This article was downloaded by: [University of California, San Francisco]On: 09 December 2014, At: 09:17Publisher: RoutledgeInforma Ltd Registered in England and Wales Registered Number: 1072954Registered office: Mortimer House, 37-41 Mortimer Street, London W1T3JH, UK

Total Quality ManagementPublication details, including instructions forauthors and subscription information:http://www.tandfonline.com/loi/ctqm19

Obstacles to the application oftotal quality management inhealth-care organizationsCharles Zabada , Patrick Asubonteng Rivers &George MunchusPublished online: 25 Aug 2010.

To cite this article: Charles Zabada , Patrick Asubonteng Rivers & George Munchus(1998) Obstacles to the application of total quality management in health-careorganizations, Total Quality Management, 9:1, 57-66, DOI: 10.1080/0954412989261

To link to this article: http://dx.doi.org/10.1080/0954412989261

PLEASE SCROLL DOWN FOR ARTICLE

Taylor & Francis makes every effort to ensure the accuracy of allthe information (the “Content”) contained in the publications on ourplatform. However, Taylor & Francis, our agents, and our licensorsmake no representations or warranties whatsoever as to the accuracy,completeness, or suitability for any purpose of the Content. Any opinionsand views expressed in this publication are the opinions and views ofthe authors, and are not the views of or endorsed by Taylor & Francis.The accuracy of the Content should not be relied upon and should beindependently verified with primary sources of information. Taylor andFrancis shall not be liable for any losses, actions, claims, proceedings,demands, costs, expenses, damages, and other liabilities whatsoeveror howsoever caused arising directly or indirectly in connection with, inrelation to or arising out of the use of the Content.

This article may be used for research, teaching, and private studypurposes. Any substantial or systematic reproduction, redistribution,reselling, loan, sub-licensing, systematic supply, or distribution in any formto anyone is expressly forbidden. Terms & Conditions of access and use canbe found at http://www.tandfonline.com/page/terms-and-conditions

Dow

nloa

ded

by [

Uni

vers

ity o

f C

alif

orni

a, S

an F

ranc

isco

] at

09:

17 0

9 D

ecem

ber

2014

TOTAL QUALITY MANAGEMENT, VOL. 9, NO. 1, 1998, 57 ± 66

Obstacles to the application of total quality

management in health-care organizations

CHARLES ZABADA, PATRICK ASUBONTENG R IVERS &GEORGE MUNCHUSGraduate School of Management and Department of Health Services Administration, University

of Alabama at B irmingham, B irmingham, AL 35294, USA.

Abstract This paper involves a signi ® cant review of the obstacles that face health-care organiza-

tions that undertake total quality management (TQM) implementation. A de® nition of the concept

of quality is thoroughly explored, along with the concept of total quality. The importance of TQM in

the health-care industry is discussed, and a comparison of TQM in manufactur ing environments to

TQM in a health-care organization environment is made . Obstacles to the application of TQM in

health-care organizations are presented and discussed and conclusions and recommendations regarding

the philosophy and practice of quality management and digni ® ed leadership are made.

Introduction

Total quality management (TQ M) has proven very successful and promising in the manufac-

turing industry. It has been said that TQM can be equally applicable with success in the

service industry. But, due to the distinctive nature of health-care services, the application

and success of TQM have been limited to administrative and other supportive functions only

in most health-care organizations. In fact, the assertion made by TQM experts that TQM

can be successfully applied in every organization is based on two implicit but important

assumptions (Arndt & Bigelow, 1995): (1) hierarchical control dominance of management

over the technical core; (2) dominance of rational decision-making processes. Most health-

care organizations depart largely from those two assumptions.

First, there exist various powerful subcultures (e.g. physicians’ subculture). Each has its

own perspective of what quality should be, and how the work should be done, and this has

created a situation where management has little control over the most strategic areas where

TQM could yield greater results. Second, the heroism (of physicians) and human (life)

factors involved in health-care services have put rational decision-making in jeopardy. The

existence of many participants with diŒerent or even opposing interests in the health-care

delivery system makes it di� cult to de® ne health-care quality.

This paper explores some of the obstacles facing health-care organizations that embark

on TQM implementation. After de ® ning the concept of quality in general and of health-care

services from the patient perspective in particular, we review the concept of TQM. The

Correspondence to G. Munchus (Tel: + 1 205 934 8840; Fax: + 1 205 975 6234).

