Canadian Journal of Nursing Informatics


This article was written on 21 Sep 2020, and is filled under Volume 15 2020, Volume 15 No 3.

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The impact of Total Quality Management (TQM) on Efficiency of Health Services in Hamad Medical Corporation – Qatar

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By Wahag Al Mashaer Osman Mahgoub, PhD Candidate, MBA, BS-IT

Nursing Informatics Project Manager 

& Noha Saleh O. S. Ahmed, MD

Nursing Informatics Research Specialist

Nursing Informatics Department Hamad Medical Corporation, Qatar

The impact of Total Quality Management (TQM)

Citation: Mahgoub, W. A., & Ahmed, N. S. (2020). The impact of Total Quality Management (TQM) on Efficiency of Health Services in Hamad Medical Corporation – Qatar. Canadian Journal of Nursing Informatics, 15(3).


Background: The healthcare sector is witnessing remarkable improvement with a noticeable dependency on technology which requires adopting quality standards to monitor, control and enhance the services provided in healthcare organizations. 

Coping with this technological advancement, Qatar has introduced a Clinical Information System into the Hamad Medical Corporation (HMC). This study was conducted to measure the impact of applying quality principles, when implementing the system, on the efficiency of the services provided.

Methods: The study used a descriptive analytical quantitative design where a questionnaire survey was completed by 3947 nurses out of a total population of 10,000 nurses in Hamad Medical Corporation.

Results: The study results revealed a direct correlation between providing efficient training and support for the system and the quality of the health services provided after the implementation of the Clinical Information System. There was also statistical correlation between end users’ satisfaction and adoption of the system and the efficiency of the services.

Conclusions: The paper concluded with a recommendation to apply total quality management (TQM) principles through a clear framework that will contribute to advanced efficiency of health services, raise the levels of satisfaction among users, and increase patient safety.

Furthermore, a training and support model has been suggested for the health sector to adopt when implementing a new Clinical Information System which will enhance performance, streamline the processes and support sustainable improvement.

Keywords: Total Quality Management, e-health solutions, System adoption, System utilization, End-user Satisfaction


Total Quality Management (TQM) first evolved in private industrial enterprises and eventually was applied to other areas like education and health services. TQM is a philosophy that aims to provide organizations with a template for success through customer satisfaction and is a way of managing to improve the effectiveness, efficiency, flexibility and competitiveness of a business as a whole (Rad, 2006; Oakland, 2003).  

Most business organizations implement TQM as a basic approach to face challenges and competition and to increase work efficiency and effectiveness. TQM is based on modern managerial philosophies that mix innovation, creation and technical specialized skills with the aim of improving performance. This approach replaces common practices with the behaviours and culture of quality that raise the organization’s image and enhance its future vision (Tóth & Jónás, 2014).

Quality management in healthcare organizations is a way to re-engineer workflows to achieve a high-quality standard of services provided, better outcomes, patient satisfaction, staff satisfaction and overall improved performance results.

TQM has become important in healthcare organizations during the past few years and recently it has become highly recommended since its eight main principles help them to compete and improve health services. These principles are as follows (American Society for Quality, n.d.2; Tóth & Jónás, 2014):

1. Customer-focused: the customer ultimately determines the level of quality. No matter what an organization does to foster quality improvement—training employees, integrating quality into the design process, upgrading computers or software, or buying new measuring tools—the customer determines whether the efforts were worthwhile. 

2. Total employee involvement: all employees participate in working toward common goals. Total employee commitment can only be obtained when empowerment has occurred, and management has provided the proper environment to integrate continuous improvement with normal business operations. Self-managed work teams are one form of empowerment. 

3. Process-centered: a fundamental part of TQM is a focus on process thinking. A process is a series of steps that take inputs from stakeholders (internal or external) and transforms them into outputs that are delivered to end users (internal or external). The steps required to carry out the process are defined, and performance measures are continuously monitored in order to detect unexpected variation.

