Total quality management in the healthcare sector: An empirical research from Ethiopia

Abstract

BACKGROUND:

TQM in health care institutions is a method for improving the effectiveness of work in general, and it is the view of the administration that tries to communicate with all stakeholders in the organization to achieve high-quality continuous improvement.

OBJECTIVE:

The objectives of the study are to analyses the feasibility of TQM in the public health organization in Ethiopia. This study deals with the implementation of the health organization by evaluating the performance of TQM.

METHODS:

The target sample was selected using the stratified random sampling method and also takes into account the quantitative methodological framework. The study is based on the Descriptive Approaches, focusing on the analysis of the sample and the main characteristics of its members.

RESULTS:

The study results show that there is significant awareness of TQM principles, benefits achieved by the TQM application, obstacles hampered by TQM application, and there are statistically significant differences in perception practitioners of the nursing profession to the importance of TQM application in the public healthcare organization in Ethiopia.

CONCLUSIONS:

Several conclusions were drawn on the subject of this study to propose appropriate recommendations for management. This study strongly recommended that hospital management should make efforts to create an advanced information system to effectively ensure TQM.

Keywords

Total quality management quality management healthcare organization health care managers

Dr. Gutama Kusse Getele is a PhD researcher scholar at Donlinks School of Economics and Management, University of Science and Technology Beijing, China. He graduated with MSc degree in computer science and technology, from university of electronics and technology of China. In 2015, Dr. Gutama has been teaching commination engineering at Chengdu University of Information Technology. He has a wealth of experience in cloud computing security, SCM & CSR. His research interests are in supply chain management, and he published many academic research papers in high-quality SSCI, EI, ESCI and international journals on SCM and CSR.

Dr. Arrive Tsitaire Jean, He is a research scholar at Donlinks School of Economics and Management, University of Science and Technology Beijing, China. He published more than 10 academic research papers in high-quality SSCI, EI and international journals on technology innovation and CSR.

1 Introduction

One of the biggest challenges in healthcare institutions facing today is how quality can be improved to reduce the cost of their services and the quality management (QM) in health care sectors. The quality of healthcare delivery can be enhanced by health care practitioners’ virtual knowledge-use communities [1]. Hence in delivering health care services, health care institutions strive for total quality management (TQM) to raise performance level in the health care system and improve patient satisfaction, as well as the likelihood of interacting with employees and managers of health care organizations [2]. Ethiopian healthcare sectors are faced with many challenges of diminishing productivity increased operating costs, lack of financial resources, and ineffective approaches to achieve the goals of the healthcare organization. Thus, each organization establishes its system for motivating its employees to do the best they can to achieve goals and objectives of the organization [3]. Likewise, the first factor that determines job satisfaction is the attitude an employee takes to their workplace and employment [4].

The level of beneficiary satisfaction, employee job satisfaction and loyalty, as well as the fierce competition at the local and global level of this challenge is aggravated by the opt-in behavior of beneficiaries considering QM as the main criterion for the choosing products or services, regardless of the origin of that product or service [5, 6]. Therefore, TQM should be extended to service institutions as a new management approach to urge these institutions out of the circle of bureaucratic methods which focus on achieving objectives and regardless of the quality of the achievement. Also, quality principles and philosophy have evolved over the years, starting with the idea of ultimate product quality and up to the concept of TQM [7].

TQM is an administrative point of view that seeks to communicate with all the members in the organization to achieve high quality and continuous improvement. Hence, TQM is needed to concentrate on the process and commitment to the internal and external customers that leads to better performance, customer satisfaction and profit for the organization [8, 9]. Therefore from this definition, it is clear that TQM in health institutions is a method for improving work efficiency and as well as a way of organization involving the entire organization and its operational activities at staff levels entirely [10].

Over the years, health institutions have become involved in an environment heavily transformed by profound and complex changes. Hence, all of which have increased exposure in a healthcare system to ways of improving the profitability of health organizations and improving the quality of managers [11]. Hospital-led health organizations have a prominent impact and influence on our lives and are urgently concerned with the most important element of production [12]. In this study, we will attempt to provide some answers to the questions that can be posed under the section on hypothesis testing that is based on TQM at health organizations in general and hospitals in particular. Eventually, in this study, we focused on: the health system, reviewing the individual managers and their organizations, hospital services, evaluating their performance, and finally we conclude by giving the summary and recommendation of the healthcare management system in Ethiopia.

2 Theoretical background

2.1 Concept of TQM in health organizations

The concept of TQM is relatively recent in health organizations and is based on principles that were introduced by quality pioneers like Deming and Juran. TQM in health institutions is defined as: “A framework within which organizations are committed health professionals and their staff monitors and evaluate all aspects of organizations’ activities (inputs and processes to output side) to be continuously improved”. It is also defined as “a comprehensive strategy that the health organization aims to achieve changes in the characteristics and attributes that enable all individuals (professionals, physicians, nursing staff, technicians and patients alike)” [13]. Likewise, also defined as “a broad philosophy of how to make different groups of individuals come together to accomplish a general-purpose and allow them to understand the nature and significance of services and to put their energies and potentials in achieving continuous improvement” [14].

This study seeks to achieve its main objective of determining the applicability of QM. Although quality has many definitions, QM means consistently achieving the customer’s expectations and desires by means of employees, products and service. Hence, it is a fundamental implementation that guarantees quality and will ultimately lead to customer satisfaction [15]. Hence, consistently management and administrative control staff must be trained for professional development. Such training is important because control of the management follows the development of the organization [16].

