## 3 Results
### Delphi Study with Expert Panels
#### 3.3.1 Delphi First Round  
The TQIM-H, after the literature review and case study analysis, and before conducting the IPA analysis, had 37 factors. The Likert-scale questionnaire results of TQIM-H factors were analyzed using IPA methodology. After the IPA analysis, we retained 23 TQIM-H factors and called them refined TQIM-H factors. Figure 4 shows the analysis of the importance and working performance level of the TQIM-H factors by the IPA graph. The \(x\)-axis provides the performance level of each TQIM-H factor scored by 30 healthcare experts while the \(y\)-axis shows the importance level of each TQIM-H factor provided by 30 expert panels. The TQIM-H factors in the first and second quadrant were used to develop the TQIM-H conceptual framework since they are important. This IPA analysis reduced TQIM-H factors from 37 factors to 23 factors. The descriptions for factors in the four quadrants (Figure 4) are demonstrated in Table 4.  
Figure 3: The integration of TQIM-H. Code A: Quality management in healthcare factor, Code B: Innovation management in healthcare factor. From analyzing the TQIM-H factors, we found high importance levels but low performance levels in the first quadrant because all of these factors did not have the organizational regulation and KPI that measured tangible performance. Thus, healthcare workers did not give priority to improving and providing effective management. In addition, the organization did not have a policy and action plan on these factors. However, expert panels recommended that organizations should focus on and emphasize TQIM-H factors in the first quadrant since the factor in the first quadrant may be the key success factor in managing effective quality and innovation in healthcare. To achieve high organizational performance, hospitals should provide an organizational strategy and plan to efficiently manage these factors. Then, after analyzing TQIM-H factors in the second quadrant, the author and expert panels found that these factors were important and had high performance because all of these factors were used as criteria and Key Performance Indicators (KPI) of an organization. Moreover, some factors in this quadrant represented medical regulation and quality stan  
\begin{table}
\begin{tabular}{c c c} \hline \hline Dimension & **Sub-Factor** & **Reference** \\ \hline \multirow{6}{*}{**Context of the Environment (Internal and External)**} & A2.1 Customer (patient, etc.) satisfaction & [41,42,45,47,48,50,54,56,57,59,60,62] \\  & A2.2 Solving the patient’s complaints. & [42,45,47,51,54,57,59,60,62] \\  & A1.1 Informing the hospital’s achievements & [41,48,50,52,53,56,56,50,62] \\  & A5.41 Histogram law refers to the rules and practices & [41,44,46,48,51,53,55,56,56,51,62] \\  & B1.1 Technological change & [43,45,45,47,49,50,53,55,56,59,61,62] \\  & B1.2 Customer segment and customer needs & [41,45,47,51,52,54,56,59,60,61] \\ \hline \multirow{6}{*}{**Leader**} & A1.1 Resources allocation from the leader & [41,43,45,45,56,58,60,62] \\  & A1.2 Leader vision, Policy & [41,43,45,45,56,58,52,58,61,61] \\  & A1.3 Assuming responsibility from the leader & [43,45,47,48,50,54,55,57,58,61,62] \\  & A1.4 Supporting employees’ suggestions from the leader & [41,46,48,50,54,56,57,60,61] \\ \hline \multirow{6}{*}{**Planning**} & A5.1 Organizational strategy & [42,45,47,48,54,56,57,60] \\  & B2.1 Creating an organizational goal & [42,43,46,50,52,56,57,59,61] \\  & B2.2 Alignment of innovation & [45,48,50,53,54,56,60] \\  & B2.3 Innovation initiative with business needs and strategy & [41,42,45,46,48,50,51,55,56,59,61,62] \\ \hline \multirow{6}{*}{**Support**} & A4.2 Educating employees and training programs. & [43,45,51,54,57,59,61,62] \\  & B3.1 Facilities, e.g., laboratories, space, etc.