Annals of Business Administrative Science 8 (2009) 55–74
Available at www.gbrc.jp

Online ISSN 1347-4456 Print ISSN 1347-4464©2009 Global Business Research Center

Successful TQM Implementation in
Sri Lankan Public Hospitals

Samantha Padmasiri KALUARACHCHI
Graduate School of Business Administration, Hosei University, Tokyo
E-mail: samankalu@hotmail.com

Abstract: The study reported in this paper examines how the TQM implementation efforts of a
Sri Lankan public hospital were accomplished alongside an attempt to change its culture. The
study revealed that the change in the cultural values of the hospital occurred as a result of theimplementation of Japanese 5S-based TQM activities. However, it was the democratic
leadership and communication of the CEO that functioned as the intermediating factor for thischange. The CEO’s personal values created and maintained an ideal type communication withthe different employee categories for the successful integration of TQM activities. Further, thestudy revealed that the selected national cultural values of Sri Lanka did not constrain the
democratic leadership values of the CEO.
Keywords: democratic communication by the CEO, Japanese 5S-based TQM activities, Sri
Lankan cultural values, Sri Lankan public hospitals, TQM implementation

1. Introduction

public health care sector, the reformation process
began in 1994. These reforms allowed for theDuring the last two decades, successive governments

establishment of District General Hospitals in eachof Sri Lanka have attempted to fulfill their obligations

district. The hospitals were aimed at providing basic

by improving the health care provisions in thespecialized services. Further, the training of healthpreventive and curative sectors. In this regard, thepersonnel was intensified, and medical as well as

preventive health care service areas were reformed toparamedical staff members were appointed to many

serve more people. Many of the existing hospitals in

hospitals. Moreover, the intensive care and laboratory

remote areas were upgraded. With regard to thefacilities were expanded with appropriate technology.
55

KASP Kaluarachchi

However, despite all these commitments of thecentral and/or provincial ministries of health; thus,

Ministry of Health, the following significant

the hospital managers rarely enjoy the authority to

deficiencies still prevail in the services provided byrecruit personnel. Furthermore, and as a result,the public hospitals in Sri Lanka.

shortages of staff exist in many employment
positions. Moreover, the remuneration packages are•The services provided by some hospitals are notalso unable to stimulate improvements in the service
focused on the expectations of the patients.
quality of the hospitals. In general, the work

•The services provided by the hospitals are notenvironment also appears to be unsatisfactory for theattractively packaged or presented to the people.
employees (Ministry of Health, Sri Lanka, & Japan•Many of the hospitals ignore the non-healthInternational Cooperation Agency, 2003).
expectations of the people such as basic human
The abovementioned service quality issues
needs, dignity, kindness and compassion, proper
predominant in Sri Lankan public hospitals is further
communication with the patients and theiraddressed in this paper, alongside the national
relatives, and prompt attention in the emergency
cultural values of Sri Lanka. This is because it iscare unit.
these values that in most cases function as•There are numerous complaints about the death

constraints to innovation efforts such as the TQM1

and/or disability of a patient due to inappropriate
implementation efforts of Sri Lankan publiccare and negligence.
hospitals.
Although the hospitals do provide valuable

Nanayakkara(1999)

examinedtheservices for the public, the services are not wellrelationship between culture and management in Sri

recognized by the people. However, some public

Lanka from a cultural perspective in order tohospitals have taken the initiative to enhance theunderstand the managerial behaviors of Sri Lankan

quality of their services by improving infrastructure,organizations. To represent the relationship between

reviewing monthly performance, preparing manuals

culture and managerial behaviors, the author

and guidelines, initiating productivity improvement

identified dependence, lack of self-confidence,programs, and so on (Ministry of Health, Sri Lanka,

acceptance of status quo, work as a means, respect2005).

for authority, and lack of system and perfection as

The major inadequacies in the services provided

the major cultural values of Sri Lanka.

by public hospitals in Sri Lanka primarily stem from

Studying new management systems (NMS),

the administration style that follows a set of rigid

some scholars (Samarathunga & Bennington, 2002;

rules and regulations imposed by the Ministry of
1

Health. Further, the hospital staff is allocated by the56

TQM is an acronym for total quality management.

Successful TQM implementation in Sri Lankan public hospitals

Gunathunga, 2003; Wickramasinghe & Hopper,

demands.

2005; Wickramasinghe, Hopper, & Rathnasiri, 2004)

Therefore, based on the above, this study was

found that the political bureaucracy and poor

motivated by the need to examine the TQM

administrative setup of public sector organizations in

implementation efforts of the said hospital within its

Sri Lanka have discouraged the implementation ofcultural setup. However, it is understood that

NMS within those organizations. Hence, NMS

modernization efforts such as TQM implementation

programs have simply become technically, rather

need to be studied from a larger perspective, because

than managerially, meaningful to the organizations.

it is regarded as a historically and culturallyAssuggestedinOpatha(2001),

theconstructed phenomenon. Moreover, such efforts

politicization and multiplicity of labor unions havelead to changes in the culture of the organization.

become the two major irritants with respect to the

According to the study, the attempt to change

creation and maintenance of good industrial relations

the culture of the hospital at stake by means of TQM

within organizations in Sri Lanka. Consequently, on

rationality is considered to be a challenge. The

the one hand, labor unions’ ability to accomplish thechallenge is mainly because of the different

objectives

throughsubcultures 2 (i.e., different employee categories)

effective relations with managers is limited, and onthat exist within an organization, which may not

the other hand, managers find it difficult to manage

necessarily

the organizations by making strategic decisions such

implementation activities.

of

their

members/workers

as automation, rationalization, technological changes,beeasilyintegrated

into

TQM

Thus, the purpose of the study reported in thisetc.

paper was to examine how TQM implementation
Although the abovementioned organizational

efforts of the abovementioned Sri Lankan public

and national culture backgrounds of Sri Lanka

hospital have been accomplished alongside thefunction as constraints to the innovation efforts ofattempt to change its culture.

the Sri Lankan public hospitals, some public
hospitals have been well recognized by the public for2

their responsive services, achieved through thesuccessful

implementation

of

new

quality

management methods. As the main example, a Sri
Lankan public hospital, namely, the Castle Street
Hospital for Women, which practices Japanese
5S-based TQM activities, has won several quality
awards for being more responsive to the public
57

The subcultures of the hospital were identified at its
managerial and non-managerial employee levels. The
managerial employee level of the hospital was identified
with its Director/CEO (senior management) anddivisional heads (middle management). The divisional
heads comprised the Senior Medical Officer, Matrons,
Administrative Officer, Accountant, and Chief
Pharmacist. Presently, there are three matrons in thehospital. The non-managerial employee level was
identified with the doctors, nursing sisters and nurses,
paramedical staff, midwifery staff, clerical staff, andsupport staff. All these different employee categories
were identified as different subculture groups of thehospital that may differently affect the TQM
implementation process.

