Southforke 26 April 1993 Semi structured 2 Quality
Case Study 1 26 August 1993 Semi structured 2 Coordinator
5 January 1994 Semi structured 2
23 May 1994 Semi structured 2
26 September 1994 Semi structured 2
interview
2 February 1995 Semi-structured 2 New Quality
interview Coordinator
Desmond 29 April 1993 Semi-structured 2 Asst. Quality
Hospital 12 August 1993 interview 2 Director
Case Study 2 6 December 1993 2 made redundant
then:
7 January 1994 Semi-structured
(due to change of interview 2 Senior Quality
personnel to Officer
establish why)
18 July 1994 Semi-structured 2 Senior Quality
(went on Maternity interview Officer
leave)
6 February 1995 Semi-structured 2 Senior Quality
interview Officer
Brookeside 10 January 1993 Semi-structured 2 Quality
Hospital 13 September 1993 interview 2 Development
Case Study 3 28 January 1994 2 Manager
17 May 1994 2
18 October 1994 2
3 February 1995 2
June 1994 Postal questionnaire: 1, 2, 3, 4 sent out to 20 TQM sites
17 January 1995 Postal questionnaire 5, sent out to 19 TQM sites
Source: Compiled by the author
During the fieldwork, telephone interviews were periodically held with the Quality Managers to double check comments that seemed confusing to the author. The Quality Managers gave very detailed accounts, and offered lengthy insights into the problems
of TQM within the healthcare setting; particularly the difficulties of getting both top management and the professional staff on board the TQM programme. Of interest was their scepticism of academic postulations and of traditional models for the implementation of TQM. They argued that academics theorise about issues in the NHS but lack the practical tools to bring change about. The biggest indictment to come out of the fieldwork was the failure of the traditional TQM paradigm to have any meaningful influence on the approaches adopted by the managers.
SAMPLING
Since the central thrust of the research was to focus on the implementation of TQM in the NHS, it would only be possible to investigate this phenomena in hospitals that have an up-and-running TQM programme. At the conceptual stage of the study, there were 23 recognised TQM sites of the 292 Trust hospitals, and 175 self managing uniti^1. The 23 sites, as earlier stated, were established in 1989 by the Department of Health to serve as demonstration sites for the implementation of TQM after the Griffiths Enquiry severely criticised the NHS for poor provision of quality care82. Armed with the list of the 23 sites, the author spent a week collecting the telephone numbers of each of the hospitals. Having collected the numbers, the hospitals were telephoned to collect the names of the person(s) in charge of quality. The author also double checked with the receptionist, or whoever the telephone call was transferred to, that the hospital had a TQM programme. On getting the names and appropriate titles, the author wrote in late February 1993 to 23 TQM managers asking for their collaboration with the research. Of the 23 letters sent out only three replied expressing their willingness to serve as collaborators to the study. A follow-up letter to the none replying organisations yielded no further response. Thus, the decision was made to use the three responding hospitals as the cases for the research. However, the identity of the three hospitals would be anonymous because of the promise of confidentiality made at the very beginning of the study. The author did not have the luxury of choosing which hospital to investigate and had to "make-do" with the hospitals which were willing to
Furthermore, the three samples met the objectives suggested by Schatzman and Strauss85:
(a) suitability: the three hospitals had been operating an on-going TQM programme since 1989; as part of the TQM demonstration project. (b) feasibility: the hospitals were accessible, allowing for regular visits.
In addition, the respective quality managers were receptive to the author throughout the entire period of fieldwork.
(c) tactics: the Quality Managers are evangelists of the quality movement. They strongly believe that TQM is the way forward for the NHS; thus enabling a common ground for discussion. This aided the frank and in- depth answers they gave to questions posed by the author.
Prior to the acceptance of collaboration by these hospitals, the author had already determined;
Who : which person would be interviewed? Where : setting for data collection
When : at what times?
What : which events, processes were to be explored?
The "who" in most organisations, be they in the private or service organisation, is the one person appointed to oversee, introduce and implement TQM organisation wide. It becomes the responsibility of this person to identify the what, how and why of TQM within the organisation’s context. Thus, a study into TQM in such an organisation demands that the person spoken to is in the position to offer the researcher a full insight into the organisation’s TQM activities and is also the person designated as having responsibility for implementing TQM. In the NHS such a person is either designated a Quality Manager or Assistant Director of Quality or the Director of Nursing and Quality. This person undertakes to move a hospital through the various stages of the TQM process to the state of continuous quality improvement.
