Best Practices of Total Quality ManagementImplementation in .docx

Best Practices of Total Quality Management
Implementation in Health Care Settings
FAISAL TALIB
Mechanical Engineering Section, University Polytechnic,
Faculty of Engineering and
Technology, Aligarh Muslim University, Aligarh, India
ZILLUR RAHMAN and MOHAMMED AZAM
Department of Management Studies, Indian Institute of
Technology Roorkee,
Roorkee, India
Due to the growing prominence of total quality management
(TQM) in health care, the present study was conducted to
identify
the set of TQM practices for its successful implementation in
healthcare institutions through a systematic review of literature.
A research strategy was performed on the selected papers
published
between 1995 and 2009. An appropriate database was chosen
and
15 peer-reviewed research papers were identified through a
screening process and were finally reviewed for this study.
Eight
supporting TQM practices, such as top-management
commitment,
teamwork and participation, process management, customer
focus
and satisfaction, resource management, organization behavior

and culture, continuous improvement, and training and educa-
tion were identified as best practices for TQM implementation
in
any health care setting. The article concludes with a set of
recom-
mendations for the future researchers to discuss, develop, and
work
upon in order to achieve better precision and generalizations.
KEYWORDS health care institutions, total quality management,
TQM implementation, TQM practices
Address correspondence to Faisal Talib, Assistant Professor,
Mechanical Engineering
Section, University Polytechnic, Faculty of Engineering and
Technology, Aligarh Muslim
University, Aligarh-202002, Uttar Pradesh, India. E-mail:
[email protected]
Health Marketing Quarterly, 28:232–252, 2011
Copyright # Taylor & Francis Group, LLC
ISSN: 0735-9683 print=1545-0864 online
DOI: 10.1080/07359683.2011.595643
232
INTRODUCTION
The health care and medical services are growing immensely
due to a high
influx of the private sector, changing disease patterns, medical
tourism,
and demographic variations. Development of new and advanced
techniques,
increased awareness on patient’s safety, intensity of

competition in health
care market, and new generation of purchasers and providers
have forced
the health care institutions to improve the efficiency and
introduce a
consumer culture in their institutions for effective cost and
quality of care
(Mosadegh Rad, 2005; Lee, Ng, & Zhang, 2002; Short, 1995).
Quality of care
is the vital issue for every health care institution and there is an
immediate
need for health care reforms in order to address and resolve the
problems
associated with quality of care, as well as patient preferences,
safety, and
choice (Koeck, 1997). Another critical issue is the consistently
increasing
operating costs of health care institutions. Rising health care
expenditures
have created serious financial burdens for the ex-chequer
(government
department in charge of national revenue or national treasury)
in many coun-
tries like Canada, the United States, the United Kingdom, and
Taiwan (Yang,
2003), and are facing a serious fall in business and a debt crisis.
In such a
situation, health care institutions need to re-examine their ways
of doing
business in order to decrease their operating costs while
increasing quality
and value in their delivery process.
To address the aforementioned issues a plethora of literature in
health
care were reviewed which showed implementation of different

quality man-
agement practices and tools such as ISO9000, continuous
quality improve-
ment, health quality improvement circle, quality management
systems, and
others are important in this respect (Yang, 2003). However, one
of the sug-
gested approaches to resolve these issues more effectively and
practically,
and to bring better quality to health care institutions, is the
adoption of total
quality management (TQM) approach (Manjunath, 2007; Yang,
2003; Moody,
Motwani, & Kumar, 1998; Short & Rahim, 1995; Kim &
Johnson, 1994). TQM
have now taken a central role in the health care quality
management
(McLaughlin & Simpson, 1999). By adapting the concepts of
TQM, the health
care institutions can transform their traditional quality
improvement system to
customer oriented system through a framework involving
customer focus, pro-
cess management, new tools and techniques, and teamwork
(Klein, Motwani,
& Cole, 1998). Within such an approach, health care institutions
focus on cre-
ating physical, psychological, and social environment that is
conducive to their
patients and staff. Externally, they also concentrate on
promoting the health
and well-being of communities and on reducing costs
(Ovretveit, 2000).
While the TQM concept and practices have been widely
accepted in

