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Quality Management System: A 90-day innovation cycle First literature review

Supporting better quality health and

social care for everyone in Scotland

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© Healthcare Improvement Scotland 2018

Published May 2018

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Content

Questions informing the literature review .................................................................................................. 4

Key findings ................................................................................................................................................. 4

Defining quality management and the core components .......................................................................... 5

Major frameworks and their principles/components ................................................................................. 5

Standards-based frameworks...................................................................................................................... 5

Award-based frameworks ........................................................................................................................... 6

Malcolm Baldrige National Quality Award (MBNQA) .......................................................................... 6

European Quality Award (EQA) ........................................................................................................... 6

Comparison of frameworks: ISO standard, MBNQA and EQA ............................................................ 7

Individual developed frameworks ............................................................................................................... 7

Deep quality concept model19 ............................................................................................................. 9

Implementation of quality management frameworks ................................................................................ 9

TQM implementation capability model22 .......................................................................................... 10

References ................................................................................................................................................. 12

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Questions informing the first literature review

What are the frameworks out there? How do they work and what are their components?

How do the frameworks compare? Are there any gaps in understanding?

What can be learned from these frameworks about an effective approach to strategic quality

management in health and social care?

Key findings

There are three major quality management frameworks or approaches that relate to the process of

adopting the core principles of total quality management, namely: the ISO 9001 quality standard,

the Malcolm Baldrige National Quality Award (MBNQA), and the European Quality Award (EQA).

There are also a number of individual models proposed in the literature to enhance the application

of total quality management principles such as the “deep quality concept” model. However, these

models have not been validated in practice.

There is no holistic or integrated framework for quality management and no standard approach for

successful implementation.

The dominant approaches or models overlap, however the MBNQA and EQA criteria are farther-

reaching and broader than the ISO 9001 requirements.

The ISO 9001 quality standard is viewed as falling short of total or strategic quality management in

terms of delivering continuous improvement in value to customers and overall performance.

The emphasis of ISO 9001 in addressing process control issues is much stronger than the award

criteria, while the MBNQA and EQA emphasise that inspection and testing be replaced by

prevention in demonstrating excellence in quality.

A number of models have been proposed for addressing gaps in implementation strategy for quality

management; these relate to issues such as achieving knowledge formalisation for transparency,

and developing capability for implementation particularly in relation to leadership.

A lack of development of quality management is suggested in relation to broadening considerations

to other relevant research and concepts such as knowledge management.

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Defining quality management and the core components

There are a number of terms used interchangeably to describe quality management, including

Continuous Quality Improvement (CQI), Strategic Quality Management (SQM) or Total Quality

Management (TQM). The term TQM is considered to encapsulate the broadest principles of quality

management1. TQM is frequently described in the literature as a diffuse concept, with 73 different

definitions being identified1.

TQM is an integrated system of principles, methods and best practices that provide a framework for

organisations. The TQM core concepts are based on the teachings of Drucker, Juran, Deming, Ishikawa,

Crosby, Feigenbaum and other experts who have studied, practiced and tried to refine the process of

quality management:

customer focus

leadership

continuous improvement

strategic quality planning

design quality

speed and prevention

people participation and partnership, and

fact-based management.

Major frameworks and their principles/components

There are also a number of frameworks or models relating to the process of achieving quality

management. Three major types are described in the literature:

standards-based approaches

quality award approaches, and

individual developed models.

Standards-based frameworks

The perspective from a review of the ISO standard is that implementing this alone does not allow

companies to gain competitive advantages. ISO could be the starting point for TQM implementation but

is not the whole solution. The latest version named ISO 9001 standardises processes and develops

procedures by examining processes and identifying discrepancies between what is actually done and

what should be done. An article by Ozturk and Swiss2 considers how the standard was implemented in

Turkish hospitals. It compares nine hospitals with ISO 9001 certification with nine similar hospitals

without. Other articles have considered the use of ISO 9001 in other settings. Curkovic and Pagell,

1999,3 is an article about the different views on ISO 9000: a tool to give competitive advantage or a

paper-driven process of limited value. An article by Martínez-Costa et al4 compares ISO 9000: 1994 with

ISO 9000: 2000 certified Spanish industrial companies to see differences in performance. They found

ISO 9000: 2000 certified companies did not perform any better than 1994 or non-certified companies

but they applied TQM at a higher level.

Singels et al, 2001,5 also investigated if ISO 9000 certification improves performance and they looked to

see if other factors could explain performance not just ISO 9000. The article by Corbett et al6 is about

financial performance of manufacturing companies that gained ISO 9000 certification compared to

firms that did not. They found ISO 9000 certified companies performed better. Najmi and Kehoe, 2000,7

developed a framework, based on surveys of over 200 industrial companies (including 18 detailed case

studies), of how to move beyond ISO 9000 to deliver quality.

