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Barriers in implementing Total Quality Management in Kraaifontein public health care facility in the Western Cape.

Vuyi Skiti

Mini Research report presented in partial fulfilment of the requirements for the degree of Masters of Business Administration at the University of Stellenbosch

Supervisor: K o n radV o n L eip zig

Degree of Confidentiality: A

D ate: D e ce m be r 20 0 9

Declaration
By submitting this research report electronically, I, Vuyi Skiti, declare that the work contained herein is in its entirety my own hence original work, that I am the owner of the copyright thereof (unless to the extent explicitly otherwise stated) and that I have not previously in its entirety or in part submitted it for obtaining any qualification.

VVB.Skiti

June 2009

Copyright 2009 Stellenbosch University All rights reserved

Acknowledgements
First and foremost, I would like to thank God for granting me the wisdom, strength and courage throughout this research report. I would like to express my sincere gratitude to my study leader Konrad Von Leipzig for believing in me, whose expertise guided and assisted me through the research and giving me invaluable insights. Thank you for your understanding and patience. This work would not have been possible without the assistance of Dr. Tony Booysen and the staff at Kraaifontein day hospital, thank you for awarding me the opportunity to conduct a study at your facility and for your contribution towards my study. I must acknowledge my fellow class mates and study group, for their assistance and insights throughout the course without you this was not going to be possible. I am grateful to my husband, Steward for his unconditional and unselfish love and endless support, understanding and tolerance throughout the research and for your unconditional assistance throughout the MB program. A special thanks to Ms. Jersusha Soomar, Mr. Willem Odendaal and Mr. Rajaan Naidoo for assisting with editing of the report. In conclusion I would like to thank my family, my beloved siblings and mostly my son, Thabang for your continued moral support and motivation. I would like to dedicate this thesis to my late mother, without you this would have just been a dream but now its a reality.

Opsomming
Doel Die gesondheidsorg sektor het vele uitdagings wat wissel van stygende mediese

kostes, lae standaarde in hospitale, die agteruitgang van gesondheidsorg dienste, en die toename in sterftes in hospitale. Hierdie en ander probleme stel groot uitdagings aan diegene verantwoordelik vir die lewering van gesondheidsorg, met die gevolg dat diesulkes nuwe bestuursmetodes moet vind om te verseker dat hulle organisasies steeds koste-effektief en doeltreffend funksioneer. Totale Gehalte Bestuur (TGB) is n geskikte en toepaslike alternatief om genoemde probleme aan te spreek, en word toenemend as oplossing gesien om organisasies se dienslewering te verbeter, en pasint-tevredenheid te verseker. Die implementering van TGB blyk egter nie altyd suksesvol te wees nie. Daar is spesifieke struikelblokke identifiseer wat as redes aangevoer word vir die onsuksesvolle implementering van TGB in verskeie sektore, insluitend die van gesondheidsorg. Die hoof doel van hierdie navorsing was om die struikelblokke te ondersoek wat verhoed dat TGB suskesvol toegepas word in Kraaifontein gesondheidsdienste in die Wes Kaap, 2008.
Ontwerp/Metode/Benadering Die studie was n kwasi kwalitatiewe en kwantitatiewe

gevalle studie; vir die kwantitatiewe komponent is n 5 punt Likert tipe skaal gebruik om die response (verskil beslis = 1; stem beslis saam = 5) te kwantifiseer. Die kwalitatiewe komponent het n fokus groep bespreking behels, waartydends die resultate van die vraelys geverifier is, wat die uitdagings van die implementering van TGB uitgewys het. Die statistiese populasie vir hierdie navorsing was al die gesondheidsorg werknemers in diens van die aptekers-departement; wat betrokke was in die implemetering van TGB in hulle organisasie. Die data is analiseer met toepaslike statistiese metodes. Die gemiddelde telling van elkeen van die dimensies was gebruik as n verteenwoordigende aanduiding van prestasie, en die kofisint van veranderlikheid was gebruik as n algemene maatstaf van die gestandardiseerde skeefheid soos gemeet op elkeen van die dimensies. n Ho gemiddelde telling was n aanduiding van die beoogde uitkomste, en lae tellings aanduidend van swak uitkomste.
Bevindinge Belangrike uitdagings wat ondervind is tydens die implementering van die

TGB in hierdie gevallestudie sluit in, die gebrek aan aktiewe betrokkenheid en toewyding van die topbestuur vir hierdie inisiatief, rigiede organisatoriese strukture, die kultuur teenoor gehalte veranderinge wat kommunikasie tussen bestuur en werknemers

belemmer, wat op sy beurt werknemer-bemagtiging verhoed. Ander struikelblokke wat geidentifiseer is, was n afwesigheid van voortdurende verbeteringsprosesse en inisiatief, swak evaluering, n gebrek aan n sisteem vir erkenning en vergoeding vir spanwerk, swak data insameling en ontleding, wat tot probleme gelei het om die data in betekenisvolle inligting te verwerk wat kon lei tot n verbetering in gehalte. Die afwesigheid van n geintegreerde prestasie-beoordeling sisteem is ook as probleem indentifiseer omdat werknemers nie ingelig was oor wat die prestasie-beoordelings behels nie. Die gebrek aan navorsings-gesteunde besluitneming, swak kommunikasie, en onbuigsame organisatoriese strukture en kultuur, was ook gesien as struikelblokke.
Navorsing-beperkinge/implikasies Alhoewel die studie in Kraaifontein gesondheidsorg-

fasiliteit gedoen is, word dit aanvaar dat die bevindinge van hierdie studie ook van toepassing is op ander gesondheidsorg departmente en fasiliteite. Die resultate kan gesondheidsorg bestuurders help om die uitdagings en struikelblokke te identifiseer in die implementering van TGB Hierdie identifikasie kan lei tot n meer effektiewe en suksesvolle implementering van TGB in gesondheidsorg fasiliteite.

Abstract
Purpose The health care industry is faced with numerous challenges ranging from rising

medical costs, poor state of hospitals, deteriorating health care services and an increasing number of hospital deaths. All these disparities present tremendous challenges for the health care managers in charge of the health care services. As a result, they are forced to try new management methods that will assist their organizations to remain cost effective and efficient. Total Quality Management (TQM) constitutes an appropriate response to these challenges and it has become the strategy of choice to improve organizations performance and patient satisfaction. However, in practice the implementation of TQM is often unsuccessful. Certain barriers have been identified which prevent the successful implementation of TQM in other industries as well as in the health care industry. The main aim of this research is to investigate the barriers to the successful implementation of Total Quality Management in Kraaifontein health care service organization in the Western Cape Province, 2008.
Design/methodology/approach The study employed a quasi- qualitative and quantitative

case study. For the quantitative section a questionnaire with a 5 point Likert style scale was used to quantify the response (strongly disagree=1; strongly agree =5). For the qualitative section a focus group discussion was conducted to verify the results obtained from the questionnaire which addressed the challenges of TQM implementation. The statistical population of this research consisted of all health care workers working the pharmacy department who were involved in the implementation of TQM in their organization. Data was analyzed using appropriate statistical procedures. The mean score of each of the dimensions was used as a representative performance indicator and the coefficient of variation (CV) was used as a general measure of standardized skewness on the performance of each dimension. A high means score indicated desired outcomes while low scores indicated poor outcomes.
Findings Major barriers that were encountered during the implementation of TQM in this

case study included the lack of top management active involvement and full commitment in the initiative, rigid organizational structure, culture towards quality changes that inhibited communication between management and employees which in turn hindered employee empowerment. Other obstacles that were encountered were lack of continuous improvement processes and initiative, improper evaluation, the lack of a recognition and reward system for of team work, poor collection and analysis of data that resulted in

difficulty to convert this data into meaningful information to improve quality. The absence of an integrated performance measurement system also exhibited a problem as employees were not aware what was being assessed during performance appraisals. Lack of evidence based decision making, poor communication and inflexible organizational structure and culture were also viewed as barriers.
Research limitations/implications Although conducted in Kraaifontein health care facility,

it is expected that the results of the study may be relevant on a broader scale to other health care departments and facilities. The results could assist the health care managers to develop a plan that addresses the barriers and challenges faced during the implementation of TQM, yielding fruitful results which allow TQM to be implemented easily, effectively, efficiently and successfully in health care facilities.

Table of contents

Conten ts
Declaration .................................................................................................................. ................ ii Acknowledgements ............................................................................................................. ...... iii Opsomming .................................................................................................................... ............ iv Abstract ..................................................................................................................... ................. vi List of Tables ............................................................................................................... ................ x List of Figures .............................................................................................................. .............. xi ABBREVIATIONS .......................................................................................................................XII DEFINITION OF TERMS ............................................................................................................XII 1 Patient .................................................................................................................... .............. xii 2 Health care................................................................................................................ ........... xii 3 Total Quality Management ...................................................................................................xii CHAPTER 1 : INTRODUCTION AND BACKGROUND............................................................... 1 1.1 INTRODUCTION...............................................................................................................1 1.2 STATEMENT OF THE PROBLEM .........................................................................................3 1.2 AIM OF THE STUDY ............................................................................................................. 4 . 1.3 OBJECTIVES..........................................................................................................................4 1.5 ASSUMPTIONS AND DELIMITATIONS.................................................................................5 1.6 PLAN OF STUDY .................................................................................................................. 5 . ........................................................................................ ERROR! BOOKMARK NOT DEFINED. . CHAPTER 2 : LITERATURE REVIEW .......................................................................................7 2.1 INTRODUCTION TO TOTAL QUALITY MANAGEMENT....................................................... 7 2.1.2 An introduction to TQM ...................................................................................................8 . 2.2 KEY CONCEPTS AND VALUES OF TQM ........................................................................... 10 2.2.1 Commitment to the customers satisfaction ...................................................................13 2.2.2 Commitment to continuous improvement:......................................................................14 2.2.3 Top management commitment ......................................................................................15 2.2.4 Commitment to employee involvement ..........................................................................16 2.2.5 Commitment to understanding and improving the organizations processes .................17 2.2.6 Evidence based decision making...................................................................................17 2.3 BENEFITS OF TQM ............................................................................................................ 18 . 2.4 DEFINITION OF TQM IN HEALTH CARE ............................................................................20

2.5 SIGNIFICANCE OF TQM IN HEALTH CARE....................................................................... 22 2.6 BARRIERS TO IMPLEMENTATION OF EFFECTIVE TQM INITIATIVES ........................... 24 2.7 QUALITY CHALLENGES IN SOUTH AFRICAN HEALTH SERVICE CONTEXT ................ 26 2.7.1 Lack of senior management commitment ......................................................................26 2.7.2 Organizational structure and culture ..............................................................................27 2.7.3 Lack of education and training of employees about TQM ..............................................29 2.7.4 Lack of employee empowerment ...................................................................................30 2.7.5 Leadership style .............................................................................................................30 2.7.6 Reward and recognition .................................................................................................31 2.8 LEAN PRODUCTION ...........................................................................................................31 CHAPTER 3 : RESEARCH DESIGN AND METHODOLOGY ................................................... 35 3.1 SETTING .................................................................................................................. ............ 35 3.2 STUDY DESIGN .................................................................................................................. 35 . 3.3 STUDY SAMPLE ............................................................................................................. 36 ..... 3.4. MEASUREMENTS............................................................................................................ 36 ... 3.5 ETHICAL ASPECTS ............................................................................................................ 36 . 3.6 DATA COLLECTION ........................................................................................................... 36 . 3.7 DATA ANALYSIS ................................................................................................................. 37 . 3.8 ACCEPTANCE OF THE STUDY ..........................................................................................37 3.9. RESOURCES ............................................................................................................... ....... 38 3.10 LIMITATIONS .................................................................................................................... 38 . CHAPTER 4 : STUDY RESULTS ..............................................................................................39 CHAPTER 5 : SUMMARY AND CONCLUSION ....................................................................... 49 5.1 INTRODUCTION ................................................................................................................. 49 . 5.2 DISCUSSION............................................................................................................... ......... 49 5.3 CONCLUSION ............................................................................................................... ....... 55 5.4 RECOMMENDATIONS.........................................................................................................57 LIST OF SOURCES .............................................................................................................. 60 .....

List of Tables
Table 2.1 : Essential elements of TQM Table 4.1 : Results on top managements involvement Table 4.2 : Summary of results on employee empowerment Table 4.3 : The responses to the questions addressing data quality Table 4.4 : Results on questions addressing use of quality data Table 4.5.1 : Recommended actions to be taken 20 44 45 48 49 64

List of Figures
Figure 2.1 : Deming Quality Chain Reactions Figure 2.2 : Six values of TQM Figure 2.3 : Benefits of TQM 8 15 22

ABBREVIATIONS Abbreviation Full word

ISO

International Organization for Standardization

SPC

Statistical Process Control

TQM

Total Quality Management

CSF

Critical Success Factors

EQA

European Quality Award

MBNQA

Malcolm Baldrige National Quality Award

DEFINITION OF TERMS 1. Patient

A patient is any person who receives medical attention, care or treatment.