health care institutions, its sincere and systematic adoption is a
must for its
success. It is evident from the studies that adoption of TQM
practices tends
Best Practices of Total Quality Management 233
to improve the health care institutions if implemented properly;
otherwise it
may result in TQM failure (Short, 1995; Claver & Molina,
2003). A number of
studies, empirical as well as exploratory, have been carried out
to explain the
factors influencing TQM implementation, and are well
documented (Wali,
Deshmukh, & Gupta, 2003; Wayhan & Balderson, 2007; Nair,
2006; Sila,
2007). However, the studies on TQM practices in health care
settings are rare.
Therefore, a systematic review of identifying the various
practices underlying
the success of TQM implementation is the need of the hour,
which may help
in developing a base for future researchers and help health care
managers in
adopting the same.
The aim of the present study is to identify a set of TQM
practices that are
helpful and are applicable in health care setting for resolving
their problems
effectively. These practices are therefore, termed as best TQM
practices in this
study.

Further, the scope of this study offers a good background in
arguing that
these identified best TQM practices, if implemented properly
and systemati-
cally, would provide a framework for quality improvement in
health care
institutions and thus, will result in delivering upgraded service
quality and
patient satisfaction with improved performance.
To achieve this objective, the article first addresses the
literature on the
development of TQM program in the health care environment. It
then
describes the methodology and lay down the objectives of the
study. Next,
the results of the study are presented in detail. The article
concludes with
providing of the brief discussion on the results of the study
together with
the direction for future research in this area.
LITERATURE REVIEW
TQM in Health Care Environment
The concept of TQM was first implemented in the
manufacturing sector in
early 1980s followed by the service sector and other sectors. In
the recent
years, many health care institutions have applied the principles
and practices
of TQM in order to solve most of the problems that they are
currently facing
(Chesanov, 1997; Counte, Glandon, Oleske, & Hill, 1995; Kim

& Johnson,
1994). The reasons behind the wide acceptability of TQM in
health care insti-
tutions are many, but before highlighting these reasons it is
necessary to
understand what TQM is in context to health care environment.
It is defined as:
The satisfaction of patients, doctors, nurses, and suppliers (i.e.,
social
shareholders) and other interested groups, achieved by
implementing
effective planning, programs, policies and strategies (i.e., hard
issues),
234 F. Talib et al.
and human and all other assets (i.e., soft issues) efficiently and
continu-
ally within a hospital context. (Arasli, 2002, p. 347)
Further, the TQM focuses on: customer (patient) satisfaction,
continuous
improvement, teamwork, process management, systemization,
organization
culture and structure, and lastly commitment from management
and support-
ive leadership. Several studies have also emphasized that
successful imple-
mentation of TQM can result in significantly superior outcomes
in health
care institutions (Short & Rahim, 1995; Yang, 2003; Counte et
al., 1995), some

of these outcomes are:
. Upgraded quality of service
. Improved health care quality and performance
. Patient satisfaction
. Reduced operating cost of health care institutions
. Employee satisfaction, and
. Patient safety
Therefore, health care institutions have started to implement it
rigorously,
even some of the hospitals associations and organizations have
directed all
its health care institutions to adopt TQM as early as possible.
Some of the stu-
dies show the positive aspects of TQM movement for hospitals
such as qual-
ity improvement, financial performance, competitive advantage,
and
employee commitment in various hospitals and nursing homes
(Alexander,
Weiner, & Griffith, 2006; Chesteen, Heigheim, Randall, &
Wardell, 2005;
Douglas & Judge. 2001).
A study conducted by Lee et al. (2007) concluded that for the
successful
implementation of TQM system in hospitals requires hospital
control, devel-
oping an incorporated performance measurement system, and a
broad