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Poksinska et al, 2006,8 reports on three case studies about small organisations that implemented ISO

9000. They found that a Quality Management System (QMS) is determined by organisational context

and how it’s implemented not by the requirements of ISO 9000. An article by Sun et al9 investigates

trends over a 10-year period in how European companies planned to implement ISO 9000 and TQM.

They found that more companies gained ISO 9000 certificates than progressed to TQM. Terziovski et al,

2003,10 investigates how manager’s motives to get ISO 9000 certification affect the performance of the

organisation. They found a positive relationship between organisations that willingly and positively

pursue certification with improved performance. Being customer focused was found to contribute the

most to improved performance.

Award-based frameworks

A number of quality award approaches to quality management have been developed. The following are

the main awards:

Malcolm Baldrige Award – a national award which is used as a basis for a number of regional

awards in the USA(described by Foster et al, 200711), and

European Quality Management Award – an international award (described by Nabitz et al, 2000,12

and Verno et al, 200713).

Malcolm Baldrige National Quality Award (MBNQA)

The MBNQA was established in the USA in 1988 following the introduction of the Malcolm Baldrige

National Improvement Act of 198711. The award is designed to improve the quality and productivity of

organisations in the USA by establishing guidelines and criteria against which organisations can

measure themselves. Healthcare organisations were included in 1999 and the first healthcare award

given in 2002. By the end of 2005, 116 healthcare organisations had applied for the award and five had

received an award. Table 1 of the article11 summarises the award criteria for healthcare.

Organisations that apply are judged on seven criteria:

leadership

strategic planning

customer and market focus

measurement, analysis and knowledge management

human resource focus

process management, and

results.

European Quality Award (EQA)

The EFQM approach was initiated in 1988 by the European Commission and 14 European organisations

(such as BT, Volkswagen and Philips) 12. The EFQM model has parallels to the Baldrige Award as well as

other national awards (like the Australian and the South African Quality Award as well as the Deming

Award in Japan). Whereas the Baldrige award has seven criteria, the EQA award has nine:

leadership

policy and strategy

people (employee) management

resources

processes

customer satisfaction

people (employee) satisfaction

impact on society, and

business results.

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Vernero et al, 200713 reports on the experience of managers experience of using EFQM in an Italian

hospital. The nine criteria for EQA can be split in to two groups, five of the criteria are enablers and four

are results. The enabler criteria describe how things are done in an organisation whilst results criteria

describe what is achieved by the enablers. The enabler criteria are leadership, policy and strategy,

people, partnerships and resources, and processes. The results criteria are customers, people, society,

and key performance.13 Vernero et al, 200713 describe that healthcare organisations in the Netherlands,

Germany, UK and Spain were the first in Europe to use EQA on a wide scale.

Comparison of frameworks: ISO standard, MBNQA and EQA

Thus, the MBNQA and EQA criteria are farther reaching and broader than the ISO 9001 requirements

according to a comparative analysis by Tummala and Tang (1996)14. Also, the ISO 9001 quality standard

is viewed as falling short of total or strategic quality management in terms of delivering continuous

improvement in value to customers and overall performance. However, the emphasis of ISO 9001 in

addressing process control issues is much stronger than the award criteria, while the MBNQA and EQA

emphasise that inspection and testing be replaced by prevention in demonstrating excellence in quality.

The president of the Registrar Accreditation Board (RAB), has explained that neither set of criteria alone

will assure total quality and that the requirements of each should be seen as complementary. The key

differences in emphasis and strength are described as follows.

The ISO standards are generic contractual quality assurance standards representing the minimum

requirements for an effective quality system to ensure that the product or service consistently

meets customer requirements. Consequently, they are thought of as being the lowest standard of

an effective quality system. From the perspective of Juran, they do not require any evidence of a

satisfactory track record of performance – for example in product quality or delivery. Similarly,

human resource development and management, and strategic quality planning are not covered at

all in ISO 9001 requirements.

Both the MBNQA and EQA emphasise competitiveness in relation to delivery of ever improving

value to customers and improvement of the company’s overall operational performance. Whereas,

the ISO focuses on establishing a documented quality system.

ISO 9001 gives considerable importance to the role of inspection and testing. On the other hand,

the MBNQA and EQA emphasise that inspection and testing be replaced by prevention in

demonstrating excellence in quality.

People participation and partnership, and strategic quality planning are not considered at all in ISO

9001 requirements, whereas they are crucial to implementing quality improvement strategies to

satisfy the MBNQA and EQA criteria.

Continuous improvement, plays a central role in planning and implementing quality improvement

efforts to satisfy the MBNQA and EQA criteria, whereas it is not an explicit requirement of ISO 9001.

Individual developed frameworks

A number of individually developed models are outlined in the literature that relate to considerations

of transferability or addressing particular gaps in relation to how quality management can be achieved.