2.2 Principles of total quality management

The activation of the philosophy of TQM is required within an organization, whether its main function is in production or service sector. Several principles commensurate and complements each other to achieve TQM objectives, we presented the most important as follows:

Senior management support: An organization’s success in adopting TQM depends on senior management support, and its dedication to persuasion supports this ideology in all of the organization’s activities operations and service sectors. According to the study by Getele, Li and Arrive [17], executives and respective managers are not often involved in team-building implementation across departmental offices around the country. This study, therefore, proposes that senior management plays a leading role in coordinating and unifying efforts to achieve the goals of organizational development [18]. As well as the implementation of the function of operational and service-oriented workers through teams based on the premise that they have more individual ability to develop and strengthen their work [19, 20]. Hence, to achieve TQM’s success, senior management must adhere to this modern concept to ensure that commitment and persuasion in its application begin at the top of the organizational pyramid, then descend to the lower levels and manage the transition from traditional management to TQM by enabling teams to implement the proposed changes without the commitment of senior management [21]. This principle will be the fate of QM’s overall failure and there will be no point in investing in it [22].

Customer focus: In TQM, the term customer includes both internal and external customers. An external customer is an individual around whom all activities revolve to fulfill wishes, to motivate to purchase the product, while the internal customer represents the individual employees in the various organizational units of the company [23].

Continuous improvement: TQM is not a program that starts and ends in advance, but rather efforts to improve and develop continuously and unceasingly, because TQM is based on the principle that opportunities for development and improvement never end no matter how efficient and effective the performance. Besides, the level of quality, desires and expectations of customers are not constant, hence quality must be evaluated and improved continuously based on information collected and analyzed periodically [24].

Considering hospital performance appraisal can be defined as to finding a measure by which the organization can achieve goals, compare those goals to the goals achieved, and quantifying deviations from what was previously expected, determining the causes of these deviations and the methods of resolving them. In other words, performance evaluation involves identifying specific indicators, then collecting the data necessary to measure specified indicators, and finally comparing the current level of performance with the desired. Figure 1 shows the TQM performance evaluation system.

Fig. 1

TQM performance evaluation system.

To evaluate the performance of the health institutions in general and hospitals in particular, this concept is largely related to how well these institutions can achieve the healthcare goals they seek attainment in terms of the preparation of health programs (health planning). Further, to accomplish the level of diversity of health services introduction and reflect its strategy and objectives in the results achieved from the progress of its work. Therefore, performance assessment in health institutions focuses on improving health programs and services within available resources, as the information system relies on them and is closely related.

From the above theoretical background and after the initial readings of the topic, we develop the following hypotheses:

Practitioners of the nursing profession in the public healthcare organization in Ethiopia are aware of the importance of the principles of TQM.

There is a high level of awareness about the benefits of TQM application’s comprehensive quality in the public healthcare organization in Ethiopia.

The practitioners of the nursing profession in the public healthcare organization in Ethiopia are aware that the application of TQM is hampered by obstacles.

There are no statistically significant differences in perception practitioners of the nursing profession to the importance of the axes of the application of TQM in the public healthcare organization in Ethiopia.

3 Research design and data collection

3.1 Analysis of the study sample

The emphasis will be on defining the research community, choosing the test sample and the most important characteristics, and then evaluating the analysis tool procedures used to ensure that it is accurate and consistent. The study population included all nurses and doctors’ practitioners in an Ethiopian health-care organization. Also, this constitutes practitioners, managers, and supervisors.

3.2 Building and testing the questionnaire

The questionnaire was used as a tool to collect the data needed for the study. It was an effective means to collect information when there is accurate knowledge of what is required and how to measure the variables to be studied. The following subtitles explain how to outline the study tool and the processes used to verify its validity and reliability.

3.3 The validity and reliability of the study tool

To ensure the validity of the questionnaire in terms of the validity of its contents and represent its paragraphs to variables before the study were subjected to study, and then presented to several professors and academic expert in the field of the study and also presented to several practitioners of the nursing occupation in the public healthcare in Ethiopia.

3.4 Statistical processing tools

Statistical data were collected using some statistical methods and the hypotheses are tested by the average relative weight difference. The following relative weight averages are obtained to test the importance of the study:

Average of 4 and above indicates very high importance.

An average of 3.25 to 3.99 indicates high importance.

An average of 2.50 to 3.24 indicates medium importance.

An average of 1.75 to 2.49 indicates low importance.

Average below 1.75 indicates very low importance.

To ensure the ease of understanding and clarity of the statements of the questionnaire, the questionnaire has been discussed with managers and nurses. Finally, several observations and suggestions were considered while designing and finalized to verify the consistency of the questionnaire. The internal coefficient of coefficient (Alpha-Cronbach) was measured for each axis. The following Table 1 shows the stability factors of the study tool.

Table 1
Stability factors of the study instrument

Themes of the study tool Alpha-Cronbach stability coefficient

Principles of TQM 0.85

Advantages of applying TQM 0.78

Obstacles to the application of TQM 0.89

Stability coefficient of the study as a whole 0.84

Themes of the study tool	Alpha-Cronbach stability coefficient
Principles of TQM	0.85
Advantages of applying TQM	0.78
Obstacles to the application of TQM	0.89
Stability coefficient of the study as a whole	0.84

It is clear from the Table 1 that the coefficient of stability has ranged between (0.89) in its upper limit for the axis of impediments to the application of TQM, and between (0.78) at a minimum which is the axis of advantages the application of TQM. The coefficient of stability of the study instrument as a whole was (0.85), hence, the coefficient of stability results of the application of the study tool is consistent, indicating the stability of the results the study tool is in its final form.