2. Health care

Is the prevention, treatment and the management of illness and the preservation of mental and physical wellbeing through the services offered by medical, nursing and allied health professionals.
3. Total Quality Management

It is a business management strategy geared to ensure that the organization processes constantly meet or exceeds customer requirements. Total quality consists of two qualities:

xiii

Quality aimed to satisfy the customers and share holders; and Quality of the product or service itself Put simply, TQM is as an action plan to produce and deliver commodities or services, which are consistent with customers needs or requirements by better, cheaper, faster, safer and easier processing than competitors with the participation of all employees under top management leadership (Dilber, Bayyurt, Zaim, Tarim, 2005).

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CHAPTER 1

INTRODUCTION AND BACKGROUND

1.1 INTRODUCTION

In recent years, health care has been undergoing fundamental changes and restructuring. Escalating health care costs, the emerging customer focus and consumerism has prompted significant changes to the health care system and to the manner in which the health care services are delivered. A study by Harvard Medical School Research in 1991, suggested that as many as 80 000 people per year in the United States America alone died from medical negligence, these results illustrates that the inefficiencies of the health care system cost lives (Brashier, Sower, Motwani and Sovoie, 1996). Additionally poor medical care, misdiagnosis, substandard surgery, improper drug therapies as well as hospital-acquired infections are resulting in longer and more frequent hospitalization (Rad, 2005). All these problems come at a cost that is financially draining on the Department of Health and life threatening to the most vulnerable patients. Looking at the South African context almost daily, newspapers and television news broadcasts feature dramatic accounts of the critical poor state of health care facilities. In some hospital the number of hospital bed has been reduced, some hospitals were subjected to the closing down of entire floors. This has resulted in unreasonably long waiting lists for surgery and other specialized medical treatment, as well as dissatisfied health care workers that are underpaid and over worked. Coupled with this is the fact that the majority of the population (75%) are dependent on public health services while, only 15% of the population is covered by medical insurance and relies mostly on private hospitals. The high cost of private medical care results in large numbers of South African citizens accessing health care from the public health care facilities (Mabope, Matsebula, and Willie, 2005). In addition, there has been an increase in medical costs, which is consistently outstripping growth of the Gross Domestic Product. This increase has created a serious financial tension resulting in less or no money available for important new health programs and cutbacks in existing programs, which has lead to angry, highly stressed and overstretched health care personnel, as they cannot deliver the services that they desire. As a direct effect, these results in frustrated and anxious patients and their families, as they feel that their rights of

accessing good quality health care and needs are not being met (Grandin, Westwood, Lagerdien, Maylene, 2006). Finally, with the advent of democracy in South Africa consumers are increasingly becoming aware of their rights and the gap between the actual and ideal health care practice. This has led to the intensifying pressure for the Department of Health to improve quality of service provision. All these disparities present tremendous challenges for the health care managers in charge of the health care services, and they are forced to try new management methods that will assist their organizations to remain cost effective and efficient. In the quest for solutions to these problems, the Department of Health has identified improvements in quality of health care as one of its key challenges facing the health sector in South Africa (Department of Health, 2007). Total Quality Management constitutes an appropriate response to this challenge. It is an approach through which an organization tries to implement procedures and techniques in a manner that satisfies the customers, and employees needs as well as to achieve excellent overall performance. This means to achieve the lowest possible cost for both the patient and the service provider while achieving desired results (Dale, 1999; Dahlgaard, Kanji and Kristensen, 1999; Youssef and Zairii, 1995). In the public health care environment, it has become abundantly clear that there is an urgent need to improve the quality of care that health care providers are providing to the patients. Emerging interest in Total Quality Management has been propelled by the need to control costs and the desire to improve the quality of care (Zabada, 1998; Hassan 2000; Rad 2005). These TQM processes and techniques are not only applicable to the administrative functions, but also applicable to the clinical aspect of the organization as they contribute to the prevention of costly and fatal mistakes that generate so much loss of life and lawsuits (Brashier et al, 1996; Zabada, 1998). A number of studies showed that TQM has been positively associated with performance outcomes, such as financial performance and profitability, as well as with human outcomes, including employee satisfaction, employee relations, and customer satisfaction (Hassan, 2003; Rad, 2005). However, the enthusiasm and the excitement for TQM seem to have fizzled over the years. The Department of Health, through health care organizations has a

sincere interest in providing quality services, but the majority of their organizations TQM initiatives and ideas were not successful (Department of Health, 2007). The majority of these organizations invested substantial amounts of time, energy and money to develop and support TQM programs in order to enhance management, increase efficiency and foster team spirit. Yet these TQM programs have lost momentum and the status and success of TQM is questionable for many health care organizations (Anwar, 1996). Numerous studies have asked the question Why it is that health care has not experienced overwhelming, "long term" success with TQM. The application of TQM principle is faced with some basic obstacles that are apparently inherent to the nature of healthcare organizations and to the process of change in general (Anwar, 1996; Rad, 2005). Youseff and Zairii (1995) concur that a number of organizations that have tried to implement TQM have experienced numerous obstacles ranging from management to structural barriers. These findings were supported by Zabada et al, (1998) and Shortell, O'Brien, Carman, Foster, Hughes, Boerstter, O'Connor, (1995), found adequate evidence in their studies that, there were obstacles to the application of TQM in health care. Resistance to the implementation of TQM in the health care industry is evident and it is well documented. Ennis and Harrington (1999) survey in the Irish health care found that there were great difficulties in the implementation of TQM in health care and these hospitals experienced resistance to the implementation of TQM. Ovretviet (2000) reiterated and acknowledged that there are difficulties that the hospitals are faced with when implementing TQM. The need to persist with TQM for the improvement of the quality of life is empirical. However, the need for TQM and for it to have full impact on the healthcare organizations, it is critical that these present obstacles be removed.

1.2 STATEMENT OF THE PROBLEM

Although TQM has been an effective tool for improving quality of care in the health care service industry (Yang and Christian, 2003), many hospitals are still struggling to provide quality care that is desirable for all the stakeholders involved. It is well documented that many organizations have attempted to implement TQM, but they were not successful in their implementation (Zabada et al, 1998). Youseff and Zairii (1995) concur that a number of organizations that have tried to implement TQM were faced with a number of obstacles ranging from management to structural barriers. This is in agreement with Zabada et al (1998) and Shortell et al (1995) who found out that there were obstacles to the application

of TQM in health care. Ennis and Harrington (1999) survey in the Irish health care found out that there were major difficulties in the implementing TQM in the health care and these hospitals experienced resistance to the implementation of TQM. Ovretviet (2000) supports that there are difficulties that the hospitals are faced with when executing TQM and many health care facilities have difficulties in implementing TQM initiatives. Furthermore, there are no studies conducted in South Africa especially in public hospitals that assess and address the barriers to the implementation of TQM. There is also minimal knowledge on and related to the implementation of TQM in the public health care. This research strives to contribute to the knowledge of barriers that prevent proper implementation of TQM in the health care industry. It bridges the gap between the ideal implementation of TQM and its benefits to the current reality of TQM implementation and performance in the health care facilities. The results from this study could be used to improve the implementation of TQM in other health care organization, as the barriers to implementation of TQM will be better understood, subsequently allowing health care managers to deal with barriers in an appropriate manner. The identification of these barriers will assist the health care planners to plan better TQM strategies that will avoid some of the problems identified by the research into the implementation of successful TQM initiatives. This study will also lay a foundation for future TQM research in the Western Cape, then to South Africa.

1.2 AIM OF THE STUDY

This study attempts to investigate the barriers to successful implementation of TQM in Kraaifontein public health care service facility. 1.3 OBJECTIVES

To establish the effects of TQM implementation on overall performance in health care services organizations To determine the expectations, preferences and perceptions of health care stakeholders about quality of health care To establish the limitations and barriers in the applicability of TQM in Kraaifontein health care services organization

1.5 ASSUMPTIONS AND DELIMITATIONS The questions addressed in the survey were designed on the principle and concept of TQM. It does not contain the technical aspects towards implementation of TQM except for where the researcher measures some quality activities that were frequently adopted in the health care environment. The research did not address other hospitals, clinics and private clinics. In addition, it will not be addressing the barriers to implementation of TQM in other departments in Kraaifontein clinic. It is only focusing at the pharmacy department. This department is the only department that that has implemented a quality improvement initiative.nThe period over which the study was conducted was limited to only three months and this limited the extent and the scope of the detail of the study.

1.6 PLAN OF STUDY

HA ER 1 P Introduction HAP ER 2 Literatu Review re HAP ER 3 Methodology CHAPTER 4 Result s CHAPTER 5 Conclusi & Recommendations on

List of sources

CHAPTER 2 LITERATURE REVIEW

2.1 INTRODUCTION TO TOTAL QUALITY MANAGEMENT
This chapter reviews the literature relevant to the study. It deals with the key definitions of quality, the key concepts of Total Quality Management, the influential factors of TQM and their relevance to health care, relationship between TQM and Lean manufacturing will be further explored and lastly the barriers that are often encountered in implementing TQM will be examined. In order to understand and appreciate the value of TQM, one needs to define and have a clear understanding of the importance of quality. Quality has been defined differently by different authors, practitioners as well as academics, with everyone having their own version of definition depending on their beliefs and perceptions about quality informed by their experiences. Experts of the quality management disciplines such as Garvin, Juran, Crosby, Deming, and Ishikawa defined the concept of quality in different ways. Despite these existing definitions of quality, for this report quality will be defined as having two meanings: 1. The characteristics of a product or service that bear on its ability to satisfy stated or implied needs (Griffin, 1995; Reeves and Bednar, 1993). 2. A product or service free of deficiencies Crosby in 1984 defined quality as conformance to requirements or specifications; in his approach he explicitly highlights the importance of people and organizational change with special reference to cultural change and commitment of top management to quality. Demings (1988) point of view is that quality is a predictable degree of uniformity and dependability, at low cost and suited to the market. His reference point is from a statistical point of view which deals with the reduction in the variation of the product using statistical process control. He also came up with 14 quality concepts which were the explanation to the development of TQM concepts (Dilber et al, 2005). Juran (1993) defined quality as fitness for use. He pays more attention on a trilogy of quality planning, quality control, and quality improvement (Dilber et al, 2005). The quality of a product or service refers not only

to the manner in which the product or service is made and delivered, it also relates to the perception of the degree to which the product or service meets the customer's expectations (Reed, Leemark and Montgomery, 1996; Reeves and Bednar, 1993). They further stated that quality has no specific meaning unless related to a specific function and or object, this statement present quality as a conditional and somewhat subjective attribute. Asuboteng, Mc Cleary and Munchus (1996) stated that in the Deming Model Quality is not a destination but rather a journey. This means that organizations need to make sure that they keep up with customer needs as their needs are constantly changing in order to remain in business. This is illustrated by the figure below.

Improved quality

Cost decrease of fewer network fewer delays and snags better use of machine time and material

Productivity improves

Capture the market with better quality

Stay in business

Provide jobs

Figure 2.1 Demings quality chain reaction (Asubonteng, Mc Cleary & Munchus, 1996)

Many different techniques and concepts have evolved to improve product or service quality, these techniques include Statistical Process Control (SPC), Zero Defects, Six Sigma, Lean production, Malcolm Baldrige National Quality Award, quality circles, Total Quality Management (TQM), Theory of Constraints (TOC), Quality Management Systems, ISO 9000 continuous improvement and others (Hansson 2003). For the interest of this paper, TQM will be reviewed in detail.
2.1.2 AN INTRODUCTION TO TQM TQM was originally introduced as a quality management model or philosophy with methods pioneered by quality management experts such as Deming, Juran, Crosby and Oacklands as a way to eliminate waste in the use of resources. It mandated the involvement of all members of the organization to work towards a common goal. As a result, it provided an ultimate way of quality thinking shared by all personnel in the organization to meet the customers specified requirements (Kanji, Gopal, Asher, Mike, 1993; Adinolfi, 2003). The first industry that implemented TQM was the manufacturing industry in the middle of the 1980s. It was later adopted by other industries following

its success in the manufacturing sector. government (Yang and Christian, 2003).