KASP Kaluarachchi

Table 1. Timeline of the TQM implementation process at CSHW
Year

Activities/EventsClassification of each activity

2000

Names used
for analysis
OD1
OD2
ST1

Implementation of the 5S program
Organization development
Implementation of kaizen activities
Organization development
2001
Training of divisional heads in productivity Staff training
improvement
Training of clerical and support staffs in Staff training
ST2
productivity improvement
Renovation of wards
Infrastructure development
ID1
Improvement of all quarters
Infrastructure development
ID2
Supply of surgical hospital furniture
Medical supplies
MS1
Renovation of Labor Rooms A and B
Infrastructure development
ID3
Publication of the Quarterly Statistical Bulletin Patient admission and transfer
PAT1
and Annual Report
Organization of the Health Information Unit
Infection control activities
ICA1
Training of clerical and support staffs in public Staff training
ST3
relations and office management
2002
Construction of Labor Room C
Infrastructure development
ID4
Renovation of Labor Rooms A and B
Infrastructure development
ID5
Improvement of offices and stores
Infrastructure development
ID6
Location management training for nursing and Staff training
ST4
midwifery staffs
Introduction of 10 CTG machines
Diagnostic activities
DA1
Improvement of the Neonatology Unit
Infection control activities
ICA2
Improvement of the OPD
Infrastructure development
ID7
Improvement of record keeping
Patient admission and transfer
PAT2
Development of tools for record keeping
Patient admission and transfer
PAT3
Establishment of a performance appraisal system Employee relations
ER1
New computers for clerical staff
Infrastructure development
ID8
2003
Introduction of laparoscopy and colposcopy
Diagnostic activities
DA2
Improvement of kitchen
Infrastructure development
ID9
Training of divisional heads and doctors in TQM Staff training
ST5
New equipment for the Operating Theatre
Diagnostic activities
DA3
Improvement of the Intensive Care Unit
Infrastructure development
ID10
2004
Training of support staff in infection control
Staff training
ST6
Improvement of the laboratory
Diagnostic activities
DA4
Training of the nursing staff in neonatal and Staff training
ST7
intensive care
Installation of a computerized information Infrastructure development
ID11
systemNotes: For analytical purpose, each historical activity was classified and named under clinical and TQM-oriented
activities. Moreover, the activities were organized according to the respective years in which they were
implemented.
Sources: Castle Street Hospital for Women (2006); Researcher’s interview transcripts.

largest maternity hospital in Sri Lanka with a capacity

2. The study of a Sri Lankan publicof 846 employees and 450 beds. It provides maternal,

hospital

gynecological, and neonatal care services. The

The Castle Street Hospital for Women (hereafter

number of deliveries every year ranges between

CSHW) is a public maternity hospital in Sri Lanka. It

16,000 and 18,000, with an average of 27% cesarean

was established in 1950 and presently functions as thedeliveries.
58

Successful TQM implementation in Sri Lankan public hospitals

Figure 1. Service outcomes of CSHW

25

20
MMR
15
SBR
Rates

NMR

10

PMR
5

0
2000

2001

2002

2003

2004

2005

2006

Years

Notes: MMR = maternal mortality rate; SBR = stillbirth rate; NMR = neonatal mortality rate; and PMR = perinatal
mortality rate. MMR/10,000 live births; SBR/1,000 total births; NMR/1,000 live births; PMR/1,000 total births(total births = live births + stillbirths). The data on MMR, SBR, NMR, and PMR were unavailable for the period
before 2000 due to the lack of maintenance of proper records in the hospital. Therefore, a review of the service
outcome for the period before 2000 could not be done. No other major internal factors of the hospital that could havespecially affected its service outcomes were noticed during the considered period. No major improvements orchanges in the public health care sector in Sri Lanka that could have specially affected the service outcome of thehospital were noticed during the considered period.
Source: Castle Street Hospital for Women (2007).

quality. The non-integral culture3 of the hospital was

During the first 50 years of its service, CSHW
functionedasagovernmental/public

hospital
3

implementing traditional administrative systems andmeasures. It did not focus on adopting NMS to deliver
better care and services to the public. Hence, themajor deficiencies in the services provided by public
hospitals in Sri Lanka (as mentioned in the firstsection of the paper) were common to CSHW as
well. Thus, during the first 50 years of service, theculture of CSHW was regarded as being non-integral
with respect to the improvement of its service

59

Since this paper deals with the issue of integrating the
subcultures of CSHW with its TQM implementation
efforts, the process of its cultural change isconceptualized as a change that occurs from a
non-integral status to an integral status. In other words,
the process of the change is conceptualized as the change
from a non-integral culture to an integral culture. Thiswasmainlyfollowedbyavalue-based
terminology. Hence, the term “integral culture” used inthis paper should be understood as a shared culture
towards TQM implementation. The opposite term
“non-integral culture” should be understood as anon-shared culture towards TQM implementation. The
paper operationalizes non-integral culture withindividualism,risk-aversion,andshort-termorientation. Contrarily, integral culture is operationalizedwith teamwork, risk recognition with respect to change,
and long-term orientation. This has been further
illustrated in Figure 2.

KASP Kaluarachchi

observed in its (1) individualistic work orientation,

the TQM implementation at CSHW since the new(2) risk-aversion with respect to change, (3)CEO’s appointment.

short-term orientation, and (4) visibly poor display of

The implementation of Japanese 5S-based

improved service facilities.