approach for quality progress.
Horng and Huarng (2002), in their study based on survey of 76
hospitals
in Taiwan, tested a multilevel model addressing the issue of
TQM adoption.
Results of the analyses indicated that the nature of the network
relationship
and prospector strategy, the two constructs out of five identified
constructs,
are positively and significantly related to the extent of TQM
adoption. Further
analysis shows that prospector strategy is related to TQM
adoption for profit
earning hospitals while network relationship is related to TQM
adoption for
nonprofit hospitals.
The study by Yasin and Alavi (1999) illustrated the use of
market share
model for achieving competitive advantage of TQM in health
care and con-
cluded that TQM contributes to increase in market share and
organizational
effectiveness.
Komashie, Mousavi, and Gore (2007) argued that though the
theory of
quality has a long history, but the supervision of quality and its
control in
health care industry is not as highly developed as in

manufacturing industry.
They mentioned several reasons, such as kind of procedures and
production
involved, and dissimilarities between the two industries in terms
of concerns
for quality.
Chow-Chua and Goh (2000) concluded that continuous
improvement
and innovative approaches such as TQM have generated cost
and time sav-
ings and helped to streamline work processes. They further
concluded that
large hospitals and public hospitals are more inclined to
implement TQM
approach while medium sized hospitals tend to use continuous
improvement
as a medium for quality improvement.
Other similar studies of interest based on TQM in the health
care
environment are those of Ovretveit (2000); Satia and Dohlie
(1999); Brennan
(1998); Nwabueze and Kanji (1997); and Aggarwal and Zairi
(1997).
Moreover, implementing TQM principle and practices will not
only miti-
gate the financial crisis of the health care institutions but will
also help to
overcome many critical problems which they are facing. It is
also pertinent
to understand that the pressure the health care institutions are
facing might
push them to implement TQM program to resolve the critical
issues involved.

Thus, TQM can become an alternative option for policy makers
as well as for
managers of health care institutions.
RESEARCH OBJECTIVE AND METHODOLOGY
The purpose of the study is to identify a set of best practices of
TQM in health
care setting that could be used by the researchers and
practitioners of the
health care institutions for its successful implementation. The
methodology
selected for this study was literature review of the published
research papers
on the current subject and area. To identify the appropriate
published
research papers for this study, a search strategy using the
following expres-
sions and phrases was conducted: ‘‘TQM strategy,’’ ‘‘quality
management,’’
‘‘Hospital guidelines and administration,’’ ‘‘Health care
organizations=
institutions,’’ ‘‘TQM framework and implementation,’’ ‘‘TQM
practices and
problems,’’ and ‘‘quality management system and practices.’’ A
comprehen-
sive computer-aided search of papers in the ProQuest Advanced
Search
Database published from 1995 to 2009 was performed using
these expres-
sions and phrases. The results were further narrowed down with
the
keywords like ‘‘health care,’’ ‘‘hospitals,’’ ‘‘TQM,’’ ‘‘QM,’’
and ‘‘TQM prac-
tices.’’ Not included were terms including ‘‘strategy,’’
‘‘guidelines,’’ ‘‘adminis-

tration,’’ ‘‘problems,’’ or ‘‘clinical methods.’’ With a
limitation on English
language, full text, and scholarly peer-reviewed papers, the
search resulted
in 836 hits.
From these selected research papers, this study further searched
for
those papers which focused on factors and practices influencing
TQM or
236 F. Talib et al.
QM in health care organization and which were either empirical
or review
studies. The QM=TQM studies which are limited on describing
one specific
quality improvement action or using service quality
approach=case based
approach=articles=commentaries=projects were excluded. The
titles and
abstracts based on these criteria were reviewed and excluded
585 publica-
tions. A total of 251 abstract were further reviewed for the
second criteria,
which concerns the identification of TQM practices in the
health care institu-
tions. This resulted in the exclusion of 173 publications and the
search now
was left with 78 publications specifically describing the TQM
or QM practices
and their implementation process. These 78 selected
publications were then
retrieved for the full text documents to evaluate their

