Implementation of Total Quality Management and its Effect on Employees’ Performance in a Teaching Hospital in Oyo State, Nigeria

Macide Artac Ozdal1* and Bamise Faith Oyebamiji2

Turkey

Keywords: Employees’ performance; External factors; Total Quality Management; Leadership

Introduction

Quality is the key component and success factor to any organization to increase organizational performance, productivity and improve employees’ performance [1]. Due to the growing global competition in quality management principles, active quality management becomes highly important for leadership and management of the entire organization, where meeting customers’ needs is the important key to organizational success [2].

Healthcare industry, which includes public and private hospitals, basic healthcare units or centers, maternity and child healthcare units, and dispensaries is a major source for healthcare provider that serves the society in delivering services for healthiness and contribute in the national development. Quality management has become an important issue with increasing attention in hospitals due to hospital management initiatives, influence of clients or patients, insurance companies, public pressure, stakeholders or management and government [3]. One of the important quality management programme is Total Quality Management (TQM), which is a designed and established organizational effort to manage quality based on participation at every level, aiming to improve customer satisfaction and performance of staff [4, 5, 6]. For any successful total quality management implementation, elements such as leadership, trust, ethics, communication, integrity, training and education, teamwork, recognition, customer focus, information analysis, employee empowerment, human resource development and management policies and strategy are required [7, 8, 9, 10]. In healthcare systems, TQM is a designed and efficient process that creates participation of entire organization in planning and implementation of continuous improvement in quality [4]. Several attempts to implement TQM across various sectors, including health care services, have been made but the success record of TQM has been dismal, which could be attributed to faulty implementation process, such as functional hierarchical, bureaucratic and authoritarian organizational structure, lack of consensus, unchallengeable leadership style, internal requirement domination and manpower shortfall [11, 12, 13].

In healthcare settings, customers/clients/patients urge for quality in services have been increasing [13]. In Nigeria, the implementation of health care management is limited by various factors, such as weak institutional and human capacity building, poor funding, disjointedness between health policy initiatives, reforms and programs of different regimes, inefficient and ineffective human resources management [14]. Developing countries, particularly Nigeria, is still lagging behind in the continuous implementation of TQM as a strategic tool and its relatedness to employees’ performance. Hospital quality management in Nigeria is one of the most important, but overlooked tool with regard to its service quality implementation and delivery, resulting in low employees’ performance and inadequate customers’ satisfaction [15]. Quality and performance management in healthcare settings becomes more demanding due to lack of effective methods for enhancing performance, leadership, accountability, managerial skills and poor strategic planning [16, 17]. This, therefore, warrants effective quality management approach, such as TQM is implemented, assessed or monitored appropriately to improve competitiveness, effectiveness and flexibility [18]. This study aims evaluation of the implementation of TQM and its impact on employees’ performance in a tertiary-level teaching hospital in Oyo State, Nigeria.

Results

The Cronbach’s alpha values of the scales ranging from Leadership to Employees’ satisfaction were between 0.65 and 0.89 (Table 1). This indicates that all the TQM constructs had acceptable reliabilities, with all values close or greater than 0.70 Cronbach alpha coefficient). The demographic characteristics (gender, level of education, age, job designation and number of years in service) of the respondents were examined (Table 2). A total number of 106 questionnaires were filled, with a predominant gender as female (51.9%). The distribution according to age shows that the most of the respondents were within the age of 21 to 30 years old (45.3%), whilst the distribution of the respondents’ educational background shows that most of the respondents were polytechnic or university graduate (83.0%). A large

The assessment of the implementation of the principles of total quality management in the hospital of interest gives a conceptual analysis of the principles of TQM under the context of leadership, continuous improvement, training and education, reward and recognition, communication, customer focus, team work, employees’ participation and satisfaction. The range of the implementation of TQM practices in the hospital depicts from leadership to employee satisfaction. From the study, the best of the critical factors of TQM implemented was Reward and recognition (mean=2.98±0.045; x2= 0.207, p-value<0.05), while the least factor was employee satisfaction (mean=2.68±0,089; x2=0,089, p-value<0.05) Table 3.

According to the findings, salary increment (mean=3.21±1.177; x2=35.132, p-value<0.05) was the major determinant factor for employees’ performance and generally, the respondents agreed that there is relationship between TQM practices and employees’ satisfaction and the result was statistically significant (Table 4). From the findings, majority of the respondents (64.2%) indicated that external factors affect their performance in the hospital while 35.8% indicated that no external factor influences their performance. Out of the external factors that influences employees’ performance, financial pressure had the highest response followed by political pressure and the least as gender bias (Figure 1).