It was then used in service industries followed by the

TQM originated after quality control and quality assurance as a measure to improve quality. Sallis (1993) differentiates the three quality ideas that are quality control, quality assurance and TQM. According to him, quality control is the oldest concept that involves the detection and elimination of some of the components of the final product or the actual final product if it does not meet the required standard. This was not an ideal concept, because the production of defective product is quite costly, as this product is manufactured close to completion or until it is completed, yet it is not functional and it will be either discarded or reworked. This gave rise to the concept of quality assurance. Quality assurance is done before, during and after the production of the product or the service to prevent faults from occurring, to make sure that the product is made to meet a predetermined specification. With quality assurance, there are individuals that are designated to check the quality of the product throughout. Although this process is effective, it is costly in terms of work force and time. TQM extended these concepts and involved the customer by creating a quality culture where the main aim of every employee is to delight the customer. In addition, it provided the structure and the environment where the employees work, enables them to delight the customers. Worldwide research has indicated that there are many descriptions of TQM concepts. As with quality, there are few variations in the definition of TQM. Dahlgaard et al. (1995) furnish two definitions of TQM. The first definition used in Japan states that TQM is a management philosophy that is characterized by the scientific base, systematic base and covers the whole organization. The second definition is that used by European countries and it states that, Quality is a culture of the organization and this culture is focused on customer satisfaction and continuous improvement. According to Adinolfi (2003); Kanji et al (1993); Youssef and Zairii (1995), TQM is a comprehensive system of continuous quality improvement that is used to make sure that the organizations processes are fit to satisfy and exceed customer expectations and requirements. The Institute of Management Services defines Total Quality Management as: "A strategy for improving business performance through the commitment and involvement of all employees to fully satisfying agreed customer requirements, at the optimum overall costs, through the continuous improvement of the products and services, business processes and people involved."(www.managers-net.com). Hellensten and Klefso (2000), confirm that, TQM is a management system that is in continuous change, with comprehensive values, techniques and tools with the overall goal of this system are to increase customer satisfaction with minimal resources. They state that TQM has three independent units, these units consists of the values, tools and techniques. They argue that although these three

units are independent they support each other. This means that the core values must be supported by the techniques that the organization employs to meet and exceed the needs and expectations of the customer with minimum resources utilized. The interaction between the tools and the techniques requires, the organization to provide appropriate tools that supports the techniques used to enhance customer satisfaction. They concluded that, in order for the organization to implement TQM successfully organization is required to identify the values that are applicable to the them, depending on the values, select organizations values. the appropriate set of tools and techniques that will complement the Smith and Offodile, (2008), concur with this as they state that, TQM

mandates that organizations processes utilize the correct tools and techniques that allow resources to be used to the best of the organizations ability to achieve improvement of their product or service. TQM is the process of enhancing the management system. Senior management should lead this management system by clearly setting and stating the mission and vision of organization. TQM also mandates that every employee be involved in continuous improvement activities. This is because TQM organizations view continuous improvement processes as the way of doing daily activities rather than a once off activity and this requires commitment from all employees and this should be carried on throughout the life of the organization, as to make sure that the customers are kept delighted. Continuous improvement assists the organization to become more effective and excel in all dimensions of the products and services that they provide to meet the needs of both the internal and external customers (Smith and Offodile 2008; Zairii and Matthew, 1995; Kanji et al, 1993). In summary, the definition of TQM can be stated very simply: the term, total means everyone in the organization should be involved, the involvement should not only be limited to management, and all staff constituents must be actively involved in the process. This can only be achieved in an organization where the core values are based on the culture of quality and everyone in the organization shares those values.

2.2 KEY CONCEPTS AND VALUES OF TQM

Many authors have contributed to laying foundation stones that form the fundamental concepts and values of TQM. As the definition of TQM varies from one author to another, the authors perceptions about the fundamental concepts and values of TQM also vary. The number of values and their formulation also differs from author to author. Deming (1988) highlighted the following as fundamental values and concepts the cornerstones of quality (Kanji et al 1993). 1. Constancy of purpose: create constancy of purpose for continual improvement of product and service.

2. Cease dependence on inspection: eliminate the need for mass inspection as a way to achieve quality. 3. The new philosophy: adapt the new philosophy. 4. Improve every process: improve constantly and forever every process for planning, production and service. 5. End lower tender contracts: end the practice of awarding business solely on the basis of price tags. 6. Institute training on the job: institute modern methods of training on the job. 7. Institute leadership: adopt and institute leadership aimed at helping people and machines to do a better job. 8. Drive out fear: encourage effective two-way communication and other means to drive out fear throughout the organization. 9. Eliminate exhortations: eliminate the use of slogans, posters and exhortations. 10. Break down barriers: break down barriers between department and staff areas. 11. Eliminate targets: eliminate work standards that prescribe numerical quotas for the workforce and numerical goals for people in management. 12. Permit pride of workmanship: remove the barriers that rob hourly workers, and people in management, of the right to pride of workmanship. 13. Encourage education: institute a vigorous program of education and encourage selfimprovement for everyone. 14. Top management commitment: clearly define top management's permanent commitment to ever-improving quality and productivity. Another concept of TQM was that of Anderson, Rungutusanatham, and Schroeder (1994) who proposed a TQM theory based on the Deming management method. They emphasise that the theoretical essence of TQM concerns the creation of an organizational system that fosters the implementation of process management practices. They believe that process management leads to the continuous improvement of product and services and to employee fulfilment. They also state that these outcomes are critical to customer satisfaction and ultimately to the organizational survival (Manley, 2000). Later in 1994, Sitkin, Sutcliffe, and Schroeder attempted to modify such theory, opposing Andersons theory and stating that TQM encompasses both control and learning and the management do not have the luxury of pursuing one or the other in isolation. They further state that these must balance the conflict between goals of stability and reliability (control)

with those of exploration and innovation (learning) within the organization, as exploration and innovation propels continuous improvement. According to Dale (1999), TQM consists of eight key concepts or values. Dahlgaard et al, (1999) suggest that TQM is characterised by five values. A survey of TQM and continuous improvement programs by the Malcom Baldrige National Quality Award indicates eleven key concepts. These are as follows: Committed leadership, adoption and communication of TQM, closer customer relationships, benchmarking, increased training, open organization, employee empowerment, zero defects mentality, flexible manufacturing, process improvement, and measurement to determine critical factors of total quality management. A study by Youssef and Zairii in 1995 was conducted to benchmark the critical factors for TQM and the results demonstrated that top management commitment, customer satisfaction, employee involvement, a change in organizational culture and continuous improvement were critical aspects and corner stones for TQM. Flynn, Schroeder and Sakakibara (1994) developed another instrument to determine critical factors of total quality management. They identified seven quality factors; these are top management support, quality information, process management, product design, workforce management, supplier involvement, and customer involvement (Dilber et al, 2005). Following a comprehensive literature based on the comprehensive analysis and examination of existing TQM frameworks and literature, Metri (2005) proposes ten critical success factors (CSFs) of TQM for construction industry. According to Metri (2005), the method that was used to select the critical success factors was based on the TQM frameworks developed by researchers. In total, fourteen important TQM frameworks which are Deming prize, MBNQA, EQA, Saraph et al., Oakland, Flynn et al., Babbar and Aspelin, Ahire et al., Black and Porter, Pheng and Teo, Ang et al., Zhang et al., Nwabueze and Thiagarajan et al., were chosen from the TQM literature for the purpose of establishing TQM CSFs. Therefore, the following ten CSFs have emerged out of the above analysis: top management commitment, quality culture, strategic quality management, design quality management, process management, supplier quality management, education and training empowerment and involvement, Information and analysis of customer satisfaction (Metri, 2005). Soltani, Merr, Gennerd and Williams (2003) confirmed that the important aspects of TQM include the above-mentioned commitments and argued that top management leadership

and commitment, fast response, actions based on facts, and a TQM culture need to be included in the development of TQM. Metri, (2005) also alluded that the core principles of TQM are: focus on customers, employees participation and teamwork, continuous improvement and learning. Swinehart and Green (1995) concluded that TQM applications are unique and they depend of the organizations preferences. They found that the above four fundamental principles were common to all organizations that implemented successful TQM. They also included strong quality leadership as another imperative principle. Huq and Martin (2000),concur and stated that the common set of principles and relationship considered important for successful implementation of TQM include strong top management and physician leadership and commitment, customer and patient satisfaction focus, employe e involvement and empowerment, a focus on continuous improvement, supplier

partnership, and the recognition of quality as a strategic management issue. It has been noticed that there are six popular or more common values in the literature reviewed These values are also extensively addressed in the TQM definition (Hasson, . 2003; Bergman and Klefsj, 2003). For the purpose of this study, the values below will be examined in detail. The six selected values are:

Top management commitme nt Based decision on fact

Employee commitment

Focus on processes

Figure 2.2: Six values of TQM (Bergman and Klefsj, 2003)

2.2.1 Commitment to the customers satisfaction

Most of the TQM experts agree that customer focus is the cornerstone and a core principle et and Christian, 2003; of TQM (Soltani al, 2003; Yang

Alavi definitio n

and

Yasin, 2007; Hasson,

2003, Bergman and Klefsj, 2003). The TQM model begins by understanding that quality has in more ways than one moved away from conforming to standard and

specification to meeting and or exceeding customers requirements. By adopting the norm that the preferences of internal and external customers are the primary determinants of quality (delight the customer), has led to the belief that customer satisfaction is the most important requirement for long term success and sustainability of any organization and these organization understand and acknowledge that customers will be satisfied if they receive what (product or the service) they are to receive, when they have to receive it (at the right time), in an appropriate manner that meet their needs. In a study conducted by Huq (1996), the observations from his study concluded that hospitals that were better performers had a high score on customer focus among other factors, and he concluded that customer focus whether final consumer or the next process, is the most important of all TQM principles (Huq, 1996). Failure to include customers in the process of product or service delivery is detrimental. The organization can design and manufacture a product or service that perfectly meets the standards and conforms to specification but that is too irrelevant to the consumer of the product or service. Thus the basic rationale of TQM is valuing the customer by understanding the basic customer needs and by maximizing customer satisfaction. This is visible in organizations with successful TQM implementation as these organizations have processes that continuously collect, analyze and act on the customers information (Lai, 2003). It is therefore clear that organizations that implement TQM initiatives achieve full customer satisfaction which in turn is demonstrated through business excellence and prosperity. Any decline in customer satisfaction due to poor service quality would be detrimental to the organization and it easily takes the organization out of business. Therefore for the organization to remain in business it is imperative to make certain that customers are kept satisfied all the time and all their improvements initiatives should be centered around the customer.

2.2.2 Commitment to continuous improvement:

Quality is a moving target; it is a never ending process. On ongoing bases it creates new standards for the organization. TQM organizations are aware that the best performance and best practices of today may be unaccepted and obsolete performance in the future. It is well known that products that used to be high quality in the past are now standard quality. Therefore organizations are continuously seeking ways and means to up their game all the

time through the process of continuous improvement. Continuous improvement of all operations and activities is at the heart of TQM (Adinolfi, 2003; Hanna, and Newman, 1995; Metri, 2005; Hansson, 2003). In order for continuous improvement to be effective, it requires that employees acquire and apply new knowledge, skills and values to improve the organizations performance. Therefore the process of continuous improvement is cyclic iterative and a never ending activity (Crosby, 1984). TQM mandates zero defect in production and in services, in other words employees must be motivated to complete the job on the first attempt of the task to prevent rework and wastage. Elimination of waste is a major component of the continuous improvement approach. There is also a strong emphasis on prevention rather than detection, and an emphasis on quality at the design stage. The customer-driven approach helps to prevent errors and achieve defect-free production. When problems do occur within the product development process, they are generally discovered and resolved before they can get to the next internal customer.

2.2.3 Top management commitment In order for TQM to work it is empirical that the top management assume a leadership role and commit strongly and actively to the implementation TQM (Hansson, 2003; Soltani et al, 2005; Yang and Christian, 2003; Alavi and Yasin, 2007; Bergman and Klefsj, 2003). The leadership needs to articulate a powerful strategic vision for the organization that defines the organizations existence and the organizations overall goal. They should at all times place emphasis on motivating and convincing the employees, so it is clear to the employees that TQM is not just the program of the year, but rather an ongoing process. Effective leadership empowers the employees and they give these employees a sense of pride and sense of the belonging so that employees can take ownership of the organization (Bergman and Klefsj, 2003). It is also of outmost importance that top management provides an environment and resources that supports and facilitates the growth of everyone in the organization regardless of the level that they are in and the organization as a whole and ultimately to achieve customer satisfaction (Brashier et al, 1996; Huq, 2005).

2.2.4 Commitment to employee involvement

Another key determinant for the success of TQM is the degree to which everyone in an organization is involved in the decision-making processes. The total element of TQM implies that every organizational member is involved in quality improvement processes (Vouzas and Psychogios, 2007). A successful TQM requires a committed and well-trained work force that participates fully in quality improvement activities. It is widely accepted that the increase of employee participation in the overall quality strategy brings an increased flow of information and knowledge and contributes in the distribution of intelligence to the bottom of the organization for resolving problems (Vouzas and Psychogios, 2007). Employee involvement is generally taken to refer to any management practice that gives employees influence over how their work is organized and carried out. According to Solanti et al (2003) the involvement factor influences employees decision on whether or not to fully engage in the job. The examples of employee involvement techniques are well documented in the literature and they involve the use of taskforces, selfmanaging teams, employee surveys, and suggestion boxes (Wilkinson, Godfrey Marchington, 1997). The positive effects of employee involvement on job satisfaction and productivity are also well documented and confirmed in literature (Solanti et al, 2003, Ahmadi, and Helms, 1995). These authors claim that the staff involvement is the key to motivating staff and improving performance in any business and at any level. According to Solanti et al (2003) involvement is one of the ten commandments of management which Kaizen has termed the people enablement index. Kaizen also points out that being consulted and involved in decision making encourages employees be committed to what they are doing. This enables them to offer and share ideas to improve organizations performance. Such participation is reinforced by reward and recognition systems which emphasize the achievement of quality objectives (Wilkinson et al, 1997). Although top management is responsible and is a key driver of TQM initiatives they are not the only people that should be familiar with TQM. All other employees should be familiar with TQM. Quality is not just management responsibility, it is recommended that everyone in the organization should fully participate, be involved and take responsibility for quality or else TQM will not even get off the ground (Huq and Martin, 2000). A lack of involvement, in contrast, hinders staff from highlighting obvious problem areas or identifying improvements.