methodology of study,
approaches, and findings. The 78 fully retrieved papers were
then further
examined for their empirical and review studies thus, excluding
41 single
case study papers, five projects papers and 17 papers on short
articles and
commentary. Only 11 empirical and four review studies were
included for
further review. Finally, a total of 15 research publications were
reviewed.
The systematic approach of present literature review is depicted
in
Figure 1. Data from these 15 studies were also extracted into a
structured
summary as shown in Table 1 where the objectives,
methodology, approach,
and main findings have been explained. All the TQM practices
identified
FIGURE 1 Systematic literature review. Process.
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241
from these 15 papers were recorded, and based on their

frequency of occur-
rence; the results were obtained as shown in Table 2.
RESULTS
Different findings and practical implications could be discerned
from
in-depth study of the 15 selected research publications with
varying terms
of their specific study approach, objectives, methodology,
sampling type
and size, setting, and respondents as shown in Table 1.
Overall, there are eight best practices in TQM implementation
identified
from the review of literature, namely, top-management
commitment (or
leadership; 11; teamwork (8); process management (8);
customer focus
and satisfaction (8); resource management (7); organization
behavior and
culture (6); continuous improvement (5); and training and
education (5).
These practices were identified on the basis of their frequency
of occurrence
in the literature review as shown in curly parentheses. The
following part of
this article will further explain each TQM practice.
Top-Management Commitment (Leadership)
Top-management commitment and support (or leadership) is
found to be
the most important enabling practice for implementing TQM in
the
health care institutions. Other elements of top-management

commitment
TABLE 2 Major TQM Practices in Health Care Setting
Investigated From Literature Review
TQM practice
Author(s) TMC TWP PM CFS RM OBC CI TE
Lin and Clousing (1995)
p p p p
Raja et al. (2007)
p p p p p
Hazilah (2009)
p p p p p
Meyer and Collier (2001)
p p p p p p
Carman et al. (1996)
p p p
Kunst and Lemmink (2000)
p p p p
Miller et al. (2009)
p p p p p
Mosadegh Rad (2005)
p p p p
Salaheldin and Mukhalalati (2009)
p p p p p

Duggirala et al. (2008)
p p
Isouard (1999)
p p p
Kozak, Asunakutlu, and Safran (2007)
p p p
Short and Rahim (1995)
p p
Wardhani et al. (2009)
p p p
Arasli and Ahmadeva (2004)
p p p p
Total 11 8 8 8 7 6 5 5
TMC ¼ top-management commitment; TWP ¼ teamwork and
participation; PM ¼ process management;
CFS ¼ customer focus and satisfaction; RM ¼ resource
management; OBC ¼ organization behavior and
culture; CI ¼ continuous improvement; and TE ¼ training and
education.
242 F. Talib et al.
include: leadership style, administrative support, upper-
management involve-
ment, support of upper-level management, and leadership for
quality.
Studies showed that quality of care has been connected to

leadership in
hospitals (Eubanks, 1992) and is an overall hospital systems
driver (Meyer
& Collier, 2001). The top-management acts as a coach to teach
and to influ-
ence the subordinate (Yang, 2003). It is generally accepted that
any
bottom-up quality action might fail without support from the
hospital top
management (Mosadegh Rad, 2005). Sometimes committed
physicians also
play an important role for successful implementation of TQM
program in
hospitals (Wakefield et al. 2001). Further, top-management
allows and
encourages everyone to contribute in the organization by
encouraging them,
and emphasize on process improvement rather than individual
account-
ability (Raja, Deshmukh, & Wadhwa, 2007). It can be
concluded that
top-management commitment is a prerequisite for effective and
successful
TQM implementation. This practice was well supported by 11
published
studies during the present literature survey (Table 2).
Teamwork and Participation
A second key practice of TQM is the development of teamwork
and partici-
pation. To overcome sectionalism, the entire organization
should cooperate
in improving quality and embark on quality improvement
activities (Yang,
2003) by forming teams with full participation. The proper

