Description
The study presents a case study over six years following the implementation of the SCQM programme in a public hospital. A validated questionnaire was used to measure employees’ job satisfaction. The impact of the intervention was measured by comparing the pre-intervention and post-intervention measures in the hospital.
Strategic collaborative quality management and employee job
satisfaction
Ali Mohammad Mosadeghrad*
Abstract
Background: This study aimed to examine Strategic Collaborative Quality Management (SCQM) impact on
employee job satisfaction.
Methods: The study presents a case study over six years following the implementation of the SCQM programme
in a public hospital. A validated questionnaire was used to measure employees’ job satisfaction. The impact of the
intervention was measured by comparing the pre-intervention and post-intervention measures in the hospital.
Results: The hospital reported a significant improvement in some dimensions of job satisfaction like management
and supervision, organisational policies, task requirement, and working conditions.
Conclusion: This paper provides detailed information on how a quality management model implementation affects
employees. A well developed, well introduced and institutionalised quality management model can improve employees’
job satisfaction. However, the success of quality management needs top management commitment and stability.
Keywords: Strategic Collaborative Quality Management, Employee Job Satisfaction, Hospital
Copyright: © 2014 by Kerman University of Medical Sciences
Citation: Mosadeghrad AM. Strategic collaborative quality management and employee job satisfaction. Int J Health
Policy Manag 2014; 2: 167–174. doi: 10.15171/ijhpm.2014.38
Correspondence to:
Ali Mohammad Mosadeghrad
Email: [email protected]
Article History:
Received: 2 December 2013
Accepted: 23 April 2014
ePublished: 27 April 2014
Original Article
*Department of Health Services Management, School of Health Management and Information Sciences, Tehran University of Medical Sciences, Tehran, Iran
htp://ijhpm.com
Int J Health Policy Manag 2014, 2(4), 167–174
doi 10.15171/ijhpm.2014.38
Introduction
Quality management has been widely used in manufacturing
and service industries to enhance employee motivation (1),
improve quality of products and services (2), increase customer
satisfaction (3), reduce rework and waste (4), increase profit
and market share (5), and enhance business competitiveness
(6–8). Quality management emphasizes customer focus,
teamwork, continuous quality improvement, and systematic
process management. Unlike the traditional quality assurance
approaches, the concept of change in quality management is
continuous and participatory, involving all employees in the
process of quality improvement of their own activities.
There are various strategies for applying quality management
in an organisation to improve products and services quality.
These include Total Quality Management (TQM), Strategic
Quality Management (SQM) (9), Strategic Total Quality
Management (STQM) (10), Global Quality Management
(GQM) (11), and Strategic Collaborative Quality Management
(SCQM) (12). Furthermore, standards-based approaches (e.g.
ISO 9000 standard) and quality award models (e.g. Deming
Quality Award, European Foundation for Quality Management
Model, and Malcolm Baldrige National Quality award) were
accepted as guides to quality management implementation.
While quality management has been suggested in theory
to be effective for improving performance, its application
in healthcare sector involves many difficulties (13–15).
The limited success of quality management in healthcare
organisations led the author to search for a more viable
solution, and as a result, the SCQM model was created (12,16).
SCQM provides a system of quality management with thirteen
constructs, of which eight are enablers and five are results. It
provides a framework to strive for excellence by continuously
improving overall organisational performance (employee
results, customer results, supplier results, society results, and
organisation results) through leadership and management,
strategic quality planning, corporate quality culture, total
continuous learning, employees management, customer
management, resource and partnership management, and
process management (16).
The SCQM model is an integrated quality management
system, a combination of strategic management, quality
management, and project management. It integrates
continuous quality improvement into all three steps of
strategic management (i.e. strategy formulation, strategy
implementation, and strategy evaluation). Organisations
formulate strategic quality goals and objectives, develop
action plans, allocate resources, implement the action plans
and evaluate the progress towards achieving strategic quality
goals. The project management approach enhances the
effectiveness and efficiency of action plans through planning,
implementing, monitoring and controlling purposeful, well-
defined and timely quality improvement projects. A project
management approach helps to build a culture of quality and
learning throughout the organisation (12).
SCQM involves changes in the structure, context (culture,
values, and political system) and processes of an organisation.
Such a change provides lasting and significant positive results.
Systems thinking, process mapping, and process capability
analysis in the SCQM model help identify opportunities to
improve outcomes by improving structures and processes.
Further, the SCQM’s approach to the change is fundamental,
gradual, and evolutionary. It considers a comprehensive change
at individual, teams, and organisational levels. The focus of
SCQM is both internal and external customers’ requirements.
Mosadeghrad
International Journal of Health Policy and Management, 2014, 2(4), 167–174 168
Employees (Internal customers) are encouraged to identify
and meet external customers’ needs and expectations. In
SCQM, the emphasis is on redesigning simpler, standardised,
and more effective processes; determining reasonable and
achievable objectives for processes; and improving them
continually and continuously until objectives are achieved.
Employees using problem-solving techniques evaluate the
ability of the processes to reduce variation and provide high
quality and defect-free services. They plan for the desired
situation and change the organisation accordingly. As a result,
they would be more motivated and committed (17).
Successful quality management implementation can increase
employees’ quality of work life (18), job satisfaction (19,20),
organisational commitment (21), and decrease employee
absenteeism (22) and turnover (23). However, some scholars
argue that quality management creates high-pressure working
environments, increases job demands, and negatively affects
employees’ well being (24–26). Thus, the impact of quality
management on employee job satisfaction remains a research
question and the empirical evidence is mixed and debatable.
Successful SCQM implementation requires employees’
support. The SCQM initiative needs employee’s knowledge,
skills, abilities, passion, motivation, persistence, responsibility,
accountability, and a quality-oriented attitude. Therefore,
the SCQM programme aims to develop and manage the
capabilities of employees, promote fairness and equality,
involve, encourage; and enable employees to contribute to
the achievement of the organisational goals and recognise
their achievements. The SCQM practices such as visionary
leadership, education, training, strategic quality planning,
effective communication, employee empowerment, teamwork,
reward, and recognition theoretically contribute positively to
employees’ satisfaction. On the other hand, SCQM practices
such as customer management, supplier management, process
management and evaluation, and control may increase job
burden and result in employees’ job dissatisfaction.
It is important to analyse how SCQM implementation
affects employees. Therefore, this study aims to describe the
consequences of SCQM implementation in the employees’
working conditions, workload, job security, task requirements,
and fringe benefits. Hence, this study attempts to investigate
the following hypothesis: “The SCQM implementation has a
positive effect on employees’ job satisfaction”.
Methods
Purpose and objectives
The SCQM model was implemented in a public hospital using
participatory action research. This study aimed to examine
the effects of the SCQM intervention on employees’ job
satisfaction in this hospital.
Design
A case study design was employed using a longitudinal
method of data collection to assess the impact of SCQM
implementation on employees’ job satisfaction in a public
hospital over a period of 6 years (between 2005 and 2011).
The data collection was a time-series design with one measure
as a baseline and three after the intervention. The objective
of the pre- mid- and post- action data collection was to
ascertain the impact of SCQM implementation on employees’
job satisfaction. Figure 1 illustrates the points in time the
measurements were carried out.
Setting
The study was conducted in a medium size public general
hospital (Hospital ‘A’), that implemented the SCQM model.
The hospital had 517 employees in January 2006.
Data collection and analysis
A questionnaire was used to measure employees’ job
satisfaction (27). The questionnaire contained nine
dimensions: salaries and benefits, recognition and promotion,
management and supervision, co-workers, task requirement,
organisation policies, working conditions, nature of the job,
and job security. This questionnaire had 36 items (4 items in
each domain). A further four items were also included in the
questionnaire: employees’ overall job satisfaction, ability to
do their job well, intention to leave the organisation if they
received a good offer from other healthcare organisations,
and the hospital recommendation to others for work. The
questionnaire utilizes a Likert-type scale with six response
alternatives ranging from ‘Strongly disagree’ (weighted 1) to
‘Strongly agree’ (weighted 6) for each of the 40 items. The
scores were then standardised to a percentage scale.
The sampling method was stratified random sampling. The
first set of data was collected before the introduction of
the SCQM model in the experimental hospital (December
2005) to be used as a benchmark. The second, third, and
fourth sets of data were collected in September 2007,
September 2008, and September 2011. There were no obvious
differences in the demographic characteristics of samples
between the four time intervals.
The difference between the four data sets was measured to
find out the impact of SCQM implementation on hospital
performance. All data were analysed using SPSS 11 (SPSS Inc.,
Chicago, IL, USA).
Results
Hospital ‘A’ began to implement the SCQM programme in
early 2006. The ambition of the Top Management Team
(TMT) was to increase hospital efficiency and reduce the
Figure 1. The time of data collection
Mosadeghrad
International Journal of Health Policy and Management, 2014, 2(4), 167–174 169
increasing trend of costs. As a result, most of front-line
managers were replaced and radical changes were applied.
Radical changes and downsizing led to changes in the personal
work situation and generated resistance among employees.
The top management team realised that personnel expenses
comprised a large proportion of hospital expenses. Therefore,
they used time and motion studies to optimize the number
of staff for each department. In addition, employees’ fringe
benefits decreased. The hospital was in debt to suppliers and
TMT thought applying these policies could help pay part of
the debt to the suppliers. Due to these policies, employees
were mostly dissatisfied with the management.
