Indonesian Enterostomal Therapy Journal

Research in Wound, Ostomy

& Continence care
IETJ Vol 1 No 1
Contents available at https://journal.wocare.org/index.php/ietj

Implementation Total Quality Management (TQM) in Wound

Care Unit
Devi Sahputra1 & Co Author : Paul Lumbantobing2
1
Faculty of Medicine, Universitas Pelita Harapan, Indonesia
2
Faculty of Business, Universitas Pelita Harapan, Indonesia

corresponding: devisahputra09@gmail.com

ABSTRACT

Background: The quality of management has become a problem and big issues of the late
decade in Indonesia's professional nursing practice. Total quality management could identify
a health organization system's performance to improve patient satisfaction and patient safety
for wound care unit services as a centre of excellence.
Purpose: The purpose of this study is to analyze the implementation of total quality
management (TQM) to the performance of professionalism in wound care unit in Jabodetabek
Methods: This study's design is a sequential explanatory design with 105 respondents as
CEOs of wound care unit. The data analysis was using PLS-SEM and running with SmartPLS
version 3.0
Results: The main results of this study are the correlations and influences among the
components of TQM including leadership, strategic planning, customer focus, measurement
analysis knowledge management, staff focus and process management on professionalism
leadership performance outcomes in wound care unit
Conclusion: The implementation of TQM improves the performance of the organization and
becomes strategic factors for evaluation and implementation of sustainability improvement

Keywords: TQM; Continuous quality improvement; Wound Care Unit

BACKGROUND
Quality is an important thing in consideration of an executive. There is increasing awareness
of the fact that quality is an important strategic issue, which must be implemented at all levels
of the organization. The quality management system is defined as "a series of coordinated
activities to direct and control the organization to continue to improve the effectiveness and
 Indonesian Enterostomal Therapy Journal

efficiency of its performance". According to Oakland (2003), organizations must make
strategic decisions to adopt a quality management system based on the organization's
strategy, objectives, structure, size, products, and services. This also applies to the health
sector. In general, Total Quality Management (TQM) is a management philosophy used by
organizations that seek to increase their efficiency and competitiveness in the business
market. TQM quality factors include top management commitment and involvement,
empowerment and employee culture. Some authors know these factors as the soft aspects of
management, whereas the hard aspects include factors such as improvement tools,
techniques and systems. Various scholars identified various quality factors based on their
experience working as consultants, managers or researchers (Thiagarajan et al., 2001).

Research conducted by Rad (2005) in investigating the success factors and obstacles to the
implementation of TQM in health service organizations in the province of Isfahan-Iran found
that health service organizations have been successful in implementing TQM in improving
performance which turned out to be more influenced by process management, customer
focus, and focus on staff, while the most important constraints are human resources, strategy
and organizational structure. While Alolayyan, Ali, & Idris (2011) conducted a study on the
application of TQM practices and assessed its effect on operational flexibility in three hospitals
in Jordan, they found that TQM practices significantly influence the intensity of operational
flexibility in Jordanian hospitals.

In Indonesia, there is no Quality Management study for wound care unit. This encourages
increased customer awareness and expectations for safety, quality, technological advances
and communications. Much research on TQM in wound care unit has been conducted in
developed countries, but very little has been done in developing countries. In Indonesia, there
are more than 600 wound care unit that provide services in the community. An important goal
of wound care unit is to help patients stay in the setting of community life. The existence of
wound care unit in Indonesia has improved patients' quality of life with injuries and reduced
the cost of hospitalization. Based on Law No. 38 of 2014 concerning nursing, nurses have the
authority to organize wound care unit. This independent wound care practice is growing rapidly
and has become at the forefront of using the latest and evidence-based methods with various
other innovations. This is because independent practice operates in the private sector and is
not tied to complex bureaucracies, and always updates knowledge and skills regularly.
However, wound care unit in Indonesia has not implemented quality standards to improve the
performance of an organization. So that through this study it is felt necessary to study the
analysis of the factors that affect the integrated quality management of the TQM method in
wound care unit to meet the demands and needs of customers/patients to achieve
performance excellence, get better competitive advantages, and patient satisfaction.
Customers in the long run.

OBJECTIVE
This study aims to analyze the application of total quality management (TQM) to the
performance of wound care unit in Jabodetabek.