3.5 Questionnaire construction

After reviewing the literature on the subject of research, the designed questionnaire consisted of the following four axes. The first axis contains personal data which includes gender, age, and status, while the second axis contains variables concerning the principles of TQM phrases are allocated. Additionally, the third axis contains variables related to the benefits achieved by the application of TQM allocated to them phrases and finally, the fourth axis concerns the obstacles that inhibit the implementation of TQM. The five-dimensional Likert scale was used, (very important = 5, important = 4, fairly important = 3, slightly important = 2, and not important = 1).

The size of the study sample is determined by two types of considerations; the degree of homogeneity of the study population and the percentage of error that the researcher can tolerate. Non-systematic considerations including a time limit for data collection and physical potential in general. According to scientific research, the proportion of the study population is an acceptable proportion to the size of the sample in descriptive studies. Therefore, the target sample was selected according to the stratified random sampling method. A questionnaire was used, 60 forms have been distributed to 60 different health care sectors in Ethiopia and 54 forms have been returned with complete response. Table 2 shows the random stratification of the sample population to the indigenous community.

Table 2
Random stratification of the sample population to the indigenous community

I. Distribution of the study sample by sex

Sex Repetition Percentage

Male 28 51.9%

Female 26 48.1%

Total 54 100%

II. Distribution of the study sample by age

Age Repetition Percentage

Less than 30 years 06 11.1%

From 30– 35 years 04 7.4%

fROM 36– 40 years 16 29.6%

From 41– 45 years 09 16.7%

From 46– 50 years 15 27.8%

More than 50 years 04 7.4%

Total 54 100%

III. Distribution of the study sample by job

Function Repetition Percentage

Principal Nurse 06 11.1%

A state nurse 24 44.4%

Qualified nurse 15 27.8%

Nursing assistant 09 16.7%

Total 54 100%

IV. Distribution of the study sample by educational level

Educational level Repetition Percentage

Average 09 16.7%

Secondary 20 37.0%

Collectors 22 40.7%

Postgraduate 03 5.6%

Total 54 100%

V. Distribution of the study sample according to the years of experience

Years of Experience Repetition Percentage

Less than 5 years 06 11.1%

10– 5 years 00 00%

11– 15 years 09 16.7%

16– 20 years 16 29.6%

21– 25 years 12 22.2%

More than 25 years 11 20.4%

Total 54 100%

I. Distribution of the study sample by sex
Sex	Repetition	Percentage
Male	28	51.9%
Female	26	48.1%
Total	54	100%
II. Distribution of the study sample by age
Age	Repetition	Percentage
Less than 30 years	06	11.1%
From 30– 35 years	04	7.4%
fROM 36– 40 years	16	29.6%
From 41– 45 years	09	16.7%
From 46– 50 years	15	27.8%
More than 50 years	04	7.4%
Total	54	100%
III. Distribution of the study sample by job
Function	Repetition	Percentage
Principal Nurse	06	11.1%
A state nurse	24	44.4%
Qualified nurse	15	27.8%
Nursing assistant	09	16.7%
Total	54	100%
IV. Distribution of the study sample by educational level
Educational level	Repetition	Percentage
Average	09	16.7%
Secondary	20	37.0%
Collectors	22	40.7%
Postgraduate	03	5.6%
Total	54	100%
V. Distribution of the study sample according to the years of experience
Years of Experience	Repetition	Percentage
Less than 5 years	06	11.1%
10– 5 years	00	00%
11– 15 years	09	16.7%
16– 20 years	16	29.6%
21– 25 years	12	22.2%
More than 25 years	11	20.4%
Total	54	100%

Table 2 (I) Show that the study sample is distributed by sex, approximately half of the respondents (51.9%) are males and that the proportion of (48.1%) are female. It is clear from the Table 2 (II) that (29.6%) of the total sample is between the ages of 36 and 40, which is characterized by vitality and activity, followed by the proportion of aged 46– 50, representing (27.8%), which is the age group with experience. While the percentage of those who are less between the ages of (41 and 45) to (16.7%), and the proportion of those under the age of (30 years) to 11.1%, and a small percentage (7.4%) between the ages of 30 and 35, over 50 years of age. It appears from the Table 2 (III) presents distributed sample of the study by a job that the percentage of nurses with a state certificate constitutes (44.4%) which is a higher percentage of those surveyed, followed by qualified nurses (27.8%) and assistants (16.7%), while the number of nurses was (11.1%).

The study sample is distributed according to educational level in Table 2 (IV) which presents, (40.7%) of the study sample are holders of university degrees, allowing them able to deal with the questionnaire questions easily and clearly. Meanwhile, the percentages (37%) of those surveyed were secondary school holders (16.7%) and the lowest (5.6%) represents the category of individuals with postgraduate studies. Moreover, the last Table 2 (V) shows the study sample distributed according to the number of years of experience. The highest proportion of study members have experience of working in the hospital ranging between (16 and 20) and up to (29.6%) of the total members of the study, followed by the proportion of those who have experience in the hospital work between (21 and 25 years) and (22.2%) as the proportion of those who have experienced more than the percentage of those whose experience ranges from (11 to 15 years) decreases to 25.4%. The percentage of those with experience (less than 5 years) is less than (11.1%), while the percentage of those who do not have experienced between 5 and 10 years.

4 Results

4.1 Hypothesis testing

The hypothesis validity was analyzed by checking the average relative weight in Table 3 for the first three hypotheses accordingly and the p-value in Table 4 for the last hypothesis (H4).