Although TMT acknowledged the need for change, their
actions were not in favour of employees. Lack of trust
between TMT and employees, and consequently employees’
apathy towards change were the main reasons for the failure
of organisational change at the hospital. Furthermore, TMT
lacked experience in initiating and managing the change. As a
result, employees’ participation in the change process was low.
Based on problems encountered in the hospital, there were
some corrective actions taken to resolve the problems. Firstly,
the hospital president was changed in early 2006. The new
president, a psychiatrist, had enough managerial experience.
The new hospital president appointed an experienced person
as the hospital manager. Subsequently, the most respected and
experienced staff were appointed as middle and front-line
managers. They all had enough managerial experience. As a
result, the fear of job security was overcome. In the next move,
the new TMT clarified the link between quality and hospital
productivity for employees.
A user-friendly SCQM guidebook was prepared to assist in
setting up the SCQM system and guide the change process.
The manual contains a general overview of SCQM’s theoretical
foundation (i.e. basic principles, benefits, and core elements),
training curriculum and implementation method.
The introduction of SCQM in the hospital was fundamental,
gradual and evolutionary. An infrastructure for the SCQM
programme was established comprising of (i) a quality
management council, (ii) a quality management department,
(iii) a quality steering committee, (iv) functional and cross-
functional quality teams, and (v) a quality audit team. The
quality management council created a 5-year strategic quality
plan and defined quality goals. The strategic quality plan
contained specific quality goals and objectives for each of the
five dimensions of performance: employee, customer, supplier,
organisation, and society. An annual operational plan was
prepared, describing actions that would help the hospital meet
its operational goals.
TMT supported a learning environment where employees
were encouraged to share their ideas and information to
enhance their knowledge and skills. Training was designed
and delivered in three stages. In the first stage, senior and
middle managers were trained in quality management
concepts, skills, and techniques. In stage two, managers
attended managerial and leadership skills training courses.
The courses included leadership, planning, motivation, HRM,
change management, participative management, teamwork,
continuous improvement, customer relationship management,
and controlling. In the third stage, sufficient quality awareness
training was delivered to employees. This training was
focused on developing quality-related knowledge and skills,
teamwork and effective communication skills. The objective
of the training programme was not only to explain the concept
of SCQM principles and practices, but also to raise morale
and soften resistance to change. Education and training were
deemed to be the biggest facilitator in SCQM implementation.
The hospital began gradually and cautiously the implemen-
tation of the SCQM programme by structural, cultural, and
procedural changes. The physical structure was changed
to suit the needs of both internal and external customers in
order to improve processes. The mechanistic structure of
the hospital was changed by initiating functional and cross-
functional teams, increasing employee responsibility and
authority, and decreasing vertical coordination and control.
In addition, personnel policies dealing with performance
appraisal and rewards were changed.
As part of structural changes, angiography, endoscopy,
peritoneal dialysis, spirometry, ICU for poisoned patients, and
echocardiography wards or units were added to the hospital.
Furthermore, Accident and Emergency (A&E) department,
internal medicine wards, CCU, dialysis, the operation theatre,
radiology, colonoscopy, sonography, ICU, central sterilisation,
the main kitchen, restaurant, stores, the switch board room,
and cash office were renovated and equipped with new
equipment. These changes were expected to result in an
increased numbers of patients.
In order to develop a participative culture, a Suggestion
Scheme was launched in early 2006. Employees contributed
to improvement by actively participating in the Suggestions
Scheme. Management has seriously considered those
suggestions and recommendations. The hospital attempted
to initiate Total Productive Management (TPM) practice in
mid 2006. Therefore, an equipment engineering office was
established and staffed with three motivated and competent
personnel to improve the overall utilisation of equipment. The
TPM programme improved effective equipment management
as well as the technical skills and morale of hospital
employees. A positive attitude, ownership, and concern were
developed among employees. As a result, equipment defects
and breakdown rates, and consequently repairing costs were
reduced. The hospital has been using the 5S system as part of
a “Total Productive Maintenance” system in order to develop
a culture of order, safety, and responsibility.
The next phase of the SCQM programme—the procedural
changes—commenced formally in September 2007. Functional
and cross-functional teams were formed to identify and solve
quality problems. A quality steering committee was created
to support functional and cross-functional teams. Extensive
education and training were provided to develop employees’
capabilities on a continuous basis. Employees were encouraged
to use the ten-step quality improvement method to optimise
their working processes. They were encouraged to identify,
flowchart, optimise, and stabilise the processes. They were
further asked to define objectives for the processes, determine
key performance indicators and achievable targets for each
process, measure processes, identify the gap between the
expected and the actual performance, identify the problems,
find the roots of the problems, build solutions, develop a
plan, execute solutions and evaluate the effectiveness of the
improvements. Involving the teams in all stages of the action
Mosadeghrad
International Journal of Health Policy and Management, 2014, 2(4), 167–174 170
research motivated them to plan and implement changes for
a better quality of care. The ten-step quality improvement
method was found very useful for learning and improvement.
The hospital CEO resigned in April 2010. Although the
new hospital president was interested in improving the
quality of healthcare services, he was not actively involved
in quality management activities. He was mainly involved
in his professional clinical duties. He did not pursue long-
term overall organisational success. He was instead focused
on meeting short-term targets. Insufficient top management
commitment, lack of a strategic quality plan, and lack of
ongoing continuous education and training de-motivate
employees in their quality improvement activities.
Employees’ job satisfaction during the baseline, pre-
intervention phase (2005) was 57.8% (Table 1). Approximately
1 in 4 employees (26.3%) were dissatisfied with their job.
Employees were least satisfied with the salaries, benefits,
recognition, promotion, working conditions, organisation
policies, and management. Employees were not recognised
and rewarded for participating in quality management
activities. They did not see the value of such work, and
therefore, did not contribute to the quality management
programme. Employees’ payment was delayed for several
months. There was a serious conflict between employees and
top management. The outcome of top management policies
created a stressful environment for employees. Inadequate
pay, inequity at work, lack of recognition, lack of promotion
prospects, lack of job security, time pressure, inadequate
equipment, too much work, staff shortages, and lack of
management support were the main stressors for employees.
Employees’ job satisfaction rose to 63.3% for the year
2007 (Table 1). Most employees expressed high levels of
satisfaction, motivation, and accountability. Employees
reported significant improvement in some dimensions of job
satisfaction like management and supervision, organisational
policies, task requirement, and working conditions. The
lowest scores still fall into the same categories as the 2005
assessment (salaries and benefits). Although public managers
do not have enough power as regards changing policies
related to employees’ salaries and promotion, work has been
done to improve employees’ satisfaction with the benefits
and recognition schemes.
Management change and consequently a change in employee
relationship management improved employees’ satisfaction
significantly. Participatory managerial behaviour improved
employee satisfaction. The planned structural change
improved employees’ satisfaction. Provision of new facilities
and resources encouraged employees’ motivation for doing
their job. Employees’ roles and responsibilities were clarified.
They were given the ability, motivation, and authority to
improve their work quality. The SCQM programme had
a great impact on personnel attitudes towards their jobs.
Involvement of staff in quality management activities was
correlated with a significantly higher job satisfaction. Many
employees felt that their jobs had become more challenging
and enjoyed the additional responsibilities. The introduction
of the SCQM programme gave employees more control over
their daily activities, thus, increasing job satisfaction. The
SCQM programme brought the management and employees
closer together. Top management paid sufficient attention to
employee satisfaction, morale, development, and well-being.
Employees’ working stress was decreased by providing suitable
resources and more facilities. Employees were encouraged to
submit their ideas and opinions. The submitted ideas were
evaluated by the quality management department and the
selected ideas were applies. Education and training, teamwork,
and management support and recognition were found to
motivate employees to participate in quality management
activities. This resulted in high employee motivation, high job
satisfaction, and low absenteeism and turnover.
Employees’ job satisfaction dropped to 62.7% for the year 2008.
Employees’ job satisfaction improved during the first year of
the introduction of SCQM, at an average rate of 5.5 % (P< 0.05).
However, this accelerated rate of increase was not maintained
after 2007. The introduction of procedural changes required
by SCQM has caused an increase in the daily workload of the
employees. In addition, employees’ satisfaction with working
conditions decreased. A fall in employees’ satisfaction with
received salaries and benefits could be related to an increase
in employees’ output and external factors (e.g. inflation rate in
2008 increased too much compared with 2007).
Employees’ job satisfaction decreased in 2011 compared to
2008. However, they were more satisfied in comparison with
the year 2005. Employees were more dissatisfied with the
Table 1. Employees’ job satisfaction (on a 100 scale)
Job satsfers
2005 2007 2008 2011
P E P-E P E P-E P E P-E P E P-E
Salaries and fringe benefts 38.8 81.2 -42.4 48.0 82.6 -34.6 44.7 73.8 -29.1 41.0 75.3 -34.3
Recogniton and promoton 45.3 78.6 -33.3 51.8 76.7 -24.9 52.2 79.6 -27.4 48.6 77.2 -28.6
Management and Supervision 61.2 79.2 -18.0 66.2 80.0 -13.8 69.3 77.5 -8.2 64.3 75.7 -11.4
Co-workers 73.8 79.6 -5.8 75.2 76.6 -1.4 74.0 79.1 -5.1 73.5 79.6 -6.1
Task requirement 65.7 76.3 -10.6 71.3 76.6 -5.3 71.5 71.1 0.4 68.0 73.2 -5.2
Working conditons 47.5 78.4 -30.9 59.2 76.6 -17.4 53.0 71.6 -18.6 51.1 70.8 -19.7
Nature of work 74.0 75.4 -1.4 73.5 76.0 -2.5 72.0 81.0 -9.0 73.1 77.4 -4.3
Organisaton policies 54.7 78.6 -23.9 64.3 73.3 -9.0 64.5 70.5 -6.0 58.7 70.0 -11.3
Job security 55.5 76.3 -20.8 60.2 74.6 -14.4 62.0 71.6 -9.6 57. 7 72.1 -14.4
Overall job satsfacton 57.8 78.2 -20.4 63.3 77.0 -13.7 62.7 75.1 -12.4 59.7 74.6 -14.9
P= Perception, E= Expectation
Mosadeghrad
International Journal of Health Policy and Management, 2014, 2(4), 167–174 171
wages and fringe benefits, management, task requirements
and organisational policies.