0954 ± 4127 /98/010057-1 0 $7.00 � 1998 Carfax Publishing Ltd

Dow

nloa

ded

by [

Uni

vers

ity o

f C

alif

orni

a, S

an F

ranc

isco

] at

09:

17 0

9 D

ecem

ber

2014

58 C. ZABADA ET AL.

remaining sections deal with the characteristics of TQM and its implications in organizations

in general and in health-care organizations in particular. We also review the obstacles to the

application of TQM in health-care organizations. In conclusion, we suggest that subcultures’

perspectives (that seems to generate most of the obstacles) can be changed, provided the

appropriate approach for doing this is adopted. In any case, the best approach will be the

one that tackles the problem at its root.

De® nitions of the concept of quality

The concept of quality as used in TQM is confusing, in the sense that its meaning changes

as the perspective in which it is used changed. For example, quality de ® ned according to the

consumer perspective refers to aspects of a product or a service that bring satisfaction to the

consumer in terms of meeting performance expectation. Similarly, quality de® ned according

to the producer or provider perspective refers to aspects of the product or the service that

bring satisfaction to the producer or the provider in terms of meeting speci® cation requirement

and cost reduction. All quality experts agree on the necessity for the manufacturing or

the provider to reconcile the apparently con¯ icting perspectives, thereby making quality

improvement process more manageable.

Some quality experts, such as Crosby (1980), de® ne quality as `conformance to require-

ment’ . In this case, it is assumed that the quality variables are taken care of by the

`requirement’ . Dr Deming de® nes quality as a ``never ending cycle of continuous improve-

ment’ ’ . In Deming’ s model, quality is not a destination, but rather a journey (Asubonteng

et al., 1996).

The concept of quality is di� cult to de® ne in the service industry. In the health-care

industry, the concept is even more di� cult to de® ne, given the fact that there are many

participants involved in the delivery of health care, each having his/her own interest in point.

For example, the tiers payer is likely to consider cost containment as the most important

thing while assessing the quality of health-care delivery; whereas the patient is likely to

consider the degree of recovery of his/her initial state of health as the most important thing.

As pointed out by Palmer (1976, p. 8) `̀ the existence of multiple de ® nitions which incorporate

only certain dimensions, corresponding to the values of particular interest groups, has led to

much confusion’ ’ .

In general, the consumer determines what in a product or a service represents quality.

The consumer determines which level of quality is high and which one is low. He/she does

this by using whatever information is available, whether from experience, expectation or

deductive reasoning. However, in the case of health-care services, the consumer is limited by

the quantity and quality of the information available to him/her (Hamilton, 1982). The

reasons for the lim itation are multiple and include the complex nature of the health practices

and ethical reasons. As a de® nition, we suggest the following: in health-care services, quality

is achieved when the outcome matches or surpasses the patient expectation. This de ® nition

assumes that the patient knows in advance what are the possible outcomes; without that

knowledge quality cannot be measured (at least not from the patient perspective).

De® nition of the concept of TQM

TQM is also referred to as continuous quality improvement (CQI). TQM has no single

theoretical formulation, nor any de® nitive shortlist of practices that are associated with it

(Lawler, 1994). TQM has been de® ned diŒerently by diŒerent authors. Ho and Cicmil

(1995) reported some de® nitions from the TQM literature:

Dow

nloa

ded

by [

Uni

vers

ity o

f C

alif

orni

a, S

an F

ranc

isco

] at

09:

17 0

9 D

ecem

ber

2014

OBSTACLES TO TQM IN HEALTH CARE 59

· TQM is a totally integrated eŒort to gain competitive advantage by continuous

improvement of every facet of organizational culture (Ho & Cicmil, 1995).

· TQM is total (every person in the ® rm is involved, and where possible its customers

and suppliers) quality (customer requirements are met exactly) management (senior

executives are fully committed) (Ho & Cicmil, 1995).

· TQM is the total quality control’ s organization-wide impact (Ho & Cicmil, 1995).

· For the US Department of Defense, TQM is both a philosophy and a set of guiding

principles that are the foundation of a continuously improving organization. TQM is

the application of quantitative methods and human resources to improve the material

services supplied to an organization, all the process within the organization and the

degree to which the needs of customers are met, now and in the future.