Table 3
Respondents’ responses towards the level TQM

Study responses to the relative importance of the principles of TQM in the public hospital

Phrase Category Very Important Important Fairly important Slightly important Not important Average the weight Relative Normative deviation

Improves quality commitment of top management services Provided at this hospital T 40 12 2 0 0 4.68 0.54

% 74.1 22.2 3.7 0 0

Patient satisfaction is the goal of the hospital T 39 14 0 1 0 4.69 0.58

% 72.2 25.9 0 1.9 0

Continuous improvement process in the hospital T 39 14 0 1 0 4.69 0.58

% 1.9 25.9 0 2.7 0

Continuous training of staff from the hospital traditional management to management comprehensive quality T 37 14 1 0 2 4.69 0.58

% 68.5 25.9 1.9 0 3.7

All operations performed include continuous improvement in different hospital departments and its departments. T 34 17 1 2 0 4.54 0.72

% 63 31.5 1.9 3.7 0

This hospital decision-making process is done in building a good analysis of the data T 33 17 2 1 1 4.48 0.82

% 61.1 31.5 3.7 1.9 1.9

To detect the use of monitoring processes deviation from standards the quality T 30 15 6 1 2 4.44 0.72

% 55.6 35.2 7.4 1.9 0

Basic (Feedback) to modify decisions taken T 30 15 6 1 2 4.3 1.00

% 55.6 27.8 11.1 1.9 3.7

Awareness of the benefits achieved by the application of TQM in the public institution hospital

Reduce errors and cost Non-quality T 40 12 2 0 0 4.7 0.54

% 74.1 22.2 4 0 0

I have high confidence Patient that his life in good hands T 42 8 7.4 0 0 4.7 0.60

% 77.8 14.8 4 0 0

The best use for devices and technologies modern in the field of medicine T 39 11 7.4 0 0 4.65 0.62

% 72.2 20.4 4 0 0

Achieve needs fully sick and in time T 36 14 7.4 0 0 4.59 0.63

% 66.7 25.9 3 0 0

Providing health service in the right way from the first time T 34 16 15.6 1 0 4.54 0.69

% 63 29.6 7 1.9 0

Speed to respond to patient complaints and their suggestions T 33 14 13 0 0 4.48 0.72

% 61.1 29.9 3.7 0 0

Increased number of patients the undecided on the hospital T 20 14 13 3 4 3.8 1.22

% 37 25.9 24.1 5.6 7.4

Importance of application obstacles TQM in the general organization of hospital

Weak management commitment high hospital support quality efforts T 21 32 0 0 1 4.33 0.67

% 38.9 59.3 0 0 1.9

Phrase Category Very Important Important Fairly important Slightly important Not important Average the weight Relative Normative deviation

Blurred concept teamwork and absence team spirit T 25 23 2 3 1 4.33 0.78

% 46.3 42.6 3.7 5.6 1.9

No programs management training comprehensive quality T 21 29 3 0 1 4.28 0.74

% 38.9 53.7 5.6 0 1.9

The weak motivation of employees hospital to improve their performance T 25 23 2 3 1 4.26 0.91

% 46.3 42.6 3.7 5.6 1.9

Lack of standards and dimensions of service health quality T 22 27 3 1 1 4.26 0.81

% 40.7 50 5.6 1.9 1.9

No metrics objective to know patient satisfaction level about hospital services T 19 29 4 2 0 4.2 0.74

% 35.2 53.7 7.4 3.7 0

Lack of experts specialists in management comprehensive quality in the hospital T 18 28 7 1 0 4.17 0.72

% 33.3 51.9 13 1.9 0

Do not allocate resources adequate T 19 27 2 5 1 4.07 0.97

% 35.2 50 3.7 9.3 1.9

Study responses to the relative importance of the principles of TQM in the public hospital
Phrase	Category	Very Important	Important	Fairly important	Slightly important	Not important	Average the weight Relative	Normative deviation
Improves quality commitment of top management services Provided at this hospital	T	40	12	2	0	0	4.68	0.54
	%	74.1	22.2	3.7	0	0
Patient satisfaction is the goal of the hospital	T	39	14	0	1	0	4.69	0.58
	%	72.2	25.9	0	1.9	0
Continuous improvement process in the hospital	T	39	14	0	1	0	4.69	0.58
	%	1.9	25.9	0	2.7	0
Continuous training of staff from the hospital traditional management to management comprehensive quality	T	37	14	1	0	2	4.69	0.58
	%	68.5	25.9	1.9	0	3.7
All operations performed include continuous improvement in different hospital departments and its departments.	T	34	17	1	2	0	4.54	0.72
	%	63	31.5	1.9	3.7	0
This hospital decision-making process is done in building a good analysis of the data	T	33	17	2	1	1	4.48	0.82
	%	61.1	31.5	3.7	1.9	1.9
To detect the use of monitoring processes deviation from standards the quality	T	30	15	6	1	2	4.44	0.72
	%	55.6	35.2	7.4	1.9	0
Basic (Feedback) to modify decisions taken	T	30	15	6	1	2	4.3	1.00
	%	55.6	27.8	11.1	1.9	3.7
Awareness of the benefits achieved by the application of TQM in the public institution hospital
Reduce errors and cost Non-quality	T	40	12	2	0	0	4.7	0.54
	%	74.1	22.2	4	0	0
I have high confidence Patient that his life in good hands	T	42	8	7.4	0	0	4.7	0.60
	%	77.8	14.8	4	0	0
The best use for devices and technologies modern in the field of medicine	T	39	11	7.4	0	0	4.65	0.62
	%	72.2	20.4	4	0	0
Achieve needs fully sick and in time	T	36	14	7.4	0	0	4.59	0.63
	%	66.7	25.9	3	0	0
Providing health service in the right way from the first time	T	34	16	15.6	1	0	4.54	0.69
	%	63	29.6	7	1.9	0
Speed to respond to patient complaints and their suggestions	T	33	14	13	0	0	4.48	0.72
	%	61.1	29.9	3.7	0	0
Increased number of patients the undecided on the hospital	T	20	14	13	3	4	3.8	1.22
	%	37	25.9	24.1	5.6	7.4
Importance of application obstacles TQM in the general organization of hospital
Weak management commitment high hospital support quality efforts	T	21	32	0	0	1	4.33	0.67
	%	38.9	59.3	0	0	1.9
Phrase	Category	Very Important	Important	Fairly important	Slightly important	Not important	Average the weight Relative	Normative deviation
Blurred concept teamwork and absence team spirit	T	25	23	2	3	1	4.33	0.78
	%	46.3	42.6	3.7	5.6	1.9
No programs management training comprehensive quality	T	21	29	3	0	1	4.28	0.74
	%	38.9	53.7	5.6	0	1.9
The weak motivation of employees hospital to improve their performance	T	25	23	2	3	1	4.26	0.91
	%	46.3	42.6	3.7	5.6	1.9
Lack of standards and dimensions of service health quality	T	22	27	3	1	1	4.26	0.81
	%	40.7	50	5.6	1.9	1.9
No metrics objective to know patient satisfaction level about hospital services	T	19	29	4	2	0	4.2	0.74
	%	35.2	53.7	7.4	3.7	0
Lack of experts specialists in management comprehensive quality in the hospital	T	18	28	7	1	0	4.17	0.72
	%	33.3	51.9	13	1.9	0
Do not allocate resources adequate	T	19	27	2	5	1	4.07	0.97
	%	35.2	50	3.7	9.3	1.9