Different authors argue that team work is another method of getting employee involvement and satisfaction. This is because teams collective effort is better than the individual effort given that diverse knowledge always works better (Huq and Martin, 2000; Lawer, 1994; Youssef and Zairii, 1995, Dilber et al, 2005 and Metri, 2005). Therefore TQM mandates that staff members in all levels of the organization, from the onset be involved and take responsibility and ownership of the quality initiatives implementation.

2.2.5 Commitment to understanding and improving the organizations processes

According to TQM theory, the best way to improve organizational output is to continually improve performance, not just holding the status quo (Vouzas and Psychogios, 2007). The TQM concept is well known for the recognition of the link between product quality and customer satisfaction. Furthermore it recognizes that product quality is the result of process quality. When organizations standardize their processes they are able to take proper quality control in the key steps of the operation procedures to prevent any defects in the process (Yang and Christian, 2003). As a result, TQM focuses on continuous improvement of the company's processes, leading to an improvement in process quality, which in turn leads to an improvement in product quality which ultimately leads to an increase in customer satisfaction.

2.2.6 Evidence based decision making

TQM advocated the need to base decision on data (Lai, 2003). Decisions that are made based on data produces remarkable results than decisions that are thumb sucked or based on a hunch or intuition. With data based decisions, the needs and the desires of the customer are well known as, a result they can be incorporated into the product or service design. Hence meeting and mostly exceeding the requirements of the customer. This greatly enhances customer satisfaction in the product and or service and improves the quality and efficiency of the company itself. The use of quality data also allows the organization to benchmark their service or product offerings, in order for them to establish areas that need improvements so that they can excel in whatever they are doing. The table below represents the authors and their view on the essential elements of TQM
Table 2.1 Essential Elements of TQM

Essential elements of TQM

Authors

Commitment to quality concepts Continuous improvements

Crosby, Deming , Juran, Huq and Martins, Anderson, Manley, Youssef, Metri Solanti et al Bergman and Klefsj ,Adinolfi P et al

Focus on customers Focus on employees Team work Evidence based decision making Process improvements Control of unwanted variation Leadership commitment Communication support/ top management

Crosby, Deming , Juran, Dilber et al, Bergman and Klefsj Metri, Solanti et al, Badyopadhyay, Huq and Martin , Ovretviet Vouzas F et al ,Yong and Christian

Youssef, Flynn et al, Dilber et al, Metri, Swinehart and Green, Huq and Martin,

Asuboteng at al Bergman and Klefsj

2.3 BENEFITS OF TQM

TQM leads to a synergy of benefits. The General Accounting Office (GAO, 1991), studied the link between organizations that had TQM processes in place and their performance. Their study revealed that there is a positive relationship between the two. Organizations that had TQM processes were better performers that those that did not have TQM processes in place. The study indicated that these organizations have improved employees relationships and retention, improved operating processes, greater customer satisfaction and increase market (Eriksson, 2003). This was because in these organizations senior management empowered all levels of management, including self management at workers level, this was done to manage quality systems, improved quality ultimately resulting in decreased costs and increased productivity. The use of TQM in organizations reduces mistakes and produces monetary savings through more efficient use of scarce resources. This enables the company to be a leader not a

follower which results in increased market share which in turn leads to increase profitability (Nagaprsad and Yogesha, 2009). TQM also makes an organization sensitive to customer needs, which makes it more readily adaptable to the ever changing customer needs. TQM fosters team work, by working together and communicating and most departmental barriers are then broken down. This results in easy access to other department information which leads to a better understanding of how the systems work, by all employees. This allows for the standard of service to be set, maintained and then improved. Improving the standards of the product and the services provided has a direct effect on the quality of the end product which ultimately increases customer satisfaction. TQM also views suppliers as customers, and as a result the suppliers view themselves as part of the organization, they start to work with rather than working for the organization, which also increases profit margins (Eriksson, 2003). TQM mandates the standard of employees and management to improve through education and empowerment, this leads to employees being able to think for themselves. The adoption of this new attitude to work; results in everyone embracing the ideas of TQM, which in turn increases productivity and profitability. There are numerous approaches to evaluating the possible benefits of TQM. Estimating the cost of poor quality has been used extensively in the past as a method to quantify the benefits of TQM. Recently TQMs customer satisfaction has been used as one of the indicators of the benefits of TQM, as it has a positive impact on market value and accounting returns (Eriksson, 2003). The benefits of TQM are shown in the figure below.

Benefits for the organization

Benefit to the customer

Benefits to the staff

Figure 2.3 Benefits of TQM (Nagaprasad and Yogesha, 2009)

2.4 DEFINITION OF TQM IN HEALTH CARE

According to Lohr (1991), quality is the degree to which health services for individuals and population increases the likelihood of desired health outcomes and is consistent with the current professional knowledge. This was followed by the modified version of quality in health care by Zairii and Matthew, (1995) as well as Asuboteng et al (1996). They described quality care as a service that is designed to meet the present and the future requirements of the customer in respect to the use, quality and satisfaction; and address the problems that are likely to be encountered in the use of the service and resolve them prior to delivery. Edward (1997) quoted Donabedien (1988) and defined high quality care as "that kind of care which is expected to maximize an inclusive measure of patient welfare, after one has

taken account of the balance of expected gains and losses that attend the process of care in all its parts. Lai, (2003) reiterated that quality in health care involves sustaining an acceptable outcome through an appropriate process or service to meet and exceed the customers expectation The South African department of health (2007) describes quality care as an interface between the health care provider and the patient and the interface between health services and the community. It further defines quality of care as doing the right thing (providing effective care, right time (efficiently) right away (meeting patient expectations of prompt care). In order to deliver quality service and for any quality initiative to be successful, customer requirements must be establish and they should also be fulfilled. TQM in health care is therefore, regarded as management technique that is designed to provide product or services that will deliver the kind of health care that meets and exceeds the customers requirements (Zairii and Matthews, 1995). The definition of quality improvement in the medical literature focuses on improving patient outcomes. Most quality initiatives in the health care field focus on improving productivity, cost-effectiveness, market share, employee morale, and efficiencies of processes. With improved process efficiencies there are less rework, fewer mistakes, fewer delays, snags and better use of equipment or materials, which in turn increases productivity and therefore enables the hospitals to become more competitive, with better chances of survival and more jobs provided (Brashier et al, 1996). In other words, quality of care involves both the provider and the user of the health services and both plays a significant role in defining quality of care. Therefore, quality of care is that care that meets an integrated view of both the required and acceptable clinical standards while meeting the requirements and perception of the patient (user) as well as the communities they live in Ovretviet (2000) adds on to say that quality in health care has to be considered from three dimensions. The first dimension involves patients quality, this is concerned with whether the service provided, renders to the patient what they want and desire. The second dimension is the professional quality. This is a professionals view of whether the services rendered by the professional as asses by the professional health board and the practitioner meets the need of the patient and whether the personnel correctly selected and carried out procedures which are believed to be necessary to meet patients needs. The third dimension is the organizational management quality dimension. This determines whether there is efficient and productive use of resources in order to meet the patients need without wastage and within the directives set by higher authority (Ovretviet, 2000).

Thornber (1991) developed a TQM model for health service organizations, which is very similar to the Deming model. In his model, TQM is defined as a method of leadership and management which: o defines quality in terms of customer perceptions of both the content and delivery of the service o analyzes systems for errors and variation, and prevents them from occurring rather than correct the errors when they occur or blame people o develops long-term partnerships with external and internal suppliers o uses accurate data to improvement o sets up effective collaborative meetings as the basis of teamwork o trains supervisors and managers in leading the on-going improvement process o engages staff in setting targets and ensures that results are fed back to the relevant people o highlights the need for senior executives to plan strategically o achieves long-term improvement through small incremental steps analyze processes and measure system

2.5 SIGNIFICANCE OF TQM IN HEALTH CARE

Over the years, one of the fastest growing industries in the service sector has been the healthcare industry. This growth has put the health care industry under tremendous pressure to change and reform for the past decade. The pressure to change has been driven by escalating costs, and increased demands from both dissatisfied patients and thirdparty payers (medical aids) (Norlund, 1991). The consumers of health care i.e. patients and their families as well as the health insurance companies believed that the health care providers were not taking their health needs seriously. In addition, their health needs were not being met adequately based on access, cost, or quality (Gaucher and Coffey, 1993). This has prompted the hospitals to strive and achieve service excellence. These hospitals needed to strive for zero defects so that they satisfy every customer that they can. A large number of hospitals attempted to enhance their service delivery and adding value to their customers. In many instances, this was achieved by using the zero defect processes that necessitated continuous efforts to improve the quality of the service delivery systems in

order to prevent costly and fatal mistakes which results and litigations (Brashier et al, 1996; Lim and Tang, 2000). In essence the use of zero defect process resulted in reduction of unnecessary wastage as reported by Hamilton (1993) that 90% of drugs prescribed result in waste of money and risk of serious side effects. He added that unnecessary surgery wasted billions of dollars and caused thousands of deaths each year. Hospitals have a great challenge, in order to be successful they need to take a closer look at their operations and find a suitable and a more efficient way to perform their business. These difficulties are not only affecting developed countries, they also affect developing countries and their impact is much more severe due to lack of resources, higher rate of infections and poor health as well as work force shortfalls. The high volume of unnecessary medical expenditures resulting from wastage of material and resources creates a serious financial burden for the government that has an already overstretched budget. Annually the medical expenditure are increasing and some of the most important health programs are unable to find funding because the governments budget cannot keep up with the escalating medical expenses. Due to this financial strain, it becomes difficult for the government to recruit and retain medical personnel as they feel that the government is not remunerating them properly. In turn, this has a huge and debilitating effect on the running as well as the quality of the service that is being provided at the public health care institutions. The government has the dire desire to provide high quality medical care despite its limited resources, in order to meet this challenge they must be able to try to pursue different management approaches. These health care crises were felt to be delicate and urgent in the health care sector, most organizations implemented TQM as a frantic attempt to solve most of the problems that they were facing to improve their operational posture. TQM has been used as a tool to attack wastage, inefficiencies and mistakes that in turn saved the system (Burda, 1991, Yang and Christian, 2003, Huq and Martin 2000), as it saved Japanese industry after World War II, and it has contributed to some remarkable and wellpublicized successes in American industry. In addition, TQM showed promising results in improving the quality of American health care (Berwick, Godfry, and Roessner, 1990). TQM has gained popularity in the health care industry for many reasons; it has been a widely adopted strategy for the improvement of patient satisfaction. This is because it provides a health care environment that focuses on quality of patient care and continuous quality improvement at all levels of the organization, from the top management down to the

lower level staff. TQM deals directly with operational issues culminating into better employee morale, high quality care and this in turn leads to fewer patient returns, which further translates into a reduced burden on the health care institutions (Yang and Christian, 2003). As health care organizations are striving to provide health care services with limited resources, it is obvious that adopting TQM will not only help the government with the financial crisis, but also it will overcome many urgent problems that are a challenge to the health care system. Although studies have demonstrated there are obstacles to the successful implementation of TQM, and the outcomes of the implementation are not always as desired, numerous studies have demonstrated that implementing TQM results in ongoing improvement by identifying areas of weaknesses and correcting them as required (Swinehart and Green, 1995; Yang and Christian, 2003; Huq 1996). The improvements will enhance the quality of health care delivery while in the same breath; it will cut the cost by increasing health care efficiency and effectiveness. In the advent of rising medical cost and limited resources organizations that implement TQM will be able to achieve both efficiency and effectiveness; this means to provide better quality health care with the resources that the organization already has or with even less.

