See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/230799675

A critical study of quality parameters in health care establishment:

Developing an integrated quality model

Article  in  International Journal of Health Care Quality Assurance · June 2012

DOI: 10.1108/09526861211235892 · Source: PubMed

CITATIONS READS

20 1,801

4 authors, including:

Mohammad Azam Zillur Rahman

University of Balochistan Indian Institute of Technology Roorkee
33 PUBLICATIONS   192 CITATIONS    325 PUBLICATIONS   3,318 CITATIONS   

SEE PROFILE SEE PROFILE

Faisal Talib
Aligarh Muslim University
110 PUBLICATIONS   1,334 CITATIONS   

SEE PROFILE

Some of the authors of this publication are also working on these related projects:

Technical Feasibility of Diversion of Shahadra Drain View project

Short Term Courses on Strategic Management View project

All content following this page was uploaded by Faisal Talib on 04 June 2014.

The user has requested enhancement of the downloaded file.

International Journal of Health Care Quality Assurance
Emerald Article: A critical study of quality parameters in health care
establishment: Developing an integrated quality model
Mohammad Azam, Zillur Rahman, Faisal Talib, K.J. Singh

Article information:
To cite this document:
Mohammad Azam, Zillur Rahman, Faisal Talib, K.J. Singh, (2012),"A critical study of quality parameters in health care
establishment: Developing an integrated quality model", International Journal of Health Care Quality Assurance, Vol. 25 Iss: 5
pp. 387 - 402
Permanent link to this document:
http://dx.doi.org/10.1108/09526861211235892
Downloaded on: 18-06-2012
References: This document contains references to 68 other documents
To copy this document: [email protected]

Access to this document was granted through an Emerald subscription provided by Emerald Author Access

For Authors:
If you would like to write for this, or any other Emerald publication, then please use our Emerald for Authors service.
Information about how to choose which publication to write for and submission guidelines are available for all. Please visit
www.emeraldinsight.com/authors for more information.
About Emerald www.emeraldinsight.com
With over forty years' experience, Emerald Group Publishing is a leading independent publisher of global research with impact in
business, society, public policy and education. In total, Emerald publishes over 275 journals and more than 130 book series, as
well as an extensive range of online products and services. Emerald is both COUNTER 3 and TRANSFER compliant. The organization is
a partner of the Committee on Publication Ethics (COPE) and also works with Portico and the LOCKSS initiative for digital archive
preservation.
*Related content and download information correct at time of download.
 The current issue and full text archive of this journal is available at
www.emeraldinsight.com/0952-6862.htm

Quality
A critical study of quality parameters in
parameters in health care health care
establishment
387
Developing an integrated quality model
Received 27 June 2010
Mohammad Azam and Zillur Rahman Revised 23 October 2010
Department of Management Studies, Indian Institute of Technology, Accepted 22 March 2011
Roorkee, India
Faisal Talib
Mechanical Engineering Section, University Polytechnic,
Aligarh Muslim University, Aligarh, India, and
K.J. Singh
Department of Hospital Administration,
International Institute of Health Management and Research (IIHMR) Dwarka,
New Delhi, India

Abstract
Purpose – The purpose of this article is to identify and critically analyze healthcare establishment
(HCE) quality parameters described in the literature. It aims to propose an integrated quality model
that includes technical quality and associated supportive quality parameters to achieve optimum
patient satisfaction.
Design/methodology/approach – The authors use an extensive in-depth healthcare quality
literature review, discerning gaps via a critical analysis in relation to their overall impact on patient
management, while identifying an integrated quality model acceptable to hospital staff.
Findings – The article provides insights into contemporary HCE quality parameters by critically
analyzing relevant literature. It also evolves and proposes an integrated HCE-quality model.
Research limitations/implications – Owing to HCE confidentiality, especially regarding patient
data, information cannot be accessed.
Practical implications – The integrated quality model parameters have practical utility for
healthcare service managers. However, further studies may be required to refine and integrate newer
parameters to ensure continuous quality improvement.
Originality/value – This article adds a new perspective to understanding quality parameters and
suggests an integrated quality model that has practical value for maintaining HCE service quality to
benefit many stakeholders.
Keywords Health care, Quality parameters, Integrated quality model, Patient care,
Service quality assurance, India
Paper type Research paper

International Journal of Health Care

Introduction Quality Assurance
One widely accepted health definition is in the World Health Organization’s constitution: Vol. 25 No. 5, 2012
pp. 387-402
q Emerald Group Publishing Limited
Health is a state of complete physical, mental and social well being and not merely an absence 0952-6862
of disease or infirmity. DOI 10.1108/09526861211235892
IJHCQA In recent years, this statement has been amplified to include leading a socially and
economically productive life (Park, 2007, p. 13). Healthcare is defined as a multitude of
25,5 services rendered to individual, families or communities by health service
professionals for promoting, maintaining, monitoring or restoring health (Last,
1993). Within these definitions, standards for maintaining health are discernible, which
healthcare staff should strive to achieve.
388
Quality defined
Quality is an important production and operations management dimension.
Establishing quality levels for goods or services and assuring that those levels are
achieved are important tasks for virtually every business organization and
government agency. It is not enough to produce goods or services in the right
quantity and at the right time. It is important to ensure that the goods and services are
the right quality to compete and for profit. Quality also is important for non-profit
making organizations like schools, colleges, universities, state and local government
agencies, where political economic and social pressures have an impact. Moreover,
social services, like public safety, healthcare, waste disposal, highway planning and
construction cost and quality are coming under increasing scrutiny. Additionally, legal
and professional standards are fixing minimum acceptable quality levels.