Table 4

Results of the analysis of variance in terms of differences between the perceptions of study members and the importance of the axes of the application of TQM in public health care organization in Ethiopia

Application axes QM overall	Source of Contrast	Degree freedom	Sum squares	Average squares	Q-values	P-value
Principles of management comprehensive quality	Between groups	7	7.5902	1.0843	1.9699	0.0577
	Within groups	424	233.3888	0.5504
Advantages of TQM application comprehensive quality	Between groups	6	32.9523	5.492	9.8177	0.001
	Within groups	371	207.537	0.5593
Application constraints QM overall	Between groups	7	2.905	0.415	0.6528	0.712
	Within groups	424	269.537	0.6357

The continuous improvement process is the responsibility of everyone in the hospital: This principle came in the third order of relative importance with an average (4.69) and standard deviation of (0.58), where it agreed on its importance (98.1%) of the sample of the study compared to (1.9%). Objective to the importance, the data indicates that (72.2%) realize that it is very important, while 25.9% believe it is important, and 1.9% accepts it as not important.

Continuous training of hospital staff to move from traditional management to TQM: This principle came in the fourth-order of relative importance with an average (4.56) and standard deviation (96.3%) of the sample of the study compared to (3.7%). They objected to this importance, as the data indicates that (68.5%) realize that it is very important, while (25.9%) realize that it as important, and only (3.7%) believe it is not important at all.

Continuous improvement includes all operations performed in different departments and management of the hospital: This principle came in the fifth order of relative importance with an average of (4.54) and standard deviation (0.72), where it agreed on the importance of (96.3%) of the sample of the study compared to (3.7%). They objected to this importance, as the data indicates that 63.0% realize that it is very important and (31.5%) realize that it is important and only (1.9%) realize that it is medium importance, while (3.7%) it’s not important.

The decision-making process at this hospital is based on a good analysis of the data: This principle came in the sixth order of relative importance with an average (4.48) and standard deviation (88.2%) of the study sample compared to (3.8%). They objected to this importance, as the data indicates that (61.1%) realize that it is very important and (31.5%) realize that it is important, and (3.7%) realize that it is of average importance, while (1.9%) think it is important, it does not matter and the same percentage (1.9%) thinks it is not important at all.

Using statistical monitoring to detect any deviation from quality standards: This principle came in the seventh order of relative importance with an average (4.44) and standard deviation (0.72), where it agreed on the importance of (98.1%) of the sample of the study compared to (1.9%). They objected to this importance, where the data indicate (55.6%) realize that it is very important, and (35.2%) realize that it is important, 7.4% identify that it is of average importance, however, only 1.9% believe it is not important.

Basic to modify decisions taken (Feedback): This principle came in the eighth order of relative importance with an average (4.30) and standard deviation (94.5%) of the study sample compared to (5.6%). They objected to this importance, as the data indicate that (55.6%) realize that it is very important, (27.8%) realize that it is important, (11.1%) realize that it is of average importance, while (1.9%) it is not important, and 3.7% says it is not important at all. The average of this axis is related to the first hypothesis (4.56) comparing it with the relative weight averages difference. Hence, we note that it indicates the very high importance and significance, therefore we accept the first hypothesis that states:

H1: Practitioners of the nursing profession in the public h ealthcare organization in Ethiopia are aware of the importance of the principles of TQM.

Benefits of applying TQM: To answer the second question of the study: What is the awareness of practitioners of professional nursing at the healthcare organization in Ethiopia about benefits achieved by the application of management comprehensive quality? The responses of the study sample were analyzed to determine the level of awareness of nursing practitioners with these advantages. The following is an analysis of the results of the answer to the second question: Table 3 shows the responses of the study sample towards the level of awareness of the benefits it achieves TQM application. Table 3 reveals the existence of six advantages, which averages above (4.00), this indicates a very high level of awareness and these advantages respectively describe as follow:

Reduce errors and cost of non-quality: This advantage came in the first order of relative importance with an average (4.70) and standard deviation (0.54%), where they agreed on the importance of all members of the study sample of 22.2% realize that it is important and 3.7% become fully aware that it is medium importance.