In the author’s opinion, for TQM to succeed entails four essential characteristics: (1) the mode or approach to implementation must be ‘holistic’.
(2) the manager or the organisation needs to be aware of the ‘pitfalls’ or the common mistakes of TQM and learn to avoid them, and improve upon them.
(3) the organisation should build on its key success factors critical to its survival.
(4) there must be constant measurement of the progress made.
Thus, in investigating the progress of TQM in the NHS, it was imperative to carry out an in-depth analysis of these four key components of any TQM initiative. This was the main failure of the Joss et al study. It failed to critically evaluate the TQM initiatives from these key interrelated sequential parts of TQM.
HOSPITALS
The three hospitals which represent the Case Studies will be called Southforke (Case 1), Desmond Hospital (Case 2) and Brookeside Hospital (Case 3) respectively to preserve their anonymity. However, the background to the hospitals is provided in Chapter Six.
DATA ANALYSIS
Qualitative data has been described as an ‘attractive nuisance’86. Its collection is often straightforward. It has a quality of ‘undeniability’ which lends verisimilitude to reports87. There is no clear and accepted set of conventions for the analysis of
meaningful and useful manner89. Bromley90 in his argument for the quasi-judicial approach for analysis of case studies, suggests that throughout the process, four important questions should be kept in mind:
(1) what is at issue?
(2) what other relevant evidence might there be? (3) how else might one make sense of the data? and (4) how was the data obtained?
The quasi-judicial approach is concerned with evidence and argument. Miles and Huberman91, Lofland and Lofland92, Tesch93, and Robson94, suggest basic rules for dealing with qualitative data:
TABLE 3
BASIC RULES FOR DEALING WITH QUALITATIVE DATA
1. Analysis of some form should start as soon as data is collected. Don’t allow data to accumulate without preliminary analysis.
2. Make sure you keep tabs on what you have collected (literally - get it indexed). 3. Generate themes, categories, codes, etc. as you go along. Start by including
rather than excluding; you can combine and modify as you go on.
4. Dealing with the data should not be a routine or mechanical task; think, reflect! Use analytical notes (memos) to help to get from the data to a conceptual level. 5. Use some form of filing system to sort your data. Be prepared to re-sort. Play
with the data.
6. There is no one ‘right’ way of analysing this kind of data - which places even more emphasis on your being systematic, organised and persevering.
7. You are seeking to take apart your data in various ways and then trying to put them together again to form some consolidated picture. Your main tool is comparison.
However, in this study, due to the sample size of 23, the author is of the opinion that descriptive statistics were most appropriate for the analysis of the data. As Goulding95 noted, ‘the methods most... useful in analysing information gained from investigations
of a limited sample are those of descriptive statistics; whether the information arises from questionnaires which respondents themselves complete, or whether it arises from a structured interview or both, makes no difference to the way the data can be handled’. Descriptive statistical methods provide ‘pictures’ of the group under investigation; these ‘pictures’ maybe in the form of Charts, Tables, Percentages, or Averages96. In line with Goulding’s argument, the analysis of the data gathered from the questionnaires would adhere to the use of descriptive statistics in which tables would be used for questionnaires 1-5 to show percentages and the patterns of responses. However, from each table, the prime aim would be to draw implications from the data. Whilst the analysis of the semi-structured interviews held with the three Quality Managers, that is the case studies, would be analysed in the context of Yin’s ‘explanation building’ theory97 because it fits this research best. In a multiple case study, as is the case with this study, the aim of explanation building is to develop a general explanation that fits each of the individual cases, even though the cases vary in their detail98. The cases consist of an accurate account and rendition of the facts and conclusions are drawn based on the simple ‘explanation’ that appears most congruent with the facts99. The research process used in this study is akin to detective work where the detective’s purpose is to establish an explanation of the crime. He is shown the scene of the crime, its description, eye-witness report and must judge the relevance of the data in devising his explanation. The requisite explanation becomes a credible depiction of a motive, and method which fully accounts for the facts than do alternative explanations100. Thus, in moving from one case to other cases, from within case to cross case, the detective may be able to use the first explanation to establish that both crimes were committed by the same person101. In this study, an accurate rendition of the cases will be undertaken, a critical appraisal of the individual cases to judge the relevance of the ‘mode of implementation’ to the holistic nature of TQM will be offered, followed by the major goal of the research; a cross-case analysis to depict elements of ‘commonality’ between the cases. This will be compared to the brief summary of twelve other individual cases (see Chapter Four) established through the wider survey. The aim being to find a common ‘explanation’ on the ‘mode’ of TQM
will provide results from which deductions can then be made. This will ensure that the theoretical postulation to be offered in this study is ‘grounded’ in data.