Healthcare quality
Feigenbaum (Bicheno and Gopalan, 2005, p. 17) defined quality as a composite product
with service characteristics like marketing, engineering, manufacturing and
maintenance through which the product and service meets customer expectation.
Besterfield (2006, p. 13) says it is also defined managerially as the degree of excellence
a product or service provides. Healthcare quality has several interpretations.
According to Smith (Long and Harrison, 1985) healthcare quality can be defined from
several perspectives: technical, personal (share holders/owners) and from a public
health perspective (customers). However, cost effectiveness is central in any
perspective. This does not mean that good quality should always be cheap, but it
should be affordable from both healthcare provider and consumers viewpoints. Crosby
(Katz and Green, 1997), a quality management (QM) pioneer, also acknowledges
quality and cost relationship. According to Crosby, quality is conformance to
requirement, which means that quality should be achieved through compliance
to defined specifications or standards. Liyanage and Egbu (2005) emphasize that to
improve quality, healthcare staff have to be medically qualified and clinically effective.
The Quality Digest (2001) introduces quality as fulfilling customer requirements at a
lower cost with built-in preventive actions in the processes, ensuring the best product
to the end user with timely delivery. Outputs and outcomes should be free from defects,
constraints and items that do not add value to customers. Crosby (1979) and Juran
(1988) emphasize that organizational performance also is closely related to the
customer factor and thus service quality, especially in healthcare. These authors
acknowledged the customer factor as the foundation to organizational services, quality
and reliability. Peters and Waterman (1982) said that staying close to customers,
learning their preferences and catering to their needs are critical success factors that
differentiate excellent companies. The customer factor remains relevant, as a business
exists for only one purpose – to serve the customer (Boyd, 1997).
 According to Sewell (1997), serious deficiencies are likely to occur if there is any attempt Quality
to achieve quality without fully understanding customer requirements and expectations.
To remain customer-focused, one must review how a business is managed; i.e. begin with
parameters in
customer problems, needs and priorities, and find ways to meet them – a U-turn from the health care
traditional provider-centered paradigm (Walters and Jones, 2001). Rose et al. (2004)
emphasize customer factors, organizational performance, and healthcare and hospital
service quality components. For patients, switching providers could be detrimental to their 389
health, as treatment and non-compliance costs could influence healthcare outcomes
(Ovretveit, 2000b; Ferguson, 2000) and create psychological trauma owing to the
uncertainty of adjusting to a new service provider (De Ruyter et al., 1998). Typical patient
complaints include long waiting times, high costs and unfriendly, apathetic and uncaring
staff (Yusoff, 2002). It is, therefore, important to identify healthcare quality parameters that
are practically useful for the organization, patient and society.

Research objectives and methodology

Our aim, therefore, is to critically examine healthcare quality parameters that are
practically useful and flexible for self-correction by applying knowledge management
in any contemporary environment. We propose an integrated model for healthcare
establishments (HCE) after critically evaluating relevant quality parameters. Our
findings should help healthcare staff achieve effective patient care by enhancing
patient satisfaction. Our objectives are to:
.
Identify and critically analyze relevant HCE quality parameters.
.
Suggest an integrated HCE quality model with components acceptable to
hospital staff that help to achieve patient satisfaction.
The integrated quality-model components were derived from the literature and
subjected to scrutiny in one healthcare establishment – a north Indian 440 bed
multi-specialty government hospital. The components were circulated and discussed
with the hospital’s chief executive and circulated among 50 hospital-staff members.
Two-thirds were 30 years or older; i.e. they were mature and experienced. All specialist
medical staff held postgraduate medical degrees. A toal of 28 percent of the logistic
staff had between five to ten years service. They ranged from graduate interns trainees
to highly experienced staff. The model was thus discussed (via questionnaires and
interviews) with hospital staff directly involved in patient care, logistics and
management. Hospital staff acceptance of the quality model was established by asking
them to consider its applicability. The patient’s hospital service perceptions, reflecting
their overall satisfaction level, were also assessed. To accomplish these objectives, our
methods were based on extant literature that identified various healthcare quality
parameters, commonly practiced and used to maintain quality within healthcare.
These were critically analyzed to discern pitfalls and shortcomings in the literature.

Literature review
Service-quality components, traditionally, are generally attributed to a few authors; for
example:
.
Swan and Combs’ (1976) seven instrumental and expressive quality attributes.
.
Donabedian’s (1980) structure, process and outcome.
.
Lehtinen and Lehtinen’s (1982) interactive, physical and corporate quality.
IJHCQA .
Maxwell’s (1984) six quality components: effectiveness, efficiency, acceptability,
access, equity and relevance.
25,5 .
Grönroos’ (1984) technical and functional quality.
Several service quality models evolved from these authors’ works. The Parasuraman
et al. (1985, 1988) SERVQUAL model is prominent. Despite controversies regarding
390 SERVQUAL validity and reliability (Teas, 1994; Newman et al., 2001); its application,
with or without modification, is common in healthcare. SERVQUAL modifications vary
from researcher to researcher: Lim and Tang (2000) added “accessibility/affordability”,
Tucker and Adams (2001) “caring and outcomes” while Johnston (1995) increased
SERVQUAL to 18 dimensions, which generally fall under those identified by Potter et al.
(1994): technical, interpersonal, amenities and environment (Table I).
Table I touches on associated supportive qualities desirable for achieving better
care by supporting clinical work and patient satisfaction. However, it does not provide
a well-defined integrated healthcare quality model, which is required for growing
knowledge-intensive services. The model’s healthcare quality parameters, therefore,