High confidence in the patient that his life in the hands of honest: This advantage came in second place of relative importance with an average (4.70) and standard deviation (0.60%), where they agreed on the importance of all members of the study sample, and the data show that 14.8% realize that it is important and 7.4% recognize that it is medium importance.

Optimization of modern equipment and technologies in the field of medicine: This advantage came in the third order of relative importance with an average (4.65) and standard deviation (0.62%), where they agreed on the importance of all members of the study sample, and the data indicate that the ratio (72.2) realize that it is important, and (20.4%) realize it as important, and (7.4%) realize that it is of medium importance (see Table 3).

Fulfill the needs of patients in full and on time: This advantage came in the fourth place of relative importance with an average (4.59) and standard deviation (0.63%), where they agreed on the importance of all members of the study sample, and the data indicate that the percentage (66.7) realize that it is very important, (25.9%) realize that it is important, and 7.4% realize that it is of medium importance.

Providing the health service with the right way from the first time: This advantage came in fifth place of relative importance with an average (4.54) and deviation (98.1%) of the sample of the study compared to (1.9) some of them objected to this importance, as the data indicate that 63% realize that it is very important, (29.6%) realize that it is important, (5.6%) realize that it is medium importance, while (1.9%) it is not important.

Rapid response to patients’ complaints and suggestions: This advantage came in the sixth place of relative importance with an average (4.48) and deviation normative (0.72), where the importance of each study sample members was agreed, the data indicate that the ratio of 61.1% perceive it as very important, 25.9% perceive it as important, and 13% perceive it as medium importance.

Increase the number of patients and visitors to the hospital: This advantage came in the awareness of the benefits achieved by the application of TQM in the sub variable. The increased number of patient’s undecided on the hospital relative importance with an average (3.8) and deviation (1.22), where it agreed on the importance of (87%) of the sample of the study compared to (13%). They objected to this importance, as the data indicate that 37% realize that it is very important, (25.9%) realize that it is important, (24.1%) realize that it is medium importance, while (5.6%) it is not important and 7.4% believe it is not important at all. The mean for this axis related to the second hypothesis was (4.49), by comparing it with the relative difference weighted averages we note that it indicates very high importance, and therefore the second hypothesis is accepted, which states that:

H2: There is high awareness about the benefits of TQM application comprehensive quality.

To answer the third of the study questions: What are the obstacles to the application of TQM in the public healthcare organization in Ethiopia? Answers were analyzed of the study sample to determine the level of importance of these constraints; the following is a presentation of the results of the answer for the third question was analyzed. Table 3 shows the responses of the study sample towards the relative importance of the obstacles that are encountered to prevent the application of TQM in the public hospital healthcare organization in Ethiopia. Table 3 reveals that the average relative weight of women with disabilities is higher than (4.00) indicates the importance is very high and these constraints respectively are:

The weak motivation of hospital staff to improve their performance: This constraint came in the fourth place of relative importance with an average of (4.26) and standard deviation (92.6%) of the sample of the study compared to (7.4%). They objected to this importance, and the data indicate that (46.3%) realize that it is very important, and (42.6%) realize that it is important, 3.7% realize that it is of average importance, while 5.6% think it is not important and (1.9%) it is not important at all.

Lack of standards and dimensions of quality of health services: This constraint ranks fifth in relative importance with an average (4.26) and standard deviation (88.2%) of the study sample compared to (3.8%). They objected to this importance, and the data indicate that (40.7%) is very important, and (50%) realize that it is important, 5.6% realize that it is of average importance, while 1.9% think it is not important and (1.9%) it is not important at all.

Lack of objective measures to determine patient satisfaction with hospital services: This constraint came in the sixth place of relative importance with an average (4.20) and deviation (96.3%) of the sample of the study compared to (3.7) of these, 35.2% are aware that it is very important, (53.7%) realize that it is important, (7.4%) realize that it is of average importance, while (3.7%) it’s not important.

Non-use of experts in TQM in the hospital: This constraint came in the seventh place of relative importance with an average (4.17) and standard deviation (0.72), where it agreed on its importance (98.2%) of the sample of the study compared to (1.9%). They objected to this importance, and the data indicate that (33.3%) realize that it is very important, and (51.9%) realize that it is important, (13%) realize it is important, while only (1.9%) think it is not important.

Insufficient allocation of resources: This constraint came in the eighth order of relative importance with an average (4.07) and standard deviation (88.8%) of the sample of the study compared to (11.2%). They objected to this importance, and the data indicate that 35.2% realize that it is very important, (50%) realize that it is important, (3.7%) realize that it is medium importance, while (9.3%) think it is not important and only (1.9%) states it is not important at all. The arithmetic mean of this axis for the third hypothesis was 4.24, and by comparing it with the relative weight averages differences, we note that it indicates very high importance, therefore, the third hypothesis is accepted which states that:

H3: The practitioners of the nursing profession in public h ealthcare organization in Ethiopia are aware that the application of TQM is hampered by obstacles.

To answer the fourth question of the study, which is the extent to which practitioners perceive a profession nursing for the importance of the axes of the application of TQM in the public organization healthcare in Ethiopia? The variance was analyzed to determine the significance of differences between the objectives of the study sample. The outcomes of the response to the fourth question are analyzed (see Table 4). Table 4 shows the outcomes of the analysis of variance in terms of dissimilarities between the perceptions of practitioners of professional nursing for the importance of the application of TQM in the public health care organization in Ethiopia.