TQM activities at CSHW not only reduced the

However, in January 2000, a new director, 4mortality rate, which was a result of the reduction in

namely, Dr. Karandagoda, was appointed as the CEO5

infection rates, but also reduced the consumption ofof the hospital. A few months after assuming his

antibiotics, resulting from the decline of nosocomial

duties, Dr. Karandagoda was surprised by the highinfections and different kinds of waste like space,maternal mortality rate of the hospital. He furthertransport, movement time, and waiting time. Figure

noted that in most cases, the high mortality was due

1 illustrates the service outcomes of the hospital forto the infections spread within the hospital or due tothe period after the implementation of 5S-basedother

TQM activities.

inappropriate

post-treatment

care.

He

The data provided in Figure 1 indicates that

concluded that the deaths could have been prevented

CSHW

by the collective effort of the staff.

gradually

improved

its

service

Hence, with the objective of reducing theoutcome/performance (i.e., reduction of MMR, SBR,

mortality rate, the new CEO (Dr. Karandagoda)

NMR, and PMR). For example, from 2000 to 2006,

began to introduce Japanese 5S 6 -based TQM

it reduced MMR from 11.0 to 3.9, which isactivities in April 2000 7 as an effort toward theapproximately a 64% improvement in service

modernization of the hospital. A timeline of theperformance. During the same period, it was able toimplementation of TQM activities is presented in

reduceTable 1. The activities were recognized as theapproximately a 35% improvement in service

historical activities or events that took place duringperformance. Moreover, both NMR and PMR were

SBR

from

11.2

to

7.3,

which

is

reduced from 7.9 to 7.1 and 19.2 to 14.1,
4

In this paper, the terms “director” and “CEO” have beenused interchangeably.
5
CEO is an acronym for chief executive officer.
6
Japanese 5S denotes the following five Japanese words
seiri (tidiness), seiton (orderliness), seiso (cleanliness),seiketsu (standardization), and shitsuke (training andself-discipline) that collectively form the foundation ofan organization methodology.
7
The introduction of Japanese 5S-based TQM activities in
the hospital forms the starting point of TQM
implementation in Sri Lankan public hospitals. After the
successful TQM implementation in this hospital, theMinistry of Health established a section called the“Quality Secretariat,” which is responsible for thecultivation and development of a quality-oriented culture
in public hospitals. Presently, the Secretariat runs the
National Quality Assurance Program (NQAP) for tertiary
hospitals in Sri Lanka.

respectively, which constitute a 10% and 26%
improvement in service performance.
Table 2 associates the service outcomes of
CSHW with its historical activities. The activities
implemented during the respective years havecontributed to improve the service outcomes (i.e.,
reduced MMR, SBR, NMR, and PMR). The
historical activities of the hospital are related to its
clinical and TQM-oriented activities. The clinical60

Successful TQM implementation in Sri Lankan public hospitals

Table 2. Linking CSHW’s service outcome with its history of TQM implementation
Year
2000
2001
2002

Historical activities
Reduced rates
OD1, OD2
MMR, SBR, NMR, PMR
ST1, ST2, ID1, ID2, MS1, ID3, PAT1, ICA1, ST3
SBR, PMR
ID4, ID5, ID6, ST4, DA1, ICA2, ID7, PAT2, PAT3, MMR, SBR, NMR, PMR
ER1, ID8
2003
DA2, ID9, ST5, DA3, ID10
MMR, NMR, PMR
2004
ST6, DA4, ST7, ID11
NMR, PMR
Notes: OD1, OD2, ST1, etc. refer to the historical activities implemented in the respective
years. Refer to Table 1 and Figure 1 for the meaning of the abbreviations.
Sources: Created based on Table 1 and Figure 1.

Table 3. Service outcome rates of CSHW in comparison to the national figures of Sri Lanka
Rates
MMR
SBR
NMR
PMR
Year
CSHW SL +/–CSHW SL +/–CSHW SL +/–CSHW SL +/–
2000
11.0
5.6
(–5.4)
11.2
23.7 (+12.5)
7.9
12.8 (+4.9)
19.2
32.0 (+12.8)
2001
6.0
4.7
(–1.3) 9.1
22.9 (+13.8)
7.8
12.7 (+4.9)
17.3
32.6 (+15.3)
2002
7.5
5.3
(–2.2) 8.1
19.1 (+11.0)
9.4
10.6 (+1.2)
17.1
26.2 (+9.1)
2003
5.8
4.3
(–1.5) 7.9
17.1 (+9.2)
9.2
9.5(+0.3)
16.2
24.4 (+8.2)
2004
3.8
3.8
(0.0)
8.8
7.3
8.0
(+0.7)
15.9
2005
5.9
4.4
(–1.5) 9.4
6.8
7.7(+0.9)
16.1
2006
3.9
3.9
(0.0)
7.3
7.1
14.1
Notes: MMR = maternal mortality rate; SBR = stillbirth rate; NMR = neonatal mortality rate; and PMR = perinatal
mortality rate. SL refers to Sri Lanka. Further, the figures shown in the +/– column were arrived at by deducting theservice outcome rates of CSHW from the relevant national figures of Sri Lanka for each year. The bolded figures depict
how the service outcome rates of CSHW have succeeded the relevant national figures of Sri Lanka. The national figures
related to SBR and PMR from 2004 to 2006 and NMR for 2006 were unavailable. Therefore, the comparative analysis
for those years could not be done.
Sources: Castle Street Hospital for Women (2007); Family Health Bureau (2006, 2009); Researcher’s interview transcripts.

activities were identified as infection control

activities that contribute to the improvement of theactivities (i.e., ICA1, ICA2); diagnostic activities

service outcomes. Further, Table 3 presents the(i.e., DA1, DA2, DA3, DA4); and patient admission

service outcome rates of the hospital in comparison toand transfer (i.e., PAT1, PAT2, PAT3). They function

the national figures of Sri Lanka.