While 68% of employees agreed to leave Hospital ‘A’ if they
could find a good job opportunity elsewhere in 2005, this
figure decreased to 43% in 2008 and then increased to 45.8%
in 2011 (Table 2). The difference between the two groups was
statistically significant at P< 0.01.
Discussion
The effectiveness of an organisation depends on the extent
to which people perform their roles and move towards the
corporate goals and objectives (28). Employees’ satisfaction
plays a critical role in organisational success. Employees’
job satisfaction is positively related to their organisational
commitment and negatively related to their turnover
intention (27). Employee satisfaction can result in customer
satisfaction (29). Satisfied employees are more likely to
work harder and provide better services (30) and enhance
organisational performance (31).
The SCQM implementation led to a higher level of
employees’ job satisfaction and their less intention to leave
the organisation. The findings are consistent with literature
suggesting that quality management implementation improves
employees’ outcome such as job satisfaction (32,33). The
SCQM application resulted in a culture change in the hospital,
with improved communication, teamwork, trust, respect, and
commitment to quality improvement. The implementation
of SCQM model was successful in bringing managers and
employees together to improve organisational performance.
As a result, employee morale, and satisfaction were improved.
The findings suggest that effective application of functional
and cross-functional quality teams is positively related to
employees’ job satisfaction, which are negatively related to
their turnover intention. These findings are consistent with
other studies (19,34).
Employees’ job satisfaction improved during the first year
of the introduction of SCQM. However, this accelerated rate
of increase was not maintained after then mainly because of
an imbalance between employees’ input and output and a
change in management team. The introduction of procedural
changes required by SCQM has caused an increase in the daily
workload of the employees. A fall in employees’ satisfaction
with received salaries and benefits could be related to an
increase in employees’ output. Similarly, Woodward and
colleagues (1999) reported significant increases in depression,
anxiety, emotional exhaustion, and job insecurity among
hospital employees, particularly during the first year of
the re-engineering change process. Job demands increased
throughout the period whereas little change occurred in the
employee’s decision latitude (35).
The hospital top management team was changed three times
during the course of SCQM implementation. The first hospital
president was more task-oriented and less employee-oriented.
Table 2. Hospital recommendation for work to others by employees
Queston 2005 2008 2011
Recommend the hospital for work to others 27.7 40.5 39.6
Agree to leave the hospital if fnd a good
opportunity
68.2 43.0 45.8
The second hospital president, a psychiatrist, was more
employee-oriented with good managerial experience. Finally,
the third hospital president was less people-oriented and task-
oriented than the second CEO. Management turnover during
the course of change programme influenced employees’
job satisfaction significantly. A feeling of trust between
employees and managers reinforces employees’ tendency and
commitment to adopt the change programme. Management
turnover is one of the most important obstacles for successful
quality management implementation (36,37). A possible
explanation for this might be that management turnover
increases the chance of subjective management, leading to
unfavourable outcomes. Management turnover increases
stress, tension, anxiety, and conflict among employees.
Top manager plays a critical role in promoting organisational
change. It is important that top manager takes a leadership role,
exhibits role model behaviour, shows a strong commitment
to quality management, creates a supportive environment,
and manages change strategically. The delivery of quality
services is dependent upon motivated, qualified, satisfied,
and committed employees. Employees prefer leaders who are
more considerate and supportive (38). Managers should pay
attention to the morale and well-being of employees.
Top managers should involve middle managers in planning
and promoting the change programme. Middle managers,
due to their position, can contribute greatly to quality
management implementation by communicating the quality
management message to employees and ensuring their
commitment, converting organisational goals, objectives
and strategies into detailed departmental objectives and
operational activities (39,40).
Employee participation in quality improvement must be
recognised, supported, and acknowledged. Employees
should have a positive attitude towards the quality
management initiative. Lack of considering employees’
benefits in the change programme at the beginning of the
SCQM implementation forced them to work against the
implementation of organisational change. Radical change
and downsizing led to changes in the personal work situation
and generated resistance. Employees were dissatisfied with
the way their organisation was being run. If employees see
no tangible benefit of the quality management programme,
they become resistant to the programme. Incurring too
much work without providing tangible benefits is the most
significant reason for employee apathy. The benefits of quality
management must be visible to employees in order for it to
succeed and become sustainable.
For SCQM to truly have an impact, change agents should
begin with the areas where such efforts result in immediate
tangible results for employees to enhance their morale and
motivation for continuous quality management activities.
Iranian healthcare employees are motivated more by fair
salaries, financial rewards, on-time payment, promotion,
improved working conditions, and supportive leadership
(38,41). Employees will become more involved if they see
the tangible benefits of the quality management programme.
Appropriate recognition and reward systems are important
tools to influence employees’ attitudes toward improving the
quality of their work. Short-term tangible results and financial
incentives increase the probability of sustained success.
Mosadeghrad
International Journal of Health Policy and Management, 2014, 2(4), 167–174 172
Recognition and non-monetary reward systems are also critical
to the long-term success of quality management initiatives.
For SCQM to have a positive impact on an organisation,
managers must recognise that the theory of ‘bad apples’
frightens and alienates the employees. They should focus
on ‘what happened?’ and ‘why?’ instead of ‘who did
it?’ They should remove feelings of fear by assuring job
security, developing a common vision, and motivating
employees by utilising various monetary and non-monetary
incentives to reward superior performance. Tension between
management and employees increases the risk of failure of
SCQM implementation.
Trust in managers is a critical factor in an employee’s tendency
to adopt the change programme. A feeling of trust between
employees and managers reinforces employees’ commitment
(42). Employees prefer leaders who are more considerate and
supportive. Therefore, the level of top management support
for the SCQM implementation process and continuous
visible leadership are vital factors in the sustainability
of the change programme. Supportive managerial and
clinical leadership facilitates the implementation of
SCQM in healthcare organisations by providing direction
and resources for continuous quality improvement. Top
management visible support helps achieve the desired
outcome of change acceptance.
Human resource systems, including employee selection
processes, training and development, performance appraisal,
and compensation and rewards must support the corporate
quality culture through the development of the necessary
motivation, attitudes, and the competencies. Jobs must be
redesigned to give employees more flexibility, autonomy and
authority, and encourage creativity. Performance appraisal
and reward systems must focus more on rewarding teamwork
and long-term performance.
A formal reward and recognition system that supports
teamwork and links quality and higher performance with pay,
encourages, and motivates employees to achieve the desired
performance (43). Managers’ recognition, appreciation, and
acknowledgement of achieving quality objectives enhance
employees’ involvement in quality management activities
and commitment to quality improvement (44). Recognition
nurtures trust and respect between managers and employees,
builds employees’ self-esteem, renews their enthusiasm and
reinforces desired behaviours.
Limitations and implications for further research
The focus of this study was a single general teaching hospital
that has implemented SCQM. Therefore, it does limit the
generalisability of the findings. Future research studies
are needed to explore the impact of quality management
programmes implementation on employees’ outcome.
Conclusion
The SCQM programme if properly implemented and
institutionalized improves employees’ job satisfaction.
SCQM practices such as visionary leadership, education,
training, empowerment, and teamwork enhance employees’
job satisfaction. Nevertheless, the implementation of the
SCQM model like any other change programmes needs
top management support and developing an appropriate
organisational climate and culture. The SCQM programme
succeeds only when the organisation is willing to change, to
discard outdated management and work methods if necessary.
Top management turnover is a major threat to the long-term
success of the SCQM intervention and makes it very difficult
to maintain the constancy of purpose expected in SCQM.
Ethical issues
Ethical codes in this study involved (i) respect for human dignity, (ii) respect for
privacy and confdentiality, and (iii) respect for autonomy.
Competing interests
The author declares that he has no competing interests.
Author’s contribution
AMM is the single author of the manuscript.
References
1. Boon OK, Arumugam V, Hwa TS. Does soft TQM predict
employees’ attitudes? The TQM Magazine 2005; 17: 279–89.
doi: 10.1108/09544780510594243
2. Forza C, Filippini R. TQM impact on quality conformance and
customer satisfaction: A causal model. International Journal of
Production Economics 1998; 55: 1–20. doi: 10.1016/s0925-
5273(98)00007-3
3. Agus A. TQM as a focus for improving overall service performance
and customer satisfaction: An empirical study on a public service
sector in Malaysia. Total Quality Management 2002; 15: 615–28.
doi: 10.1080/14783360410001680107
4. Martinez-Costa M, Jimenez-Jimenez D. Are companies that
implement TQM better learning organizations? An empirical
study. Total Quality Management 2008; 19: 1101–15. doi:
10.1080/14783360802323446
5. Rahman S. Total quality management practices and business
outcome: evidence from small and medium enterprises in
Western Australia. Total Quality Management 2001; 12: 201–10.
doi: 10.1080/09544120120011424
6. Agus A, Abdullah M. Total quality management practices in
manufacturing companies in Malaysia: An exploratory analysis.