4. Integrated system: although an organization may consist of many different functional specialties often organized into vertically structured departments, it is the horizontal processes interconnecting these functions that are the focus of TQM. Every organization has a unique work culture, and it is virtually impossible to achieve excellence in its products and services unless a good quality culture has been fostered. Thus, an integrated system connects business improvement elements to continually improve and exceed the expectations of customers, employees, and other stakeholders. Micro-processes add up to larger processes, and all processes aggregate into the business processes required for defining and implementing strategy. Everyone must understand the vision, mission, and guiding principles as well as the quality policies, objectives, and critical processes of the organization. 

5. Strategic and systematic approach: a critical part of the management of quality is the strategic and systematic approach to achieve an organization’s vision, mission, and goals. This process, called strategic planning or strategic management, includes the formulation of a strategic plan that integrates quality as a core component. 

6. Continual improvement: a major thrust of TQM is continual process improvement. It drives an organization to be both analytical and creative in finding ways to become more competitive and more effective at meeting stakeholder expectations. 

7. Fact-based decision-making: in order to know how well an organization is performing, data on performance measures are necessary. TQM requires that an organization continually collect and analyze data in order to improve decision-making accuracy, achieve consensus, and allow predictions based on history. 

8. Communications: during times of organizational change, as well as part of day-to-day operation, effective communications plays a large part in maintaining morale and in motivating employees at all levels. Communication involve strategies, method, and timeliness. These elements are considered so essential to TQM that many organizations define them, in some format, as a set of core values and principles on which the organization is to operate. 

Managing healthcare organizations is a challenging task within a competitive marketplace serving clients with high expectations. Changes in environment, societal expectations and governmental regulations have significantly impacted the role of government as a main provider of healthcare services with more focus on quality due to, public influence, changes in policies and hospital management initiatives. 

The increasing influence of clients on the healthcare industry turned it to a customer-oriented market rather than a producer or product provider-oriented market forcing governments to find the right balance between standardization and market responsiveness in order to satisfy customer requirements which seek high quality standards (Al-Shdaifat, 2015). 

In healthcare, patients and health care providers are the customers or better yet, are direct strategic partners that participate in important decision-making. A customer-oriented health care system attends to customer needs, providing timely and adequate information, communication, education and training and promoting physical health (Spath, 2013).

With technological advancements ever escalating over time and the rapid adoption of digital health care technologies, all nations are looking to develop easier ways to enable the provision of services in an effective way which led to health organizations paying more attention to total quality programs due to the direct link between TQM and population health. This led to an international focus to exploit the potential of the digital world and provide solutions that can improve and enhance the quality and safety of health care. The main components of e-health solutions that help provide high quality health care to patients include safe systems that comprehensively cover all potential medical conditions (Al-Assaf & Schmele, 1993).

Maintaining high quality standards is very important for health care facilities to gain staff and patient confidence and to provide confirmation of the medical facility’s ability to provide quality services. Hamad Medical Corporation adopted quality standards for many of the services provided many years ago and now with the implementation of the new Clinical Information System the need to adopt TQM became a high priority. In order to assess the impact of TQM on the efficiency of health services when implementing e-Health solutions and to aid decision and policy makers to introduce policies and standards of practice, this study provides a systematic assessment of the impact of adopting e-Health technologies on the quality of care, by drawing on theories, knowledge, and methods from a range of disciplines and applied research and informatics concepts.

The purpose of this paper is to provide a framework for adopting TQM principles during Clinical Information System implementation in the Hamad Medical Corporation facilities which should eventually lead to improvements in the health services provided. The rationale behind this study is to enhance the understanding of the relationship between TQM in implementing e-health solutions, level of performance and staff satisfaction in the hospital under study through the diagnosing of the factors that may affect the quality of the services. Seeking and receiving health care is frequently associated with delays due to the time spent by care providers in completing paperwork. Failure to provide timely care can critically affect the people needing the services or hinder health care delivery and outcomes. This study also investigates how time spent in nursing documentation when minimized by applying e-health solutions leads to staff satisfaction and hence to better quality of care.

Aim of the Study 

The study main aim was:

  • To illustrate the effectiveness of the health care services when adopting TQM in the implementation of a Clinical Information System.