Author/researcher Country Service quality parameter

Parasuraman et al. (1985) USA Tangibles, reliability, responsiveness, communication,

credibility, security, competence, courtesy, understanding
and access
Parasuraman et al. (1988) USA Tangibles, reliability, responsiveness, assurance and
empathy
Reidenbach and Sandifer- USA Patient confidence, empathy, waiting time, physical
Smallwood (1990) appearance, support services and business
Cunningham (1991) USA Clinical quality, patient and economics-driven quality.
Tomes and Ng (1995) UK Empathy, understanding illness, mutual respect, religious
needs, dignity, food and physical environment
Andaleeb (1998) USA Communication, cost, facility, competence and demeanor
Zairi (1998) UK Deming Prize, Malcolm Baldridge National Quality Award
(MBNQA), European Quality Award and the George M
Low NASA quality award
Gross and Nirel (1998) Ireland Accessibility, structure, atmosphere and interpersonal
relation.
Camilleri and O’Callaghan Malta Professional and technical care, service personalization,
(1998) accessibility, catering, price, environment and patient
amenities
Ovretveit (2000a) Sweden Client, professional and management quality
Carman (2000) USA Technical aspects (professional care) and accommodation
(food, noise, room temperature, cleanliness, privacy and
parking)
Walters and Jones (2001) New Security, performance, aesthetics, convenience, economy
Zealand and reliability
Table I.
Hospital service quality Hasin et al. (2001) Thailand Communication, responsiveness, courtesy, cost and
parameters from selected cleanliness
studies Raja et al. (2007) India MBQNA and EFQM
require critical analysis using relevant literature to avoid vagueness, which has serious Quality
and profound effects on society at large.
parameters in
Critically analyzing existing healthcare quality parameters
health care
After reviewing the healthcare quality literature, we noted several problems,
shortcomings and pitfalls. Additional parameters, therefore, are proposed (Table II).
The parameters, criteria and awards in the quality assurance literature seem to have 391
not been developed specifically for healthcare, therefore they remain ambiguous.
Piecemeal attempts have been made to adopt hospital quality criteria. However, they
remain general attributes, which may not fully meet an integrated model’s specific
requirements. Quality parameters were based on a basic assumption that patient care is
comparable to service products and after-sale service. This assumption is flawed as it
involves four tangibles: manufacturer/service provider; seller; product and customer. It is
the customer who judges product utility and after-sale service, thus emphasizing service
quality. However, in many healthcare services situations, it may not always be possible
to apply this model as customers in this case are patients – some critically ill. These
customers may not be in a position to evaluate service quality. Healthcare quality
parameters, therefore, need developing separately to keep hospital environment facets
intact by correlating quality criteria/parameters with professional functions and hospital
supportive services. The healthcare quality model thus has practical utility/applicability
to external and internal customer satisfaction.
Quality expectations lead to a debate among personnel overseeing complex
organizations such as modern HCEs. Raja et al. (2007) used a quality assessment
instrument combining MBQNA, EFQM and KBEM criteria; however, their results show
that doctors, nurses, technicians and patients attach different importance to hospital
sub-factors. They claim their evidence supports actions to overcome unworkable quality
and process management actions. They emphasize developing a quality award based on
a model that interprets relationships between service quality and award factors. Dey et al.
(2006) advocate developing an integrated quality management model to overcome
inherent flaws in other healthcare quality management tools. Therefore, there is a need to
develop a specific quality model that integrates and covers important parameters related
to HCE functions. Facilities, knowledge and performance management are emphasized
by Liyanage and Egbu (2005) and HCE survival is dependent on multiple factors like
managing human resources, worker attitude and practices to achieve desired objectives
within existing resources.

Discussion
Hospitals are not manufacturing units that use raw inputs; nor are they purely service
industries where mainly intangible services are provided to mostly healthy populations
– customers who enjoy the products or services. A patient is a person with deranged
function and has voluntarily sought medical help. The patient is the input and part of the
process and, therefore, the most important output factor. It is the intangible and tangible
interactive processes in a particular disease process that challenge clinicians struggling
with myriad complex facts and figures to change disease processes and restore normal
functions so that the patient is rehabilitated to a fully functioning individual in society.
Output will depend upon patient-generated inputs and his/her treatment response. The
remedy can be planned using modern medical science and may be achieved with
appropriate application and management that conforms to knowledge-intensive EBM
IJHCQA
Researcher/ Area/approach/research/main idea
25,5 proponent postulate Gaps identified/comments

Fowdar (2005) Healthcare quality – identifying SERVQUAL cannot be replicated fully