· TQM integrates fundamental management techniques, existing improvement eŒorts

and technical tools in a disciplined approach focused on continuous improvement (Ho

& Cicmil, 1995).

We summarize these de® nitions through some of the words used by one or the other. First,

the word `total ’ invokes the concept of system and wholeness. This implies that the activities

of TQM are not limited to a few components or processes in the organization: all the staŒ

constituents Ð physicians, nurses, management, etc.Ð must be highly involved. Second, we

have the word `continuous’ , which invokes the concepts of commitment and dedication. It

implies that hospital staŒmust not consider TQM activities as `one-time’ activities; on the

contrary, they should consider TQM activities as the normal way of doing their everyday

work. They see TQM as an on-going process that must be carried on as long as the system

(organization) lives. Third, the world `culture’ touches on the concept of human behavior. It

implies that the commitment must come from a shared belief ; the various professional

subgroups in hospital settings must work hard to ® nd a common ground in dealing with

TQM implementation. The health care organization’s culture must have precedence over

any other professional subgroup’ s culture for TQM to be successful. Finally, the words `tools’

and `methods’ touch on many other ideas, such as variation and measurement. They imply

that there must be a systematic way of carrying out each activity and measuring it; this

implies that physicians and other staŒmust accept and learn to use TQM tools as decision-

making help.

Importance of TQM in the health-care industry

TQM was ® rst popularized in Japan by Japanese manufacturing ® rms. The whole philosophy

was based mostly on the teachings of Drs Deming and Juran, two important American

experts in quality, who went to Japan to teach Japanese how to run modern manufacturing

plants after World War II. The old fashion of management became less and less productive

in the face of increasing customer demand for products of greater quality. The heavy emphasis

placed on inspection to satisfy the growing demand for quality product turned many

successful companies of the 1950s and 1960s into unproductive ones by the end of the

1970s. This created a situation whereby American companies felt that they must try the new

idea that, reportedly, had been so successful in Japanese companies.

Among the most reported TQM bene® ts was a study carried out by Garving (cited in

Dobyns & Crawford-M asson, 1991), who studied the quality of American and Japanese

room air conditioners over several years in the early 1980s. The conclusion of his study was

that ``Japanese companies were far superior to their US counterparts: their average assembly-

line defect rate was almost 70 times lower and their average ® rst-year service call rate nearly

Dow

nloa

ded

by [

Uni

vers

ity o

f C

alif

orni

a, S

an F

ranc

isco

] at

09:

17 0

9 D

ecem

ber

2014

60 C. ZABADA ET AL.

17 times better’ ’ . The best American manufacture was about 10% worse than the worse

Japanese manufacturer, and the Japanese spent less to produce quality than the Americans

spent to produce something less (Dobyns & Crawford-M asson, 1991).

This revelation by Garving, coupled with the 1980s NBC documentary If Japan Can

. . . , Why Can’ t We?, helped to underline the importance of TQM practices in the US. In

manufacturing industry, where its bene® ts become ® rst evident, TQM improves the perfor-

mance of companies in several areas by eliminating product defects, enhancing attractiveness

of product design, speeding service delivery and reducing cost. In health care, TQM

encompasses a number of strategies designed to improve quality and reduce costs (Asubon-

teng et al., 1996). These strategies include:

· identifying and meeting customer needs;

· reducing the cost of non-compliance with standards;

· striving for zero defects;

· reducing outcome variability;

· using statistical methods to identify and monitor processes;

· continually working for improved quality (Asubonteng et al., 1996).

The quality chain reaction popularized by Dr Deming speci® es that quality improvement is

followed by reduction in cost (because of less rework, fewer mistakes, fewer delays, snags

and better use of machine time/material), which in turn increases productivity and therefore

enables the company to become more competitive, with better chances of survival and more

jobs provided (Ho & Cicmil, 1995).

In the health-care industry, if TQM is successfully adhered to, Deming’ s chain reaction

suggests that TQM will not only result in cost reduction in the administrative functions, but

also prevent costly or fatal mistakes that generate so much loss of life and law suites: Hamilton

(1982) reported that 90% of drugs prescribed result in waste of money and risk of serious

side-eŒects, and unnecessary surgery wastes billions of dollars and causes thousands of deaths

each year.