Other Objectives 

  • To investigate how the time spent in nursing documentation affected the quality of health care and how the time spared enhanced that level.
  • To examine the relationships between system adoption and staff satisfaction.
  • To reflect the strategic and systematic approach followed when adopting eHealth solutions. 


Study design 

This study used a quantitative descriptive analytical design to measure the impact of TQM on the effficiency of health services at Hamad Medical Corporation – Qatar.


The research focused on the end users affected by the Clinical Information System implementation at the Hamad Medical Corporation which is the entire population of nurses (10,000).

Out of 10,000 nurses, 3947 (39%) responded to the survey including;

  • Senior Leadership: Directors of Nursing, Nursing House Supervisors and Head Nurses 
  • End users: Charge Nurses and Staff nurses

Data Collection 

The data for this research was collected by a survey questionnaire that was developed by the authors based on a literature review of previous studies (Alzoubi et al., 2019; Boerstler et al., 1996; Campanella et al., 2016; Huryk, 2010). 

The survey questionnaire included eight sections including:

1. End-User Demographics: included age, gender, nationality, job title, facility, education, experience in the corporation, and experience using the system. 

2. Understanding the Customer Focus: to evaluate end user satisfaction, patient safety and equity regarding the system. 

3. Total Employee Involvement: to evaluate the staff adoption of the new electronic system by assessing the ease of navigating the system, ease and time taken in documentation and the involvement of the staff during the life cycle of the system. 

4. Measuring System Integration: in the respect to its effectiveness and utilization.

5. Strategic and Systematic Approach: mainly considering the training and support model adopted during system implementation. 

6. Fact-Based Decision-Making: to assess the post implementation phase and the additional requirements of the staff to close gaps if there are any. 

7. Continual Improvement: to assess what be adopted after implementation to ensure the quality of deliverables and continuous support for decision-making. 

8.Assessing Communication Improvement: among health care providers and knowledge transfer through proper communication strategies. 

Each of the sections (1 to 8) consisted of variable-related questions which were measured using a five-point Likert scale where 1 denoted “Strongly Disagree” and 5 denoted “Strongly Agree”.

The survey questionnaire was launched one year after the Clinical Information System implementation was completed at Hamad Medical Corporation (HMC) to give enough time to evaluate the effectiveness of the system. It was distributed via email to all designated participants. The response to the survey was voluntary and confidential. Participating in the research was not mandatory, thus answering the questionnaire and emailing it back to the researcher was considered equivalent to providing informed consent to participate in the research study.

Data Validation and Reliability

Validity is an essential aspect of quantitative research – both construct validity and content validity that shows the degree of accuracy, objectivity, empirical conceptions, truth, evidence, fact, actuality, and reason in a research work (Kirk & Miller, 1986).   To ensure content validity of the data collection tool, the questionnaire was validated by experts in the fields of Nursing Informatics, Information Technology and Nursing to ascertain its relevance and questions were modified accordingly.

Reliability is the extent to which results are consistent over time and are an accurate representation of the total population under study. A research instrument can be considered to be reliable if the result of a study can be reproduced under a similar methodology; that is the ability of an instrument to be applicable and repeatable, with stability of measurement over time (Golafshani, 2003; Vituri & Martinez Évora, 2015).

In order to check the reliability of the scale used for measuring the responses of the sample, a Cronbach alpha test was performed to validate the data collection instrument and the scale. The questions for the variables were measured using a five-point Likert scale where 1 denoted “Strongly Disagree” and 5 denoted “Strongly Agree” (Table 1). 

Table 1: Reliability Statistics

Table 1: Reliability Statistics

The results of the reliability statistics showed an Cronbach alpha value of 0.925 which indicated that the data collected is valid and reliable and the results of the research can be generalized to the whole population.

Limitations of the Study

The study was conducted in the Hamad Medical Corporation (HMC), the premier not-for-profit governmental provider of secondary and tertiary healthcare in the State of Qatar. The study did not cover the private sector and other healthcare sectors that are implementing health information systems.

The population targeted in this paper was all nursing staff at HMC without considering other healthcare professionals and evaluated a single process (documentation) rather than a set of potential processes involved in care delivery.