healthcare quality attributes in healthcare. Professionalism and core
outcomes are critical attributes for
392 patients
Cesarotti and Quality management standards for Stresses facility management for
Di Silvio (2006) services in the Italian healthcare sector organizational excellence
Stahr (2001) Healthcare quality culture – European Foundation for Quality
developing a quality culture within the Management (EFQM) criteria are not
UK healthcare system specifically related to core competence
or service quality as routinely
actionable measures
Newman et al. Quality care and patient satisfaction – Management chain in hospital consists
(2001) nurse retention, care quality and of internal quality (working
patient satisfaction environment), service capability (nurse
satisfaction and nurse retention)
Dopson and Knowledge to action and evidence- Scientific and change management
Fitzgerald (2006) based healthcare (EBHC) – comes of knowledge and clinical leaders are
age. Using a qualitative approach, case required to support EBHC
studies are analyzed using information
and new knowledge in real-world
healthcare
Ahmet (2005) Optimal quality and application – Emphasizes optimal quality in
developing an optimal private healthcare; however, professional
healthcare quality model in Turkey quality-related objectives need
studying
Ovretveit (2000a) Total quality management (TQM) in Stresses healthcare TQM projects.
European healthcare – promises much Controlling team-quality is emphasized
for service industry and is better used
in European healthcare. Study defines
healthcare TQM and considers some
results
Mills and Rorty Total quality management and the Total quality management techniques
(2002) silent patient – examines impact of in healthcare cannot prevent shifting
imposing business techniques specially attention to other components and
associated with TQM on healthcare industrial TQM models cannot be
payers, managed care organizations imported to healthcare organizations
(MCO), institutional and individual
providers, enrolees and patients
Jackson (2001) What are the key actions for Many TQM initiatives fail owing to
implementing healthcare TQM? lacking knowledge and skills resulting
Successfully implementing healthcare in opposite effects that were intended
TQM tools
Yasin and Alavi Analytical approach to determining the Total quality management is a partial
(1999) TQM’s competitive advantage in remedy for healthcare industry ills and
Table II. healthcare has questionable impact on
Healthcare sector quality operational, financial and strategic
parameters/dimensions health
in the literature (continued)
Researcher/ Area/approach/research/main idea
Quality
proponent postulate Gaps identified/comments parameters in
Dijkstra and Bij Quality function deployment (QFD) in Quality function deployment in
health care
(2002) healthcare – methods for meeting professional services causes problems
customer requirements to re-design especially to customers in the
functional aspects healthcare domain 393
Nyatanga (2005) Integrated care pathways (ICP) are Integrated care pathways for specific
clinical quality improvement patient group care as part of healthcare
techniques for continuous quality CQI
improvement (CQI)
Creedon (2006) Behavioral issues for healthcare Infection control and related behavior.
workers such as infection control Advocates reasoned action
Dey et al.(2006) Managing healthcare quality using Advocates developing an integrated
logical framework analysis quality management model owing to
inherent flaws in other quality
management tools
Walters and Jones Healthcare quality value chains Indicates that healthcare quality and
(2001) value are convergent, laying down
management perspectives and the
value chain’s importance to healthcare
Kennedy et al. Continuous quality improvement and Stresses an organized HMO approach
(1996) HMOs – applying the Health Plan to CQI in the Clinton healthcare reform
Employer Data and Information Set program
(HEDIS) model
Kellet et al. (2005) Continuous quality improvement using Uses PIM to generate clinical outcomes
a practice improvement model (PIM) based on group-based cognitive
behavioral therapy for anxiety
disorders
Taleb-Bendiab et al. Designing healthcare systems using Presents a computer implemented
(2006) computer programming to improve format to improve process quality
clinical practice and core professional (QoP) and service quality (QoS)
competence for disease management in specifically for managing breast cancer
clinical governance – a principled cases. Stresses IT access problems and
approach designing healthcare decision models or clinician team
systems – autonomy verses members
governance
Rose et al. (2004) Hospital service quality: a managerial Provides a more holistic service quality
challenge – an attempt to develop a regarding customer perceived hospital
more holistic approach to predicting service quality, based on quality
quality dimensions in the literature. Advocates
that technical quality is what patients
seek. However, impact on patient
perception needs studying
Som (2004) Clinical governance: a fresh look at its Takes a fresh look at clinical
definition: New clinical governance governance definitions – an integrated
definition based on input, structure, approach using input, structure,
process and outcomes to continuously process and outcome
improve healthcare quality
(continued) Table II.
IJHCQA Researcher/ Area/approach/research/main idea
25,5 proponent postulate Gaps identified/comments

Zairi (1998) Human resource management (HRM) Describes the Deming Prize, Malcolm
from a world class practice perspective Baldridge National Quality Award
(MBNQA), European Quality Award
394 and George M Low NASA quality
award, which may be carefully applied
after an HRM analysis
Bujak and Lister Evidence-based medicine (EBM) – Emphasizes doctor-patient relationship
(2006) appropriately applying medical science and EBM, which requires in-depth
to ensure patient satisfaction study
Liyanage and Egbu Facilities management (FM) healthcare Improving healthcare by controlling
(2005) quality – its role in controlling HAI through a three dimensional
healthcare associated infections (HAI) approach: facility management (FM);
to achieve healthcare quality – a three knowledge management (KM); and
dimensional view performance management (PM).
Integration is facilitated by KM
Adshead and Healthcare cost and quality in the UK Analyzes the Wanless report and
Thorpe (2006) – prevention is better than cure stresses prevention regarding disease
prevention and health promotion in
chronic diseases context. Marketing
strategies to communicate with target
groups using the media, instead only
the legislation has been emphasized
Raja et al. (2007) Quality award dimensions – a Using MBQNA, EFQM and Kanji
strategic instrument for measuring Business Excellence Model (KBEM) to
health service quality show that doctors, nurses, technicians
and patient attach different importance
to quality and process management
Table II. options, which are unworkable

(Liyanage and Egbu, 2005; Dopson and Fitzgerald, 2006; Bujak and Lister, 2006). In
complex HCE situations, the patient is neither able to perceive disease complexities nor
can the physician accurately forecast the outcomes. Therefore, HCE/hospital quality
models have to be considered and designed by specifically keeping patient care in mind.
This undoubtedly is a patient-medical scientist – hospital interactive relationship model.
Thus, its quality parameters cannot be similar in content and impact to the
manufacturer-seller-product-customer and after-sale service or service industry model,
which deal mostly with healthy customers, which principally cannot be similarly
replicated in healthcare (Yasin and Alavi, 1999; Mills and Rorty, 2002; Stahr, 2001;
Fowdar, 2005; Raja et al., 2007).