Even though TQM promises to oŒer a lot of bene® ts to hospitals, the application of its

principle is faced with some basic obstacles that are apparently inherent to the nature of

health-care organizations. For TQM to have a full impact on the health-care organizations,

those obstacles must be removed in one way or the other.

Comparison of TQM in manufacturing settings versus health-care organization

settings

TQM teaches us that understanding and ful® lling the expectations of customers is the best

and only lasting means to business success. TQM in health-care organization settings is

based on a number of principles that vary from organization to organization. Several studies

(e.g. Asubonteng et al., 1996) have outlined a range of key concepts used by the Henry Ford

system to implement TQM. They are:

· top management leadership;

· creating a corporate framework for quality;

· transforming corporate culture;

· customer focus;

· a collaborative approach to process improvement;

· employee education and training;

· benchmarking;

Dow

nloa

ded

by [

Uni

vers

ity o

f C

alif

orni

a, S

an F

ranc

isco

] at

09:

17 0

9 D

ecem

ber

2014

OBSTACLES TO TQM IN HEALTH CARE 61

· quality measurement and statistical report;

· recognition and reward;

· integration with the process.

These concepts are not diŒerent from the ones used in manufacturing settings.

TQM application needs a strong leadership that must be initiated by the top manage-

ment. It must be a part of the strategic plans of the organization. An appropriate culture

must be created for TQM to yield full bene® ts. Every activity within the organization must

be tied to and must contribute toward the total satisfaction of patients. EŒorts must be made

to formalize each activity in terms of process, a process being more measurable and

controllable than guesswork. System approaches must be institutionalized to help to hold

together diŒerent functions and diŒerent activities; teamwork must be used extensively.

Employee training and continuous education must be institutionalized in order to address

subjects such as usage of TQM tools and profound knowledge acquisition. Benchmarking

must also be institutionalized. As de® ned by Kearns (chief executive o� cer, Xerox Corpora-

tion), benchmarking is the continuous process of measuring products, services and practices

against the toughest competitors or those companies recognized as industry leaders (Shoji

et al., 1993). TQM statistical tools must be used on a regular basis to monitor and measure

progress and performance. Recognition and reward must be revised and made compatible

with the TQM philosophy; especially, piecework compensation should not be used.

Obstacles to the application of TQM in health-care organizations

Review of the literature (Shortell et al., 1995) suggests one noticeable diŒerence between

TQM applications in health-care and other ® elds. The vast majority of applications in other

® elds of endeavour have been directed at the core processes of the ® rm in areas of greatest

strategic priority. In contrast, in health care, the vast majority of applications to date have

been in functions providing administrative support to patient care activities rather than

directly addressing clinical processes themselves. This ® nding is to be correlated with the

belief among the health-care organizations that TQM is used for the sole purpose of cost

containment; therefore the most evident area where it can be applied is administrative and

other support functions.

Deming’s 14 points do not refer solely to the function of a `quality department’ but

instead to the function of a `quality organization’ . Similarly, health-care organization should

not limit application of TQM to the administrative and other supportive activities. TQM

should be applied organization-wide, throughout all activities and functions; it should be the

manifestation of a fundamental and shared belief in total customer satisfaction. TQM is

more than a set of tools that can be learned in short order and simply applied in an existing

organization. It is a basic philosophy of management (Lengnick-Hall et al., 1995).

Among all the obstacles to the application of TQM in health-care organizations, it seems

that cultural obstacles are the hardest to remove. Obstacles to the application of TQM related

to culture in health-care organizations are documented by Shortell et al. (1995). These

obstacles are as follows:

· Health-care organizations are inward-looking; they tend to focus more on the needs

of care-givers and professionals than on the needs of external customers.

· Large health-care organizations are typically organized on a relatively hierarchical

basis, exemplifying bureaucratic cultures that are resistant to employee empowerment.

· There is a lack of senior management commitment to TQM in most health-care

organizations.

Dow

nloa

ded

by [

Uni

vers

ity o

f C

alif

orni

a, S

an F

ranc

isco

] at

09:

17 0

9 D

ecem

ber

2014

62 C. ZABADA ET AL.

· In health-care organizations, leadership styles are based on command and control and

hero/heroine models, rather than empowerment and `m anager as developer’ (or

manager as coach) models (Shortell et al., 1995).