formation of qual-
ity improvement teams is vital to an organization’s TQM
success. It is essential
that each issue and organizational problem is analyzed by all
the team mem-
bers who are responsible for its improvement (Brashier, Sower,
Motwani, &
Savoie, 1996). In hospitals, a team should be composed of
personnel from
each department and should be capable to improve a process.
One of the
important objectives of teamwork and participation is that they
should solve
the quality related issues in quick time who are sometimes
called as quality
action teams (Mayer, 1992). Hence, teamwork and participation
is essential
in health care institutions, as it requires cooperation among all
related depart-
ments. This practice is well supported by eight published
studies (Table 2).
The other elements of teamwork and participation are: people
management,
staff focus, work system, employee relations, and teamwork
development.
Process Management
Process management is a critical practice of health care quality
which empha-
sizes conformance to patient (customer) requirements by means
of error-free
services in the most efficient way or in other words the
experience of the
patient with different processes that are a part of their stay in
hospital

(Duggirala, Rajendran, & Anantharaman, 2008). The key
aspects of this
practice covers: maintenance, setting standards, sincerity,
effectiveness,
management by fact, giving priority to patient’s need,
emergency of service
system, admission procedure, registration procedure, security
system, and
process of clinical care. These elements ensure error free
quality output. It
emphasizes the way staff strengthen the processes through
quality
improvement and operational performance (Raja et al., 2007).
Zeithaml,
Parasuraman, and Berry (1990) described process management
as the actual
procedures, mechanism, and flow of activities by which the
service (health
care service) is delivered. Finally, it concludes that process
management
examines the patient’s perception with regard to the treatment
process and
the outcome of the treatment process. This practice was
highlighted by eight
published studies of the current literature survey (Table 2).
Customer Focus and Satisfaction
Customer focus and satisfaction is another important practice of
the TQM
movement because health care institutions can outsource their

competitors
by effectively addressing patients’ (customers’) needs and
demands, and
by anticipating and responding to their evolving interests and
wants
(Sureshchandar, Rajendran, and Anantharaman, 2001). Their
primary duty
is to provide the patients (customers) with the best possible
services. These
services begin with arrival of patient into hospital premises and
at the regis-
tration counter by delivering online registration and taking
immediate action
as per the condition of the patient without loss of time. Hence,
first
impression is formed at the very first service rendered to the
patient and this
activity plays a key role in the patient’s perception towards the
hospital and
may act as motivating force in his recovery. Effective food
management and
availability of hygienic food in the hospitals is also important in
providing
patients with high quality services. The amount of food offered
to patients
should be sufficient to satisfy their needs and suitable to all
groups of patient
(Arasali & Ahmadeva, 2004). Beside this, other items include:
emergency ser-
vices, customer expectations, confidence, treatment cost, patient
focus, and
complaint resolution. However, customer satisfaction is a short-
term concept,
which may or may not lead to commitment. The management’s
responsibility
is to ensure that satisfaction is converted into commitment in

the long run.
Every patient needs proficient and skilled medical personnel for
sound diag-
nosis, treatment and care (Raja et al., 2007). Hence, the ultimate
aim is to
satisfy customer. This practice was considered by eight
published studies
during the present literature survey (Table 2).
Resource Management
This practice of TQM assesses the patient’s perception of
quality with regard
to physical facilities in the health care institutions. Resource
management is
basically concerned with management of available resources
which are
244 F. Talib et al.
needed right from patients’ entry in the hospital to their
discharge and
therefore, is a critical factor for any health care institution. This
practice
includes: resource measurement, infrastructure, cleanliness,
maintenance,
and availability of service such as ambulance, laboratory,
operation theaters,
wards, materials, information system, ATM, banks, and drug
stores. Good
service cannot be provided if there is insufficient provision of
the aforemen-
tioned items, no matter how professional doctors, physicians,
and supporting

