Exploring staff perspectives of the barriers and facilitators to implementation of total quality management in two Jordanian hospitals

Background and Rationale: ‘Total quality management‘ (TQM) is defined as the philosophy of seeking to satisfy customers’ needs and continually improve quality (Stevenson, 2002). In the 1980s, the concept of TQM first emerged in Japan’s industrial sector, moving to the West and Australia in the 1990s. It grew in importance and many companies strove to implement it as a means of developing and upgrading their services. It is significant for healthcare organisations in the enhancement of their care service quality, as well as helping them to improve their management, achieve more effective organisation, increase staff satisfaction, promote commitment to the organisation, encourage teamwork among staff and management, and increase patient satisfaction. TQM is therefore a relatively new philosophy, but it has rapidly become one of the most widely used strategies for enhancing organisational performance. TQM has only very recently been adopted in Jordan’s service sector, particularly in its healthcare organisations, where it has faced major challenges. A review of the literature in this study revealed a gap in the area of TQM implementation in Jordanian healthcare organisations, indicating the pressing need to understand and manage the factors that impact on it. Purpose: The purpose of this study was to explore the barriers and facilitators of TQM in order to gain a better understanding of TQM implementation in the Jordanian healthcare sector; particularly from the staff perspective, namely managers, nurses and doctors in two Jordanian hospitals. Methods: This study is qualitative in nature, using a multiple case study methodology. It was conducted in two hospitals in Jordan, one private (Hospital A) and one public (Hospital B). Three data collection approaches were used: face-to-face semi-structured interviews, document review and observation. The interviews comprised the main data collection tool, whereby a sample of 35 participants were interviewed at the two hospitals (managers, nurse and doctors). Documentary review and partial-participant observation were then employed for the purpose of triangulation and to obtain a deeper understanding of TQM barriers and facilitators. The data collected from the case studies were subjected to thematic analysis, using a framework analysis technique and guided by Normalisation Process Theory (NPT). The Application of NPT promoted a better understanding of the implementation process and provided an appropriate theoretical framework for this study. Findings: Eleven themes were derived from the synthesised study findings, using NPT. Thus, the key barriers and facilitators of TQM were explored to promote successful TQM implementation in Jordanian hospitals. The interviews, document review and observations suggested that commitment and support from the top management were important facilitators of TQM implementation; increasing training and staff awareness, and thereby empowering staff in the workplace. Other important TQM facilitators included communication; the recruitment of qualified and efficient hospital managers; patient involvement and engagement, and teamwork, with the breaking down of professional barriers in Hospital A. However, conflicting results were obtained for motivation, wages and benefits, which proved to be facilitators in Hospital B and barriers in Hospital A. In short, the Hospitals faced three main barriers to TQM: cost, especially evident from the interviews and document review in both Hospitals; lack of motivation, and low salary and incentives (leading to staff shortages and high staff turnover), and resistance from doctors, particularly in Hospital A. Staff resistance in general was also found to be a significant barrier to TQM implementation, but this was more evident in Hospital B. Conclusion: This study explored the main barriers and facilitators of successful TQM in Jordanian hospitals, based on responses from managers, nurses and doctors. The main barriers were found to be cost, lack of motivation, low salary and incentive, staff shortages and high staff turnover, excessive workload, doctors` resistance, and general staff resistance. If these barriers are not promptly addressed, they can impede TQM in hospitals and negatively affect the quality of services provided, with potentially serious outcomes. In contrast, successful TQM implementation depends on important facilitators such as commitment and support from top management, training, staff awareness, communication, teamwork, patient involvement and engagement, the recruitment of qualified and efficient hospital managers, motivation, and attractive wages and incentive. Attention to these areas could improve the effectiveness and efficiency of TQM programmes in Jordanian hospitals. The present study makes an original contribution to existing knowledge, as it is the first empirical exploration of TQM implementation in Jordanian hospitals; endeavouring to provide an in-depth understanding of the factors affecting this process. It therefore also contributes to the literature in the wider context of the Middle East. It is hoped that these results will be used in future to help healthcare service providers understand the importance of TQM practices and overcome the difficulties encountered when attempting to implement them. Therefore, it offers valuable insights to managers and policymakers in the Jordanian healthcare context, with regard to the future planning and monitoring of TQM programmes.