HOW THE QUESTIONNAIRES WOULD BE ANALYSED QUESTIONNAIRE Is
A tabulation representing a brief summary of the implementation process of the 12 hospitals that replied to the survey. As Yin102 suggests... ‘there is no need for any simple case report but a brief summary of individual cases’. The aim of the tabulation is to support the ‘explanation’ that the NHS has adopted individualised approaches to TQM rather than the orthodox TQM models.
QUESTIONNAIRE 2:
The Crosby Quality Maturity Grid103 will be analysed using Crosby’s suggested scoring format. Each stage of the grid has a score corresponding to the stage number. Example: Stage 1, Score = 1; Stage 3, Score = 3. Each stage has five categories, hence a maximum score of 30 is achievable.
QUESTIONNAIRE 3:
Stoner and Freeman104 identified four interrelated activities expected of any managerial process; planning, organising, controlling and leading. Similarly, in extending Stoner and Freemans’ work, the author has identified four key elements of any managerial process, essential for the successful implementation of TQM. These include:
(1) management systems and processes (2) workforce
(3) senior management
The 40 generic factors were broadly categorised to fit each of the four elements. Thus, questionnaire 3 will be analysed from the four complementary perspectives which are essential and which must work in unison for TQM to work. Furthermore, a table with percentages will be provided to show the pattern of responses. The percentages represent highest scoring statements of which 40 per cent is seen as least score. Scores between 40-100 are taken as significant. The computation of the percentages will be done using the Statistical Package for Social Science (SPSS). Thus, Table 18 in Chapter Five will show hospitals by obstacles, observation rate and row percentages. This is in contrast with the widely held view that qualitative research is incapable of statistical analysis.
QUESTIONNAIRE 4:
The analysis of questionnaire four would be based on the presentation of a table which shows the pattern of responses for each of the seven gaps in percentages for the individual hospitals.
QUESTIONNAIRE 5:
Because questionnaire 5 asked the respondents to answer Yes or No to each of Parker and Porters’ eight critical success factors, for the purpose of coding, before the questionnaires were sent out, two numbers were attached to each question. For example, question number one in the questionnaire reads:
‘Necessary Management Behaviour: Clear leadership, commitment and vision is required for senior management’. Is this significant in the NHS in your experience?
YES NO
The numbering is known as nominal scales106. For instance, the analysis of the nominal data collected in the 23 TQM sites would be the totalling of the ‘yes’ responses (coded 1) and the ‘no’ responses (coded 2). For example, if out of the 20 returned data, eleven have responded yes, the percentages would be represented in a table of the total number, i.e.
For the yes responses, it would read:
i i
20 x 100 = 55%
Thus, the table for each of the questionnaires 2-5 will show percentage scores. Nevertheless, the aim is to draw implications from the data in order to build theory. Qualitative and quantitative research, as earlier noted, differ in that qualitative research is often developed when little information is available on a topic107. The researcher plans to look for and describe attributes, themes, and underlying dimensions of a particular unit in order to discover what distinguishes the characteristics or attributes of the unit. The quantitative research aims to measure the magnitude, size, or extent of the units108. Although polar types of qualitative and quantitative research may be developed, this research contains features of both.
Features of qualitative research include the case study method which is usually inductive and deductive. The methods for data collection, included in-depth face-to- face semi structured interviews. This enabled the collation of the opinions of experts; that is the Quality Managers. Features of quantitative research include the use of postal questionnaires which were mainly deductive i.e. to identify modes of TQM, difficulties, measurement and critical success factors of TQM in the NHS.
Lastly, the author will argue that in considering the choice of techniques for research, irrespective of whether the methodology chosen is quantitative or qualitative, three features are important:
(1) how well does the technique illuminate the views or experiences of the respondents?