Core and supportive quality parameters

Hospital managers have to ensure that core quality factors – basic professional
functional requirements – have to be supported positively by associated services. In
any HCE, it is important to identify core quality and associated supportive quality
parameters acting in synergy to achieve the best results for patients and to control
costs. Even though various authors touch upon core quality and associated supportive
quality parameters (Tables I and II), these have not been well defined, identified and Quality
described in the literature. We have attempted, therefore, to conceptualize, define, and
identify these qualities to act as HCE benchmarks.
parameters in
health care
Core quality in healthcare
These are qualities required by the medical profession to manage patients using EBM
for optimal patient rehabilitation. These may include ethical and professional-technical 395
essential core competences. Clinical quality (Cunningham, 1991), understanding illness
(Tomes and Ng, 1995), professional and technical care (Camilleri and O’Callaghan,
1998), professional quality (Ovretveit, 2000a) and technical aspects (Carman, 2000)
indicate HCE core quality features (Figure 1).

Associated supportive quality

These are qualities required to support core quality attributes and to provide optimal
patient comfort and care. These supportive attributes are meant to improve

Figure 1.
Core quality and
associated supportive
quality parameters, and
patient management
IJHCQA satisfaction in related interest groups; i.e. patients, family members payers and family
25,5 doctor, which emphasize choice, cost and quality (Parasuraman et al., 1985, 1988;
Reidenbach and Sandifer-Smallwood, 1990; Walters and Jones, 2001; Hasin et al., 2001;
Raja et al., 2007) (Figure 1).
Appropriate billing structures and processes provide funds that affect service
provision. Healthcare facilities affect input, process and outcome in a cyclical manner.
396 Core quality and associated supportive quality parameters, therefore, form important
components. There should be no conflict between core quality and the associated
supportive quality parameters. The core quality and associated supportive quality
parameters have to act in synergy to achieve maximum positive outcomes. Thus TQM
practices should be positively modified to meet healthcare requirements. This has to be
undertaken within the core quality and associated supportive quality parameters
acting in tandem to achieve positive health (Mills and Rorty, 2002; Jackson, 2001; Yasin
and Alavi, 1999). Managing internal customers; i.e. staff whose services are interlinked,
needs addressing, further adding value by integrating quality parameters in a cohesive
model (Porter, 1985; Walters and Jones, 2001; Newman et al., 2001; Som, 2004; Rose
et al., 2004; Dey et al., 2006).
The QFD methods must be carefully applied to healthcare (Dijkstra and Bij, 2002).
The main problem is to identify HCE quality parameters and to classify them as core or
associated. This requires in-depth clinical and management knowledge. Conflict among
medical and management staff, therefore, should be avoided in the patient’s interest.
Six Sigma is an effective strategic tool, which can be adopted by healthcare staff to
improve service efficiency and effectiveness (Carrigan and Kujawa, 2006). Crago (2010)
describes Six Sigma Qualtec, a leading Six Sigma consulting firm and defines sigma as
a metric that indicates how well processes are performing. Higher sigma values
indicate superior performance. Six Sigma measures process capability to perform
defect-free work, with a defect being anything that results in customer dissatisfaction.
Crago explains that the International Organization for Standardization (ISO) defines
Six Sigma as a statistical business-improvement approach, which finds and eliminates
defects and their causes, focusing on outputs that are critically important to customers.
He emphasizes that in a technological world, healthcare delivery is a complex
diagnostic, operational and administrative process, which must be coordinated to
ensure quality patient care. Yet, the healthcare industry’s quality practice causes it to
operate at a three- to four-sigma quality level compared to the aerospace industry’s five
to six. He clarifies the sigma definition by relating it to a business or manufacturing
process. He emphasizes that as in any other industry, quality healthcare requires
systematically integrated and synchronized operational, clinical and administrative
inputs, processes and outputs to ensure the organization’s goals are met.

An integrated quality model

After our extensive and critical analysis of quality parameters and their close
relationships among core and associated parameters, we delineated essential HCE
objectives that influence patient management. We can innovate and evolve the quality
parameters derived from the literature, which can be used to develop and suggest an
HCE integrated quality model (Table III), which were fully accepted by the hospital
staff (n ¼ 50).
Integrated quality model parameters validation/acceptance Quality
The model components derived from literature were already validated by their
respective authors. Additionally, our hospital staff approved the parameters thus
parameters in
signifying their importance unequivocally (Table III). Technical accuracy, health care
applicability, usefulness, practical utility, relevance, inbuilt mechanism to self
correct, knowledge management and ability to improve continuously were explored in
the interviews. The managerial and professional/medical technical synergy in the 397
integrated quality model was well appreciated. It emerged that these components were
indirectly and directly being applied in the hospital; however, they needed further
application as an integrated quality model to improve patient satisfaction (Table IV).

Patients’ hospital-service perceptions

Hospital services were graded ‘very good’ by 40 percent of our patients (Table IV),
which suggests higher satisfaction with hospital services. These outcomes, coupled
with our own hospital facilities and process observations and discussion with staff,

HCE/hospital objectives Quality parameters

To optimize care and cost to society Services designed for the societal disease burden
(WHO, 2002)
To continuously self-correct and improve service Knowledge management (Thothathri, 2003)
quality
To refine quality dimensions at the professional Core quality and associated quality parameters
technical and managerial levels to synergize quality at functional/operational
level (Dijkstra et al., 2002; van Hees, 1998)
To achieve optimal critical care Priority areas include accident/casualty/
emergency, operation room/theatre (OT) and
intensive care unit (ICU) services (Dey et al.,
2006)
To improve input, structure, process, outcome Clinical governance (Som, 2004; WHO, 2000)
and clinical governance
To achieve better patient management and Treatment-chain management qualities (internal
improve healthcare quality customer input, referral and evacuation chain
management including documentation/
maintaining records) (Porter, 1985)
To study the quality parameters’ overall impact Patients’ service expectation and perception Table III.
on hospital services correlated with overall patient satisfaction (Lim Integrated quality model
and Tang, 2000) components

Hospital services – patient perceptions that imply satisfaction

Very good Good Fair Poor Total
Patient gender n % n % n % n % n % Table IV.
Overall patient
Male 96 38.4 106 42.4 48 19.2% – – 250 100 perception regarding
Female 64 42.7 70 46.7 14 9.3 02 1.3 150 100 hospital services that
Total 160 40 176 44 62 15.5 02 0.5 400 100 imply satisfaction
IJHCQA revealed that the quality model parameters were being applied indirectly or directly
though not in an organized manner. They reflect utility and effect, which is expected to
25,5 be enhanced owing to the integrated quality model’s cascade effects. However, this
requires long-term study. The integrated quality model’s acceptance by the staff
indicates its utility for the hospital supported the clientele’s positive image.