Total Quality Management & Business Excellence 2000; 11:
1041–51. doi: 10.1080/095441200440313
7. Hansson J, Eriksson H. The impact of TQM on financial
performance. Measuring Business Excellence 2002; 6: 44–54.
doi: 10.1108/13683040210451714
8. Joiner TA. Total quality management and performance: The role
of organisation support and co-worker support. International
Journal of Quality & Reliability Management 2007; 24: 617–27.
doi: 10.1108/02656710710757808
9. Garvin D. Managing quality: The strategic and competitive edge.
New York: Free Press; 1988.
10. Madu CN, Kuei C. Strategic Total Quality Management:
Transformation process overview. Total Quality Management
1994; 5: 255–66. doi: 10.1080/09544129400000046
11. Kim KY, Chang DR. Global quality management: A research
focus. Decision Sciences 1995; 26: 561–8. doi: 10.1111/j.1540-
5915.1995.tb01440.x
12. Mosadeghrad AM. A theory of quality management. International
Journal of Modelling in Operations Management 2012; 2:
89–118. doi: 10.1504/ijmom.2012.043962
13. Ennis K, Harrington D. Quality management in Irish health
care. Int J Health Care Qual Assur 1999; 12: 232–43. doi:
10.1108/09526869910287305
14. Mosadeghrad AM. Obstacles to TQM success in health care
Mosadeghrad
International Journal of Health Policy and Management, 2014, 2(4), 167–174 173
systems. Int J Health Care Qual Assur 2013; 26: 147–73. doi:
10.1108/09526861311297352
15. Zabada CP, Rivers A, Munchus G. Obstacles to the application of
total quality management in health care organisations. Total Quality
Management 1998; 9: 57–66. doi: 10.1080/0954412989261
16. Mosadeghrad AM. Verification of a quality management theory:
Using a Delphi study. Int J Health Policy Manag 2013; 1: 261–71.
doi: 10.1080/0954412989261
17. Mosadeghrad AM. Implementing Strategic Collaborative Quality
Management in Health Care Sector. International Journal of
Strategic Change Management 2012; 4: 203–28.
18. Mohrman SA, Tenkasi RV, Lawler EE III, Ledford GG Jr.
Total quality management: Practice and outcomes in the
largest US firms. Employee Relations 1995; 17: 26–41. doi:
10.1108/01425459510086866
19. Lee LC, Yang KP, Chen TY. A quasi-experimental study on a
quality circle program in a Taiwanese hospital. Int J Qual Health
Care 2000; 12: 413–8. doi: 10.1093/intqhc/12.5.413
20. Alsughayir A. Does practicing total quality management affect
employee job satisfaction in Saudi Arabian organizations?
European Journal of Business and Management 2014; 6:
169–75.
21. Guimaraes T. TQM’s impact on employee attitudes. The TQM
Magazine 1996; 8: 20. doi: 10.1108/09544789610107225
22. McAdam R, Bannister A. Business performance measurement
and change management within a TQM framework’, International
Journal of Operations and Production Management 2001; 21:
88–107. doi: 10.1108/01443570110358477
23. Boselie P, van der Wiele T. Employee perceptions of HRM
and TQM, and the effects on satisfaction and intention to
leave.Managing Service Quality 2002; 12: 165–73. doi:
10.1108/09604520210429231
24. Parker SK. Longitudinal effects of lean production on employee
outcomes and the mediating role of work characteristics. J Appl
Psychol 2003; 88: 620–34. doi: 10.1037/0021-9010.88.4.620
25. Landsbergis PA, Cahill J, Schnall P. The impact of lean production
and related new systems of work organization on worker health.
J Occup Health Psychol 1999; 4: 108–30. doi: 10.1037/1076-
8998.4.2.108
26. Vidal M. Lean production, worker employment, and job
satisfaction: A qualitative analysis and critique. Critical Sociology
2007; 33: 247–78. doi: 10.1163/156916307x168656
27. Mosadeghrad AM, Ferlie E, Rosenberg D. A study of relationship
between job satisfaction, organisational commitment and
turnover intention among hospital employees. Health Serv
Manage Res 2008; 21: 211–27. doi: 10.1258/hsmr.2007.007015
28. Oakland JS. Total quality management: Text with cases. 3rd ed.
Oxford: Butterworth- Heinemann; 2003.
29. Brown S, Lam S. A meta-analysis of relationships linking
employee satisfaction to customer responses. Journal of
Retailing 2008; 84: 243–55. doi: 10.1016/j.jretai.2008.06.001
30. Capelli P. A market driven approach to retaining talent. Harv Bus
Rev 2000; 78: 103–11.
31. Akdere M. A multi-level examination of quality-focused
human resource practices and firm performance: Evidence
from the US healthcare industry. International Journal of
Human Resource Management 2009; 20: 1945–64. doi:
10.1080/09585190903142399
32. Sila I. Examining the effects of contextual factors on TQM and
performance through the lens of organisational theories: An
empirical study. Journal of Operations Management 2007; 25:
83–109. doi: 10.1016/j.jom.2006.02.003
33. Karia N, Asaari MH. The effects of total quality management
practices on employees’ work-related attitudes. The TQM
Magazine 2006; 18: 30–43. doi: 10.1108/09544780610637677
34. Lagrosen Y, Backstrom I, Lagrosen S. Quality management
and health: A double connection. International Journal of
Quality & Reliability Management 2007; 24: 49–61. doi:
10.1108/02656710710720321
35. Woodward CA, Shannon HS, Cunningham C, McIntosh J,
Lendrum B, Rosenbloom D, et al. The impact of re-engineering
and other cost reduction strategies on the staff of a large teaching
hospital: a longitudinal study. Med Care 1999; 37: 556–69. doi:
10.1097/00005650-199906000-00005
36. Mosadeghrad AM, Ferdosi M, Afshar H, Hosseini-Nejhad M.
The impact of top management turnover on quality management
implementation. Med Arh 2013; 67: 134–40. doi: 10.5455/
medarh.2013.67.134-140
37. Taylor WA, Wright GH. The impact of senior managers’ commitment
on the success of TQM programmes: An empirical study. Int J
Manpow 2003; 24: 535–50. doi: 10.1108/01437720310491071
38. Rad AM, Yarmohammadian MH. A study of relationship between
managers’ leadership style and employees’ job satisfaction. Int
J Health Care Qual Assur Inc Leadersh Health Serv 2006; 19:
xi-xxviii. doi: 10.1108/13660750610665008
39. Baidoun S. An empirical study of critical factors of TQM in
Palestinian organizations. Logistics Information Management
2003; 16: 156–71. doi: 10.1108/09576050310467296
40. Wimalasir JS, Kouzmin A. A comparative Study of employee
involvement initiatives in Hong Kong and the USA. Int J Manpow
2000; 21: 614–34. doi: 10.1108/01437720010379510
41. Hamidi Y, Eivazi Z. The Relationships Among Employees’ Job
Stress, Job Satisfaction, and the Organizational Performance
of Hamadan Urban Health Centers. Social Behavior and
Personality: An international Journal 2010; 38: 963–8. doi:
10.2224/sbp.2010.38.7.963
42. Gallear D, Ghobadian A. An empirical investigation of the channels
that facilitate a total quality culture. Total Quality Management
2004; 15: 1043–67. doi: 10.1080/1478336042000255497
43. Wilkinson A. Quality and the Human Factor. Total Quality Manage-
ment 2004; 15: 1019–24. doi: 10.1080/1478336042000255415
44. Kassicieh SK, Yourstone SA. Training, performance evaluation,
rewards, and TQM implementation success. Journal of
Quality Management 1998; 3: 25–38. doi: 10.1016/s1084-
8568(99)80102-3
Mosadeghrad
International Journal of Health Policy and Management, 2014, 2(4), 167–174 174
Implications for policy makers
• Contemporary industrial quality management practices
and techniques can be adopted, adapted and successfully
applied within professional healthcare organisations
to achieve excellence. A well-developed and well-
implemented quality management programme offers
significant benefits to organisations. Using the SCQM
framework, ugmented by strategic management and
project management approaches, healthcare organisations
may sustain continuous quality improvement.
• Managers choosing a quality management model should
remember that the model itself does not bring about
improvement. Institutionalising of quality management
requires commitment, effort, and resources. The SCQM
model will not succeed unless a receptive context and
supportive environment (supportive leadership, culture
and structure) is created.
• A strong committed leadership is necessary for
SCQM implementation to be successful. Without top
management’s stability, commitment and support,
SCQM will be just another “management fad”.
Implications for public
Quality has become an increasingly predominant part of
our lives. People are constantly looking for quality products
and services. Healthcare providers particularly doctors and
nurses play crucial roles in the delivery of quality healthcare
services to the public. Quality management practices such
as leadership, planning, training, employee empowerment,
engagement, and evaluation affect employee satisfaction
and commitment, which in turn influence patient
satisfaction and loyalty.