(2) representativeness; to which other groups in the population or the organisation does the information elicited relate?
(3) resources; what expertise, people, time, cash, would be required by the technique?
RELIABILITY AND VALIDITY
To ensure that the data collected is reliable and valid, on writing up the three cases, the author sent it to the respective Quality Managers for their review and input, in order to ensure that the rendition of the cases are accurate from the information they gave during interviews.
EXTERNAL VALIDITY
The findings in the study were compared to earlier studies in the field which had previously evaluated TQM initiatives in the NHS. This was done in order to establish:
(a) consistency of results (b) provision of new evidence
In the final analysis, it would suffice to note that the theories and TQM models generated in this study, in the words of Glaser and Strauss, ‘is grounded in empirical data’109.
REFERENCES
1. Kogan, M., Henkel, M. and Spink, M. (1991) "Evaluation of Total Quality Management Projects in the NHS", First Interim Report to the Department of Health, Centre for the Evaluation of Public Policy and Practice, Brunei University.
2. Kogan et al, op. cit. 3. Kogan et al, op. cit.
4. Ente, B. H. (1989) Brief Overview of the Joint Commission’s "Agenda for Change", Chicago.
5. Deming, W. E. (1986) ‘Out of the Crisis’, Cambridge Massachusetts Institute of Technology.
6. Juran, J. M. (1988) "Juran on Planning for Quality", New York; Free Press. 7. Feigenbaum, A. V. (1983) "Total Quality Control", McGraw Hill.
8. McLaughlin, C. P. and Kaluzny (1990) Total Quality Management in Health: Making it Work. Health Care Management Review 15:7-14.
9. Personal communication (1993).
10. Donabedian, A. (1988) Quality Assessment and Assurance: Unity of Purpose, Diversity of Means. Inquiry 25:173-192.
11. Nwabueze, U., Morris, D. and Haigh, R. (1994) "Quality: The Linkage between Definition and Doing in the British National Health Service". Paper presented at the EFQM Conference, Barcelona, Spain.
12. Lanning, J. A. (1990) "The Healthcare Quality Quagmire: Some Signposts". Hospital and Health Services Administration 35:1 Spring.
13. Kelman, H. (1976) "Evaluation of Health Care Quality by Consumers". Journal of Health Services 6, No. 3.
14. Sandrick, K. (1986) "Quality: Will it Make or Break Your Hospital?" Hospitals 60, No. 13:54-58.
15. Eskildson, L. (1994) ‘Improving the Odds of TQM’s Success’. Quality Progress, April.
17. Clemmer, J. and Sheehy, B. (1992) "Firing on All Cylinders: The Quality Management System for High-Powered Corporate Performance". Piatkus Publishers.
18. See BBC Business Programme September 1993.
19. Smith, S., Whittle, S., Tranfield, D. and Forster, M. (1991) "Implementing Total Quality: Erecting Tents or Building Palaces". Paper presented at the Sixth International Conference of OMA. U.K.
20. Kogan et al, op. cit.
21. Shani, A. B. and Rogberg, M. (1994) "Quality, Strategy and Structural Configuration". Journal of Organisational Change Management. Vol. 7 No. 2. 22. Joss, R., Kogan, M. and Henkel, M. (1994) "Total Quality Management in the
National Health Service: Final Report of an Evaluation". Centre for the Evaluation of Public Policy and Practice, Brunei University.
23. Grant, R. M., Shani, A. B., and Krishnan, R. (1994) "TQM’s Challenge to Management Theory and Practice", Sloan Management Review. Vol. 35 No. 2, pp. 25-35.
24. Joss et al, op. cit.
25. Dailey, G., Baldwin, S., Carr-Hill, R., Hennessey, S. and Smedley, E. (1991) "Quality Management Initiatives in the NHS: Strategic Approaches to Improving Quality". OMI Series No. 3. University of York.
26. Haigh, R. and Morris, D. (1991) "Introducing Total Quality Management into an Alien Organisational Culture". Paper presented at the Annual National Quality Conference, Atlanta, Georgia, February 14-15.
27. Yin, R. K. (1989) "Case Study Research: Design and Methods". Applied Social Research Methods Series Vol. 5, Sage Publications.
28. Yin, R. K., op. cit. 29. Yin, R. K., op. cit. 30. Yin, R. K., op. cit.