398 Conclusions and recommendations

Healthcare means providing evidence-based services to patients, who her/himself has
an input. The objective primarily is to save life and limb by managing disease
processes. Patients cannot be treated as goods or inputs in a manufacturing or a service
system and these quality standards do not apply. After thoroughly reviewing the
healthcare-quality literature and its overall impact, important medical and managerial
aspects have emerged. We developed an integrated HCE-quality model, validated by
healthcare staff. Our HCE integrated quality model includes important components
like services designed to:
.
meet disease burdens;
.
optimize care and cost;
.
use knowledge to continuously improve healthcare quality;
.
incorporate core and associated supportive quality parameters;
.
refine and synergize services at the professional/technical and managerial levels;
.
address priority areas to achieve optimal critical care for casualty cases,
operation room/theatre and intensive care unit services; and
.
use clinical governance to improve service structure, process and outcome.
Our model also includes the treatment chain for improving internal customer inputs
such as referral to other services. We include evacuation management provided by
modern ambulance services and appropriate documentation and maintaining
appropriate records to improve healthcare management at every level. Additionally,
patient hospital-service expectation and perception is included to gain an overall
picture. Our HCE integrated quality model should help staff and services to
continuously self improve. It should synergize medical, technical and managerial
processes with an ultimate aim to optimize resources and cost, which will benefit
patients and related interest groups/stakeholders such as families, payers, insurers,
government and society at large. Further research should be carried out to assess
quality parameter impact by analyzing patient perceptions, thus correlating our
quality parameters with satisfaction levels. We recommend that our integrated quality
model is analyzed and developed in other HCEs, especially government healthcare
services. We recommend that alternate quality parameters, suited to particular HCEs,
are developed for effective healthcare management.