as the direct or primary activities that contribute to

The comparative figures shown in Table 3enhance service outcomes. The TQM-oriented

indicate that after the implementation of Japaneseactivities were identified as medical supplies (i.e.,

5S-based TQM activities in 2000, CSHW graduallyMS1); employee relations (i.e., ER1); staff training

overcame the negative growth of MMR. Moreover,(i.e., ST1, ST2, ST3, ST4, ST5, ST6, ST7);

CSHW was able to meet the national figures ofinfrastructure development (i.e., ID1, ID2, ID3, ID4,

MMR:

ID5, ID6, ID7, ID8, ID9, ID10, ID11); andrespectively. This can be regarded as a substantial

organization development (i.e., OD1, OD2). These

improvement in its service performance following thefunction as indirect or secondary or supportive

implementation
61

3.8

and

of

3.9

in

Japanese

2004

and

5S-based

2006,

TQM

KASP Kaluarachchi

CEO introduced Japanese 5S concepts in order toTable 4. Quality awards won by CSHW
organize the hospital and create a pleasant and safe
Year
2001

AwardsAkimoto 5S Award (Best 5S Implementer in
Service Sector)
National Productivity Award (Service Sector)
Kaizen Award Runner-up
Sri Lanka National Quality Merit Award(Large-Scale Service Sector)
National Productivity Gold Award (Service
Sector)

2002

2003

environment for both patents and employees.
The 5S program was introduced as a basis for
improvement towards performance excellence (i.e.,
TQM). The key benefits that CSHW gained throughthe implementation of 5S concepts were less waste,
less waiting time, less human error, less accidents,

activities. With regard to SBR, NMR, and PMR, theand reduced deaths and disabilities of patients. The

hospital performed better than the corresponding

5S program of CSHW has been briefly explained

national figures for all the years in consideration (seebelow.

the bolded figures in Table 3). This is a remarkable
improvement in the service performance of CSHW

•Tidiness (Seiri): This deals with the systematic

after the implementation of Japanese 5S-based TQM

removal of unwanted items. It includes waste

activities. Consequently, CSHW was able to win

disposal by using a color code and arranging

several quality awards for being more responsive tocentral unwanted item stores to collect and repair

publicthe unwanted items and medical equipment

demands

throughsuccessful

TQM

implementation. Table 4 presents the quality awards

accordingtowon by the hospital.

regulations. Further, the stores also help in
eliminatingthegovernment

unwantedbuilding

rules

and

materials,

2-1. Japanese 5S-based TQM activities

unplanned building structures, and trees, and in

Similar to many other large-scale organizations (e.g.,organizing used documents and files according tolarge-scale manufacturing organizations), CSHW isthe audit procedures.

also a large-scale maternal hospital, consisting of•Orderliness

different categories of employees who treat patients

systematic arrangement of items, areas, and staff

by

and

to facilitate use. The items are placed such thatprocedures. In addition, there are large amounts ofthey are easy to see, easy to pick up, and easy tounwanted items, such as clinical waste, that are

return. In keeping with this, CSHW has

collected in the hospital premises. This increases thesystematically

risk

the

equipment, emergency areas, and staff. In

hospital. Mostly, disorganized situations endanger

particularly, CSHW has organized the Central

the lives of patients and employees. Thus, the new

Sterile and Linen Supplies Divisions with special

using

of

different

associated

kinds

of

equipment

infections

within(Seiton):arranged

This

its

involves

servicetheareas,

care. Further, the General and Medical Supplies
62Successful TQM implementation in Sri Lankan public hospitals

Stores have also been updated and arranged

tools and items that can harm the lives of patients

systematically.

and employees; and development of checklists toMoreover,thehospitalhas

addressed a wide range of activities such as the

avoid

mistakes

basic needs of patients, emergency care, supplies

procedures.

duringmedicalandsurgicaland equipment, and identification of directions to

In addition, it utilizes safety tools such as red

places and areas with specific indicators andtags, alignment, numbering, labeling, zones, isles,

activities.

name boards, sign boards, safety signs, street lines,•Cleanliness (Seiso): This refers to systematic andchecklists and stickers, instructions and guidelines,

meaningful cleaning. CSHW has implemented aand visual controls. The visual controls have been

preplanned cleaning program. Further, a registerdeveloped using locally and internationally accepted

is maintained for the cleaning of floors andcolor codes. For example, black is used for general

toiletsofitems, areas, and waste; yellow is used for infected

trolleys. Preventive maintenance of equipment isareas and waste; red is used for anything negative,

conducted regularly.

urgent, dirty, un-sterile, and of high risk; blue is used

•Standardization (Seiketsu): Under this practice,for anything positive, clean, and sterile; and green iswhat is being organized and implemented isused for safe areas. Following the implementation ofrecorded and standards are prepared to makethe 5S program, the hospital has become orderly,

supervisionandclean, and pleasant, with a sense of quality.

comfortable.
monitoring

and

the

oilingandservicingmonitoring

more

Further,somechecklists

andFurthermore, based on the 5S program, CSHW

indicatorsarepreparedfor

adopted a step-by-step approach to improve its

recommendation.

systems by practicing TQM concepts. This was to•Training and self-discipline (Shitsuke): In thesatisfy the needs and expectations of patients andhospital,

in-service

employees. By conducting customer satisfaction

trainings are carried out to improve the staff’s

surveys, it improved the basic needs and counterknowledge of the 5S concepts. Further, the staff

services at the front line. Moreover, by developingis self-disciplined to continue the practice of 5S.

leadership at top, middle, and operational levels, it

bothintroductoryandused a systematic approach to performance reviews
Overall, 5S implementation in the hospital has
and

human

resource

development

andfulfilled all the requirements of safety. The hospital
deployment. In addition, it carries out in-service
uses some safety measures in the form of safety sign
training programs for its employees, depending on
belts (black and yellow strips) at high-risk areas;
the service needs.
safety signs; fire extinguishers; concealment of risky
In its process of TQM implementation, CSHW
pits; removal of dilapidated buildings and dangerous
63