· In general, middle managers perceived TQM as a threat that might eliminate their

jobs. Therefore they resist its introduction to their organization.

Perhaps the most common obstacle to the application of TQM in health-care organizations

is the compensation system (Reinertsen, 1995). In general, piecework reimbursement systems

constitute a powerful obstacle to the application of TQM because it places the individual

worker at risk from innovation. Other obstacles mentioned by Reinertsen include fuzzy

missions, poor communication of organization purpose and strategies, lack of commitment

to training and learning, and corporate symbols, such as parking spaces.

In reviewing the literature, we ® nd other obstacles to the application of TQM in health-

care organization settings:

· Physicians in most health-care organizations do not feel concerned by TQM activities.

They feel that TQM is not applicable to their job. This point is crucial for the success

of TQM in any organizational settings, whether it is a manufacturing or a service

organization, as proven by a study at a Northern Telecom plant (Shortell et al., 1995).

This study found that employees’ inability to see beyond their own departments’

(specialities’ ) goal to the broader, ® rm-wide (hospital-wide), strategic quality issues

demanded by the environment was a major reason for TQM implementation failure.

· The under-involvement of physicians in TQM eŒorts (Shortell et al., 1995). This

includes the unavailability of time, physicians’ beliefs that they are already doing

quality work, physicians’ relative inexperience or unwillingness to work as members of

teams and physicians’ perception that TQM is primarily a cost-control mechanism.

· In addressing process approaches to the measurement of the quality of medical care,

health-care organizations do not pay enough attention to the presence of the patient

as both product and participant (Greene et al., 1976), even if this may be the crucial

determinant of the outcome of any medical intervention. It is obvious that hospitals

deal with human beingsÐ the patients. On the one hand, they are a product in the

sense that work is done on their physical or mental being; on the other hand, they are

a participant in the sense that their knowledge (information) and collaborations

(compliance to instructions) are required. As such, patients’ behavior has an impact

on the quality of the health-care outcome.

· It is reported (Hamilton, 1982) that many health-care providers strongly oppose

consumer involvement in the health-care system. Some of the reasons they advance

are: (a) health care is too esoteric for the consumer to understand, much less control;

(b) there is such a wide variety of consumer opinion about how to change the health-

care system that there is no one who can speak for consumers in general; (c) patient

involvement in the health-care delivery process will ham per the smooth operation of

some programmes.

· Rigid hierarchical and authoritative structures do not allow peer workers to make

suggestions for a change. For example, Hamilton (1982) reported that nurses and

other health-care providers who are sympathetic to consumer causes are vulnerable to

harassment. Some who have spoken out or acted too strongly for change have been

® red or have lost their license to practice their profession.

· The health-care consumers are powerless to alter health-care providers’ behavior

through market transactions. In a free economy society, consumer sovereignty is a very

important concept that every business organization takes into consideration in one

Dow

nloa

ded

by [

Uni

vers

ity o

f C

alif

orni

a, S

an F

ranc

isco

] at

09:

17 0

9 D

ecem

ber

2014

OBSTACLES TO TQM IN HEALTH CARE 63

Table 1. Comparison of hospital professional and TQM models

Professional TQM

Individual responsibilities Collective responsibilities

Professional leadership Managerial leadership

Autonomy Accountability

Administrative authority Participation

Goal expectations Performance and process expectations

Rigid planning Flexible planning

Responses to complaints Benchmarking

Retrospective performance appraisal Concurrent performance appraisal

Quality assurance Continuous improvement

Source : Short & Rahim (1995, p. 261).

way or another. It is a law that has proven eŒective in teaching most business

organizations the right behavior to adopt. Basically, the `consumer as sovereign’ theory

explains production decisions as being the producer’ s response to consumer mandate.