References
Adshead, F. and Thorpe, A. (2006), “Better than cure: public health”, Journal of the Royal Institute
of Public Health, Vol. 120, pp. 1008-12.
Ahmet, K. (2005), “A concept of optimal quality and an application”, Total Quality Management,
Vol. 16 No. 2, pp. 243-55.
Andaleeb, S.S. (1998), “Determinants of customer satisfaction with hospitals: a managerial Quality
model”, International Journal of Health Care Quality Assurance, Vol. 11 No. 6, pp. 181-7.
parameters in
Besterfield, D.H. (2006), Total Quality Management, 3rd ed., Pearson Prentice Hall, Upper Saddle
River, NJ. health care
Bicheno, J. and Gopalan, M.R. (2005), Management Guide to Quality and Productivity, 2nd ed.,
Biztantra Publication, New Delhi.
Boyd, F.J. (1997), “The customer may be always right-but who the customer is?”, Records 399
Management Quarterly, Vol. 31 No. 2, pp. 38-42.
Bujak, J.S. and Lister, E. (2006), “Is the science of medicine trumping the art of medicine?”,
The Physician Executive, Vol. 32 No. 5, pp. 18-21.
Camilleri, D. and O’Callaghan, M. (1998), “Comparing public and private care service quality”,
International Journal of Health Care Quality Assurance, Vol. 11 No. 4, pp. 127-33.
Carman, J. (2000), “Patient perceptions of service quality: combining the dimensions”, Journal of
Management in Medicine, Vol. 14 Nos 5/6, pp. 339-56.
Carrigan, M.D. and Kujawa, D. (2006), “Six Sigma in health care management and strategy”,
The Healthcare Manager, Vol. 25 No. 2, pp. 133-41.
Cesarotti, V.S. and Bruna, D.S. (2006), “Quality management standard for facility services in the
Italian healthcare sector”, International Journal of Health Care Quality Assurance, Vol. 19
No. 6, pp. 451-62.
Crago, M.G. (2010), “Patient safety, Six Sigma and ISO 9000 quality management: a new
emphasis on quality management is essential to improve US healthcare”, available at:
www.qualitydigest.com/nov00/html/patient.html (accessed June 2010).
Creedon, S.A. (2006), “Infection control: behavioural issues for healthcare workers”, Clinical
Governance: An International Journal, Vol. 11 No. 4, pp. 316-25.
Crosby, P.B. (1979), Quality Is Free, McGraw-Hill, New York, NY.
Cunningham, L. (1991), The Quality Connection in Healthcare; Integrating Patient Satisfaction
and Risk Management, Jossey-Bass, San-Francisco, CA.
De Ruyter, K., Wetzels, M. and Bloemer, J. (1998), “On the relationship between perceived service
quality, service loyalty and switching costs”, International Journal of Service Industry
Management, Vol. 19 No. 5, pp. 436-53.
Dey, P.K., Seetharam, H. and Naomi, B. (2006), “Managing healthcare quality using logical
framework analysis”, Managing Service Quality, Vol. 16 No. 2, pp. 203-22.
Dijkstra, L. and Bij, H. (2002), “Quality function deployment (QFD) in healthcare: methods for
meeting customer requirements in redesign and renewal”, International Journal of Quality
Reliability Management, Vol. 19 No. 1, pp. 67-89.
Donabedian, A. (1980), The Definition of Quality and Approaches to its Assessment, Health
Administration Press, Ann Arbor, MI.
Dopson, S. and Fitzgerald, L. (2006), Knowledge to Action? Evidence Based Healthcare in Action,
Oxford University Press, New York, NY, pp. 324-7.
Ferguson, T. (2000), “Online patient-helpers and physicians working together: a new partnership
for high quality healthcare”, British Medical Journal, Vol. 321 No. 7269, pp. 1129-32.
Fowdar, R.R.R. (2005), “Identifying healthcare quality attributes”, Journal of Health and Human
Services Administrations, Vol. 27 No. 4, pp. 428-43.
Grönroos, C.A. (1984), “Service quality model and its marketing implications”, European Journal
of Marketing, Vol. 18 No. 4, pp. 36-44.
IJHCQA Gross, R. and Nirel, N. (1998), “Quality of care and patient satisfaction in budget-holding clinics”,
International Journal of Health Care Quality Assurance, Vol. 11 No. 3, pp. 77-89.
25,5
Hasin, M.A.A., Seeluangsawat, R. and Shareef, M.A. (2001), “Statistical measures of customer
satisfaction for healthcare quality assurance: a case study”, International Journal of Health
Care Quality Assurance, Vol. 14 No. 1, pp. 6-14.
Jackson, S. (2001), “Successfully implementing total quality management tools within healthcare:
400 what are key actions?”, International Journal of Health Care Quality Assurance, Vol. 14
No. 4, pp. 157-63.
Johnston, R. (1995), “The determinants of service quality; satisfiers and dissatisfies”,
International Journal of Service Industry Management, Vol. 6 No. 5, pp. 53-71.
Juran, J.M. (1988), Quality Control Handbook, Prentice Hall, Englewood Cliffs, NJ.
Katz, M. and Green, E. (1997), Managing Quality: A Guide to System-wide Performance
Management in Healthcare, 2nd ed., Mosby, St Louis, MO.
Kellet, S., Clarke, S. and Matthews, L. (2005), “Continuous quality improvement using a practice
improvement model (PIM)”, Clinical Governance: An International Journal, Vol. 10 No. 3,
pp. 206-11.
Kennedy, K., Sam, M. and Rick, S. (1996), “Continuous quality improvement in health
maintenance organizations: an application of HEDIS model”, International Journal of
Health Care Quality Assurance, Vol. 9 No. 4, pp. 4-9.
Last, J.M. (1993), A Dictionary of Epidemiology, Oxford University Press, New York, NY.
Lehtinen, J.R. and Lehtinen, O. (1982), “Service quality: a study of quality dimensions”,
unpublished working paper, Service Management Institute, Helsinki.
Lim, P.C. and Tang, N.K.H. (2000), “A study of patients expectation and satisfaction in Singapore
hospital”, International Journal of Health Care Quality Assurance, Vol. 13 No. 7, pp. 290-9.
Liyanage, C. and Egbu, C. (2005), “Controlling healthcare associated infections (HAI) and the role
of facilities management in achieving quality in health care: a three-dimensional view”,
Facilities, Vol. 23 Nos 5/6, pp. 194-215.
Long, A.F. and Harrison, S. (1985), Health Services Performance: Effectiveness and Efficiency,
Croom Helm, London.
Maxwell, R.J. (1984), “Prospectus in NHS management: quality assessment in health”, British
Medical Journal, No. 288, pp. 148-72.
Mills, A.E. and Rorty, M.V. (2002), “Total quality management and the silent patient”, Business
Ethics Quarterly, Vol. 12 No. 4, pp. 481-504.
Newman, K., Maylor, U. and Chansarkar, B. (2001), “The nurse retention, quality of care and
patient satisfaction chain”, International Journal of Health Care Quality Assurance, Vol. 14
No. 2, pp. 57-68.
Nyatanga, T. (2005), “Integrated care pathways (ICPs) and infection control”, Clinical
Governance: An International Journal, Vol. 10 No. 2, pp. 106-17.
Ovretveit, J. (2000a), “Total quality management in European healthcare”, International Journal
of Health Care Quality Assurance, Vol. 13 No. 2, pp. 74-9.
Ovretveit, J. (2000b), “The economics of quality”, International Journal of Health Care Quality
Assurance, Vol. 13 No. 5, pp. 200-7.
Parasuraman, A., Zeithaml, V.A. and Berry, L.L. (1985), “A conceptual model of service quality
and its implications for future research”, Journal of Marketing, Vol. 49 No. 4, pp. 41-50.
Parasuraman, A., Zeithaml, V.A. and Berry, L.L. (1988), “SERVQUAL: a multiple-item scale for Quality
measuring customer perceptions of service quality”, Journal of Retailing, Vol. 64 No. 1,
pp. 12-37. parameters in
Park, K. (2007), Parks Textbook of Preventive and Social Medicine, 19th ed., Banarsidas Bhanot health care
Publishers, Jabalpur.
Peters, T. and Waterman, R.H. (1982), In Search of Excellence, Lessons from America’s Best Run
Companies, Warner Books, New York, NY. 401
Porter, M. (1985), Competitive Advantage: Creating and Sustaining Superior Performance,
Free Press, New York, NY.
Potter, C., Morgan, P. and Thompson, A. (1994), “Continuous quality improvement in an acute
hospital: a report of an action research project in three hospital departments”, International
Journal of Health Care Quality Assurance, Vol. 7 No. 1, pp. 4-29.
Quality Digest (2001), “Quality: how to define it?”, available at: www.qualitydigest.com/html/
qualitydef.html (accessed October 2009).
Raja, M.P.N., Deshmukh, S.G. and Wadhawa, S. (2007), “Quality award dimensions: a strategic
instrument for measuring health service quality”, International Journal of Health Care
Quality Assurance, Vol. 20 No. 5, pp. 363-78.
Reidenbach, R.E. and Sandifer-Smallwood, B. (1990), “Exploring perceptions of hospital
operations by a modified SERVQUAL approach”, Journal of Health Care Marketing,
Vol. 10 No. 4, pp. 47-55.
Rose, R.C., Jegak, U., Mohani, A. and Kim, L.N. (2004), “Hospital service quality: a managerial
challenge”, International Journal of Health Care Quality Assurance, Vol. 17 No. 3,
pp. 146-59.
Sewell, N. (1997), “Continuous quality improvement in acute healthcare: creating the holistic and
integrated approach”, International Journal of Health Care Quality Assurance, Vol. 10 No. 1,
pp. 20-6.
Som, C.V. (2004), “Clinical governance: a fresh look at its definition”, Clinical Governance:
An International Journal, Vol. 9 No. 2, pp. 87-90.
Stahr, H. (2001), “Developing a culture of quality within the United Kingdom healthcare system”,
International Journal of Health Care Quality Assurance, Vol. 14 No. 4, pp. 174-80.
Swan, J.E. and Combs, L.J. (1976), “Product performance and consumer satisfaction: a new
concept”, Journal of Marketing, Vol. 40 No. 2, pp. 26-32.
Taleb-Bendiab, A., England, D., Randles, M., Miseldine, P. and Murphy, K. (2006), “A principled
approach to the design of healthcare systems: autonomy vs governance”, Reliability
Engineering and System Safety, Vol. 91 No. 12, pp. 1576-85.
Teas, R.K. (1994), “Expectations as a comparison standard in measuring service quality:
an assessment of a reassessment”, Journal of Marketing, Vol. 58, January, pp. 132-9.
Thothathri, R.A. (2003), Knowledge Management, a Resource Book, 1st ed., Excel Books,
New Delhi, pp. 41-6.
Tomes, A.E. and Ng, S.C.P. (1995), “Service quality in hospital care; the development of inpatient
questionnaire”, International Journal of Health Care Quality Assurance, Vol. 8 No. 3,
pp. 25-33.
Tucker, J.L. and Adams, S.R. (2001), “Incorporating patients assessments of satisfaction and
quality: an integrative model of patients’ evaluations of their care”, Managing Service
Quality, Vol. 11 No. 4, pp. 272-87.
van Hees, M. (1998), “Verslaving nuchter bekeken”, Master’s thesis, Faculty of Technology
Management, Eindhoven University of Technology, Eindhoven (in Dutch).
IJHCQA Walters, D. and Jones, P. (2001), “Value and value chains in healthcare: a quality management
perspective”, The TQM Magazine, Vol. 13 No. 5, pp. 319-35.
25,5 World Health Organization (WHO) (2000), “Health systems: improving performance”, The World
Health Report 2000, WHO, Geneva.
World Health Organization (WHO) (2002), “Reducing risks, promoting healthy life”, The World
Health Report 2002, WHO, Geneva.
402 Yasin, M. and Alavi, J. (1999), “An analytical approach to determining the competitive advantage
of TQM in healthcare”, International Journal of Health Care Quality Assurance, Vol. 12
No. 1, pp. 18-24.
Yusoff, R. (2002), “Life and times: affordable healthcare: a concern”, New Straits Times, No. 3,
April.
Zairi, M. (1998), “Managing human resources in healthcare: learning from world class practices –
part I”, Health Manpower Management, Vol. 24 No. 2, pp. 48-57.