staff are (Arasali & Ahmadeva, 2004). The provision of these
facilities and
materials has a direct impact on patient satisfaction (Hancock,
1999). Use
of resource management as TQM practice was supported by
seven studies
in this literature survey (Table 2).
Organizational Behavior and Culture
The role of organizational behavior and culture plays an
important role in
successful implementation of TQM in health care institutions.
The atmos-
phere of the hospital should be friendly and respectful, both
among staff
and between staff and patients, and it has a great impact on the
physical con-
dition of patients (Arasali & Ahmadeva, 2004). A total quality
culture creates
an atmosphere where people freely help each other to achieve
goals and
have fun during the process. In a positive culture, people feel
appreciated,
their opinions are prioritized, and actions follow suggestions
(Short & Rahim,
1995). Further, the hospitals should be free of organisms and
clean, develop
an environment to work as a team in improving the quality, and
the objective
should be problem solving and shared accountability. For TQM
to be
adopted successfully, the organizational culture and behavior
must be able
to sustain and nurture it (Atchison, 1992). Six empirical studies
tested and

supported this practice (Table 2).
Continuous Improvement
Continuous improvement is also an influencing practice in the
implemen-
tation of TQM. Five empirical studies found to support this
quality manage-
ment practice (Table 2). Institutionalizing continuous quality
improvement in
every department of health care institution will result in
elimination of bar-
riers, patient’s dissatisfaction, and complaints. The aim of
customer improve-
ment is to fulfill patient’s (customer) needs (Yang, 2003).
Continuous quality
improvement needs training and education of all staff and
physicians
together with the use of different quality improvement
approaches, tools,
and techniques. This practice ensures that organizations and
staff do not
settle for minimum standards but strive to do their best they can
with avail-
able resources (Satia & Dohlie, 1999). The items for this
practice also
includes: measurement of quality care, performance
measurement, innova-
tiveness, and performance analysis. Furthermore, the quest for
quality
improvement is not a definable task, but a continuous journey

that throws up
more and more opportunities for improvement. It has no
definable objective
other than the desire to strive for continuous improvement
(Sureshchandar
et al., 2001) and to achieve patient’s satisfaction as a goal.
Training and Education
Training and education was also noted as supporting practice
for implement-
ing TQM approach. This practice was cited by atleast five
research studies in
the present review (Table 2). This practice reflects the
organization’s
capability to use the quality management tools and techniques
(Wardhani,
Utarini, van Dijk, & Post, 2009). It includes: technical support,
management
training, statistical process control, employee training,
scientific problem-
solving approach, and information system. It is generally
accepted that
success in TQM relies on continuing education and training of
all levels of
personnel (Brashier et al., 1996). Technical training also intends
to meet
the needs of high performance at the workplace, as it effects
employee
and staff efficiency and safety. Further, the employees and staff
need to be
trained in statistical techniques for better quality management
(Mahadevappa
& Kotreshwar, 2004). Therefore, employee and staff training
and education
are the fundamental engineering during the implementation of

TQM.
DISCUSSION AND CONCLUSIONS
From the present review of literature, eight important TQM
practices were
identified: top-management commitment (or leadership),
teamwork and par-
ticipation, process management, customer focus and
satisfaction, resource
management, organizational behavior and culture, continuous
improvement,
and training and education. It was found that these eight TQM
practices
are critical for the successful implementation of TQM in the
health care
institutions and will result in improved performance, patient
satisfaction,
improved quality of care, and reduced operating cost of health
care institu-
tions (Figure 2). Therefore, these practices are termed best
practices of
TQM in present study.
However, the findings of this study are, to some extent,
different from
previous studies related to the identification of TQM practices.
Other studies
have identified different number of practices as well as some
other practices
which are not found in the present study outcome. This
inconsistency in find-
ings may be due to several reasons. Some of them are due to:
. Limitations of the research methodology adopted in the study