KASP Kaluarachchi

has been practicing kaizen concepts for continuous

shortcomings, and possible improvements in theirimprovement. This requires the participation of all

relevant divisions. When problems arise in relation

employees on a daily basis. The kaizen activities

to other divisions, they call a member from that WIT

have contributed in many aspects such as theto discuss the issue. Each month, the WIT leaders

simplification of processes; reduction of different

meet the CEO to discuss cross-functional problems

kinds of waste like space, transport and movement

and to obtain his support.

time, and waiting time; minimization of storage;

Thesuggestion

scheme

(SS)

has

been

improvement in the work efficiency of vehicles andimplemented through external customers (i.e.,

machinery;

supplypatients, their relatives, and other visitors) andsystem. Moreover, they have ensured employee

internal customers (i.e., employees). CSHW has

participation in the analysis of problems andplaced suggestion boxes at selected locations. Once a

incidents and the determining of solutions. CSHW

week,

has adopted kaizen activities in the form of work

recorded.

improvement

scheme,suggestions in these forms as well as at the WIT

just-in-time, total productivity maintenance, andmeetings. The suggestions received by post andmistake proofing.

those

and

improvement

teams,ainthesuggestion

thesuggestions

The

appearing

employees

in

the

are

collected

and

can

provide

their

media

are

also

Work improvement teams (WIT) have been

considered. The suggestions of patients are also

introduced as an alternative to the quality circles

taken at the time of discharge by means of(QC). In comparison with QC, a WIT is moresuggestion forms. Further, customer satisfaction

informal, and it does not involve considerable

surveys also provide valuable suggestions of thescientific analysis. Hence, a WIT provides different

patients. All suggestions are discussed at thekinds of employees with an increased opportunity toMonthly Steering Committee and Management

participate in quality management activities. A WIT

Committee meetings. The management provides

of CSHW consists of a small group of 6–12

feedback to the relevant parties appreciating theiremployees, who belong to a particular division. For

suggestions.

example, the WIT of the Nursing Division consistsofmatrons,

nursingsisters,

nurses,

The concept of just-in-time (JIT) or leanandproductivity has been applied in the hospital to

midwives. Likewise, other divisions have their own

minimize storage and to ensure a timely supply of

WITs. WITs have been appropriately named. They

different materials to the working areas. Any item

include a chairman, a secretary, and a treasurer. The

that is supplied centrally and periodically should not

WIT members gather during leisure hours on a

be stored in excess in the wards and divisions. The

monthly or fortnightly basis to discuss problems,

central stores supply stocks by assessing the64Successful TQM implementation in Sri Lankan public hospitals

statistics. Any unwanted item wasting away in theand employees and developing audio-visual materials

workplaces is removed to a centrally locatedto ease the understanding of 5S and TQM concepts.8

unwanted item store for disposal and/or repair. The

The program for training the trainers was targeted at

items collected that are suitable for use are

the teaching units of the nursing and middle-level

redistributed

grades. The employee training programs covered

to

other

divisions

and/orother

hospitals.

topics such as introduction to quality, 5S andUnder the concept of total productivity

productivity concepts, TQM, leadership, public

maintenance (TPM), the hospital has a maintenancerelations and communication skills, and staff

unit and a calendar for the preventive maintenance ofcommitment toward responsive maternal care. A

equipment, machinery, vehicles, utility trolleys,

video film was shown to educate the employees on

etc.

and

quality improvement and responsive health care. In

guidelines have been displayed at the site of theaddition, employees were instructed on the concepts

equipment. All equipment has a display sticker toof 5S and TQM by means of poster displays and otheridentify its model and price as well as the contact

visuals aids.

Preventive

maintenancechecklists

details of the maintenance agents. For every

The application phase involved three specificequipment and machine, there is a “personal file.”

steps. The first step was to introduce Japanese 5S

With respect to mistake proofing (MP), CSHW

practices.

Some

productivity

concepts

weremaintains a mistake identification register to record

introduced in the second step. The third step was tothe mistakes in medical, nursing, and general

introduce the concepts of TQM. This phase involved

procedures. The mistakes are discussed at the WIT

the determining of kaizen practices; preparation of

meetings and the Monthly Management Committee

action plans; identification of key areas formeetings in order to determine the appropriate

improvement; implementation of no cost and urgently

action. Due recognition is given for infection control

needed activities through which employees could be

activities, and every ward maintains an Infection

motivated to proceed; establishment of work

Identification Register. Death and Near-Death

improvement teams and a steering committee;

Reviews comprise the essential activities of MP.

development of positive attitudes toward change
among divisional heads; development of data

2-2. TQM implementation process
8

The implementation of TQM activities at CSHW wasa three-phase process: (1) introductory phase, (2)application phase, and (3) maintenance phase. The
introductory phase comprised of training the trainers
65

The training of trainers, training of employees, and otheractivities that contributed to enhance the quality
management knowledge and skills of employees weremainly facilitated by external consultants. External
consultants from the Sri Lanka Institute of Development
Administration (SLIDA) played a major role in thiseffort. In fact, Mr. Thilakasiri, a senior consultant at
SLIDA, is still popular among the employees.

KASP Kaluarachchicollection registers for mistake proofing; organization

service or service quality. Second, specific indicatorsofaccountablethat have designed to address clinical care or clinicaldocuments; development of a rational color code

quality matters related to the intensive care unit,

system; introduction of a kaizen suggestion scheme

operating theatre, labor rooms, laboratories, etc.

audit

procedures

todisposewith suggestion boxes, suggestions at discharge, andsuggestions by post; execution of periodical

2-3. Managing the process of cultural change

competitions

and the role of leadership

among

employees

toincrease

motivation toward quality management activities;

The

ongoing

implementationofdevelopment of monitoring indicators with a

improvement-oriented activities at CSHW (see Table

maximum of 15–20 indicators; and appointment of a1) has contributed toward changing its culture from amonitoring team, comprising five senior staff

non-integral one to an integral one. However, themembers who are knowledgeable, communicative,

process of change has been initiated and managed byand possess leadership qualities.