Key Messages
doc_721377512.pdf
The study presents a case study over six years following the implementation of the SCQM programme in a public hospital. A validated questionnaire was used to measure employees’ job satisfaction. The impact of the intervention was measured by comparing the pre-intervention and post-intervention measures in the hospital.
Strategic collaborative quality management and employee job
satisfaction
Ali Mohammad Mosadeghrad*
Abstract
Background: This study aimed to examine Strategic Collaborative Quality Management (SCQM) impact on
employee job satisfaction.
Methods: The study presents a case study over six years following the implementation of the SCQM programme
in a public hospital. A validated questionnaire was used to measure employees’ job satisfaction. The impact of the
intervention was measured by comparing the pre-intervention and post-intervention measures in the hospital.
Results: The hospital reported a significant improvement in some dimensions of job satisfaction like management
and supervision, organisational policies, task requirement, and working conditions.
Conclusion: This paper provides detailed information on how a quality management model implementation affects
employees. A well developed, well introduced and institutionalised quality management model can improve employees’
job satisfaction. However, the success of quality management needs top management commitment and stability.
Keywords: Strategic Collaborative Quality Management, Employee Job Satisfaction, Hospital
Copyright: © 2014 by Kerman University of Medical Sciences
Citation: Mosadeghrad AM. Strategic collaborative quality management and employee job satisfaction. Int J Health
Policy Manag 2014; 2: 167–174. doi: 10.15171/ijhpm.2014.38
Correspondence to:
Ali Mohammad Mosadeghrad
Email: [email protected]
Article History:
Received: 2 December 2013
Accepted: 23 April 2014
ePublished: 27 April 2014
Original Article
*Department of Health Services Management, School of Health Management and Information Sciences, Tehran University of Medical Sciences, Tehran, Iran
htp://ijhpm.com
Int J Health Policy Manag 2014, 2(4), 167–174
doi 10.15171/ijhpm.2014.38
Introduction
Quality management has been widely used in manufacturing
and service industries to enhance employee motivation (1),
improve quality of products and services (2), increase customer
satisfaction (3), reduce rework and waste (4), increase profit
and market share (5), and enhance business competitiveness
(6–8). Quality management emphasizes customer focus,
teamwork, continuous quality improvement, and systematic
process management. Unlike the traditional quality assurance
approaches, the concept of change in quality management is
continuous and participatory, involving all employees in the
process of quality improvement of their own activities.
There are various strategies for applying quality management
in an organisation to improve products and services quality.
These include Total Quality Management (TQM), Strategic
Quality Management (SQM) (9), Strategic Total Quality
Management (STQM) (10), Global Quality Management
(GQM) (11), and Strategic Collaborative Quality Management
(SCQM) (12). Furthermore, standards-based approaches (e.g.
ISO 9000 standard) and quality award models (e.g. Deming
Quality Award, European Foundation for Quality Management
Model, and Malcolm Baldrige National Quality award) were
accepted as guides to quality management implementation.
While quality management has been suggested in theory
to be effective for improving performance, its application
in healthcare sector involves many difficulties (13–15).
The limited success of quality management in healthcare
organisations led the author to search for a more viable
solution, and as a result, the SCQM model was created (12,16).
SCQM provides a system of quality management with thirteen
constructs, of which eight are enablers and five are results. It
provides a framework to strive for excellence by continuously
improving overall organisational performance (employee
results, customer results, supplier results, society results, and
organisation results) through leadership and management,
strategic quality planning, corporate quality culture, total
continuous learning, employees management, customer
management, resource and partnership management, and
process management (16).
The SCQM model is an integrated quality management
system, a combination of strategic management, quality
management, and project management. It integrates
continuous quality improvement into all three steps of
strategic management (i.e. strategy formulation, strategy
implementation, and strategy evaluation). Organisations
formulate strategic quality goals and objectives, develop
action plans, allocate resources, implement the action plans
and evaluate the progress towards achieving strategic quality
goals. The project management approach enhances the
effectiveness and efficiency of action plans through planning,
implementing, monitoring and controlling purposeful, well-
defined and timely quality improvement projects. A project
management approach helps to build a culture of quality and
learning throughout the organisation (12).
SCQM involves changes in the structure, context (culture,
values, and political system) and processes of an organisation.
Such a change provides lasting and significant positive results.
Systems thinking, process mapping, and process capability
analysis in the SCQM model help identify opportunities to
improve outcomes by improving structures and processes.
Further, the SCQM’s approach to the change is fundamental,
gradual, and evolutionary. It considers a comprehensive change
at individual, teams, and organisational levels. The focus of
SCQM is both internal and external customers’ requirements.
Mosadeghrad
International Journal of Health Policy and Management, 2014, 2(4), 167–174 168
Employees (Internal customers) are encouraged to identify
and meet external customers’ needs and expectations. In
SCQM, the emphasis is on redesigning simpler, standardised,
and more effective processes; determining reasonable and
achievable objectives for processes; and improving them
continually and continuously until objectives are achieved.
Employees using problem-solving techniques evaluate the
ability of the processes to reduce variation and provide high
quality and defect-free services. They plan for the desired
situation and change the organisation accordingly. As a result,
they would be more motivated and committed (17).
Successful quality management implementation can increase
employees’ quality of work life (18), job satisfaction (19,20),
organisational commitment (21), and decrease employee
absenteeism (22) and turnover (23). However, some scholars
argue that quality management creates high-pressure working
environments, increases job demands, and negatively affects
employees’ well being (24–26). Thus, the impact of quality
management on employee job satisfaction remains a research
question and the empirical evidence is mixed and debatable.
Successful SCQM implementation requires employees’
support. The SCQM initiative needs employee’s knowledge,
skills, abilities, passion, motivation, persistence, responsibility,
accountability, and a quality-oriented attitude. Therefore,
the SCQM programme aims to develop and manage the
capabilities of employees, promote fairness and equality,
involve, encourage; and enable employees to contribute to
the achievement of the organisational goals and recognise
their achievements. The SCQM practices such as visionary
leadership, education, training, strategic quality planning,
effective communication, employee empowerment, teamwork,
reward, and recognition theoretically contribute positively to
employees’ satisfaction. On the other hand, SCQM practices
such as customer management, supplier management, process
management and evaluation, and control may increase job
burden and result in employees’ job dissatisfaction.
It is important to analyse how SCQM implementation
affects employees. Therefore, this study aims to describe the
consequences of SCQM implementation in the employees’
working conditions, workload, job security, task requirements,
and fringe benefits. Hence, this study attempts to investigate
the following hypothesis: “The SCQM implementation has a
positive effect on employees’ job satisfaction”.
Methods
Purpose and objectives
The SCQM model was implemented in a public hospital using
participatory action research. This study aimed to examine
the effects of the SCQM intervention on employees’ job
satisfaction in this hospital.
Design
A case study design was employed using a longitudinal
method of data collection to assess the impact of SCQM
implementation on employees’ job satisfaction in a public
hospital over a period of 6 years (between 2005 and 2011).
The data collection was a time-series design with one measure
as a baseline and three after the intervention. The objective
of the pre- mid- and post- action data collection was to
ascertain the impact of SCQM implementation on employees’
job satisfaction. Figure 1 illustrates the points in time the
measurements were carried out.
Setting
The study was conducted in a medium size public general
hospital (Hospital ‘A’), that implemented the SCQM model.
The hospital had 517 employees in January 2006.
Data collection and analysis
A questionnaire was used to measure employees’ job
satisfaction (27). The questionnaire contained nine
dimensions: salaries and benefits, recognition and promotion,
management and supervision, co-workers, task requirement,
organisation policies, working conditions, nature of the job,
and job security. This questionnaire had 36 items (4 items in
each domain). A further four items were also included in the
questionnaire: employees’ overall job satisfaction, ability to
do their job well, intention to leave the organisation if they
received a good offer from other healthcare organisations,
and the hospital recommendation to others for work. The
questionnaire utilizes a Likert-type scale with six response
alternatives ranging from ‘Strongly disagree’ (weighted 1) to
‘Strongly agree’ (weighted 6) for each of the 40 items. The
scores were then standardised to a percentage scale.
The sampling method was stratified random sampling. The
first set of data was collected before the introduction of
the SCQM model in the experimental hospital (December
2005) to be used as a benchmark. The second, third, and
fourth sets of data were collected in September 2007,
September 2008, and September 2011. There were no obvious
differences in the demographic characteristics of samples
between the four time intervals.
The difference between the four data sets was measured to
find out the impact of SCQM implementation on hospital
performance. All data were analysed using SPSS 11 (SPSS Inc.,
Chicago, IL, USA).
Results
Hospital ‘A’ began to implement the SCQM programme in
early 2006. The ambition of the Top Management Team
(TMT) was to increase hospital efficiency and reduce the
Figure 1. The time of data collection
Mosadeghrad
International Journal of Health Policy and Management, 2014, 2(4), 167–174 169
increasing trend of costs. As a result, most of front-line
managers were replaced and radical changes were applied.
Radical changes and downsizing led to changes in the personal
work situation and generated resistance among employees.
The top management team realised that personnel expenses
comprised a large proportion of hospital expenses. Therefore,
they used time and motion studies to optimize the number
of staff for each department. In addition, employees’ fringe
benefits decreased. The hospital was in debt to suppliers and
TMT thought applying these policies could help pay part of
the debt to the suppliers. Due to these policies, employees
were mostly dissatisfied with the management.
