Interpretation of findings
This study is largely based on the premise that it is possible to apply the principles of Total Quality Management to healthcare organizations. Despite the fact that this model was initially developed for the needs of manufacturing companies, it can be of great use to medical institutions (Bowling, 1997). The results of literature review and the survey that has been undertaken did not undermine the validity of this approach.
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More likely they have demonstrated that administrators should take into account the peculiarities of the organization, itself, and cultural environment in the region; otherwise such strategies TQM and JCI accreditation will not be successfully implemented. The growing number of healthcare organizations in the Kingdom of Saudi Arabia is willing to implement JCI standards. At the moment, there are more than thirty JCI-accredited hospitals in thirteen cities (JCI, 2011, unpaged). To some degree this evidence indicates that, JCI standards and TQM approach are growing more and more popular in this country.
However, one should take into account that the administration of a hospital should regard JCI accreditation only as the first step to continuous improvement; otherwise their attempts will be doomed to failure. On the whole, academic sources as well as the experiences of Saudi Arabian medical workers suggest JCI accreditation is conducive to better performance of medical institutions. Yet, one can say that implementation of JCI standards varies across countries and hospitals. Furthermore, total quality management and JCI accreditation should not be perceived as interchangeable notions. In the following sections, this argument will be further elaborated.
The quantitative information provided by hospitals indicates that there is statistically significant relationship between the adoption JCI standards and patient safety. In particular, according to the report issued by Dr. Soliman Fakeeh Hospital, the number of non-compliance cases was reduced by almost 75 per cent (Dr. Soliman Fakeeh Hospital, 2010, p 52). Moreover, the same statement can be applied to the level of patient and staff satisfaction.
It should be noted that the administration of Dr. Soliman Fakeeh hospitals conducts surveys among patients and employees regularly. This attentiveness toward the opinions of the staff and customers is an inherent part of total quality management. In part, these data partially support the argument that adoption of JCI standards can improve workplace practices in a medical organization. It is worth mentioning that the administration of Dr. Soliman Fakeeh Hospital referred primarily to JCI accreditation; they did not focus on total quality management. However, judging from their report, one can say that this institution actively embraced the principle of TQM, namely regular training offered to the staff, strong committeemen to the needs of the customers, and regular assessment of service quality.
One should bear in mind that statistical data about Saudi Arabian hospitals is not sufficient for giving any definite answer about the effectiveness of JCI accreditation and total quality management. The thing is that Saudi Arabian hospitals began to adopt JCI standards only in 2001, while others did it in later years. This period is too short for in-depth analysis, and one has to take this limitation into account. Still, despite this limitation the statistical information that JCI-accredited hospitals have already made considerable progress, and they can enhance their performance even more in the year to come.
Apart from that, Saudi hospitals, which received JCI accreditation, were able to dramatically increase their revenues, but their total costs were increased (Dr. Soliman Fakeeh Hospital, 2010, p 6). In part, this fact contradicts the principles of TQM which strived to reduce operational expenses of an organization. This is the difference between Saudi Arabian hospitals and Western medical institutions. Nonetheless, it is quite probable that the situation will change in the future because TQM cannot yield results immediately. The findings point to a very curious pattern; at the very beginning, JCI-accredited hospitals can record higher levels of injuries and other cases of non-compliance; such situation was observed in Dr. Soliman Fakeeh Hospital, especially during the first two years after accreditation (Soliman Fakeeh Hospital. 2008, p 22).
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However, in subsequent years the number of non-compliance cases declined. There are several ways of interpreting these data; one of them is that very often non-compliance cases such as medication errors or needle injuries are poorly reported. In turn, TQM approach is based on the premise that every deficiency has to be reported. Judging from this information, one can conclude that a hospitals, implementing TQM and JCI standards, should not look only for short-term gains. Such expectation overlooks the underlying principles of total quality management. These issues should be taken into consideration by administrators, who intend to change the policies and performance standards of Saudi healthcare organizations.