the democratic leadership of the CEO. The CEO’s

During the maintenance phase (CSHW is now in

personal values, namely, teamwork, openness,this phase), a sound monitoring mechanism was

responsiveness, forgiveness, practical orientation,

implemented. Periodical reviews were conducted toand continuation, have collectively created andidentify the management development needs andmaintained an ideal type of communication withsustain continuous improvement. The monitoring

different employee categories (i.e., divisional heads,

mechanism is simple, rational, convenient, anddoctors, nursing sisters and nurses, paramedical staff,

user-friendly. Monitoring is done on monthly,

midwifery staff, clerical staff, and support staff) for

quarterly, and annual bases, through monitoring

integration with 5S-based TQM activities.

indicators, general staff meetings and periodical

When 5S-based TQM implementation resumed,

returns, staff and customer surveys, clinical andthe CEO was faced with the problem of how tomanagement meetings, and the Quarterly Statisticalcorrespond TQM activities with staff awareness andBulletin and Annual Report. CSHW has implemented

knowledge. In response, the CEO conducted a staff

managerial functions to address areas such as

survey to determine staff awareness regarding basic

reception, cleanliness, infection control, humanquality management activities. The staff survey

resource management, finance and budget, basic

covered three major techniques: work improvement

needs of patients, etc. The monitoring indicators areteams,of mainly two types. First, general indicators thatknowledge testing. The results of the staff survey

have

generalrevealed that although the staff members had basic

management activities and responsive health careknowledge about quality management, they did not

been

preparedtoaddress

the66inter-groupinteractions,andgeneralSuccessful TQM implementation in Sri Lankan public hospitals

havesufficientknowledge

about

productivity

administrative setup of the Ministry of Health andimprovement and TQM. Subsequently, the CEO

other political interventions such as trade union

began to organize team-based training programs for

activities) over the change effort would prevent thethe different employee categories.

employees from being involved in the TQM
implementation process. Thus, he inferred that

The employees were targeted as separate groups
and were asked to engage in quality
management activities. When a particulargroup displayed poor knowledge about thequality management activities, the group wasthen instructed by the Health Education
Unit. The Health Education Unit rearranged theeducational programs to educate suchgroups. This method is known as “pick[ing] up”
quality management activities (CEO).9

achieving successful TQM implementation would be
impossible without achieving a consensus among theemployees who were the key participants in the TQM
implementation process.
With regard to the changes implemented by the
management, the employees perceived thesechanges as opportunities for continuous
improvement. On the other hand, with respect tomost of the national level or external changes,
the employees treated them as threats to theirjobs. But, the problems were resolved throughcontinuous discussions with the employees andtheir unions (CEO).11

The CEO’s policy towards the TQM implementation
process, as described above, did not only follow a
top-down

approach.

Instead,heemployedabottom-up approach through which the staff members
were welcome to forward their ideas and suggestions

With regard to participation in TQM activities,

towards the quality management activities.

the CEO granted the employees autonomy, and only
monitored the progress. Most of the time, he

The staff members’ proposals were used tomatch the quality management activities with
their
requirements.
The
newquality
management activities were designed anddeployed in a simple manner such that thegeneral staff members could understand themeasily. As an example, these days, themanagement is discussing with the staff
members on how the midnight reporting system
can be further simplified (CEO).10

encouraged and motivated the employees, even when
they made a mistake. This enabled him to continue
and sustain the TQM effort along with the highintegrity of the employees.
I normally do not punish my employees when
they make a mistake. I discuss the matter withthem, and then forgive them, asking them not torepeat the same mistake again. In most of thecases, I personally address the issue in order to
respond to them without delay. In this way, theissue can be resolved at the very beginning and

The CEO as the change agent even addressed theforces against the change. In this regard, he realizedthat direct control of the external forces (e.g., the rigid
9

The CEO of CSHW was interviewed on 17/12/2007 in his
office.
10
The CEO of CSHW was interviewed on 17/12/2007 in
his office.

11

67

The CEO of CSHW was interviewed on 17/12/2007 in
his office.

KASP Kaluarachchiin a friendly manner (CEO).12

TQM activities was clearly evident. By interacting

arrange the things in an orderly manner. Then,time to time, he introduced the other 5S
principles by motivating the staff continuously(Accountant).14

with the employees, he was able to motivate them to

The investigation as a whole helps to understandcooperate and participate in the change. In fact, thethe salient feature of efficient communication of

The commitment of the CEO to implement the

CEO’s aim to achieve TQM implementation became

TQM implementation to the different employee

a personal aim of the employees who participated in

categories of CSHW. It highlights the importance ofthe change, increasing their faith in the superiority ofleadership values, including a practical orientation

the common purpose. In other words, the hightoward overcoming possible bottlenecks with respect

integrity of the employees to work toward a common

to the implementation. The leadership competency of

purpose was the key factor for the success of thethe CEO was characterized by nothing more than theimplementation. Further, the creation of faith by thecreation and maintenance of an ideal type ofCEO has ensured the enduring cooperation ofcommunication with the different categories of

employees with respect to his efforts to bring about

employees who were involved in the change effort

change. Hence, the employees’ responses to theand possessed high integrity. Therefore, the CEO wasleadership competency and commitment of the CEOable to change the culture of CSHW from aappeared considerably positive in this regard.

non-integral one to an integral one with positive

The leadership commitment of the director isthe main reason for the success of 5S
implementation in the hospital. Our director
played a key role in delegating 5S activities tothe different kinds of employees and ensuring
their active involvement in continuous
improvement (Public Relations Assistant).13

teamwork, change-oriented risk recognition, andThe commitment and the way in which thedirector communicated the 5S practices in 2000
have had a considerable impact on their present
success. He actually used a bottom-up approach
which motivated the different employee
categories to deal with 5S. At the very
beginning, he educated the staff to remove theunnecessary items from the hospital and to

Sri Lanka. CSHW has been awarded with several

long-term orientation.
Consequently, CSHW was able to improve its
service outcome/performance over time. Overall, theservice outcome/performance rates have improved
and have succeeded the relevant national figures ofquality awards (see Table 4) for being more
responsive to the public demands through successful
5S-based

TQM

implementation.

Presently,

functions as a model public hospital in Sri Lanka.