There are a number of articles considering how quality management should be adopted in developing

countries where there is little history of application such as in the Palestinian context15 and Malaysian

Industry16. There have also been efforts to develop a framework for transferring TQM to the context of

education17. There is also consideration in the literature in relation to how TQM translates to managing

quality in service organisations18.

From a review of the quality management literature, this study proposes a conceptual model relevant

to service organisations consisting of 12 dimensions:

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top management commitment and visionary leadership

human resource management

technical system

information and analysis system

benchmarking

continuous improvement

customer focus

employee satisfaction

union intervention

social responsibility

servicescapes, and

service culture.

The rationale for developing this model relates to the unaddressed issues of transferability of quality

management dimensions from manufacturing to services and the absence of a holistic framework.

Furthermore, the author has considered how these dimensions relate to those that have been

identified as relevant to quality management as it was originally conceived from the perspective of

manufacturing. These dimensions can be broadly grouped under three categories: dimensions seen to

be generic to both sectors; those that are common to both but not addressed in relation to

manufacturing such as social responsibility and union intervention recognised; and factors unique to a

service context such as service culture .

A quality management model based on a “deep quality concept” has been developed to address the

perceived gap in relation to the role of knowledge19. The rationale for this being that tacit knowledge

has a key role in determining quality performance. The framework considers dimensions of quality

management in relation to knowledge availability and reliability, instead of only data and information

reliability. Situations in which knowledge that is related to people is not available, sufficient or reliable.

The authors believe that a lack of consideration of knowledge related to people that may not be

available or reliable is a consequence of the models or frameworks being based predominately on

Taylorian philosophy of manufacturing. According to Peklenik (1995), the basic presumptions of the

Taylorian philosophy of manufacturing were:

determinism of operations

predictable behaviour of the system, and

a priori information which is reliable, complete and accurate.

The authors also outline how there is lack of a generalised model that incorporates an integrated

perspective of quality management dimensions and which includes consideration of the role of

knowledge formalisation. They propose a deep quality management (DWM) model with the following

core concepts:

standardisation of domain concepts

processes specifications

knowledge specifications related to processes

data on individual educational history, knowledge and background

expertly designed databases and Management Information System (MIS)

systematic recording of relevant data and information

knowledge synthesis and representation

knowledge bases and repositories

involvement of people and teamwork, and

fair and motivating managerial mechanisms.

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Figure 1. Deep quality concept model (Srdoc et al, 2008, p. 293) 19

Implementation of quality management frameworks

Despite there being a number of frameworks, there is no standard approach for how they can be

successfully implemented. Furthermore, implementation of quality management in the healthcare

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context is viewed as having limited success. Successful quality management projects tend to be limited

to individual organisations or departments or in a specific area of organisational performance. Øvretveit

(2000)20 analysed all European TQM implementations in the healthcare sector concluding that only few

small-scale efforts have had great success. Mosadeghrad (2013)1 found three categories of failures from

a review of implementation-related literature relevant to healthcare that included inappropriate

environment for TQM implementation. According to Mosadeghrad (2013), the most inappropriate

environment is where there is a lack of supportive leadership. The author suggest that “complementary

management theories” are needed to guide TQM implementation. The application of hard factors of

TQM without addressing structural issues and soft factors is also described as a cause of

implementation failure1.

A review of leadership difficulties in relation to implementing quality management in healthcare

suggests that TQM implementation needs “monolithic” visionary leadership, as described by Deming21.

One recognised category of a lack of leadership is a lack of senior management involvement and

commitment. The authors propose two other categories of causes, namely “combined leadership” and

“political leadership”. The former is described as being typical of large healthcare organisations with

many departments and senior managers who need to be aligned and aware of a sole TQM leadership.

The second category is the effect of political influence which is particular to public healthcare. This

political influence can hinder leadership required for the successful implementation of TQM.

Nasim et al, 201422 propose a conceptual framework for quality management implementation that

addresses the gap of implementation capability. Their work attempts to answer a number of questions

in relation to developing implementation capability: the role of (i) human resource practices, (ii)

management commitment and (iii) organisational support. Their resulting integrated framework for

TQM implementation capability, shown in Figure 2, focusses on the soft aspects of TQM and how these

are interrelated.

Figure 2. TQM implementation capability model (Nasim et al 2014, p.1400 )22

The framework includes integrated relationships based on several constituent models, that is,

management commitment, effective communication, person–environment fit and organisational

support.