. Some external environmental factors at each research site, and
. Outcome measures
246 F. Talib et al.
Analyzing briefly these reasons, it was found that all empirical
studies con-
sidered in this study were based on cross-sectional analysis
except for few
exploratory studies that have utilized literature review
(descriptive) as method-
ology. Besides this, sampling type and size was also found to be
varying in each
study. This may affect the outcome of the present study. Further
going through
all the 15 research studies, it was found that four studies were
conducted in
United States, two in India, and one each in Cyprus, Australia,
Canada, United
Kingdom, Malaysia, Turkey, Iran, and Qatar. Two studies were
also undertaken
based on cross-country data. This supports that a set of TQM
practices are not
identical across the globe=world but they may vary from
country to country
depending upon the structure, size, and ownership of health care
institutions.
In the present study, hospitals of different sizes, structures, and
ownership
were considered for literature review. This may be another
factor for the incon-
sistency in the result. Lastly, another reason for the
inconsistency is related to

the outcome measures. Most of the selected research studies
utilized different
standard models, such as the Malcolm Baldrige National Quality
Award, the
European Foundation for Quality Management, and Kanji’s
Business Excel-
lence Model as a measure of the degree of TQM implementation
and hence,
this approach also affects the results of the present study.
Further, it is concluded from the results of this study that top-
management commitment is considered as the first requirement
for
FIGURE 2 Conceptual model of TQM practices influencing its
implementation in health care
institutions.
implementing TQM as many research findings supported this
practice.
Hence, top-management should lead the effort in improving the
quality of
the health care institutions. While teamwork and participation,
process man-
agement, and customer focus and satisfaction are considered as
other impor-
tant practices for successful TQM implementation. These
practices are also
well supported by many research studies and play a dominating
role in
health care institutions. Similarly, other practices like resource
management,

organizational behavior and culture, continuous improvement,
and training
and education also play an important role as explained in earlier
section.
Thus, it is concluded that all these eight identified TQM
practices are very
effective and are considered critical to the successful TQM
implementation
in health care institutions. Therefore, they may be treated as
best TQM prac-
tices for health care institutions.
Managerial Implications
For the successful implementation of TQM philosophy in the
health care
institution some of the managerial implications of the current
study are:
. Managers can use TQM philosophy as a strategic competitive
weapon for
achieving desirable outcome such as patient satisfaction,
improved quality
of care, and improved performance.
. Managers as well as quality policy makers in health care
institutions should
pay more attention to the vital role of top-management and
employees and
staff in the TQM initiation, implementation, and success stages.
. Managers can draw attention in enhancing the organization
culture and
developing teamwork and participation at all levels as well as
the impor-
tance of giving training and education to their employees for the

successful
implementation of TQM philosophy.
. Finally, managers can understand the importance of satisfying
all internal
and external stakeholders upon the introduction of TQM
strategy.
Recommendation for Future Research
The scope and suggested direction for further research work in
this area are:
. Further study can be undertaken to understand the barriers in
the imple-
mentation of TQM program and to broaden this study to other
developing
countries.
. A comparative study with other less developed countries may
be carried
out to observe the similarities and dissimilarities concerning
TQM imple-
mentation in health care institutions.
. Further studies need to be undertaken concerning the detailed
impact of
identified eight best practices of this study on TQM
implementation.
248 F. Talib et al.
. Empirical research should be conducted to evaluate the
understanding and

the TQM practices based on customer’s point of view.
Finally, the results of the present study will help the managers
and prac-
titioners to adopt TQM program successfully in their
organizations and will
open new dimensions for other researchers in this area,
contributing to the
knowledge in enhancing the implementation of TQM
philosophy.
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