These people must know what kind of pitfalls should be expected and how these pitfalls can be avoided. It is also possible to argue both scholars and practitioners are not unanimous in their evaluation of the benefits, brought by JCI accreditation. Their key argument is that the outcome of JCI implementation greatly depends on the goals, pursued by the administration of the hospital. For example, the critics of this accreditation believe that many hospitals implement JCI accreditation for marketing purposes; however, they do not apply the principles of total quality management and especially total quality management (Kowalczyk, 2007, p 1). As a result, the quality of their work was improved significantly.
This claim was supported by some of the respondents who were interviewed in the course of this study. Thus, one can argue JCI accreditation can yield fruits only the management of medical institution continuously assesses the results and promotes the adoption of best practices. Hence, the criticism of JCI accreditation can be explained by the fact that different hospitals approach this task, bearing different goals in mind. If the primary intention is to increase patient’s awareness about the clinic, the new policies are rather unlikely to bring significant quality improvement. Nonetheless, if administration genuinely intends to assure patient’s safety and promote employee education, they will genuinely benefit from adopting JCI standards and adopting TQM principles. This is probably the most important issue that has been identified in the course of this study.
Another pattern that becomes quite noticeable is that successful adoption of JCI standards is inevitably connected with deep organizational changes. Namely, one can speak about such changes to the shift toward patient-centered healthcare, elimination of formal barriers among the colleagues, willingness of the management to assist employees with their tasks, for example, by providing training to the staff. These changes are indispensable components of TQM philosophy, and they normally accompany JCI accreditation. Another very important issue, related to the introduction of JCI standards is that they are good tools for the evaluation of hospital’s performance.
In this case, one has to speak about the scales which help to measure customer satisfaction or patient satisfaction. Furthermore, one should not overlook the important of such measurements as the number of non-compliance cases, like infection or injuries. Both Western and Saudi Arabian hospitals make full use of these assessment tools (Walston, Al-Omar, & Al-Mutari, 2010; Dr. Soliman Fakeeh Hospital).
These are the patterns, which are described in academic sources and which are supported by the empirical research. It has to be acknowledged that JCI accreditation remains very costly, and many medical institutions in Saudi Arabia and other countries cannot afford it. Therefore, the administration of medical institutions must make sure this investment is not spent in vain. By focusing only on marketing and short-term gains, they will overlook many benefits which total quality management can yield.
Difference between this research and findings of other people
At this stage, it is necessary to compare the results of the interview with the information provided by other researchers. Certainly, the scholars as well as our respondents expect JCI accreditation to improve the quality of patient care (Pasternak, 2009). Nonetheless, one should point out that in some cases, the expectations set for JCI model do not coincide. For instance, none of the respondents believed that cost-reduction was the main rationale of introducing TQM principles and JCI standards. As it has been mentioned in the previous section, the advocates of TQM approach to medicine also emphasize the importance of cost reduction (Kanji & Moura, 2003).
Those people, who were interviewed during this study, also expected the new model to contain costs. However, judging from their responses, the adoption of JCI standards enabled them to improve the quality of care, but it did not allow them to reduce their expenses. Thus, business administrators should determine why this goal was not attained. By doing it they manage to improve financial performance of Saudi Arabian hospitals in the future.
Still, one should assume a very skeptical attitude toward JCI standards and total quality management. The outcomes of these innovations should be assessed from the long-term perspective. More importantly, the experts, who were surveyed, spoke about the necessity to enhance people’s trust in Saudi Arabian hospitals. Hence, it is possible to argue that failure to achieve cost reduction can be accounted by the difference in expectations.
Another example that attracts attention is attitude toward patients’ rights. Joint Commission International strives to achieve better protection of patients’ rights (Joint Commission 2010b). Those medical workers, who were interviewed, did not mention this task. To some degree, this difference can be explained by the fact that the respondents viewed protection of patients’ rights as something self-evident.
Currently, Saudi Arabian hospitals are willing to embrace TQM approach which proved to be effective in other countries. At the moment, this country has the largest proportion of JCI-accredited hospitals in the Middle East. Moreover, Saudi medical workers are fully aware of the improvements brought by this method. Apart from that, Saudi Arabian experience indicates that JCI can productively cooperate with governmental organizations, such as CABHI (Central Board for Accreditation of Healthcare Institutions). This partnership ensures that medical institutions do try to reach the highest performance standards.