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In relation to management commitment, this is viewed as being achieved through leadership to ensure

product and process conformance, management by process, face-based management, training and

team work. Furthermore, the achievement of management commitment is then seen as being able to

influence job satisfaction, a learning culture and behavioural change. If teams and managers

communicate with each other on different issues, the capability to successfully implement TQM should

be enhanced. The participation of employees has been reported as being proportionate with the level

of commitment shown by the top management. Some soft factors such as team climate and team

diversity can also affect team performance. Similarly, team autonomy can also play a crucial role in

minimising complexity in team formation. All these factors are viewed as capable of being optimised for

results through the active involvement and commitment of top management.

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References

1. Mosadeghrad AM. Obstacles to TQM success in health care systems. International journal of health care quality assurance. 2013;26(2):147-73.

2. Ozturk AO, Swiss JE. Implementing management tools in Turkish public hospitals: the impact of culture, politics and role status. Public Administration and Development. 2008;28(2):138-48.

3. Curkovic S, Pagell M. A critical examination of the ability of ISO 9000 certification to lead to a competitive advantage. Journal of Quality Management. 1999;4(1):51-67.

4. Martínez-Costa M, Choi TY, Martínez JA, Martínez-Lorente AR. ISO 9000/1994, ISO 9001/2000 and TQM: The performance debate revisited. Journal of Operations Management. 2009;27(6):495-511.

5. Singels J, Ruël G, Water Hvd. ISO 9000 series ‐ Certification and performance. International Journal of Quality & Reliability Management. 2001;18(1):62-75.

6. Corbett CJ, Montes-Sancho MJ, Kirsch DA. The Financial Impact of ISO 9000 Certification in the United States: An Empirical Analysis. Management Science. 2005;51(7):1046-59.

7. Najmi M, Kehoe DF. An integrated framework for post‐ISO 9000 quality development. International Journal of Quality & Reliability Management. 2000;17(3):226-58.

8. Poksinska B, Eklund JAE, Dahlgaard JJ. ISO 9001:2000 in small organisations: Lost opportunities, benefits and influencing factors. International Journal of Quality & Reliability Management. 2006;23(5):490-512.

9. Sun H, Li S, Ho K, Gertsen F, Hansen P, Frick J. The trajectory of implementing ISO 9000 standards versus total quality management in Western Europe. International Journal of Quality & Reliability Management. 2004;21(2):131-53.

10. Terziovski M, Power D, Sohal AS. The longitudinal effects of the ISO 9000 certification process on business performance. European Journal of Operational Research. 2003;146(3):580-95.

11. Foster TC, Johnson JK, Nelson EC, Batalden PB. Using a Malcolm Baldrige framework to understand high-performing clinical microsystems. Quality and Safety in Health Care. 2007;16(5):334.

12. Nabitz UDO, Klazinga N, Walburg JAN. The EFQM excellence model: European and Dutch experiences with the EFQM approach in health care. International Journal for Quality in Health Care. 2000;12(3):191-202.

13. Vernero S, Nabitz U, Bragonzi G, Rebelli A, Molinari R. A two‐level EFQM self‐assessment in an Italian hospital. International Journal of Health Care Quality Assurance. 2007;20(3):215-31.

14. V.M. Rao Tummala, C.L. Tang, (1996) "Strategic quality management, Malcolm Baldrige and European quality awards and ISO 9000 certification: Core concepts and comparative analysis", International Journal of Quality & Reliability Management, Vol. 13 Issue: 4, pp.8-38

15. Baidoun, S. and Zairi, M. (2003), A proposed model for TQM implementation in the Palestinian context, Total Quality Management and Business Excellence, Vol. 14 No. 10, pp. 1193-211.

16. Thiagaragan, T., Zairi, M. and Dale, B.G. (2000), A proposed model of TQM implementation based on an empirical study of Malaysian industry, International Journal of Quality & Reliability Management, Vol. 18 No. 3, pp. 289-306.

17. Venkatraman, S. (2007), A framework for implementing TQM in higher education programs, Quality Assurance in Education, Vol. 15 No. 1, pp. 92-112.

18. Sureschchandler, G.S., Rajendran, C. and Anantharam, R.N. (2001), A conceptual model for TQM in service organisation, Total Quality Management, Vol. 12 No. 3, pp. 343-69.

19. Srdoc, A., Sluga, A. and Bratko, I. (2005), A quality management model based on the ‘deep quality concept’, International Journal of Quality & Reliability Management, Vol. 22 No. 3, pp. 278-302.

20. John Øvretveit, (2000) "Total quality management in European healthcare", International Journal of Health Care Quality Assurance, Vol. 13 Issue: 2, pp.74-80.

21. Andrea Chiarini, Emidia Vagnoni, (2017) TQM implementation for the healthcare sector: The relevance of leadership and possible causes of lack of leadership, Leadership in Health Services, Vol. 30 Issue: 3, pp.210-216.

22. Nasim, K., Iqbal, M., & Khan, I. (2014). Antecedents of TQM implementation capability: A review with a conceptual model. Total Quality Management & Business Excellence, 25(11-12), 1395-1409.

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