Although TMT acknowledged the need for change, their
actions were not in favour of employees. Lack of trust
between TMT and employees, and consequently employees’
apathy towards change were the main reasons for the failure
of organisational change at the hospital. Furthermore, TMT
lacked experience in initiating and managing the change. As a
result, employees’ participation in the change process was low.
Based on problems encountered in the hospital, there were
some corrective actions taken to resolve the problems. Firstly,
the hospital president was changed in early 2006. The new
president, a psychiatrist, had enough managerial experience.
The new hospital president appointed an experienced person
as the hospital manager. Subsequently, the most respected and
experienced staff were appointed as middle and front-line
managers. They all had enough managerial experience. As a
result, the fear of job security was overcome. In the next move,
the new TMT clarified the link between quality and hospital
productivity for employees.
A user-friendly SCQM guidebook was prepared to assist in
setting up the SCQM system and guide the change process.
The manual contains a general overview of SCQM’s theoretical
foundation (i.e. basic principles, benefits, and core elements),
training curriculum and implementation method.
The introduction of SCQM in the hospital was fundamental,
gradual and evolutionary. An infrastructure for the SCQM
programme was established comprising of (i) a quality
management council, (ii) a quality management department,
(iii) a quality steering committee, (iv) functional and cross-
functional quality teams, and (v) a quality audit team. The
quality management council created a 5-year strategic quality
plan and defined quality goals. The strategic quality plan
contained specific quality goals and objectives for each of the
five dimensions of performance: employee, customer, supplier,
organisation, and society. An annual operational plan was
prepared, describing actions that would help the hospital meet
its operational goals.
TMT supported a learning environment where employees
were encouraged to share their ideas and information to
enhance their knowledge and skills. Training was designed
and delivered in three stages. In the first stage, senior and
middle managers were trained in quality management
concepts, skills, and techniques. In stage two, managers
attended managerial and leadership skills training courses.
The courses included leadership, planning, motivation, HRM,
change management, participative management, teamwork,
continuous improvement, customer relationship management,
and controlling. In the third stage, sufficient quality awareness
training was delivered to employees. This training was
focused on developing quality-related knowledge and skills,
teamwork and effective communication skills. The objective
of the training programme was not only to explain the concept
of SCQM principles and practices, but also to raise morale
and soften resistance to change. Education and training were
deemed to be the biggest facilitator in SCQM implementation.
The hospital began gradually and cautiously the implemen-
tation of the SCQM programme by structural, cultural, and
procedural changes. The physical structure was changed
to suit the needs of both internal and external customers in
order to improve processes. The mechanistic structure of
the hospital was changed by initiating functional and cross-
functional teams, increasing employee responsibility and
authority, and decreasing vertical coordination and control.
In addition, personnel policies dealing with performance
appraisal and rewards were changed.
As part of structural changes, angiography, endoscopy,
peritoneal dialysis, spirometry, ICU for poisoned patients, and
echocardiography wards or units were added to the hospital.
Furthermore, Accident and Emergency (A&E) department,
internal medicine wards, CCU, dialysis, the operation theatre,
radiology, colonoscopy, sonography, ICU, central sterilisation,
the main kitchen, restaurant, stores, the switch board room,
and cash office were renovated and equipped with new
equipment. These changes were expected to result in an
increased numbers of patients.
In order to develop a participative culture, a Suggestion
Scheme was launched in early 2006. Employees contributed
to improvement by actively participating in the Suggestions
Scheme. Management has seriously considered those
suggestions and recommendations. The hospital attempted
to initiate Total Productive Management (TPM) practice in
mid 2006. Therefore, an equipment engineering office was
established and staffed with three motivated and competent
personnel to improve the overall utilisation of equipment. The
TPM programme improved effective equipment management
as well as the technical skills and morale of hospital
employees. A positive attitude, ownership, and concern were
developed among employees. As a result, equipment defects
and breakdown rates, and consequently repairing costs were
reduced. The hospital has been using the 5S system as part of
a “Total Productive Maintenance” system in order to develop
a culture of order, safety, and responsibility.
The next phase of the SCQM programme—the procedural
changes—commenced formally in September 2007. Functional
and cross-functional teams were formed to identify and solve
quality problems. A quality steering committee was created
to support functional and cross-functional teams. Extensive
education and training were provided to develop employees’
capabilities on a continuous basis. Employees were encouraged
to use the ten-step quality improvement method to optimise
their working processes. They were encouraged to identify,
flowchart, optimise, and stabilise the processes. They were
further asked to define objectives for the processes, determine
key performance indicators and achievable targets for each
process, measure processes, identify the gap between the
expected and the actual performance, identify the problems,
find the roots of the problems, build solutions, develop a
plan, execute solutions and evaluate the effectiveness of the
improvements. Involving the teams in all stages of the action
Mosadeghrad
International Journal of Health Policy and Management, 2014, 2(4), 167–174 170
research motivated them to plan and implement changes for
a better quality of care. The ten-step quality improvement
method was found very useful for learning and improvement.
The hospital CEO resigned in April 2010. Although the
new hospital president was interested in improving the
quality of healthcare services, he was not actively involved
in quality management activities. He was mainly involved
in his professional clinical duties. He did not pursue long-
term overall organisational success. He was instead focused
on meeting short-term targets. Insufficient top management
commitment, lack of a strategic quality plan, and lack of
ongoing continuous education and training de-motivate
employees in their quality improvement activities.
Employees’ job satisfaction during the baseline, pre-
intervention phase (2005) was 57.8% (Table 1). Approximately
1 in 4 employees (26.3%) were dissatisfied with their job.
Employees were least satisfied with the salaries, benefits,
recognition, promotion, working conditions, organisation
policies, and management. Employees were not recognised
and rewarded for participating in quality management
activities. They did not see the value of such work, and
therefore, did not contribute to the quality management
programme. Employees’ payment was delayed for several
months. There was a serious conflict between employees and
top management. The outcome of top management policies
created a stressful environment for employees. Inadequate
pay, inequity at work, lack of recognition, lack of promotion
prospects, lack of job security, time pressure, inadequate
equipment, too much work, staff shortages, and lack of
management support were the main stressors for employees.
Employees’ job satisfaction rose to 63.3% for the year
2007 (Table 1). Most employees expressed high levels of
satisfaction, motivation, and accountability. Employees
reported significant improvement in some dimensions of job
satisfaction like management and supervision, organisational
policies, task requirement, and working conditions. The
lowest scores still fall into the same categories as the 2005
assessment (salaries and benefits). Although public managers
do not have enough power as regards changing policies
related to employees’ salaries and promotion, work has been
done to improve employees’ satisfaction with the benefits
and recognition schemes.
Management change and consequently a change in employee
relationship management improved employees’ satisfaction
significantly. Participatory managerial behaviour improved
employee satisfaction. The planned structural change
improved employees’ satisfaction. Provision of new facilities
and resources encouraged employees’ motivation for doing
their job. Employees’ roles and responsibilities were clarified.
They were given the ability, motivation, and authority to
improve their work quality. The SCQM programme had
a great impact on personnel attitudes towards their jobs.
Involvement of staff in quality management activities was
correlated with a significantly higher job satisfaction. Many
employees felt that their jobs had become more challenging
and enjoyed the additional responsibilities. The introduction
of the SCQM programme gave employees more control over
their daily activities, thus, increasing job satisfaction. The
SCQM programme brought the management and employees
closer together. Top management paid sufficient attention to
employee satisfaction, morale, development, and well-being.
Employees’ working stress was decreased by providing suitable
resources and more facilities. Employees were encouraged to
submit their ideas and opinions. The submitted ideas were
evaluated by the quality management department and the
selected ideas were applies. Education and training, teamwork,
and management support and recognition were found to
motivate employees to participate in quality management
activities. This resulted in high employee motivation, high job
satisfaction, and low absenteeism and turnover.
Employees’ job satisfaction dropped to 62.7% for the year 2008.
Employees’ job satisfaction improved during the first year of
the introduction of SCQM, at an average rate of 5.5 % (P< 0.05).
However, this accelerated rate of increase was not maintained
after 2007. The introduction of procedural changes required
by SCQM has caused an increase in the daily workload of the
employees. In addition, employees’ satisfaction with working
conditions decreased. A fall in employees’ satisfaction with
received salaries and benefits could be related to an increase
in employees’ output and external factors (e.g. inflation rate in
2008 increased too much compared with 2007).
Employees’ job satisfaction decreased in 2011 compared to
2008. However, they were more satisfied in comparison with
the year 2005. Employees were more dissatisfied with the
Table 1. Employees’ job satisfaction (on a 100 scale)
Job satsfers
2005 2007 2008 2011
P E P-E P E P-E P E P-E P E P-E
Salaries and fringe benefts 38.8 81.2 -42.4 48.0 82.6 -34.6 44.7 73.8 -29.1 41.0 75.3 -34.3
Recogniton and promoton 45.3 78.6 -33.3 51.8 76.7 -24.9 52.2 79.6 -27.4 48.6 77.2 -28.6
Management and Supervision 61.2 79.2 -18.0 66.2 80.0 -13.8 69.3 77.5 -8.2 64.3 75.7 -11.4
Co-workers 73.8 79.6 -5.8 75.2 76.6 -1.4 74.0 79.1 -5.1 73.5 79.6 -6.1
Task requirement 65.7 76.3 -10.6 71.3 76.6 -5.3 71.5 71.1 0.4 68.0 73.2 -5.2
Working conditons 47.5 78.4 -30.9 59.2 76.6 -17.4 53.0 71.6 -18.6 51.1 70.8 -19.7
Nature of work 74.0 75.4 -1.4 73.5 76.0 -2.5 72.0 81.0 -9.0 73.1 77.4 -4.3
Organisaton policies 54.7 78.6 -23.9 64.3 73.3 -9.0 64.5 70.5 -6.0 58.7 70.0 -11.3
Job security 55.5 76.3 -20.8 60.2 74.6 -14.4 62.0 71.6 -9.6 57. 7 72.1 -14.4
Overall job satsfacton 57.8 78.2 -20.4 63.3 77.0 -13.7 62.7 75.1 -12.4 59.7 74.6 -14.9
P= Perception, E= Expectation
Mosadeghrad
International Journal of Health Policy and Management, 2014, 2(4), 167–174 171
wages and fringe benefits, management, task requirements
and organisational policies.