2.6 BARRIERS TO IMPLEMENTATION OF EFFECTIVE TQM INITIATIVES

In practice, TQM initiatives are not easy to achieve (Bergquist, Frederiksson and Svensson, 2005). Despite its theoretical promise and enthusiastic response from different industries, recent evidence suggests that attempts to implement it are often unsuccessful (Bergquist et al, 2005). Many organizations and companies have difficulties in implementing TQM. Reports of the variances in the success and failures are well documented (Dahlgaard and Dahlgaard, 2006; Rad 2005; Bergquist et al, 2005) Huq and Martin in 2000 reported high failure rates (60-70%) of implementing TQM, on the 36 articles that the reviewed. It is generally accepted that these failures are not because of the basic flaws in the principles of TQM. It is also not the characteristics of quality of the program, but mainly to the ineffective implementation of the system. According to Huq (2005), there are various reasons for the failure of TQM implementation, the majority of the cited reasons boil down to managements inability to implement a total system. It is evident that management implements TQM partially and not as a full system. Many organizations apply TQM concepts selectively and are not committed to apply the full range of TQM procedures. Seetharaman, Sreenivanash

and Boon (2006) argued that the main reason why TQM failed was the lack of knowledge concerning the proper TQM implementation. In their research, they discovered that TQM fails because of the following reasons: Lack of management commitment and management understanding on Quality Lack of awareness on the benefits of TQM implementation in the organization Inadequate knowledge of TQM and improper understanding of the measurement techniques that are used to measure the effectiveness of TQM implementation. Lack of clarity in the guideline, implementation plan and implementation methods Lack of understanding about the positive results of continuous improvement Ignoring the importance of customers

The department of health 2007 reported that most provincial authorities are struggling with the mechanism to integrate TQM into the health system as a whole. This has prompted the need to identify these barriers in order to improve the TQM implementation model to reduce the variance between the success and failure of TQM initiatives. Numerous barriers to successful implementation of TQM in the health care services organizations have been identified. According to the survey of health care organizations in Isfahaan province of Iran, a substantial number of barriers were identified. These barriers included: the lack of senior management commitment and involvement, inability to change the organizational culture, inflexibility of or cultural toward quality changes, incorrect planning (policy development and effective goal deployment), lack of education and training for employees and managers, inadequate knowledge and understanding of TQM philosophy, poor team work, poor accessibility of data and results as well as the lack of attention to the needs of the internal and external customers (Rad, 2005). Brashier et al (1996) as well identified the lack of management commitment and employee interest, lack of good plans and lack of focus. They also added physician indifference towards TQM as a critical barrier. Although Huq and Martin (2000) highlighted some of the barriers mentioned above, they emphasized work force culture as the major barriers in implementing TQM initiatives in health care service organizations. Whereas Mc Fadden, Stock and Gregory, (2006) identified that, internal barriers such as lack of incentives, lack of knowledge and understanding implementation. of the TQM philosophy were major barriers to TQM initiatives

According to McLaughlin and Kaluzny (1990), the most difficult barrier to implementing TQM in hospitals is their complex, bureaucratic and highly departmentalized structure, and the multiple layers of authority. Other barriers that were mentioned in literature include unclear strategy and conflicting priorities, leadership style, poor coordination, inadequate skills to implement TQM and lack of communication.

2.7 QUALITY CHALLENGES IN SOUTH AFRICAN HEALTH SERVICE CONTEXT

According to the department of health, 2004 the following were the major quality challenges that the South African health service facilities are faced with: A number of health facilities do not have quality management systems in place, including data collection, analysis, teams to monitor quality, and continuous educationAttitudes of providers are often poor, with few avenues for user complaints and redress. Little or no accountability of the health personnel for their practicesLittle or no data processes and outcomes of care ( facility level and higher) Rigid and inefficient management structures that limit what hospital management can doFacility infrastructure and supplies are often too poor and inefficiently managed Inadequate and inappropriate systems of facility supervision, punitive and authoritarian system management It is clear that all the barriers that have been mentioned above have the following factors in common

2.7.1 Lack of senior management commitment

Numerous studies by Youssef, and Zairii, (1995); Flynn et al, (1994);Dilber et al, (2005); Metri (2005); Swinehart and Green (1995); Huq and Martin, (2000); Asuboteng et al, (1996); Bergman and Klefsj,(2003), have indicated that for TQM to be introduced successfully the top management commitment is a prerequisite. TQM has to be introduced and led by the top management. A strong management support and commitment should be shown through various activities such as creating and setting clear quality vision and values that are aligned to the organization mission and vision. It is important that top leaders communicate with their employees and explain the reasons and the value of adopting and integrating

TQM to the mission and the vision of the organization. In most cases where TQM initiatives have failed it has been due to the lack of management involvement or top management doesnt lead or get committed, and in these cases management only pays a lip service and not act on the initiative. Therefore lack of management commitment is seen as the most and the biggest barrier in implementing TQM.

2.7.2 Organizational structure and culture

Many hospitals are structured in elements of the functional-hierarchical fashion (Huq and Martin, 2000; Johnson, and Omachonu, 1995). Successful TQM program fits perfectly in an organization that exhibit a structure that is more flat and with minimum layers of management. TQM success is obtained through a shift from the ordinary traditional approach to the new TQM way of life (Schein, 2004; Soltani et al, 2005; Rad, 2005). This structural change enables, empowers and motivates employees; it installs new values, beliefs and assumptions to the new ways of thinking. This allows the breaking down of communication barriers and fosters the creativity of the workforce. Resulting in a style that is based on efficiency and efficient communication and high performance ethic, without taking away authority and responsibility rather sharing decision making, and encouraging members of the team to work together within the facility and across all levels of work (Hamilton, 1993; Koch, 1991)

When organizations are structured along strict departmental lines (clinical services, food services, laboratory, nursing, etc.) problem identification and solutions are departmentalized. This leads to poor communication rivalry among functional and professional groups, and partial problem identification and solution (Rad, 2005). For TQM programs to be successful, it requires decentralization of power to be considered and form part of the quality culture. Decentralization will improve employees' involvement, communication and participation in decision-making and will reduce power distance within organization. If the hospital culture is refusing to embrace the change needed for TQM implementation, these initiatives will not succeed regardless of the desire and effort of the people involved (Huq and Martin, 2000). The change in the structure is required to improve quality of health care services.

Administrators wishing to introduce TQM will have to find ways of ensuring that a positive culture exists. Cultural change is the most effective way to manage TQM within an organization. The change in the structure is required to improve quality of health care services. According to Huq and Martin (2000), organizations have individual and unique dominant cultures that are fundamental to all actions, operations and relationships in the organization. A more precise definition of culture is that by Schein (2004) who define culture in a development context, meaning that culture is: a pattern of shared basic assumptions that has been learnt whilst solving problems, that has worked well enough to be considered valid, and therefore, to be taught to new members as the correct way to perceive, think, and feel in relation to those problems This culture is the key driver of the underlying assumption that employees have the rules of the organizations, and the way of thinking which then become the norm of behaviour for the group about accepting a TQM initiative, that will determine the success or the failure of the implementation (Huq and Martin, 2000; Johnson and Omachonu, 1995). The organizational dictates whether the organizations will accept or reject the changes brought about TQM. When the organizational culture is formed it becomes they way of doing things. It plays a significant role in how the organization runs and ultimately the culture is passed through generations. As new employees become absorbed into the workforce, the new workforce acquires the new culture through the process of adaptation (Johnson and Omachonu, 1995). It is imperative that organizations monitor their culture to ensure that it is conducive and it supports TQM implementation, as organizational culture is one of the major barriers in implementation of TQM. The critical challenge for top management is the creation of a work culture that unites every employee around the needs, wants and expectations of customers. In a mature TQM culture, every employee treats every customer as if he or she is the only customer (Johnson and Omachonu, 1995). According to Johnson and Omachonu, (1995) if the concept of TQM is to have any chance of success, most or all of the individuals in the organization must be culturally socialized on the importance of the customers.

2.7.3 Lack of education and training of employees about TQM

Education and training are fundamental for the successful implementation of TQM (Deming, 1988). TQM requires employees participation, each employee needs to learn and understand the underlying principles of TQM. Employees need to have the right skills and they should be granted a platform that enables them to implement the principles of TQM. They need to have the right attitude for participating in TQM and they also need to be able to apply this understanding and attitude in their area of work so that the process of continuous improvement can be achieved. Clearly adequate training for all employees involved is required. In order for this to happen, organizations should create an environment that encourages learning to take place as a prerequisite for TQM implementation. Employees in a medical care environment must receive education and training in error prevention techniques as part of TQM implementation to carry out new approaches to patient safety effectively, (McFadden et al, 2006; Huq and Martin, 2000). In a study done by McFadden et al, (2006) authenticated that extensive training in using computerized medication order-entry systems has resulted in a reduction in medication errors. They also mentioned that education has been used extensively in aviation to enhance safety and security it could also be used in TQM hospitals to enhance patient safety. All these examples endorse the importance of education and training in the implementation of TQM. Huq and Martin (2000) suggested that employees requires three basic areas of training (a) instruction in the philosophy and principle of TQM; (b) specific skills training such as in the use of statistical process control; and (c) the interpersonal skill training to improve problem solving abilities.

It is illustrated that health-care workers in many instances are speaking about TQM without knowing it. This is highly indicative of the need for continuing medical education and training programs that will be part of the overall quality strategy and aiming at improving the necessary skills for continuous quality improvement (Vouzas and Psychogios, 2007). In a study, that Huq and Martin (2000) conducted it was clear that poor education and training presented a major obstacle in the development and implementation of TQM initiatives.

2.7.4 Lack of employee empowerment

Employee empowerment is defined as the voluntary transfer of ownership of a task or situation to an individual or a group. The empowered individual or the group need to have the will and the ability to act in an appropriate manner in that situation (Wilkinson et al, 1997). Another empirical part of empowerment is an enabling environment that allows people to be able to take ownership of the process and commit to its continuous development (Huq and Martin, 2000). When employees are empowered, they acquire skills, experience, and understanding of the task requirements. This leads to increased motivation and confidence. In addition, the commitment and a willing attitude increase. This can only take place in an environment that does not hinder the transfer of ownership (Huq and Martin, 2000). Failure to achieve this becomes a barrier to implementation of TQM.

2.7.5 Leadership style

Deming considered leadership significant in shaping policies and behaviours required to produce high quality, reduce waste and bring about customer satisfaction (Sosik and Dionne, 1997). Leaders can be regarded as a driving force that powers the complex relationship in the implementation of TQM and plays a vital role in all the building block of TQM fundamental commitments. Leaders determines an appropriate organization culture and play a role in organization cultural change, by guiding the process of change through analyzing the organizational need for change, isolating and eliminating invalid and dead structure and routines that hinders the effective implementation of TQM (Wickramaratne, 2005). The main tasks of leadership is to provide and share the vision of the organization, through setting specific objectives and measurable goals to satisfy customer requirements while giving direction and the sense of urgency of the implementation plan. It also plays a significant role in team work by serving and addressing team members and provide both task and emotional support to the team so that every member of the team feels that they worthy to be part of the team. Dilber et al, (2005) emphasises that leaders are also required to provide adequate resources to the implementation of quality efforts, these resources includes time, work force and appropriate funding to make the implementation of TQM successful. Those firms that have succeeded in making total quality work for them have been able to do so because of strong leadership (Juran, 1988)

The most effective leadership style is transformational leadership (Sosik and Dionne, 1997) and it is consistent with the TQM fundamental commitments. It is more effective in achieving the desired outcomes of TQM. On the contrary, most leaders of health care organizations are professionals and they have authority in their environments. As a result, they take offence, refuse to be challenged by their subordinates or even accept the opinions from their subordinates (Yang and Christian, 2003). Using transformational leadership such as quality circles and autonomous work groups has been showed to have more synergistic effects on TQM success (Yang and Christian, 2003). Transformational leadership style empowers employees to take any necessary action to ensure customer satisfaction. Thus, this indicates the importance of managers leadership style is in TQM success.

2.7.6 Reward and recognition

For organizations to implement a successful TQM initiative, they need to develop a formal reward and recognition system that encourages employee involvement, and supports teamwork. In most cases, leaders have the tendency to forget to motivate their staff. Recognition of employees achievements is one of the most important factors to motivate employees. In cases where eemployees exhibit outstanding perforce, they expect that their contributions will be recognized or the top management will appreciate them (Ismail and Zaki, 2004). When they are recognized for the effort that they have put in TQM initiative, they become more involved and take ownership of the quality improvement initiative. As a result, they become motivated to work at and further improve the quality of the service they provide to patients. Hence, increased patient satisfaction ought to be the barometer for the reward and recognition of the employees performance. Failure to recognize employees and their efforts can be a barrier in successful implementation of TQM. It is evident that barriers to implementing successful TQM exist in hospitals and they are a cause for concern.