12

The CEO of CSHW was interviewed on 17/12/2007 in
his office.
13
The Public Relations Assistant of CSHW wasinterviewed on 17/12/2007 in his office.

14

68

The Accountant of CSHW was interviewed on
18/12/2007 in her office.

itSuccessful TQM implementation in Sri Lankan public hospitals

2-4. Beyond the national cultural constraints

orientation). Consequently, an integral culture was

It has already been mentioned that the democratic

created by using values such as teamwork,

leadership and communication of the CEO of CSHW

change-oriented risk recognition, and long-term

was the intermediating factor for the cultural changeorientation.

that occurred. The democratic leadership values of

Although the selected national cultural values

the CEO (i.e., teamwork, openness, responsiveness,of Sri Lanka, namely, dependence, lack of self

forgiveness, practical orientation, and continuation)

confidence, acceptance of status quo, work as a

as a whole contributed to the change frommeans, respect for authority, lack of system andnon-integral cultural values (i.e., individualism, risk

perfection, political bureaucracy, and poor industrial

aversion with respect to change, and short-term

relations, influenced the non-integral cultural values

Figure 2. Cultural change at CSHW within the national cultural values of Sri Lanka

Non-integral cultural valuesof CSHW
Individualism

Change-oriented
risk-aversion
Short-term orientation

Process ofcultural change

Integral cultural values of
CSHW
Teamwork

Change-oriented risk
recognition
Long-term orientation

TQM
process

Influenced

TQM practices
Managerial commitment

National cultural values of
Sri Lanka
Dependence
Lack of self-confidence
Acceptance of status quo
Work as a means
Respect for authority
Lack of system andperfection
Political bureaucracy

Impacted

Non-managerial
commitment
Strategic focus
Customer focus
Human resource focus
Process management
Managing supplier
relationsManaging employee
relationsGlobal focus

Poor industrial relations

Source: Author

69

Democratic leadershipvalues of the CEO
Teamwork
Openness
ResponsivenessForgiveness
Practical orientation
Continuation

KASP Kaluarachchiof the hospital, they were unable to constrain the

3. Discussion

democratic leadership values of the CEO. Instead,the democratic leadership values of the CEO

Successful TQM implementation at CSHW revealed

impacted the process of cultural change in the

one important aspect pertaining to the CEO’s

hospital.

personal values, namely, teamwork, openness,
responsiveness, forgiveness, practical orientation,

The director as the CEO initiated andcoordinated the quality improvement activities
tactfully. He maintained a supportive
communication environment, where managerial
andnon-managerial
employees
could
cooperatively
acttowardcontinuous
improvement. Even many external forces likepolitical interventions that came from the
Ministry were also handled by the director infavor of the hospital (Senior Medical Officer).15

and continuation. These values contributed as a wholein the creation and maintenance of an ideal type ofcommunication with different employee categories inorder to integrate Japanese 5S-based TQM activities
within the organizational boundary. As a result, forces
against the change, both internal and external, were
overcome. The CEO’s bottom-up management
approach supported by his democratic leadership and

The CEO’s personal values (i.e., teamwork,communication style functioned as the intermediating
openness, responsiveness, forgiveness, practicalfactors with respect to changing the mindset of theorientation, and continuation) as a whole created andemployees. Consequently, the employees engaged inmaintained an ideal type communication with the
5S-based

TQM

activities,

displaying

highdifferent categories of employees who were involved
integrity. This has served as the core strategy for thein the TQM implementation process and possessed
successful employment of other strategies for change,high integrity. Consequently, the CEO was able tosuch as executing educational and training programs,
change the culture from a non-integral one to an
enhancing employee involvement in decision-making,integral one in order to successfully implement
creating a new organizational culture with small
5S-based TQM activities. Thus, the democratic
group activities and teamwork, introducing newleadership values of the CEO with the TQM
policies and procedures to reward the employees, andpractices have intermediated the process of cultural
executingevolutionarychanges

that

were

change at the hospital, taking it beyond the national
enthusiastically accepted by the employees. All thesecultural constraints. These relationships have been
strategies employed by the CEO can be collectively
illustrated in Figure 2.
regarded as a successful behavioral or organizational
development approach toward change management.
Successful TQM implementation at CSHW has
15

contributed

The Senior Medical Officer of CSHW was interviewed
on 19/12/2007 in the hospital library.

70

byimproving

its

serviceSuccessful TQM implementation in Sri Lankan public hospitals

outcome/performance over time. Most of its service

4. Conclusion

outcome/performance rates have succeeded therelevant national figures of Sri Lanka. Consequently,

The purpose of the study reported in this paper was toit has been awarded with several quality awards for

examine how TQM implementation has been

being more responsive to the public demands throughachieved within a Sri Lankan public hospital

successful TQM implementation. Presently, it

alongside an attempt to change its core culturalfunctions as a model public hospital in Sri Lanka.

values. The paper concludes the related findings as

In comparison to the rigid administrative

follows.

setup of the other public hospitals in Sri Lanka

The change of culture at the hospital has(Ministry of Health, Sri Lanka, 2005; Ministry ofoccurred as a result of its Japanese 5S-based TQMHealth, Sri Lanka, & Japan International Cooperation

activities that were implemented in 2000. However, it

Agency, 2003), the employees of CSHW did not

was the democratic leadership and communication ofembrace such rigid organizational structures andthe CEO that functioned as the intermediating factor

thinking,

TQM

for the change from a non-integral culture to an

activities. Moreover, compared to the selected

integral culture. The CEO’s personal values, namely,

national cultural values of Sri Lanka (Nanayakkara,

teamwork, openness, responsiveness, forgiveness,

1999;

practical orientation, and continuation,when

engaging

Samarathunga&in

5S-based

Bennington,

2002;

servedGunathunga, 2003; Wickramasinghe & Hopper,

collectively to create and maintain an ideal type of

2005; Wickramasinghe et al., 2004; Opatha, 2001),

communication with the different categories ofthe employees did not hold on the ingrained schemas

employees (i.e., divisional heads, doctors, nursingthat would have prevented them from being able tosisters and nurses, paramedical staff, midwifery staff,

function using new strategies. Instead, the employees

clerical staff, and support staff) who were engaged in

had faith in the superiority of the common shared

5S-based TQM activities and possessed highpurpose and regarded participation in the process of

integrity. Thus, the CEO’s bottom-up managementchange as a personal aim. Thus, based on an analysis

approach supported by his democratic leadership andof CSHW, it can be argued that communicating with

communication style ensured the ongoing change in

different

the mindset of employees toward the TQM

employee

categories

using

a

bottom-up management approach with democratic

implementation.