But the very nature of the health-care market does not lend itself to the law of the free

market. Hazel Kyrk wrote (Hamilton, 1982), in `A theory of consumption’ , that

consumers need a neutral and independent sources of information to use in making

informed choices in spending. For a market to be considered a free market, it must

obey four basic conditions (Hamilton, 1982): (a) consumer demand must determine

production of goods and provision of services; (b) consumers must have the informa-

tion necessary to judge the quality, utility and safety of products and services that give

the greatest utility for the lowest price; (c) consumers must choose products and

services that give the greatest utility for the lowest price; (d) both consumers and

providers must have free access to the market-place. Clearly, the health-care industry

market meets very few, if any, of these conditions: until very recently there have been

few independent and neutral sources of information for consumers of health care.

A comparative analysis of the professional and TQM models was done by Short and Rahim

(1995). Table 1 summarizes the areas of con¯ icts of the two models.

Discussion

Hospitals are generally organized by occupations. These groups form what can be called

occupational subcultures, in the sense that they share in common a distinctive ideology and

identi ® able cultural forms or practices that are inherent to their occupation. For example, in

a typical nursing station you may ® nd such groups as registered nurses, pharmacists,

secretaries, nurse assistants and house keepers doing things that are particular to their

respective trade. As subcultures, these groups are diŒerent one from the other, but they still

have a common denominator by which all of them can claim their feeling of belonging to the

organization (the hospital) they work for. For the hospital to show good performance, these

various groups must work as a single one, but the feeling of the common denominator often

seemed to take a back seat in most health-care organizations, therefore hindering the

introduction and development of TQM in hospital. In fact, these subcultures seem to let

their professional needs take precedence on every other thing else, including TQM. Referring

to one of the most powerful of these subcultures (physicians), Andt and Bigelow (1995),

after pointing out that TQM assigns responsibilities to management that are vast under any

circumstances, stated: `̀ The special role of physicians, the behavioral and political aspects of

Dow

nloa

ded

by [

Uni

vers

ity o

f C

alif

orni

a, S

an F

ranc

isco

] at

09:

17 0

9 D

ecem

ber

2014

64 C. ZABADA ET AL.

decision making in hospitals, and the ambiguities surrounding de® nitions of quality make the

job creating unity of purpose and of enforcing rational decision making even more daunting

and perhaps unrealistic in hospital’ ’ (p. 11).

As we have already mentioned, most physicians feel that they are already doing a quality

job and are even against patients’ participation in the health-care delivery process. This

behavior agrees with the outdated `product-out’ concept, which places emphasis on the

product. It focuses on the product (the medical procedure) as the purpose of work. This

traditional management orientation teaches that a job is done and done well if a product is

produced according to the manual for making it and the product works to its speci® cation or

standard. The focus is on the company’ s eŒort to produce what it considers to be a good

product (medical procedure). The product-out concept is often in a fashion that suggests

that the customers (patients in the case of hospitals) are stupid, that they do not understand

their real needs.

It is important for a hospital that is contemplating adopting TQM to help its subcultures

to get rid of all practices and thinking that are based on the product-out concept. Once the

product-out concept is discarded, the `market-in’ concept must be institutionalized and made

an important element of the new philosophy on which the hospital must operate. The market-

in concept places the emphasis on the customer’s (here the meaning of customer is extended

to a previous stage, process or function, within the hospital itself ) satisfaction as the purpose

of work.

The market-in concept focuses on input from the market (or from the previous stage,

process or function, within the hospital itself ), and suggests that the job is not done well

until the customer is satis ® ed (Shoji et al., 1993). To get the full bene® t of the market-in

concept, it must be applied throughout the organization and across all functions and activities.

This application should be within the system approach (which is a way of seeing the whole

instead of individual par ts of a phenomenon) framework, with, in the background, Deming’ s

profound knowledge (Lengnick-Hall, 1995). Figure 1 outlines the linkage of knowledge

required for continual improvement.

Deming advanced the concepts of profound knowledge of system, variation, psychology

and theory of knowledge. According to Deming, knowledge of a system emphasizes the

Figure 1. The knowledge linkage required for continual improvement (from Young, 1995, p. 42).

Dow

nloa

ded

by [

Uni

vers

ity o

f C

alif

orni

a, S

an F

ranc

isco

] at

09:

17 0

9 D

ecem

ber

2014

OBSTACLES TO TQM IN HEALTH CARE 65

importance of knowing the aim of a system and the interrelatedness and interdependency of

its components and processes. Knowledge of variation acknowledges the inherent variability

of all processes, from the production system in the manufacturing plant to the temperature

or blood pressure of a living organism (Young, 1995). Knowledge of psychology includes a

special focus on understanding the intrinsic motivation that underlies much of human

behavior; this understanding implies a de-emphasis on external motivators and increased

emphasis on removing obstacles to pride and joy in work (Deming, 1993; Young, 1995).