While 68% of employees agreed to leave Hospital ‘A’ if they
could find a good job opportunity elsewhere in 2005, this
figure decreased to 43% in 2008 and then increased to 45.8%
in 2011 (Table 2). The difference between the two groups was
statistically significant at P< 0.01.
Discussion
The effectiveness of an organisation depends on the extent
to which people perform their roles and move towards the
corporate goals and objectives (28). Employees’ satisfaction
plays a critical role in organisational success. Employees’
job satisfaction is positively related to their organisational
commitment and negatively related to their turnover
intention (27). Employee satisfaction can result in customer
satisfaction (29). Satisfied employees are more likely to
work harder and provide better services (30) and enhance
organisational performance (31).
The SCQM implementation led to a higher level of
employees’ job satisfaction and their less intention to leave
the organisation. The findings are consistent with literature
suggesting that quality management implementation improves
employees’ outcome such as job satisfaction (32,33). The
SCQM application resulted in a culture change in the hospital,
with improved communication, teamwork, trust, respect, and
commitment to quality improvement. The implementation
of SCQM model was successful in bringing managers and
employees together to improve organisational performance.
As a result, employee morale, and satisfaction were improved.
The findings suggest that effective application of functional
and cross-functional quality teams is positively related to
employees’ job satisfaction, which are negatively related to
their turnover intention. These findings are consistent with
other studies (19,34).
Employees’ job satisfaction improved during the first year
of the introduction of SCQM. However, this accelerated rate
of increase was not maintained after then mainly because of
an imbalance between employees’ input and output and a
change in management team. The introduction of procedural
changes required by SCQM has caused an increase in the daily
workload of the employees. A fall in employees’ satisfaction
with received salaries and benefits could be related to an
increase in employees’ output. Similarly, Woodward and
colleagues (1999) reported significant increases in depression,
anxiety, emotional exhaustion, and job insecurity among
hospital employees, particularly during the first year of
the re-engineering change process. Job demands increased
throughout the period whereas little change occurred in the
employee’s decision latitude (35).
The hospital top management team was changed three times
during the course of SCQM implementation. The first hospital
president was more task-oriented and less employee-oriented.
Table 2. Hospital recommendation for work to others by employees
Queston 2005 2008 2011
Recommend the hospital for work to others 27.7 40.5 39.6
Agree to leave the hospital if fnd a good
opportunity
68.2 43.0 45.8
The second hospital president, a psychiatrist, was more
employee-oriented with good managerial experience. Finally,
the third hospital president was less people-oriented and task-
oriented than the second CEO. Management turnover during
the course of change programme influenced employees’
job satisfaction significantly. A feeling of trust between
employees and managers reinforces employees’ tendency and
commitment to adopt the change programme. Management
turnover is one of the most important obstacles for successful
quality management implementation (36,37). A possible
explanation for this might be that management turnover
increases the chance of subjective management, leading to
unfavourable outcomes. Management turnover increases
stress, tension, anxiety, and conflict among employees.
Top manager plays a critical role in promoting organisational
change. It is important that top manager takes a leadership role,
exhibits role model behaviour, shows a strong commitment
to quality management, creates a supportive environment,
and manages change strategically. The delivery of quality
services is dependent upon motivated, qualified, satisfied,
and committed employees. Employees prefer leaders who are
more considerate and supportive (38). Managers should pay
attention to the morale and well-being of employees.
Top managers should involve middle managers in planning
and promoting the change programme. Middle managers,
due to their position, can contribute greatly to quality
management implementation by communicating the quality
management message to employees and ensuring their
commitment, converting organisational goals, objectives
and strategies into detailed departmental objectives and
operational activities (39,40).
Employee participation in quality improvement must be
recognised, supported, and acknowledged. Employees
should have a positive attitude towards the quality
management initiative. Lack of considering employees’
benefits in the change programme at the beginning of the
SCQM implementation forced them to work against the
implementation of organisational change. Radical change
and downsizing led to changes in the personal work situation
and generated resistance. Employees were dissatisfied with
the way their organisation was being run. If employees see
no tangible benefit of the quality management programme,
they become resistant to the programme. Incurring too
much work without providing tangible benefits is the most
significant reason for employee apathy. The benefits of quality
management must be visible to employees in order for it to
succeed and become sustainable.
For SCQM to truly have an impact, change agents should
begin with the areas where such efforts result in immediate
tangible results for employees to enhance their morale and
motivation for continuous quality management activities.
Iranian healthcare employees are motivated more by fair
salaries, financial rewards, on-time payment, promotion,
improved working conditions, and supportive leadership
(38,41). Employees will become more involved if they see
the tangible benefits of the quality management programme.
Appropriate recognition and reward systems are important
tools to influence employees’ attitudes toward improving the
quality of their work. Short-term tangible results and financial
incentives increase the probability of sustained success.
Mosadeghrad
International Journal of Health Policy and Management, 2014, 2(4), 167–174 172
Recognition and non-monetary reward systems are also critical
to the long-term success of quality management initiatives.
For SCQM to have a positive impact on an organisation,
managers must recognise that the theory of ‘bad apples’
frightens and alienates the employees. They should focus
on ‘what happened?’ and ‘why?’ instead of ‘who did
it?’ They should remove feelings of fear by assuring job
security, developing a common vision, and motivating
employees by utilising various monetary and non-monetary
incentives to reward superior performance. Tension between
management and employees increases the risk of failure of
SCQM implementation.
Trust in managers is a critical factor in an employee’s tendency
to adopt the change programme. A feeling of trust between
employees and managers reinforces employees’ commitment
(42). Employees prefer leaders who are more considerate and
supportive. Therefore, the level of top management support
for the SCQM implementation process and continuous
visible leadership are vital factors in the sustainability
of the change programme. Supportive managerial and
clinical leadership facilitates the implementation of
SCQM in healthcare organisations by providing direction
and resources for continuous quality improvement. Top
management visible support helps achieve the desired
outcome of change acceptance.
Human resource systems, including employee selection
processes, training and development, performance appraisal,
and compensation and rewards must support the corporate
quality culture through the development of the necessary
motivation, attitudes, and the competencies. Jobs must be
redesigned to give employees more flexibility, autonomy and
authority, and encourage creativity. Performance appraisal
and reward systems must focus more on rewarding teamwork
and long-term performance.
A formal reward and recognition system that supports
teamwork and links quality and higher performance with pay,
encourages, and motivates employees to achieve the desired
performance (43). Managers’ recognition, appreciation, and
acknowledgement of achieving quality objectives enhance
employees’ involvement in quality management activities
and commitment to quality improvement (44). Recognition
nurtures trust and respect between managers and employees,
builds employees’ self-esteem, renews their enthusiasm and
reinforces desired behaviours.
Limitations and implications for further research
The focus of this study was a single general teaching hospital
that has implemented SCQM. Therefore, it does limit the
generalisability of the findings. Future research studies
are needed to explore the impact of quality management
programmes implementation on employees’ outcome.
Conclusion
The SCQM programme if properly implemented and
institutionalized improves employees’ job satisfaction.
SCQM practices such as visionary leadership, education,
training, empowerment, and teamwork enhance employees’
job satisfaction. Nevertheless, the implementation of the
SCQM model like any other change programmes needs
top management support and developing an appropriate
organisational climate and culture. The SCQM programme
succeeds only when the organisation is willing to change, to
discard outdated management and work methods if necessary.
Top management turnover is a major threat to the long-term
success of the SCQM intervention and makes it very difficult
to maintain the constancy of purpose expected in SCQM.
Ethical issues
Ethical codes in this study involved (i) respect for human dignity, (ii) respect for
privacy and confdentiality, and (iii) respect for autonomy.
Competing interests
The author declares that he has no competing interests.
Author’s contribution
AMM is the single author of the manuscript.
References
1. Boon OK, Arumugam V, Hwa TS. Does soft TQM predict
employees’ attitudes? The TQM Magazine 2005; 17: 279–89.
doi: 10.1108/09544780510594243
2. Forza C, Filippini R. TQM impact on quality conformance and
customer satisfaction: A causal model. International Journal of
Production Economics 1998; 55: 1–20. doi: 10.1016/s0925-
5273(98)00007-3
3. Agus A. TQM as a focus for improving overall service performance
and customer satisfaction: An empirical study on a public service
sector in Malaysia. Total Quality Management 2002; 15: 615–28.
doi: 10.1080/14783360410001680107
4. Martinez-Costa M, Jimenez-Jimenez D. Are companies that
implement TQM better learning organizations? An empirical
study. Total Quality Management 2008; 19: 1101–15. doi:
10.1080/14783360802323446
5. Rahman S. Total quality management practices and business
outcome: evidence from small and medium enterprises in
Western Australia. Total Quality Management 2001; 12: 201–10.
doi: 10.1080/09544120120011424
6. Agus A, Abdullah M. Total quality management practices in
manufacturing companies in Malaysia: An exploratory analysis.