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Discussion

In this study, nine important factors were identified as leadership, continuous improvement, training and education, reward and recognition, communication, customer satisfaction, team work, employee participation and employees’ satisfaction. Reward and recognition was the most implemented principle, while employees’ satisfaction was the least implemented. The study also revealed that there is a general approval that the level of TQM implementation was above average (moderate). This suggests that there is awareness from the top (executive) management to adapt the TQM concept as important directive for competition. This is in agreement with previous research that identified customer focus, training and development, recognition and rewards, as the critical factors in TQM implementation [21, 22, 23]. The success of quality efforts of an organization depends largely on concentrating on the objectives and communication between management, employees and customers/patients.

Implementing TQM requires additional skills training, which is vital to its success and it provides an opportunity to empower and motivate employees. Service quality can be increased by rewards and recognition through implementation of employee empowerment and involvement initiatives. In healthcare organization, leadership is one of the major factors for implementing TQM, which involves the integration of quality improvement into planning process throughout the entire organization [24]. In this study, executive management was shown as having positive impact on the successful implementation of TQM and is one of the determinants (second highest in TQM plan), mostly in the organizational and employee performance to achieve greater quality service. This is similar to the report by Rad MA, who investigated on the success of TQM and its barriers to the successful implementation in healthcare organization in Iran [25]. Customer focus is essential in any organization for delivering a superior quality customer experience [26]. According to the study, customer focus (mean 2.85 out of 5.0) also plays important role in the TQM implementation as all activities, from the outpatient to marketing, treatment and care services are built around the customer/patient. This is in accordance to the study by Garcia Herrero, et al. who identified customer focus as one of the highest implemented principle of TQM [27]. Training and education are important in achieving a successful adoption of TQM. Improper implementation of TQM may be attributed to the inadequate knowledge about the importance of its principles and practices through training programs for improving healthcare services and customers’ satisfaction as seen in the study, training and education being one of the least implemented TQM practices (mean 2.72). This is similar with the findings of Al-Shdaifat, who explored the extent at which TQM practices such as continuous improvement, teamwork, top manager commitment, customer focus and training are implemented in Jordanian hospitals among which training falls as one of the least implemented practice in Jordanian government hospital [19], but inconsistent with the findings of Ramseook-Munhurrun, et al. who reported a high perception for training as one of the TQM practices implemented in Mauritian public hospital [28]. Employees are the initiators of the organization’s visions and strategies through delivering value for customer needs and expectations therefore, reward, which is an effective concept for describing the progressive value an individual or employee attributes to an object, behavioral act, or internal physical state or job is a regular review of employees’ performance.

Increment in salary serves as a motivation for employees’ performance as reported in the findings. Appropriate reward and recognition systems are important strategy to impact employees’ attitudes toward successful quality of their work. This is similar to the work by Hamidi Y & Eivazi Z who reported that healthcare workers are motivated by increased salaries, on-time payment, financial rewards, promotion and improved working conditions [29]. The goal of any healthcare organization is that employees’ performance and behaviour contribute to the organizational growth and performance [30]. Employees’ performance can be affected by external factors such as competition, financial pressure, gender bias, political pressure, pressure from clients and decentralization. In the present study, most of the participants were affected by mostly financial and political pressure in the hospital, which could in turn affect the customers’ satisfaction.

Conclusion

TQM is an operational system for incorporating organization’s quality development, maintenance and improvement efforts of different aspects to enable products and/or services at most reasonable level and achieve full satisfaction. It has gained increasing attractiveness as an approach to lead transformational change in an organization’s managerial philosophy and operational efficiency. Proper implementation of TQM can be a very effective alternative or solution in improving the health care service quality, growing employees’ performance and customers’ or patients’ satisfaction in University College Hospital, Oyo State, Nigeria. The present study identified nine important factors in implementation of TQM practices, which include leadership, continuous improvement, training and education, reward and recognition, communication, customer satisfaction, teamwork, employee participation and employees’ satisfaction. From the evaluation, it can be concluded that leadership, customer focus, reward and recognition are the most important determining factors in enhancing employees’ performance and satisfaction. It is not unexpected that most TQM ideologies and practices presented in this study are important basic to the success of any healthcare organization, which can be implemented to different circumstances. Therefore, executive healthcare managers can use the validated instrument for evaluating the effectiveness of TQM implementation in their organizations. It, likewise, can serve as a model for healthcare organizations, who aim at better healthcare quality.

Competing Interests

All authors declare that there is no competing interest.

Acknowledgement

The authors acknowledge the support of the Department of Healthcare Organizations Management, Cyprus International University, Northern Cyprus and the entire Staff of the University College Hospital (UCH) Ibadan, Oyo state, Nigeria).