The concept of time efficiency reported in the study was opposed by some of the health informatics literature indicating that it is not a reduction in the time used for documentation but rather adapting to the system which saves time in accomplishing a specific task. As well, equity and evaluation indicators in the study were analyzed as the most significant gaps and need to be further investigated.

Finally, most of the papers examined to formulate the literature review for this study were old papers during which technology rapidly changed. However, the results did not reflect the hardware or software evolution. Further studies are required to examine the impact of technological advancement in applying quality standards.


Table 2 summarizes the demographic data for the 3,947 nurses who participated in the study. 79.5 % were female nurses and (46.6%) were between 31– 40 years of age. Staff nurses constituted 80.8% of the participants, while charge nurses and Head nurses were 13.6% and 3.2% respectively. Regarding their educational level, 74.9 % of the surveyed participants had bachelor’s degree in nursing and 19.7% had nursing diplomas. 30.9% had worked one to five years at the Hamad Medical Corporation while half of the participants had used the clinical information system for more than 2 years.  

Table 2: Demographic Data

Table 2: Demographic Data

Table 3 illustrates the findings of adopting TQM principles into the implementation of the Clinical Information System. TQM variables were measured using a five-point Likert scale where 1 denoted “Strongly Disagree” and 5 denoted “Strongly Agree”. In general, the findings revealed that the lowest mean score was obtained for Equity and Evaluation indicators and the second lowest mean was obtained at Utilization and Decision-making which reflected that the most significant gaps existed in Equity and Evaluation. Evaluation may be due to need to reach the system optimization phase while equity concerns questions on the workforce system which needs more elaboration however, some gaps were also seen in the utilization and decision making indicators.  

Table 3: Adopting TQM in the implementation of the Clinical Information System

Table 3: Adopting TQM in the implementation of the Clinical Information System.

Overall, all Total Quality Management (TQM) variables scored over 90% agreement by nurses except for equity where 87.73% of the end users agreed that workforce management assignment permits fair assignments, where both the workforce management system and the clinical information system were recently integrated for managing staff assignments according to patients’ Care Hours (PCH). The majority of the participants (96.78%) were satisfied with the training and support pre, during and post implementation and agreed that the new system increased their confidence and met their expectations and needs by 96.91% and 94.6% respectively. In regard to patient safety, participants showed notable agreement that the implementation of the new clinical system protected patient data privacy and confidentiality (95.08%) and minimized medical errors (94.89%). As for the training, most of the nurses (96.20 %) agreed that the training conducted was effective and provided the necessary knowledge and skills which was reflected by their high satisfaction and easy adoption of the system. 

Correlation Results

This section presents the correlations between all the important variables assessed to measure the nature and strength of the relationship between variables.

The results show that there is a significant, positive and strong correlation between satisfaction and Adoption (R = 0.747, p = 0.000, N = 3947). If adoption increases, then satisfaction also increases (Table 4).

Table 4 Correlation between Satisfaction and Adoption

Table 4 Correlation between Satisfaction and Adoption

The results show that there is a significant, positive and strong correlation between satisfaction and Effectiveness (R = 0.721, p = 0.000, N = 3947). If Effectiveness increases, then satisfaction will also increase (Table 5).

Table 5 Correlation between Satisfaction and Effectiveness

Table 5 Correlation between Satisfaction and Effectiveness

The results show that there is a significant, positive and strong correlation between Satisfaction and Utilization (R = 0.618, p = 0.000, N = 3947). If Utilization increases, then satisfaction will also increase. (Table 6).

Table 6 Correlation between Satisfaction and Utilization

Table 6 Correlation between Satisfaction and Utilization

The results show that there is a significant, positive and strong correlation between Satisfaction and Training (R = 0.614, p = 0.000, N = 3947). If Training increases, then satisfaction will also increase (Table 7).

Table 7 Correlation between Satisfaction and Training

Table 7 Correlation between Satisfaction and Training

The results show that there is a significant, positive and moderate correlation between Satisfaction and Support (R = 0.593, p = 0.000, N = 3947). If Support increases, then satisfaction will also increase (Table 8).