Table 4 shows that the P-values are not statistically significant for two axes of the TQM application at the level 0.05, those axes are the principles of management comprehensive quality and application constraints QM overall, suggesting that there are no statistically significant differences in the study members’ perception of the importance of these two axes. Table 4 also shows that the p-value is statistically significant at level 0.01 for advantages of TQM application. This indicates that there are statistically significant differences in the perception of the importance of the nursing profession to the importance of the axes of the application of TQM in the public healthcare organization in Ethiopia. By testing the fourth hypothesis, which states that: there are no statistically significant differences in perception practitioners of the nursing profession to the importance of the axes of the application of TQM in the public healthcare organization in Ethiopia, the hypothesis is rejected as regards the result shows P-value is statistically significant at 0.01.

5 Discussion

QM in healthcare institutions must be distinguished comprehensive decisions based on facts and data are correct, not just suggestions or expectations based on personal opinion. Especially, as institutions face rapid changes in science and technology, competition, where uncertainties must be minimized, depends on quantitative methods and purpose such as decision tree, etc., Furthermore, it is also possible to use MIS and computing in this area, to help managers diagnose strengths, weaknesses, opportunities and threat [25].

The scientific significance of the research is shown in enriching the facts about the possibility of applying TQM in health institutions and recognizing the benefits of these recent applications. It also highlights the applied importance of the research and suggestions it produces which it is hoped that benefiting from the public hospital and organization in Ethiopia to support the application of management overall quality by demonstrating the difficulties in application, and modifying as senior management tends to be more positive in the application of this modern strategy [26]. TQM has become a significant management method for progressing success in a healthcare organization, hence this kind of study is of assessment to scholars and managers [27].

Therefore, TQM allows an organization to make decisions based on information, and that it adopts the practical concept of problem-solving by focusing on an accurate database by having an input storing system and retrieving information helps to make decisions and even periodically analyze the continuous situation development can be achieved [28, 29]. Hence, understanding the essential elements of TQM itself is the first major step in achieving quality. It is believed that the application of the concept of TQM in the healthcare institutions services can be done through identifying the elements of quality in the organization [30]. Moreover, knowing expectations of the beneficiary, creating a strong support system and then providing feedback on the progress of the application program [31, 32].

Subsequently, according to the result of this research, we conclude that for a successful application of TQM in health institutions must be a group of the requirements summarized as follows:

Senior management of health institutions must be convinced of the importance and benefits of implementing overall quality management.

Senior management must convince all employees of the organization of the benefits of TQM.

The management of the institution should expect some constraints and resistance of some individuals to apply TQM, hence, the more everyone understands its importance, the lower resistance and its magnitude.

The costs of implementing TQM initially increase and then gradually decrease so it settles at a certain size, and then the system begins to reveal its advantages and benefits.

The application of TQM in many respects requires changes in policies and concepts and organizational structures in health institutions.

TQM is not a substitute for traditional management, but a key and essential tool look for outstanding high performance from start to finish and prevent errors or limitations ones to the maximum.

For the successful application of TQM, the institution needs effective and supportive systems, the most important of which are the organization and its clients (patients, external audiences, suppliers, etc.).

A clear understanding of the methods, statistical control and effective system of data operation and efficient information system to supports the decision-making process [33].

Before applying TQM, intensive training courses are required, as well as utilization from the experiences of institutions that have succeeded in this area.

5.1 Recommendations

Based on the results of the study, the following recommendations may be proposed:

Work hard to spread the culture of TQM among all employees, in preparation for the application of TQM, possibly by starting a unit or department specialized in TQM and improvement and provide them with the necessary competencies and expertise, and give them responsibilities to adopt the culture of TQM.

The senior management of the hospital should work to create an advanced information system to provide management in the hospital and other departments with data and information supporting the right decision-making process.

Attention to the formation of homogeneous teams within the hospital to encourage cooperative teamwork and to support the participation of workers in continuous improvement.

Provide an effective system of material and moral incentives in line with the rates of performance and reward employees for their outstanding achievements with praise in different situations. The more employees are satisfied, the more they will contribute to the organization [34].

Conduct further studies on the subject and different samples of workers in hospitals as well as on other hospitals, because this type of studies will contribute to lifting the level of quality of health services provided by hospitals.

The use of qualified experts in the holding of meetings and periodic meetings with hospital staff.

6 Conclusion and managerial implications

By assessing the applicability of TQM in the public hospital health care organization in Ethiopia, several conclusions were reached regarding the subject of the research to propose appropriate recommendations for the management of the health care organization that helps to create the appropriate environment for the application of management overall quality. Due to the importance of health services that seek public hospital institutions in Ethiopia to its achievement and the fact that it did not include any item indicating interest in TQM, so its performance was made an exploratory study on this institution to reveal the applicability of TQM. The study results were that there is significant and positive awareness of TQM principles, benefits achieved by the TQM applications, and obstacles hampered by TQM applications at public healthcare sector in Ethiopia. Furthermore, there are statistically significant differences in the perception of practitioners of the nursing profession to the importance of TQM application in the public healthcare organization in Ethiopia. Suitable features of TQM are rapidly applied in private health institutions have high potential and effective human elements. This research examined the TQM application in the public healthcare sector in Ethiopia, however, in the future we suggest that scholars should give more attention and focus examining the TQM application in the private healthcare sector as well.

Footnotes

Acknowledgments

I would like to express my sincere gratitude to my supervisor, Professor Tieke Li for the massive support of my research, for his patience, motivation, enthusiasm, and immense knowledge. Also, I would like to thanks, Miss Wang Bailin for the support of my research. Thanks to the University of Science and Technology Beijing (USTB) for cooperation.