leadership is vital for the successful integration of a

Successful TQM implementation in the hospitalchange effort, such as the TQM implementation,

contributed

within the organizational boundaries of public

outcome/performance over time. Most of its service

hospitals in Sri Lanka.

outcome/performance rates succeeded the relevant
71

towardimproving

its

serviceKASP Kaluarachchi

national figures of Sri Lanka. Consequently, theTo overcome the limitations of this single case

hospital was awarded with several quality awards forstudy, future studies on this subject need to be

being more responsive to the public demands throughconducted. Further, comparative studies and survey

successful TQM implementation. Presently, it

research, including private hospitals in Sri Lanka,

functions as a model public hospital in Srishould also be carried out.

Lanka. Thus, the findings reinterpret the previous

Acknowledgments

evidence on public hospitals in Sri Lanka (Ministry of
Health, Sri Lanka, 2005; Ministry of Health, Sri

The author would like to extend his gratitude toLanka, & Japan International Cooperation Agency,

Professors Masao Yokouchi, Yongdo Kim, Noriko

2003).

Taji,andTomofumi

Amano

for

their

The selected national cultural values of Sriguidance. Further, the author would like to thank all

Lanka, i.e., dependence, lack of self confidence,

the members of the MMRC research group of theacceptance of status quo, work as a means, respect for

University of Tokyo for their comments on theauthority, lack of system and perfection, political

paper. Last, but not the least, the author would like tobureaucracy, and poor industrial relations, did not

express his gratitude toward all the study participants

constrain the democratic leadership values of theof the Castle Street Hospital for Women for their kindCEO.

cooperation during the data gathering phase.

On

the

contrary,thedemocratic

leadership values of the CEO impacted the process ofReferences

cultural change at the hospital. Consequently, theCEO was able to change the culture of the hospital

Castle Street Hospital for Women. (2006). Action

from a non-integral one to an integral one in order toplans, 2006. Colombo: Castle Street Hospital for

successfully

Women.

implement

5S-based

TQM

activities. Further, the CEO’s personal values as aCastle Street Hospital for Women. (2007). Annual

whole created and maintained an ideal type

report, 2006. Colombo: Castle Street Hospital forcommunication

Women.

withdifferent

categories

ofemployees, who were engaged in the TQM

Family Health Bureau, Ministry of Health, Sriimplementation process and had high integrity. Hence,

Lanka. (2006). Annual report on family health in

the findings reinterpret previous evidence on the

Sri Lanka 2003–2004. Colombo: Family Healthnational cultural values of Sri Lanka (Nanayakkara,

Bureau, Ministry of Health, Sri Lanka.

1999;

Samarathunga&

Bennington,

2002;

Family Health Bureau, Ministry of Health, Sri

Gunathunga, 2003; Wickramasinghe & Hopper,

Lanka. (2009). Annual report on family health in2005; Wickramasinghe et al., 2004; Opatha, 2001).

Sri Lanka 2006–2007. Colombo: Family Health72

Successful TQM implementation in Sri Lankan public hospitals

Bureau, Ministry of Health, Sri Lanka.

multiplicity: Two major irritants to good industrial

Gunathunga, R. S. (2003). Habermasian way ofrelationsin

Sri

Lanka.

Human

Resource

understanding information systems development inManagement: Interpretive and Explanatory Papers,

organizations in Sri Lanka. Proceedings from: The

1, 10–17.

Ninth International Conference on Sri Lanka

Samarathunga, R., & Bennington, L. (2002). New

Studies, 28–30 November 2009. Matara, Sri Lanka:

publicFaculty of Management and Finance, University of

Lanka. Asian Journal of Public Administration,

Ruhuna.

24(3), 87–109.

Ministry of Health, Sri Lanka. (2005). National

management:

Challenge

for

Sri

Wickramasinghe, D. P., & Hopper, T. (2005). A

quality assurance program for the health services

culturalinaccounting controls: A case study of a textile mill

Sri

Lanka:A

practical

guide

for

hospitals. Colombo: Ministry of Health.

in

Ministry of Health, Sri Lanka, & Japan Internationalapolitical

traditional

economySinhaleseofmanagement

village.

Critical

Perspectives on Accounting, 16(4), 473

Cooperation Agency. (2003). Master plan study for

Wickramasinghe, D. P., Hopper, T., & Rathnasiri,

the strengthening of health systems in the

C. (2004). Japanese cost management meets Sri

Democratic

Lankan politics: Disappearance and reappearance

Lanka.

Socialist
Colombo:Republic
PacificofSriConsultantsof bureaucratic

International.

privatized

Nanayakkara, G. (1999). Culture and Management inutility.

management controls in
Accounting,

Auditinga&Accountability Journal, 17(1), 85–120.

Sri Lanka. Colombo: Postgraduate Institute ofManagement.

[Received October 13, 2009; accepted November 5 2009]

Opatha, H. D. N. P. (2001). Politicization and union73

KASP Kaluarachchi74

ABAS: Annals of Business Administrative ScienceVol. 8 December 2009

CHIEF EDITOR

Junjiro Shintaku, the University of TokyoEDITORIAL BOARD

Makoto Abe, the University of Tokyo
Takahiro Fujimoto, the University of Tokyo
Makoto Kasuya, the University of Tokyo
Nobuo Takahashi, the University of Tokyo
Technical Editor: Maki Nishida, Global Business Research Center

ABAS: Annals of Business Administrative Science is published annually by Global
Business Research Center, Marunouchi, Chiyoda-ku, Tokyo, JAPAN. http://www.gbrc.jp