2.8 LEAN PRODUCTION

Lean production is a Japanese approach that originated from the philosophy of striving to achieve and ensuring quality improvements with special focus on eliminating waste and reducing cost Dahlgaard, (2006). According to Womack and Jones (1996) Lean is a systematic method of removal of waste by all members of the organization from all areas of the value stream. By waste removal, organizations become more competitive due to increased efficiency and decreasing cost incurred from all the non-value adding activities and inefficiencies in the end process (Dahlgaard, 2006). As a result, the cycle time

decreases and the organizations profit increases. The Lean concept become very popular and it became one of the methods used in quality improvement (Dahlgaard, 2006) and it was widely known as Toyota production system in Japan and it became later on, in1986 labelled as Lean production and Lean thinking by Womack (1990) and Dahlgaard, 2006). Therefore, most organizations implemented Lean as a method to reduce wasted work force, unnecessary movement of people in and around the work place and unneeded efforts in production or services. It has also been implemented to reduce wastage of material which are inventories and excess processing, waste created by repairing defects and rework as well as waste of time caused by waiting and transportation. Recently Lean has moved away from a merely shop-floor-focus on waste and cost reduction, to a worldwide concept with a main aim of constantly augmenting the value (or perceived value) to customers by adding product or service features and/or removing wasteful activities (Dahlgaard, 2006). TQM, Six Sigma and Lean manufacturing have been implemented by many different organizations as quality management techniques to improve total organizational performance. The aim of these techniques seems to be very similar as they all involve quality improvements by means of eliminating waste and preserving resources (doing more with less), while improving customer satisfaction and organizational financial results (Andersson , Eriksson and Torstensson, 2006). According to Dahlgaard and Dahlgaard (2001), TQM and Lean manufacturing share the same origin, Japan, following the quality evolution after the World War II. Dahlgaard and Dahlgaard (2001) argue that there is a significant overlap between the principles of Lean thinking or Lean production and TQM. They have a symbiotic relationship and TQM is a major component and a cornerstone of most Lean initiatives. The TQM process orientation eventually leads to the same results as Lean manufacturing. In addition, the team development and problem-solving skills of TQM enhance other Lean elements (Dahlgaard and Dahlgaard, 2001). The goal of Lean production is to get the right things to the right place at the right time, the first time, while minimizing waste and being open to change. TQM movement cannot be separated from Lean Manufacturing. TQM is a comprehensive and structured approach to organizational management that seeks to improve the quality of products and services

through ongoing refinements in response to continuous feedback (Dahlgaard and Dahlgaard, 2006) With Lean, it has been shown that all employees are highly valued for their ability to contribute to problem solving and improved productivity. In the same way that the employees are seen as long-term assets, the suppliers are viewed as a source of competitive advantage. Within a Lean production system, there are three overriding imperatives: 1. The management of processes and the integrated logistics flow 2. The management of relationships with employees, teams, and suppliers 3. The management of the change from traditional mass production In essence, TQM and Lean production can be implemented in conjunction so that the organization can benefit from both of the quality management approaches to enhance the organization performance. As stated by various authors the idea behind TQM is to provide customer satisfaction and possibly exceeding customer needs and expectations. A process of continuous improvement may achieve this, which is one of the cornerstones of TQM. As organizations strive to satisfy their customers they continuously improve their operating processes by eliminating waste, rework and striving for zero defects in their production or services. This allows the organization to be more efficient that is making more with fewer resources, while achieving customer satisfaction.n In essence, Lean comprises of the management and manufacturing philosophies and concepts that are the same as the TQM management and principles (Dalhgaard and Dalhgaard, 2001). They stressed that the principles, the tools and the concepts of Lean should not be seen as the alternative to TQM rather as a collection of concepts and tools that supports the overall principle of TQM. In summary, for hospital to deliver quality health care, it is imperative to reduce health care costs and increase patient satisfaction. Acquiring tools and management philosophy that eliminates waste, inefficiencies and fatal mistakes can achieve this. Therefore, TQM provides such a tool. In addition, TQM requires a change management model, which plays a pivotal role in bringing about quality improvements that ultimately improves patient care

delivery. It is clear that for TQM to be successful certain elements or critical factors need to be satisfied and all these factors are included in the principles of TQM. These factors include top management involvement, customer focus, continuous improvement, process management, evidence based management and education and training. Studies have shown that there have been significant improvements in performance in organization that have adopted TQM and it had a greater impact on staff morale, staff turnover and staff satisfaction. These inevitably translate to customer satisfaction. Despite all these benefits TQM implementation is still limited in health care organizations. A number of organizations attempted to implement TQM have failed. As a result, certain barriers have been identified that prevent these organizations from implementing successful TQM. Studies have shown that if the critical success factor are not adhered to or if the essential elements of TQM are not adhered to, it makes it difficult for the organization to implement successful TQM as these critical factors become barriers if they are not satisfied. In this chapter, literature has been reviewed concerning the origin of TQM, the key concepts of TQM, the key success factors or the essential elements of TQM and their relevance to the health care industry were explored. The relationship between TQM and Lean Manufacturing was investigated and finally it was found to have major similarities.

CHAPTER 3 RESEARCH DESIGN AND METHODOLOGY

3.1 SETTING
The study was conducted at the Kraaifontein Day Hospital, a state owned hospital located in the Northern Suburbs of Cape Town, South Africa. One department in the hospital, namely the pharmacy, was chosen for the study. The pharmacy serves about 500 patients a day in house, and has extended its services into the community, serving the old age homes, special care units such as mental health and caring for people living with Human Immunodeficiency Virus / Acquired Immune Deficiency Syndrome Hospices. The department also has a chronic dispensing unit which provides services to the patients on chronic medication. Kraaifontein Day Hospital was chosen for this study as it was one of the hospitals that implemented a quality initiative to meet the increasing demand for quality coming from dissatisfied patients as well as the pressure from the Department of Health to improve service delivery. The hospital implemented a Lean approach as a quality improvement initiative and this approach was relevant to the research topic. Another reason for choosing this hospital and especially the pharmacy department was that the pharmacy was concentrating on both the quality of care as well as health care outcomes and it has been voted the best pharmacy of the year 2008, in the Western Cape.

3.2 STUDY DESIGN

The study design was a case study. The study employed a quasi- qualitative and quantitative survey in the evaluation of the state of Lean implementation in this hospital. Questionnaires were used with a Likert scale and a number of open ended questions to try to assess possible barriers to TQM. Following the results obtained from the questionnaires a qualitative research technique appropriate for this study was used, implemented through a focus group discussion to gain information from the staff members who were involved in the implementation of Lean.

3.3 STUDY SAMPLE

The statistical population of this research consisted of health care workers who were involved in the implementation of the Lean approach in the pharmacy department. Seven staff members working in the pharmacy department were all interviewed and the consultant that was involved in the Lean implementation was also interviewed to narrate the implementation of the quality program.

3.4. MEASUREMENTS
A structured interview with the respondents was scheduled at appropriate times. The questionnaire was self administered and it was written in English. A pretest questionnaire was disseminated prior to the actual interview to test if the questions were understandable and unambiguous. Changes were made where necessary prior to the actual interviews. The study was carried out over a period of three weeks. A 5 point Likert style scale, ranging from strongly disagree to strongly agree with the statement mentioned was used to quantify the response to that particular question (strongly disagree=1;strongly agree =5).

3.5 ETHICAL ASPECTS

In order to perform the study ethical clearance was obtained from The administration of the hospital The University of Stellenbosch The professionals that participated in the study were asked for a signed consent.

3.6 DATA COLLECTION

In the first stage of the study data was gathered on the quality improvement techniques implemented in this clinic. This was done to orientate the researcher about the organizations overall strategy to improve service quality. A case study report with information regarding the implementation of Lean health care as a method of improving quality at the clinic was obtained from the consultant and used to assess the problems encountered during implementation. The second stage of the study included data collection using a self administered questionnaire. The questionnaires were hand delivered to the respective individuals and they had to complete the questionnaire at work and returned it

anonymously after the scheduled time. The third part of the study was a focus group to clarify all the questions that required further investigation.

3.7 DATA ANALYSIS

Data was analyzed using the Statistical Package for Social Sciences (SPSS 11) software and Microsoft excel spread sheet (2007). The data analysis technique drew heavily on the reported data by categorizing it based on high score (a score of 4 and 5) medium score (a score of 3) and a low score (a score of 2 and 1). Appropriate statistical procedures for description and inference were used. The mean score of each of the dimensions was used as a representative performance indicator and the coefficients of variation (CV) were used as a general measure of standardized skewness on the performance of each dimension, where CV was measured by CV = Standard deviation of the dimension score/mean A high mean score indicated desired outcomes while low scores indicated poor outcomes. A high mean score with a low CV on a dimension was used as an indicator of excellence of the organization in that particular dimension and these results were used to draw conclusions. A low mean score and a low CV were the indicators of poor performance on the organization in that particular dimension. Responses with a mean score of less than 3.5 and a CV of 30% or more indicated that there was too much variation between the participants responses and this necessitated further investigation by means of a focus group. The responses were analyzed to asses if there were barriers that were hindering proper implementation of TQM.

3.8 ACCEPTANCE OF THE STUDY

It is essential that instruments such as TQM success and TQM implementation barriers questionnaires are acceptable to participants in order to obtain high response rates thus making trial results easier to interpret, more generalized and less prone to bias from nonresponse (Rad 2005).Acceptability was assessed in terms of refusal rates, and rates of missing responses. A total of 7 (100 per cent) health care workers filled out the questionnaires. Missing data analysis showed that 100 per cent of respondents had no missing values for the entire set of 43 items.

3.9. RESOURCES
The resources required for this study was stationery for the questionnaires, and this was provided by the researcher.n

3.10 LIMITATIONS
The crucial limitation of this study was that the sample was very small; the sample size was only seven individuals working in the pharmacy department. Another limitation of this study was that the research sample for the study included the views of the pharmacy staff only and not the views of the management staff on the implementation of TQM which the researcher feels in hindsight was supposed to be included to prevent biasness. The research was mainly based on the opinion and perspective of the participants and no other methods were used to gather information. TQM is a broad topic and only certain aspects were taken into consideration as only six values of.TQM were used which were focus on customers, commitment decision based on facts, continuous improvement, top management and focus process and employee commitment other elements were can be

added for further studies of the evaluation of TQM barriers.

nn

CHAPTER 4 STUDY RESULTS

In the previous chapter, the research methodology for this particular study was explained. This chapter addresses the results of the questionnaire that was administered to the health care workers in the pharmacy department. The results of the questionnaire and the focus group included demographic profiles of the employees and TQM common principles. This chapter presents the results and explains the statistical analysis of the result. The demographic questionnaire consisted of four items which required the respondents biographical and educational information and the techniques that were used in this health care organization to improve the quality of the health care service that they provide. There were also questions about the kind of health care organizations the respondents were working in, and their activities within the organization. The pharmacy department had seven staff members which were divided into: two pharmacist, two post basic pharmacy assistants and three basic pharmacist assistants. The hospital services approximately 500 patients per day and it has been involved in the quality improvement process for less than a year. Six of the most common principles of TQM were chosen and included in the development of the questionnaire. These principles were; leadership management focus, customer focus, employee empowerment through awareness, education and training, team work, and continuous improvement. The first part of the questionnaire evaluated the management participation in TQM. The dimension management commitment specifically involved the leadership within the organization and the manner in which management dealt with the leadership issues. Table 4.1 below indicates the response to the management questions.

Table 4.1 Top managements involvement QUESTI ON NUMBE R High scores (4-5) median score (3) low score (1-2) std deviati on coefficie nt of variation

DESCRIPTION
The top management is able to mobilize its work force towards the achievements of the mission, vision, long term and short term goals of organization Top management has clarified organizational policies about TQM concepts and objectives to staff Top management is committed and support TQM initiatives Top management helps the employees to improve their performance

mean score

Q7

3.571

0.976

27%

Q8 Q9

6 5

1 2

0 0

4.143 3.857

0.690 0.690

17% 18%

Q10

3.286

1.113

34%

Q11

Top management acts as a coach to teach and influence staff members

2.714

1.113

41%

Five questions were used to investigate top management involvement in the initiative. In response to the question that dealt with the manner in which the top management was able to mobilize the work force towards achieving the organizations mission, vision, the organizations long term and short term goals, the respondents gave an average score of 3.57 (on a scale of 1-5), with a coefficient of variation of 27%. For this question, the mean score was relatively high with a low coefficient of variation and this indicated that the staff members felt that management did well in this dimension. On another leadership issue which involved the manner in which the management clarified the organizations policies about the TQM initiative, its concepts and objectives, it was interesting to find out that respondents gave a mean score of 4.1 (on a scale of 1-5) with a low coefficient of variation of 17% which was indicative of the excellent performance of management in this dimension. On the dimension of top management acting as a coach to teach and influence the staff members the respondents mean score was low at 2.74 (on a scale of 1-5) with CV of 41%, a low mean score indicated that the management performance was poor in this dimension and a high CV indicates a great variation in the responses provided by the respondents. This question was taken for a focus group.

With regards to staff awareness to the concept of TQM initiative (Q12) as well as staff responsibility for quality (Q13) the response was quite high with a high mean score of 4.42 with a low CV of 13%. This showed that the organization fared well in this dimension. Education and training of staff members involved in the initiative in this organization was rated very high with a mean score 4.1 with a low CV score of 18%. The organizational performance in this dimension was relatively good.