Total Quality Management & Business Excellence 2000; 11:
1041–51. doi: 10.1080/095441200440313
7. Hansson J, Eriksson H. The impact of TQM on financial
performance. Measuring Business Excellence 2002; 6: 44–54.
doi: 10.1108/13683040210451714
8. Joiner TA. Total quality management and performance: The role
of organisation support and co-worker support. International
Journal of Quality & Reliability Management 2007; 24: 617–27.
doi: 10.1108/02656710710757808
9. Garvin D. Managing quality: The strategic and competitive edge.
New York: Free Press; 1988.
10. Madu CN, Kuei C. Strategic Total Quality Management:
Transformation process overview. Total Quality Management
1994; 5: 255–66. doi: 10.1080/09544129400000046
11. Kim KY, Chang DR. Global quality management: A research
focus. Decision Sciences 1995; 26: 561–8. doi: 10.1111/j.1540-
5915.1995.tb01440.x
12. Mosadeghrad AM. A theory of quality management. International
Journal of Modelling in Operations Management 2012; 2:
89–118. doi: 10.1504/ijmom.2012.043962
13. Ennis K, Harrington D. Quality management in Irish health
care. Int J Health Care Qual Assur 1999; 12: 232–43. doi:
10.1108/09526869910287305
14. Mosadeghrad AM. Obstacles to TQM success in health care
Mosadeghrad
International Journal of Health Policy and Management, 2014, 2(4), 167–174 173
systems. Int J Health Care Qual Assur 2013; 26: 147–73. doi:
10.1108/09526861311297352
15. Zabada CP, Rivers A, Munchus G. Obstacles to the application of
total quality management in health care organisations. Total Quality
Management 1998; 9: 57–66. doi: 10.1080/0954412989261
16. Mosadeghrad AM. Verification of a quality management theory:
Using a Delphi study. Int J Health Policy Manag 2013; 1: 261–71.
doi: 10.1080/0954412989261
17. Mosadeghrad AM. Implementing Strategic Collaborative Quality
Management in Health Care Sector. International Journal of
Strategic Change Management 2012; 4: 203–28.
18. Mohrman SA, Tenkasi RV, Lawler EE III, Ledford GG Jr.
Total quality management: Practice and outcomes in the
largest US firms. Employee Relations 1995; 17: 26–41. doi:
10.1108/01425459510086866
19. Lee LC, Yang KP, Chen TY. A quasi-experimental study on a
quality circle program in a Taiwanese hospital. Int J Qual Health
Care 2000; 12: 413–8. doi: 10.1093/intqhc/12.5.413
20. Alsughayir A. Does practicing total quality management affect
employee job satisfaction in Saudi Arabian organizations?
European Journal of Business and Management 2014; 6:
169–75.
21. Guimaraes T. TQM’s impact on employee attitudes. The TQM
Magazine 1996; 8: 20. doi: 10.1108/09544789610107225
22. McAdam R, Bannister A. Business performance measurement
and change management within a TQM framework’, International
Journal of Operations and Production Management 2001; 21:
88–107. doi: 10.1108/01443570110358477
23. Boselie P, van der Wiele T. Employee perceptions of HRM
and TQM, and the effects on satisfaction and intention to
leave.Managing Service Quality 2002; 12: 165–73. doi:
10.1108/09604520210429231
24. Parker SK. Longitudinal effects of lean production on employee
outcomes and the mediating role of work characteristics. J Appl
Psychol 2003; 88: 620–34. doi: 10.1037/0021-9010.88.4.620
25. Landsbergis PA, Cahill J, Schnall P. The impact of lean production
and related new systems of work organization on worker health.
J Occup Health Psychol 1999; 4: 108–30. doi: 10.1037/1076-
8998.4.2.108
26. Vidal M. Lean production, worker employment, and job
satisfaction: A qualitative analysis and critique. Critical Sociology
2007; 33: 247–78. doi: 10.1163/156916307x168656
27. Mosadeghrad AM, Ferlie E, Rosenberg D. A study of relationship
between job satisfaction, organisational commitment and
turnover intention among hospital employees. Health Serv
Manage Res 2008; 21: 211–27. doi: 10.1258/hsmr.2007.007015
28. Oakland JS. Total quality management: Text with cases. 3rd ed.
Oxford: Butterworth- Heinemann; 2003.
29. Brown S, Lam S. A meta-analysis of relationships linking
employee satisfaction to customer responses. Journal of
Retailing 2008; 84: 243–55. doi: 10.1016/j.jretai.2008.06.001
30. Capelli P. A market driven approach to retaining talent. Harv Bus
Rev 2000; 78: 103–11.
31. Akdere M. A multi-level examination of quality-focused
human resource practices and firm performance: Evidence
from the US healthcare industry. International Journal of
Human Resource Management 2009; 20: 1945–64. doi:
10.1080/09585190903142399
32. Sila I. Examining the effects of contextual factors on TQM and
performance through the lens of organisational theories: An
empirical study. Journal of Operations Management 2007; 25:
83–109. doi: 10.1016/j.jom.2006.02.003
33. Karia N, Asaari MH. The effects of total quality management
practices on employees’ work-related attitudes. The TQM
Magazine 2006; 18: 30–43. doi: 10.1108/09544780610637677
34. Lagrosen Y, Backstrom I, Lagrosen S. Quality management
and health: A double connection. International Journal of
Quality & Reliability Management 2007; 24: 49–61. doi:
10.1108/02656710710720321
35. Woodward CA, Shannon HS, Cunningham C, McIntosh J,
Lendrum B, Rosenbloom D, et al. The impact of re-engineering
and other cost reduction strategies on the staff of a large teaching
hospital: a longitudinal study. Med Care 1999; 37: 556–69. doi:
10.1097/00005650-199906000-00005
36. Mosadeghrad AM, Ferdosi M, Afshar H, Hosseini-Nejhad M.
The impact of top management turnover on quality management
implementation. Med Arh 2013; 67: 134–40. doi: 10.5455/
medarh.2013.67.134-140
37. Taylor WA, Wright GH. The impact of senior managers’ commitment
on the success of TQM programmes: An empirical study. Int J
Manpow 2003; 24: 535–50. doi: 10.1108/01437720310491071
38. Rad AM, Yarmohammadian MH. A study of relationship between
managers’ leadership style and employees’ job satisfaction. Int
J Health Care Qual Assur Inc Leadersh Health Serv 2006; 19:
xi-xxviii. doi: 10.1108/13660750610665008
39. Baidoun S. An empirical study of critical factors of TQM in
Palestinian organizations. Logistics Information Management
2003; 16: 156–71. doi: 10.1108/09576050310467296
40. Wimalasir JS, Kouzmin A. A comparative Study of employee
involvement initiatives in Hong Kong and the USA. Int J Manpow
2000; 21: 614–34. doi: 10.1108/01437720010379510
41. Hamidi Y, Eivazi Z. The Relationships Among Employees’ Job
Stress, Job Satisfaction, and the Organizational Performance
of Hamadan Urban Health Centers. Social Behavior and
Personality: An international Journal 2010; 38: 963–8. doi:
10.2224/sbp.2010.38.7.963
42. Gallear D, Ghobadian A. An empirical investigation of the channels
that facilitate a total quality culture. Total Quality Management
2004; 15: 1043–67. doi: 10.1080/1478336042000255497
43. Wilkinson A. Quality and the Human Factor. Total Quality Manage-
ment 2004; 15: 1019–24. doi: 10.1080/1478336042000255415
44. Kassicieh SK, Yourstone SA. Training, performance evaluation,
rewards, and TQM implementation success. Journal of
Quality Management 1998; 3: 25–38. doi: 10.1016/s1084-
8568(99)80102-3
Mosadeghrad
International Journal of Health Policy and Management, 2014, 2(4), 167–174 174
Implications for policy makers
• Contemporary industrial quality management practices
and techniques can be adopted, adapted and successfully
applied within professional healthcare organisations
to achieve excellence. A well-developed and well-
implemented quality management programme offers
significant benefits to organisations. Using the SCQM
framework, ugmented by strategic management and
project management approaches, healthcare organisations
may sustain continuous quality improvement.
• Managers choosing a quality management model should
remember that the model itself does not bring about
improvement. Institutionalising of quality management
requires commitment, effort, and resources. The SCQM
model will not succeed unless a receptive context and
supportive environment (supportive leadership, culture
and structure) is created.
• A strong committed leadership is necessary for
SCQM implementation to be successful. Without top
management’s stability, commitment and support,
SCQM will be just another “management fad”.
Implications for public
Quality has become an increasingly predominant part of
our lives. People are constantly looking for quality products
and services. Healthcare providers particularly doctors and
nurses play crucial roles in the delivery of quality healthcare
services to the public. Quality management practices such
as leadership, planning, training, employee empowerment,
engagement, and evaluation affect employee satisfaction
and commitment, which in turn influence patient
satisfaction and loyalty.
Key Messages
doc_721377512.pdf