References

Rajabion

, Nazari

, Bandarchi

, et al Knowledge sharing mechanisms in virtual communities: A review of the current literature and recommendations for future research. Human Systems Management. 2019;38:365–84.

Faloudah

, Qasim

, Bahumayd

. Total Quality Management in Healthcare. International Journal of Computer Applications. 2015;120:22–4.

Cieciora

. Challenges connected with building a motivation system for programmers in Poland – A pilot study. Human Systems Management. 2019;38:339–46.

Boštjančič

, Petrovčič

. Exploring the relationship between job satisfaction, work engagement and career satisfaction: The study from public university. Human Systems Management. 2019;38:411–22.

Siama

, Alkhateeb

, Al-Waqqad

. The Role of Information Systems in Implementing Total Quality Management. American Journal of Applied Sciences. 2012;9:666–72.

Zameer

, Wang

, Yasmeen

, et al Corporate image and customer satisfaction by virtue of employee engagement. Human Systems Management. 2018;37:233–48.

Bouranta

, Psomas

, Suárez-barraza

, et al study The key factors of total quality management in the service sector: a cross-cultural study. Benchmarking: An International Journal. 2019;20:1–29.

Mohideen

OMH

, Vijayavel

. Principles of total quality management (TQM) governing automotive industries with reference to skill enhancement and capacity addition. International Journal of Pharmaceutical Sciences and Business Management. 2014;2:36–41.

Boadi

, Guoxin

, Antwi

. Customer satisfaction, co-creation intentions and diligent business response. Human Systems Management. 2017;36:251–7.

10.

Hanges

MAC

. Managing Technical Professionals: Things to Remember (Part 2). IEEE Engineering Management Review. 2017;45:13–4.

11.

Yang

. The influence of income and working time of rural migrant workers on health: The mediating effect of life stress and the moderating effect of marital status. Human Systems Management. 2020;39:69–80.

12.

Swain

. How does economic and social disadvantage affect health? Focus (Madison). 2016;33:1–6.

13.

Short

. Total quality management in hospitals. Total Quality Management. 2017;6:255–64.

14.

Balasubramanian

. Total Quality Management [TQM] in the Healthcare Industry – Challenges, Barriers and Implementation Developing a Framework for TQM Implementation in a Healthcare Setup. Science Journal of Public Health. 2016;4:271–8.

15.

Sadik

. Impact of Total Quality Management on Customer Satisfaction (E-Services). International Journal of Advances in Computer Science and Technology. 2018;7:31–5.

16.

Arrive

, Feng

. The complexity of the environment, management control and firm performance. Business strategy and environment. 2018;27:1347–1354.

17.

Getele

, Li

, Arrive

. Risk management in Service Supply Chain: Evidence From the healthcare Sector. IEEE Engineering Management Review. 2019;47:1–10.

18.

Novak

, Breznik

. How leaders can initiate knowledge management in organizations: Role of leadership style in building knowledge infrastructure. Human Systems Management. 2020;39:37–50.

19.

Singh

, Singh

. Total quality management: today’s business excellence International Letters of Social and Humanistic Sciences. 2014;32:188–96.

20.

Abbas

, Wu

. Employee innovativeness, fairness and organizational support: An empirical assessment. Human Systems Management. 2019;38:169–77.

21.

Abbas

, Wu

. The moderating role of intrapreneurial personality in relation between leader humility and innovative behavior. Human Systems Managemen.t. 2019;38:329–37.

22.

Wiki

. Leadership and Management or Leading and Managing. IEEE Engineering Management Review. 2017;45:6–8.

23.

Quarter

. Systems Thinking: Three System Archetypes Every Manager Should Know. IEEE Engineering Management Review. 2018;46:32–41.

24.

Quarter

. HRM’s Importance Throughout the Organization: Analyzed Through the Concepts and Views Portrayed in Eli Goldratt’s The Goal. IEEE Engineering Management Review. 2017;45:54–63.

25.

Paliukas

, Savanevičienė

. Harmonization of rational and creative decisions in quality management using AI technologies. Economics and Business. 2018;32:195–208.

26.

José

Álvarez-García

, Río-Rama

M de la C del

, Miras-Rodríguez

M del M

. How Do Quality Practices Affect the Results?: The Experience of Thalassotherapy Centres in Spain. Sustainability. 2017;9:1–19.

27.

Ahmad

, Al-hamdan

. Total quality management in the health-care context: integrating the literature and directing future research. Risk Management Healthc Policy. 2019;12:167–77.

28.

Chandra

. A Study on Implementation of Total Quality Management in Businesses. In ternational Journal of Engineering Science and Innovative Technology. 2013;2:440–6.

29.

Rangkuti

, Mangesti

. The effects of Tier-1 capital to risk management, and profitability on performance using multiple fixed effect panel data model. Human Systems Management. 2020;39:117–28.

30.

Al-Damen

. The impact of Total Quality Management on organizational performance Case of Jordan Oil Petroleum Company. International Journal of Business and Social Science. 2017;8:192–202.

31.

Lin

, Chuang

, Shih

. Development stage and relationship of mis and tqm in the e-business era. International journal of electronic business management. 2012;10:50–60.

32.

Djikhy

, Moustaghfir

. International faculty, knowledge transfer, and innovation in higher education: A human resource development perspective. Human Systems Management. 2019;38:423–31.

33.

Shahzad

, Jianqiu

, Sardar

, et al Hospital information-system (HIS) acceptance: A physician’s stance. Human Systems Management. 2019;38:159–68.

34.

Supriyanto

. Compensation effects on job satisfaction and performance. Human Systems Management. 2018;37:281–5.