The theory of knowledge speci® es that management is prediction (Deming, 1993; Young,

1995).

Conclusions

In conclusion, while acknowledging the success of TQM in the manufacturing and other

service sectors, we can still doubt the applicability and success of TQM in the health-care

sector. This doubt stems from the fact that there are a lot of incompatibilities between TQM

philosophy and the practices on which health-care organization’s management is currently

based. We feel that this situation can be reversed if enough resources and time are devoted

to changing health-care organization culture, from one built around the perspective of

heroism to one built around the perspective of commercial goals, without losing the dignity

that health-care services deserve. An approach to initiating a solution to the problem will be

for health-care learning institutions to accept a leading role. In this leading role, health-care

learning institutions should start putting increased emphasis on the teaching of TQM,

its overall philosophy (from team work to system approach in problem solving) and its

various tools.

References

ARNDT, M. & BIGELOW, B. (1995) The implementation of total quality management in hospitals: how good is

the ® t?, Health Care Management Review, 20, pp. 7 ± 14.

ASUBONTENG, P., MCCLEARY, K. & MUNCHUS, G. (1996 ) The evolution of quality in the US health care

industry: an old wine in a new bottle, International Journal of Health Care Quality Assurance, 9, pp. 11 ± 19.

CROSBY, B.P. (1980) Quality Is FreeÐ The Art of Making Quality Free (New York, Penguin).

DOBYNS, L. & CRAWFORD-MASSON, C. (1991) Quality or ElseÐ The Revolution in World Business (Boston,

Houghton-Miç in).

GREENE, R., SIMMONS, J. & GOLDEN, J. (1976 ) The role of consumer behavior in the outcome of health

services intervention. In: R. GREENE (ED.) Assuring Quality in Medica l Care: The State of the Art (New

York, Ballinger).

HAMILTON, A.P. (1982) Health Care Consumerism (St Louis, MO, C.V. Mosby).

HO, S. & CICMIL, S. (1995) Total quality management transfer to small and medium industries in Malaysia

by SIRIM, Total Quality Management, 8, pp. 273 ± 285.

LAWLER, E. III (1994) Total quality management and employee involvement: are they compatible?, Academy

of Management Executive, 8, pp. 68 ± 76.

LENGNICK-HALL, A.C. (1995) The patient as the pivot point for quality in health care delivery, Journal of the

Foundation of the American College of Health Executive s, 40, pp. 25 ± 39.

PALMER, R.H. (1976) De® nitions and data. In: R. GREENE (Ed.) Assuring Quality in Medical Care: The State

of the Art (New York, Ballinger).

REINERTSEN, L.J. (1995) Transformation: the new knowledge needed for health care administrators, Journal

of Health Administration Education, 13, pp. 39 ± 51.

SHOJI, S., GRAHAM, A. & WALDEN, D. (1993) A New American TQMÐ Four Practical Revolutions in Management

(Cambridge, MA, Productivity Press).

Dow

nloa

ded

by [

Uni

vers

ity o

f C

alif

orni

a, S

an F

ranc

isco

] at

09:

17 0

9 D

ecem

ber

2014

66 C. ZABADA ET AL.

SHORT, P.J. & RAHIM, M.A. (1995) Total quality management in hospitals, Total Quality Management, 6,

pp. 255 ± 263.

SHORTELL, S., LEVIN, D., O’BRIEN, J. & HUGHES, E. (1995) Assessing the evidence on CQI: is the glass half

empty or half full?, Journal of the Foundation of the American College of Healthcare Executive s, 40, pp. 4 ± 24.

YOUNG, J.M. (1995) Patients, physicians, and professional knowledge: implications for CQI, Journal of the

Foundation of the American College of Healthcare Executives, 40, pp. 40 ± 49.

Dow

nloa

ded

by [

Uni

vers

ity o

f C

alif

orni

a, S

an F

ranc

isco

] at

09:

17 0

9 D

ecem

ber

2014