Table 4.2 Summary of the results on employee empowerment

DESCRIPTI ON OF QUESTI QUESTION ON NO

As employees we carry out instructions, we are not encouraged to take out own actions. In

High scor es (4

mediu m score (3)

low std scor mea deviat e io n n (1 scor

coeffici ent of variatio n

Indicati on

Q19

2.85 7

1.57 4

55% HIGH

my organizati on there is a more open and democrat Q20 ic an As employee I have no fear to provide suggestions to my Q21 leaders

3.14 3

1.57 4

50% HIGH

3.57 1

1.13 4

32% HIGH

DESCRIPTI ON OF QUESTI ON are There open ended discussion on errors, ideas and suggestion Teams and employees are rewarded and recognized for their improveme nt efforts

QUESTI ON NO

High scor es (4

mediu m scor e (3)

low scor mea e n (1 scor

std devia ti on

coeffici ent of variatio n

Indicati on

Q22

3.286 1.254

38%

HIGH

Q23

2.857 1.464

51%

HIGH

On the employees empowerment there were different views with regards to the way things were done in the organization. Half of the employees felt that there was no open and democratic or participative management style. This was indicated by a higher number of respondents that gave low scores on this dimension. They also feared to give their suggestions to their leaders with more that 50% of the respondents giving the high score of strongly agree to the question. Since there was high variation in the scores given by the respondents, the question was then taken up for focus group discussion. On staff reward and recognition, the staff members indicated that they were not satisfied with the recognition and reward system of the organization by giving low ranking on this dimension with a mean score of 2.8 (on a scale of 1-5). On the customer focus dimension the respondents gave a consistent high score of 4.8 with a low CV score of 8% which indicated that the organization was indeed very customer focused, which is an excellent performance with regards to this dimension. The performance on the team work factor was consistently high as it is indicated by a high average score and a low coefficient of variation.

On the continuous improvement dimension the mean score was high but there was a great variation in the response of the participants as indicated by the mean and the CV scores respectively (3.4 and 37%). This illustrated that the respondents had different opinions regarding the manner in which the organization strived to discover problems, analyze their root cause and eliminate those problems. Two respondents gave a score of two, the other two gave a score of three, one respondent gave a score of 4 and two had a score of 5. This question was then taken further to be discussed in the focus group meeting. On the other hand the participants indicated that the way in which the organization standardizes their processes and takes proper quality controls in their key steps to prevent defects in the process was excellent as it scored relatively high with a mean score of 4.2 and a CV of 11%. The questions on the dimension of management responsibility for quality included questions that asked about the extent to which the top management assumed responsibility for quality performance. The response to this question differed between the respondents with a CV of 36% and a mean of 3.6. This reflected a wide variation within these responses. The other question related to management was, to which extent top management has objectives for quality performance and the extent to which top management has developed and communicated a vision for quality as part of a strategic vision of the organization. The responses to these questions were fairly similar with a mean of 3.5 and 3.4 and CV of 22% and 28% respectively. Based on these two questions on management responsibility for quality, the organization performance was reasonably good. This is summarized in table 4.4.

Table 4.3 The responses to the questions addressing data quality.

DESCRIPTIO N OF QUESTION Top executives

assume responsibility for quality performance Top management has objectives for quality performance Top management developed and communicated a vision for quality as part of a strategic vision of the

QUE S TIO N

Hig h scor e s (4

medi um score (3)

low scor e (1

mea n scor

std devia coefficie ti on nt of variation

Indic ati on

Q30

3.57 1

1.27 2

36% HIGH

Q31

3.57 1

0.78 7

22% LOW

Q32

3.42 9

0.97 6

28% LOW

Quality data measured the amount of inspection, review and checking of work and the extent to which quality data was used as a tool to manage quality. For both of these questions the organization scored very low with a mean score of 2.8 and a CV of 43% for the first question and a 2.7 mean score with a CV of 41% for the second question. There was also a high variation on the question of quality awareness building among employees on an ongoing basis with an average score of 3.4 and a CV of 37%. This score was the same for the question on employees being recognized for superior quality performance. This question as well was taken up for discussion in the focus group meeting.

Table 4.4 Questions addressing use of quality data

DESCRIPTI ON OF QUESTION Amount

QUESTI ON NO

High scor es (4
1

mediu m score (3)

4

low scor mea std e n deviati (1 scor on

2 2.85 7 1.21 5

coeffici ent of Indi variatio c n atio

43% HIGH

of preventiv e Q33 equipme of Amount inspectio n, review, or checking Q34 of workof Clarity work or process instructio ns given Q35 to Availability of quality data Extent to which quality data are used of the as Scope quality data includes clinical performance Extent to which quality awareness building among employees is ongoing Q36

3.28 6

0.95 1

29% LOW

4 1

3 3

0 3

3.71 4 3.71 4

0.75 6 0.75 6

20% LOW 20% LOW

Q37

2.71 4

1.11 3

41% HIGH

Q38

3.42 9

0.78 7

23% LOW

Q39

3.42 9

1.27 2

37% HIGH

All the respondents viewed the initiative a success and they were willing to continue with the initiative in their organization. With the question on whether or not they were willing to recommend the initiatives to other organization, 28% of the respondents indicated that they were not willing to recommend it because of certain problems encountered during implementation.

All the questions that had a high coefficient of variation were then taken to the focus group discussion meeting for further investigation. In this case study the focus group discussion provided an opportunity to clarify why there was so much variation between the respondents. The views of the respondents from the focus group were somehow more explicit with regards to the issues discussed. Focus groups have become a well known qualitative research method in social science as an appropriate means of collecting in depth knowledge on sensitive research subject in order to provide improved health care service (Lai, 2003). In this focus group discussion the participants and researcher were able to interact directly, allowing for clarification and follow on questions. The use of this research method aided the researcher to uncover information and responses that were not covered by the questionnaire and the individual interviews. Also the synergy of the focus group assisted to uncover valuable insights and thoughts of people who were otherwise not able to express themselves. For this case study the group discussion involved a very small number of participants to discuss the topic in detail. The focus group was made up of people that were familiar with each other and this allowed people not only to share their experiences, they also shared their perspectives. According to (Lai, 2003) the more the participants are familiar with each other, the easier it is for them to disclose the information. This is because they are more comfortable with each other. In the focus group interviews the participants were allowed to share their experiences and particular areas of interests. Focus group discussion On top management involvement there were two questions that were taken to the focus group. A question that assessed how top management helped employees to improve their performance; the response from this question was very surprising. Most of the employees felt that only certain people were allowed and encouraged to improve. All the employees knew that there were policies and procedures in place to optimize their talent. However certain people within the organization felt that they were denied the opportunity to improve while others were granted the opportunity. Those that felt that they were denied the opportunity felt that this missed opportunity could have improved their ability to do their work effectively and efficiently. This would have benefited both the organization and the

individual. The respondents mentioned that among other reasons staff members could not attend certain training programs for improvements was because of lack of funding, difficulty in getting training days and time to allocate personnel to run the programs of due to staff shortages. On the question of top management acting as a coach to teach and influence employees, the response from the focus group indicated that in this organization this dimension did not fare very well. The respondents felt that although the top management supported the initiative, top managements involvement was not visible enough and the monitoring of the program was lacking. The main problem that was indicated from this case was that there was no one in the facility that was monitoring the progress of the initiative. The person that was responsible for the implementation was not an internal person, it was an external consultant. They felt that it would have been much better if there was an internal person who was responsible for the implementation and who was available if they needed assistance as the project continued. Although they had received training on the program they felt that they were left to proceed with the implementation without any one in the department to coach them except for the external consultant. The health care organization managers were involved in the program but not there to give full support to the system implementation. With regards to employee empowerment, the question assessed whether the employees were merely carrying out instructions or whether they were actively encouraged to take own actions. This interview revealed that employees felt that they were unable to carry out their own initiative as the culture of the organization did not allow that. According to one of the respondents there is a do as you are told culture in this organization. Even when staff members were willing to do more they had the feeling that top management says it is not in your job description. This interview showed that employees did not have the final say and they could not make any changes. If they could make changes those changes were very limited. Some of the employees feared to provide suggestions to their leaders, as they were scared to that they would be judged and victimized.

On the question that was based on employees being rewarded and recognized for their improvements efforts the interview showed that, employees felt that the manner that they

were rewarded and recognized was not proportional to the amount of work that they were putting in. In addition although staff were meant to be working as a team, the staff performance appraisals were done on an individual bases. According to the respondents the current reward system was defeating the purpose of team work, and it promoted individualism. People worked to out shine some members of the team at the expense of the other members of the team to get recognition. Some members felt that they were not at all recognized for the work that they do. They believe that the current appraisal system is not a true indication and reflection of the amount of effort they put into their work. There were also inconsistencies in the manner in which management dealt with rewarding and reprimanding employees when these employees met or underperformed on these standards. As a result some employees felt that some employees received preferential treatment. In one instant two employees committed a similar error and one was reprimanded severely while the other one was barely punished. The employees blamed this on inconsistent standard setting. On the question about continuous improvement the discussion revealed that the organization had no system in place to continuously discover problems and analyze their root cause and eliminate the causes completely. These employees felt that they were not equipped or empowered enough to do so. They also mentioned that there were no guidelines or scientific processes used to prevent problems from occurring, in this organization people dealt with problems as and when they occurred. This meant they are not proactive in problem solving but are reactive, in turn to compromising quality. From the discussion it appeared that monitoring and measuring quality was very poor. From the discussion it also emanated that the organization only utilized data sheets that indicate the number of patients they serve and the quantities of medicines they dispensed. At the time when the discussion was conducted they did not have records of patient satisfaction, errors that have occurred and incorrect dispensation. They also did not have any formal system to collect these measurements on a daily or regular basis. Also participants felt that the numeric measurement system that was used was not a good indicator of the amount and quality of the work that these employees put in to improve the quality of service in this organization. This chapter has explained the results of the barriers encountered during the implementation of an initiative in order to improve quality.

CHAPTER 5 SUMMARY AND CONCLUSION

5.1 INTRODUCTION
The intention of this study was to identify barriers to TQM that health care organizations were faced with and that prevent these organizations from implementing successful TQM programs. In this research, barriers in general were identified from literature, and then tested in a case study. In order to meet the ever changing needs of the internal and the external stake holders, the hospital studied was requested by the Department of Health to implement a quality improvement initiative to enhance their service provision through quality improvements after identifying that the customers they were serving were not satisfied with the long waiting times for receiving services.

5.2 DISCUSSION
A quality improvement program was initiated at Kraaifontein day hospital pharmacy department in June 2008. The first phase of his quality improvement program was in general TQM principles and it was followed by the implementation of Lean health approach as an important method of quality improvement. The aim of these approaches was to allow the organizations work to be done efficiently and effectively so as to eliminate wastage. The main finding from this study revealed that it is not possible to single out one factor as a cause or the barrier to the implementation of a TQM program successfully. Not only are these factors related but theoretically they are of equal importance. Yet each factor can also have unique importance in a specific environment or hospital setting. Top management support and commitment is recommended by quality experts and is well documented in the literature (Bergman and Klefsj, 2003; Dilber et al, 2005; Huq and Martin 2000; Metri,2005; Soltani et al 2003; Youssef, 1995; Schroeder and Sakaribara 1994; Streiem, Ovretveit, Brommels, 2003). In the healthcare industry, successes of TQM implementations depend largely on a strong leadership that must be exhibited by the top management (Dilber et al, 2005; Streiem, Ovretveit, Brommel, 2003). According to the TQM

principles top management of the hospitals are mandated to determine an appropriate organization culture, vision, and quality policy. They should also determine objectives, and set specific measurable goals to satisfy customer expectations and improve their organizations performance (Dilber et al 2005). In this case study it appeared that senior management made an effort to provide directions to the roll out of the project. This was achieved by clearly establishing and stating vision, mission, objectives as well as the quality policy for the organization. In addition, they explained how the quality improvement initiative fitted in with the bigger picture, as well as to the organizations aims and objectives. This was in line with the view of Deming (1988) as he stressed the responsibility of top management in creating and communicating the vision of the organization and the purpose of adopting TQM in order to create an environment of continuous improvement. nWhile this organization had its mission and vision in place, it underperformed when it came to setting specific measurable goals and consistency in evaluating these set goals in satisfying customer expectations and improving the organizations performance. In other words this organization did not have clear standard setting on quality. They did not have any explicit criteria on how to measure quality. In addition they did not have solid criteria to measure the desired results, which is required for any evaluation of any quality program that is implemented to improve service delivery. The method of evaluating these standards was not operated fairly among all employees. If and when the evaluation was performed there were inconsistencies and irregularities on evaluation of the standards within the organization. This was true to such an extent that employees were not quite clear about the required quality standards that were expected from them. TQM principles emphasize that it is the responsibility of the top management to give employees clear and consistent standards for what is considered acceptable work and outline the methods of providing it. It is important for the organization to provide a conducive and an appropriate work environment where employees are free to learn and do not fear to be victimized or blamed (Deming 1988; Nel and Beudekers, 2009). Failure to do so becomes a barrier in implementing successful TQM. TQM advocates that management must establish a process of setting goals and allocating authority. This is intended to make sure that everyones contributions to the organization supports the organizational priorities and to have each person knowing exactly what to do and how to do it in measurable terms, to accomplish the goals. It is also required that