Overall, it is possible to say that the differences in JCI implementation can be accounted by the fact Saudi hospitals are closely monitored by the state, while Western hospitals are more independent. This examples indicate that implementation of total quality management and JCI accreditation is strongly influenced by political culture of the country. Additionally, this case illustrates that assistance of governmental institutions can be quite beneficial for Joint Commission International.
The responses of the interviewees show that there is a significant relation between the JCI accreditation and improvement of patient care. Moreover, it is quite permissible for us to reject the null hypothesis. These improvements include better risk management and infection prevention, better organizational processes, and improved cooperation. Yet, researchers and business administrators stress the importance of employee empowerment (Al-Dabal, 1999, p 14).
The healthcare professional, who participated in this study, did not pay the same attention to this issue. Thus, one can say that the expectations set for JCI accreditation often vary. These expectations may depend on social or cultural environment in the country. The thing is that in Saudi Arabian organizations the power distance between employees is very long, and people are more likely to pay attention to the formal barriers existing between the top-management and frontline personnel (Hoftede, 2011, unpaged). Furthermore, one should bear in mind that the level of uncertainty avoidance is much higher in Arab countries than in the Western world.
This means that the employees of Saudi Arabian hospitals are less willing to take risks unlike their American or European counterparts (Hoftede, 2011, unpaged). Overall, the notions of power distance and uncertainty avoidance can help us understand why some of the TQM principles such as employee empowerment were not fully applicable to Saudi Arabian hospitals. Yet, it is necessary to emphasize the point that the exact outcomes of JCE accreditation can be effectively measured only after a longer period of time. Erasure of formal barriers and democratization of the workplace cannot happen instantaneously. Many Saudi hospitals were accredited by Joint Commission International only several years ago. It is quite probable that changes in managerial style will occur only in the future.
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This information can be used by those administrators who will try to implement TQM approach in Saudi Arabian hospitals. For instance, they should bear in mind that in many Saudi Arabian hospitals the establishment of JCI standards did not contribute to the cost reduction. Moreover, employee empowerment is an inseparable part of TQM, and this organizational change was not observed in Saudi Arabian hospitals. On the whole, these results have made me firmly convinced that there is no universal pattern for the adoption of TQM principles. The management has to consider such issues as business culture, political system of the country, the values of employees and patients and so forth; otherwise their efforts will not succeed.
The key conclusions
These findings can change several perceptions of JCI accreditation and Total Quality Management. First of all, these notions should not be considered as something synonymous. In itself, JCI accreditation only indicates that at a certain point in time, a hospital can meet certain performance standards. Moreover, it shows that its employees possess certain skills and competencies. However, as it has been said many organization adopt this approach mostly for marketing purposes, and in this case, one cannot speak about genuine shift to TQM approach. The second issue that should not be overlooked is that one should not expect JCI and TQM implementation to bring immediate improvements.
The thing is that at the beginning the adoption of TQM approach can only allow the hospitals to pinpoint the deficiencies in organizational design. Only through continuous training of the personnel and meticulous reporting the administration will be able to eliminate these deficiencies. The third aspect is cultural differences which can exist between countries. The business culture of Saudi Arabian organization is not similar to that one of Western medical institutions.
In Saudi Arabia, formal relations among members of the staff play more important role, and these barriers cannot be easily erased. Therefore, people should not perceive TQM and JCI accreditation as universal experiences, which are similar in different countries of the world. This discussion leads to the conclusion that JCI accreditation is only a part of TQM philosophy. Overall, the findings suggest that there is a positive relation between the adoption JCI standards and improvement of patient safety and customer satisfaction. It is possible to single out such perquisites for successful implementation of JCI standards and TQM principles:
- willingness of the administration to improve quality of patient care, rather than intention to advertise the hospital;
- skillful use of different measurement tools, which evaluate the degree of patient and employee satisfaction;
- meticulous reporting of non-compliance cases such as infections or needle injuries;
- regular training provided to the employees;
- patient-centered healthcare.
These conditions are indispensable for the success. The findings of this research can be utilized by those Saudi hospitals, ambulatory services and medical laboratories, intending to apply the principles of total quality management.
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