Table 8 Correlation between Satisfaction and Support

Table 8 Correlation between Satisfaction and Support

The results show that there is a significant, positive and strong correlation between Satisfaction and Quality of Deliverables (R = 0.651, p = 0.000, N = 3947). If Quality of Deliverables increases, then satisfaction will also increase (Table 9).

Table 9 Correlation between Satisfaction and Quality of Deliverables

Table 9 Correlation between Satisfaction and Quality of Deliverables

The results show that there is a significant, positive and strong correlation between Satisfaction and Communication (R = 0.667, p = 0.000, N = 3947). If Communication increases, then satisfaction will also increase. All the independent variables had a significant and positive correlation with the dependent variable (Satisfaction) (Table 10).

Table 10 Correlation between Satisfaction and Communication

Table 10 Correlation between Satisfaction and Communication

There was a significant, positive and moderate correlation between Adoption and Training as the sig value (p = 0.000) is less than 0.05 and correlation value is 0.636. It shows that if training increases, adoption will also increase moderately (Table 11).

Table 11 Correlation Between Training and Adoption

Table 11 Correlation Between Training and Adoption

There was a significant, positive and moderate correlation between Training and Patient Safety as the sig value is 0.000 which is less than 0.05 and the Pearson Correlation value iwas 0.579. It shows that if training increases, patient safety will also increase moderately (Table 12).

Table 12 Correlation Between Training and Patient Safety

Table 12 Correlation Between Training and Patient Safety

There was a significant, positive and moderate correlation between Training and Quality as the sig value was 0.000 which is less than 0.05 and the Pearson Correlation value was 0.637. It shows that if training increases, quality will also increase moderately (Table 13).

Table 13 Correlation Between Training and Quality

Table 13 Correlation Between Training and Quality

There was a significant, positive and moderate correlation between Support and Utilization as the sig value was 0.000 which is less than 0.05 and the Pearson Correlation value was 0.543. It shows that if support increases, utilization will also increase moderately (Table 14).

Table 14 Correlation Between Support and Utilization

Table 14 Correlation Between Support and Utilization


The study was conducted one year after the implementation of a clinical information system with an aim to measure the impact of applying quality principles, satisfaction, support, training, adoption, and decision making on the efficiency of the services provided. In general, this result is supported by several studies (Vituri & Martinez Évora, 2015; Talib, et al., 2013). A systematic review of the literature revealed that TQM has been fully adopted in some health institutions for enhancing the quality of services. Alzoubi et al., (2019) concluded that the researched literature showed positive effects of TQM in the health-care context, indicating that TQM implementation, which contains the identified core predictors, will result in higher levels of performance. Furthermore, TQM implementation can help healthcare professionals to develop more quality related behaviors with total commitment to work with patients, which in the long run augments their performance.

The most supported TQM principles in this study were Customer Focus and Total Employee Involvement. The results showed there was significant correlation between end-user satisfaction and the efficiency of the services provided (as shown in the previous correlation results section). This correlation was supported by the case study by Al-Shdaifat (2015) who concluded that efforts should be focused on establishing foundational processes that can inspect and accredit quality in the health care system.

The results of the study showed that the Customer focused principle which included end user satisfaction, patient safety and equity, was supported with the use of the information system, since a notable degree of end user satisfaction and perceived increase in patient safety occurred when patient data privacy and confidentiality were secured, more time was allotted for patient care, medical devices were integrated with the system and minimized errors and staff access to the system was secured. Likewise, Moody et al. (2004) reported information about barriers, frustrations, needs, and preferences of nursing staff. Overall, nurse-respondents perceived EHRs as having the potential to improve patient care and patient safety. in contrast to other study findings by Kukafka et al. (2003) that reflected that training without setting realistic expectations for end users has led to less confident end users in many aspects of system. in other words, adopting strategic and systematic approaches in training and support will set realistic end-user expectations when adopting the clinical system information into their practice thus increasing their satisfaction, perception of augmented patient safety. Patrick et al. (2013) named factors that supported effective Health Information Technology (HIT) which included human behavior, system design, equipment performance, IT skills of participants and the operational framework. Similarly, the findings of this current study support a profound framework for ensuring effective adoption, end user satisfaction and streamlining clinical workflows for ensuring patient safety.

