-experimental design	200 patients (Iranian general military hospitals)	TQM intervention: focused on improving patient satisfaction via nursing performance, commitment and service quality in emergency department	TQM resulted in a significant 20% improvement of patient satisfaction score for nursing performance quality (p<0.001)
15	Sagy (2009)^Citation48	Experimental design	–	TQM intervention (training) to improve nurse commitment and performance regarding clinical processes in a children’s hospital	The intervention is found effective in improving nurse commitment and performance regarding clinical processes as the waiting time for insertion of a peripheral catheter was reduced
16	Navipour et al (2011)^Citation33	Experimental design	44 patients (Iranian hospitals)	TQM intervention using the FOCUS-PCDA method on nurses to improve patient satisfaction	Consequent upon the intervention, there was an incremental level of satisfaction, but there was no statistically significant difference with that before the intervention (P>0.05) in the control group and experimental group
17	Danial (2009)^Citation26	Randomized control trial	80 critical wards nurses (Iran)	TQM and nursing performance through education	TQM had a significant impact (p<0.01) on nurses’ educational needs; about 47% of the intervention group performed below average while 70% of the control group performed below average (effect size=0.23, p<0.01)
18	Mosadeghrad (2015)^Citation34	Cross-sectional design	90 managers and quality managers (Iranian hospitals and health-care centers)	Customer management, process management, leadership, employee management, and information management	TQM practices (employee management, customer management, process management, information management, leadership) have “synergistic” effect on TQM success
19	Mosadeghrad (2014)^Citation35	Cross-sectional design	20 workers in Iranian health-care organizations and 30 participants working in three ISO-certified hospitals (50 persons)	Poor planning, inconsistent employees’ commitment, top management turnover, short-term improvement objectivesand inconsistent managers’ commitment	TQM implementation and its impact depend on the ability of managers to adopt and adapt its values and concepts in professional health-care organizations
20	Mosadeghrad (2012)^Citation36	Longitudinal design	517 employees of an Iranian hospital (70 doctors and 170 nurses)	Performance, practice, leadership and management, process management, strategic quality planning, total continuous learning, customer results, customer management, employee results and employee management	SCQM TQM was effective in improving total quality scores from 38% at baseline to 73.7% post intervention
21	Jones et al (2013)^Citation37	Two quasi-experimental designs: cross-sectional comparison and pre–post comparison	37 US hospitals	Teamwork, training and education, and continuous improvement	Intervention group HSOPS scores were significantly higher than static group scores in the three dimensions of TQM
22	Ullah et al (2011)^Citation38	Quasi-experimental design	220 health-care facilities	Strategy, structure, system, staff, skill, style and stakeholder/shared value factors	There was marked improvement in all TQM practices ranging from 20 to 77% following a training program of 3 months
23	François et al (2005)^Citation50	Quasi-experimental design	98 trained employees and 100 untrained employees (in a French 2000-bed university hospital)	Training and education, continuous improvement, nurse leader, technical quality, TQM methods and quality improvement	In the experimental departments the untrained staff’s knowledge of CQI methods and their participation in work groups did not differ from that of control department staff
24	El-Tohamy and Al Raoush (2015)^Citation51	Cross-sectional design	1290 health-care professionals in accredited governmental hospitals in Jordan	Leadership commitment to quality, customer focus, continuous improvement, teamwork, employee involvement, education and training	A significant impact of all TQM principles on the overall hospital effectiveness (p<0.05); using multiple linear regression analysis showed that TQM is a strong predictor of hospital performance (β=0.818, t=46.613, R^2=0.669, p=0.000).
25	Ramseook-Munhurrun et al (2011)^Citation40	Cross-sectional design	200 respondents from public hospital in Mauritius	Teamwork, continuous improvement, management commitment, training, customer focus, employee involvement and organizational culture	TQM dimensions have a significant impact on the perception of management and employees, and management perceives TQM adoption as being relevant and effective, in the case of public hospitals

Abbreviations: HR, human resources; TQM, total quality management.

Table 2 TQM predictors in the reviewed studies

Study number	TQM predictors in the reviewed studies	% of occurrence	Ranking (based on frequency)
1	Education and training	52	1
2	Continuous quality improvement	36	2
3	Customer (patient) focus/satisfaction	32	3
4	Top management commitment	32	3
5	Teamwork	24	4
6	Others (human resources focus [employee management process, reward, etc]; management structure; quality tools; leadership and management style; interpersonal relations/communications; cooperation and participation; information analysis; job satisfaction)	40	5

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