About the authors

Mohammad Azam is a MD (in Social and Preventive Medicine), MBA (with Hospital Management
and Quality Management as specialist subject) and LLB (with Administrative Law as specialist
subject). He has a long experience in the practice of public health, community medicine and also as
a hospital administrator, being in charge of various Cantonment General Hospitals as well as
Director of Health at various levels with administrative jurisdiction over a number of hospitals
while serving in the Indian Army. After retirement he is currently engaged in pursuing research
work in Indian Institute of Technology Roorkee in the Department of Management Studies.
Mohammad Azam is the corresponding author and can be contacted at: [email protected]
Zillur Rahman is Associate Professor in the Department of Management Studies, at Indian
Institute of Technology Roorkee, India. He was the recipient of the Emerald Literati Club Highly
Commended Award in 2004. One of his papers was the Science Direct Top 25 Hottest Article within
the journal for the period October-December 2004. His teaching and research interests are in the
area of international business, information systems, marketing, and strategic management. His
work has been published and cited in various international journals, including Management
Decision, Managing Service Quality, International Journal of Information Management, Industrial
Management & Data Systems, European Business Review, Journal of Database Marketing and
Customer Strategy Management, International Journal of Service Industry Management,
Information Systems Journal, Decision Support Systems, Journal of Business & Industrial
Marketing, and International Journal of Computer Integrated Manufacturing.
Faisal Talib is Assistant Professor at Mechanical Engineering Section, University
Polytechnic, Aligarh Muslim University, Aligarh, (UP), India. He holds a Master’s in
Industrial and Production Engineering and is currently pursuing a PhD in Total Quality
Management in Service Sector from the Indian Institute of Technology Roorkee, (UKh), India. He
has more than 12 years of teaching experience. He has 25 publications to his credit in
national/international journals and conferences. His special interest includes quality engineering,
TQM, service quality, quality concepts, Taguchi methods, and quality management in service
industries.
K.J. Singh is Professor and Head in the Department of Hospital Administration, International
Institute of Health Management and Research, (IIHMR) Dwarka, New Delhi.

To purchase reprints of this article please e-mail: [email protected]

Or visit our web site for further details: www.emeraldinsight.com/reprints

View publication stats