Moreover, applying a strategic and systematic approach showed that the support and training provided to end-users in an effective and efficient manner enhances the health services provided. The training and support model adopted resulted in increased users’ satisfaction and was reflected on employees’ involvement as well, where the end users easily adopted the new technology introduced. This approach was supported by Zhang’s (2014) case study, where it stated that effective training will help organizations overcome barriers and enhance adoption and satisfaction. The findings of the current study showed that the variables of TQM are interrelated, where adopting a strategic and systematic approach to training and support has influenced the findings of other principles.

The implementation of the clinical system has also reduced the time spent in documentation which resulted in less effort, more efficiency and increased end-user satisfaction especially when adopting effective training which enhances system adoption and utilization (Campanella, et al., 2016).

Communication was another effective tool as all the necessary information was made available to the users which ensured their involvement and resulted in end-user satisfaction. Farzandipur et al., (2016) also supported the importance of human factors when implementing a clinical information system, where end user training and preparation of guidelines suited to the user specialty or department, incorporating users’ work needs into the capabilities of the hospital information system, and improving the system to an ideal level are important considerations. In conclusion, the adoption of TQM principles when implementing Clinical Information Systems improves the quality of healthcare services.

Conclusions and Recommendations

The impact of TQM on organizational performance have been discussed in many previous studies. This reflects the importance of quality measures in presenting efficient services. This importance is even greater in healthcare settings where patients’ safety, information security, and staff professionalism are variables that cannot be compromised. The study presented a significant relationship between each of the eight principles of TQM and the efficiency of the services provided which indicates that staff performance and practice is highly influenced and improved.

The adoption of TQM principles in the implementation of the Clinical Information System, not only has ensured easy adoption and effective utilization of the new technology introduced but also assisted to maintain the patient safety and quality of healthcare services provided. Nursing Informatics – Hamad Medical Corporation had ensured adopting the appropriate model for training and support for nurses thus enhancing their performance, increasing their satisfaction and their easily adoption and utilization of the system which ensured patient safety.

From the literature in the area of workflow and time efficiency the benefits of the electronic health systems are still under evaluation form an end-user’s perspective. Future research should be conducted to examine the capacity of the Clinical Information System to further improve the overall care delivery process after identifying gaps of clinical workflow, streamlining process, revising policies and guidelines and adopting best practices in knowledge transfer in addition to optimizing the clinical information systems. It is essential to conduct indepth studies for measuring the return of investment and realizing the benefits of implementation after optimization of the system. 

The study recommends developing new methods to measure the impact of TQM on Efficiency of Health Services from a system perspective. Further research is required to examine the impact of TQM on the Efficiency of Health Services when adopting a standard model developed for healthcare facilities supporting electronic systems according to TQM standards. It is recommended as well that HMC will increase awareness of TQM principles among hospital leaders that can help with hospital accreditation and strategy design, and ensure sustainable improvement.


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Author Bios

Wahag Al Mashaer Osman Mahgoub – Project Manager

Wahag Al Mashaer Osman Mahgoub

Ms. Wahag has been a Project Manager at Hamad Medical Corporation, Qatar since 2007. She holds a Bachelor of Information Technology -Sudan, MBA in E-Business-India, MBA in Quality-Sudan and currently finishing a PhD in Business Administration-Sudan. Before joining HMC, Ms. Wahag was an Academic Supervisor & Teaching Assistant at Future University – Sudan.

Noha Saleh Ahmed -Nursing Informatics Specialist

Noha Saleh Ahmed

Ms. Noha Saleh O. S. Ahmed has been a Nursing Informatics Specialist at Hamad Medical Corporation, Qatar since 2007. She received her M.D. from Alexandria University, Egypt. She  earned a postgraduate diploma in computer applications, from Annamalai University, India. She also had an eleven-year long career as a clinical instructor in the Faculty of Nursing at Alexandria University. Egypt. 

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