employees progress be monitored on a regular basis , according to agreed standards and checkpoints, so that everyone has the same level of understanding with regards to the organizational aims and objectives. This creates a culture of accountability. This organization failed to set the agreed standards hence this dimension was viewed as a barrier to the successful implementation of TQM. In order for the program to be successful, the leadership within the organization should be able to motivate staff members and work with them (Seetharaman, et al, 2006; Streiem et al 2003). Leadership in this case was not in constant contact with the employees, and the employees felt that they were deserted after the program was initiated. According to the employees, the management efforts to assist the employees were not sufficient enough to help them improve their performance. The need for management support was also evident in a study by Huq (2005), where he discovered that for a successful implementation of TQM regular contact of top management with employees was essential. In his study contact between management and employees was kept by means of the intranet, seminars and group discussion. These methods demonstrated that employees were valued and kept informed with all the developments with regards to the initiative. Top management was constantly available and supportive to the employees. In this case study employees felt that there was no active leadership from the immediate superiors and only the consultant was responsible for the implementation, which was according to them insufficient. Hence they believed that management lacked in coaching and influencing them in upholding the quality principles as stated in their quality policy. It is clear that from this case study that leadership commitment to TQM initiative was limited and it has not been continuous and this was viewed as a barrier to the implementation of successful TQM. It has been seen from many organizations that had successful implementations that their TQM system has been wholeheartedly accepted by top management who in turn, conveyed their commitment to all members in the organization. Several studies revealed that training and education are critical to successful TQM implementation. For a smooth implementation of TQM, education and training plays a fundamental role in achieving improvements in quality. It is a prerequisite that employees should be familiar with the TQM principles and they also need to have the right skills. It is apparent from this study that this hospital employed a good education and training system

as all staff members knew the principles and the philosophical aspect of TQM, but they did not have adequate hands on experience and necessary TQM tools. Although the employees felt that they received thorough training, they felt that the training was not practical enough to translate the conceptual learning to practical experience. It was difficult for the employees to understand the applicability of the approach and the methods offered by the trainers. This was considered to be a barrier in this organization. The other interesting observation of this study was that, although the staff members received adequate training with regards to TQM principles, they felt that they were not empowered to take action or make decisions on their own. TQM advocates agree that employee empowerment is an important aspect and it has a synergistic effect on the success of a TQM implementation as it challenges the status quo, allows for individual autonomy, and the employees to be motivated and confident and thus have the will to take ownership of the initiative (Huq, 1995; Huq and Martin, 2000; Manley, 2000). It is clear from this study that the lack of employee empowerment was a barrier in the implementation of TQM. This is highly likely to be due to the bureaucratic, hierarchical structure of this health care organization where the culture of command and control still exists within management. It was evident that employees were not given enough scope to exercise their opinions, as well as taking actions and ownership of the TQM program. The results of this study were in line with the report of Yang and Christian (2003). They mentioned that the unchallengeable leadership of most health care leaders does not allow and accept opinion from the subordinates and this leadership style conflicts with the idea of empowerment embedded in TQM. Coupled with this, was the manner in which this organization was structured. It was structured in a functional hierarchical nature, which also contributes to diminished empowerment and poor communication. TQM gurus agreed that for it to be successful it should be led by top management, hence they all agree with Deming that TQM is a management approach, in which management must take charge and they should also empower employees to take responsibility to improve quality (Streiem, et al 2003). The other interesting outcome of this study was that there was a high degree of team work among the employees. The management encouraged the staff members to work as a team and this is widely practiced within the organization. Team work is a prerequisite and conducive for implementation of TQM. In this organization team work was more prominent

between staff members but was lacking between staff members and the management. This is not conducive for the implementation of TQM and it is one of the barriers that this organization encountered during its TQM implementation. Another interesting observation was that the reward system in this organization did not encourage team work as it was based on individual performance. This has lead to people doing their best as individuals so that they can reap the rewards. This behavior came at the expense of team work as staff members started working as individuals rather than as a team. In addition it posed a huge challenge as it has the potential to create a wedge between staff members in future, as some felt that other people were using them as stepping stones to get to the next level. This case study was a reflection of an organization that has strived to eliminate wastage and inefficiencies in their operations. They have streamlined their processes to the extent that there is less wastage in terms of resources utilized and in terms of the lead times for patients that receive the service. This was a good effort from the organization and it was in line with the TQM principles. The problem that they are facing at the moment was that of not having a structured procedure to deal with mistakes, defects and undetected problems. They also did not have a proper reporting system on the errors that have taken place. There has not been a specific initiative that focuses on reporting and that commits employees to be responsible and accountable for correcting errors. This was viewed as a barrier as under the TQM system organizations are encouraged to identify problems and errors so as to eliminate the defects in the system and continuously improve in order to achieve maximum quality (Manley, 2000). The method of reporting and data collection that was used at this facility was based on simple statistics and head count, this only explained the performance outcome of the service, it did not provide the meaningful measure of performance and the quality of the service, as well as patient satisfaction. The employees alluded that their data collecting processes were not an effective measuring technique as it was failing to analyze and maintain accurate and reliable data that is critical for decision making. The data that was collected in this organization was not critically analyzed as the employees were not trained in data analysis and hence they did not pay enough attention to this part of their work.

Organizations that implement TQM have processes that continuously collect, store, analyze and report information on quality that assist them in decision making, where all decisions are made based on facts and not on hunch. For effective decision making and improvements quality data is required. The fact that this organization is not using quality data with performance evaluation increases the difficulty of implementing TQM as employees perceive TQM implementation as additional work which does not value their contribution and undermines the quality of the service they provide to their patients. This organization did not use the results of quality of service as perceived by patients as a means for continuous improvement which TQM advocates as it sets out standards that should constantly strive to meet and exceed patients expectations, as the data for patient satisfaction was not collected in this organization. In this organization there was a lack of emphasis on finding out the root cause of the problem and why the problem has occurred in the first place so that it can be prevented from recurring. This has been partly because this organization has met the required standards set by the regulatory board, and there were very few incidence of errors reported since these errors were poorly recorded. This has led to a decrease in pressure to improve. Even if errors were reported there were no further actions that are taken to address the error and prevent it from happening again. This has made the performance of the hospital slack in this dimension. TQM mandates zero defect in production and in services therefore employees must not just finish the job they must finish correctly as well the first time around to prevent rework and scrap (Adinolfi, 2003, Hanna and Newman, 2007). Failure to prevent defects has dangerous consequences and it is more expensive to inspect and fix undetected problems which can even threatened and cost lives. This has been identified as one of the barriers since it is not in line with TQMs principle of continuous improvement. Recognition and reward is an important feature of any quality improvement program, which according to Juran (1993) are conferred for general superior performance with respect to the goals and Deming (1986) states that it is an important source of human motivation. In this case study there was some compensation for the staff for implementing TQM initially, it was in the form of acknowledgment for an outstanding clinic, but it was on a short term basis. As time went by there was no recognition what so ever. This has de-motivated the

employees and inhibited them from putting a lot of effort in the program as they do not get the recognition for the work that they have put in. It was clear that the reward system that was used at this facility was based on day to day operations rather than on evaluating and rewarding employees based on their development and contribution to quality improvements. The majority of firms that have implemented TQM modified their performance The measurements and reward systems to show due recognition for improved quality goals (Nagaprasad and Yogesha, 2009), this was not the case in this organization. employees felt that the program has placed additional work on them with no recognition from the top management. The success of TQM relies greatly on the effort from the employees. Effective recognition and reward for employees can stimulate the employees and teams commitment to the organization. When the employees feel that they are too stretched and not recognized for their efforts, they become resistant and not committed to the program. This limits the success and acts as a barrier to the success of the TQM initiative. It is obvious from this study that an organization should not adopt a TQM initiative as a defensive mechanism or because it was forced by the situation, or simply because the customers wanted or the state prescribed it to them. The organizations should adopt it as a strategic tool and aid to develop and improve the manner in which they deliver service, so that they can be efficient and cost effective while delivering improved quality service and hence be in a better position for further sustainability. If TQM is adopted as a defense mechanism as it was in this study it follows that there will be a definite lack of commitment from the top management which will result in difficulties in sustaining the initiative in the long run.

5.3 CONCLUSION
This study commenced with the research problem statements and the research objectives. Then the literature review revealed the key factors that are the cornerstone for successful TQM in the public health care facilities as well as the barriers in implementation of successful TQM. This section will highlight and wrap up the findings of the study and recommendations will then be offered. The health care organizations are faced with major challenges due to many internal and external changes that are taking place. These organizations are well aware of these

changes and they are forced to develop strategic and management philosophies to deal with these challenges. The organization in this study implemented a quality improvement initiative as part of Total Quality Management to improve their service provision. It has been shown from this study that there are some benefits that are obtained from implementing TQM. These benefits include staff productivity which leads to organizational efficiency, provision of quality care which leads to increased patient satisfaction. However this specific health care organization still has a long way to go to have a successful and a smooth running TQM initiative. This case study reveals that there are considerable barriers and difficulties that this organization was faced with during implementing and sustaining their quality improvement initiative. The obstacles that were revealed from this case study were not different from those that were reported in the literature, not only from health care but from other industries as well. The major barriers that were encountered during the implementation of TQM in this case study included the lack of active top management involvement and full commitment in the initiative, rigid organizational structures and a culture that inhibits communication between management and employees which in turn hinders employee empowerment, which is one of the core values of TQM. Other obstacles that were encountered were a lack of continuous improvement processes and initiative, an improper evaluation, recognition and reward system for team work, poor accessibility and quality data and results and the difficulty to use this data to improve quality. The absence of a performance measurement system also exhibited a problem as employees were not aware what was being assessed during performance appraisals. Lack of evidence based decision making, poor communication and an inflexible organizational structure and culture were also viewed as barriers. It is said that for a TQM initiative to be successful it should be management led, and for it to have a long lasting effect it should involve everyone in the organization. This means that management should be actively involved, committed to the initiative and needs to provide an environment that nurtures employees talents and efforts and should not just pay lip service and boast about the initiative.

It is clear that continuous improvement is the only way in which the organization can excel in their performance, leading to customer satisfaction. Therefore the organization should remove all barriers that prevent it from continuously improving. Teamwork is the key to involvement and participation. Teams should be motivated and encouraged to work effectively and the reward system also should be centered on team efforts and should not be individual based. This study emphasizes that all barriers related to the six TQM dimensions or values need to be eliminated as they make it difficult to implement and obtain the benefits that are brought about with successful implementation of TQM.

5.4 RECOMMENDATIONS
The objectives of this final section is to highlight the recommendations to the public health care facility in which this study was conducted in order to assist this organization to overcome the barriers that faced this organization during their TQM implementation. There should be a periodical performance measurement system that will highlight and include the quality of the service provided to the patients rather than a simple head count or the number of people than have been served. The organization needs to develop a valid measure of team performance. The reward system for performance should not be based on individual performance but rather on team work. Outstanding team performance should be reimbursed so that the whole team could be encouraged to participate in the TQM initiative. When team members are encouraged they will perform even better thus increasing their satisfaction with the job that they are doing while increasing their self esteem. This will enhance team building, problem solving, cooperation and innovation. This organization needs to come up with a strategy that will address the lack of staff involvement and paying attention to quality. They can achieve this by combining quality related data with the general staff performance evaluation. The quality related data should be used as a means for improvement and not to criticize or discourage employees. The table below illustrates the suggested actions to be taken by this organization.

Table 5.4.1 Recommended actions to be taken

ACTION 1

Core values to develop

Actions to be taken

Committed and actively involved leadership

Establish a joint views of the need for changing and how to change from vertical to horizontal integration making sure that all departments are accessible and the information is freely available across the board Maintain close contact and communication with the employees by means of regular debriefing sessions, intranets and meetings

Every bodys commitment

ACTION 2

Activities

Core values to develop

Every bodys commitment

Establish a structure with cross functional teams. Educate and train for working towards the groups objective

Customer orientation

Educate employees about the importance of the customer and install values that are customer focused Change effort from individual based reward and

Reward and recognition

recognition to team based, rewards teams for good

ACTION 3

Activities

Core values to develop

Process focus

Provide environment that promotes both stability of processes innovation while encouraging learning and

Fact bases decisions

Educate employees on the importance of collecting quality data, and on data handling and data manipulation and as well as analysis for decision making

Continuous improvements

Educate and train for future group objectives and continuously evaluate the change process

Adapted from Hansson, J. 2000

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