METHODS
The design of this study is a sequential explanatory design (sequence of proof), where the
researcher collects data and analyzes quantitative data in the first stage, and is followed by
qualitative data collection in the second stage, to strengthen the results of quantitative
research carried out in the first stage with questioners Malcolm Baldrige Health Care Criteria
for Performance Excellence (MBHCfPE). The samples were recruited by cluster sampling with
 Indonesian Enterostomal Therapy Journal

105 CEO wound care unit for quantitative and 6 informants for qualitative. The inclusion criteria
were CEO Nursing Private Practice, aged ≥18 and ≤65, Length of work > 1 year, and reading
and communicating in the Indonesian language. Content validity for this study was conducted
by comparing between the measurement items of each variable with an extensive review of
the literature related to the critical success factors of TQM implementation and evaluation
criteria of MBHCfPE; measures used in this study were capable of capturing TQM factors.

RESULTS
The study participants included 105 participants who were recruited from Ceo’s wound care
unit Jabodetabek area. Table 1 show that 34% of respondent form Jakarta. Most of participant
58.6% were male. More than half of the participant had a bachelor level (54%), and 5.7% had
nursing specialist. The most type of service is wound care (57.5%). The most case in wound
care unit were Diabetic ulcer (78%). The most participant working experience were 5 until 10
years (55.2%). CEOs whose gross income is less than 10 million have a higher frequency of
51.7%, compared to CEOs with gross revenues of 51 to 100 and more than 100 million, which
is 5.7%. The Nursing Private Practice with the Number of Visits less than 50 visits has a higher
frequency, namely 52.9%, compared to wound care unit with 101-200 Visits, which is 5.7%.

Table 1. The socio-demographic data of the sample

Respondent Variables
Area Practice Jakarta Tangerang Depok Bogor Bekasi
Percent (%) 34% 13% 17.2% 19% 16.8%
Sex Male Female
Percent (%) 58.6% 41.4%
Education Level Diploma Bachelor Magister Specialist
Percent (%) 16.1% 54% 24% 5.7%
Type of Services Wound Wound, Nurse General
Ostomy and Specialist
Continence
Percent (%) 57.5% 32.3% 2.2% 8.1%
Type of Cases Diabetic Ulcer Cancer Pressure Injury Acute
Wound Wound
Percent (%) 78.2% 7% 7.8% 7%
Experience <1 Years 1-5 Years 6-10 Years >10 Years
Percent (%) 11.5% 55.2% 24.1% 9.2%
Total Income <10 Million 10 – 50 51 – 100 >100 Million
Million Million
Percent (%) 51.7% 36.9% 5.7% 5.7%
Visited per Month <10 51 – 100 101 – 200 >200
Percent (%) 52.9% 34.5% 5.7% 6.9%
 Indonesian Enterostomal Therapy Journal

To the analyst, the degree of implementation of the seven MBHCfPE Criteria such as
(leadership, strategic planning, customer focus, Measurement of Knowledge Management
Analysis, staff focus, process management and performance results). In addition to the mean
score obtained on a 4-point Likert scale for the MBHCfPE criteria, percentage degree of
implementation was calculated for each item by dividing the mean by the maximum possible
rate on the 4-point Likert-type response format, in this case, 5. The analysis results are
summarized in Table II, which shows the mean and factor loadings for each measurement
item for the seven factors and the Average Variance Extract (AVE) scores for each factor.
Table II. Validity Convergent Actual: Mean, Factor Loading & AVE
Item Variable Mean Factor Loading AVE
KP1 3.28 0.79 0.66
KP2 3.13 0.80
KP5 3.43 0.84
KP7 3.14 0.89
KP8 3.18 0.89
KP9 3.06 0.78
KP10 2.90 0.71
KP11 3.31 0.85
KP12 3.52 0.76
KP13 3.15 0.78
KP14 3.30 0.78
PS 1 3.16 0.86 0.70
PS 2 3.29 0.86
PS 3 3.09 0.87
PS 4 3.11 0.80
PS 5 3.28 0.87
PS 6 3.19 0.78
PS 7 3.18 0.83
PS 8 3.2 0.83
FP 2 3.51 0.82 0.61
FP 3 3.16 0.76
FP 4 3.27 0.67
FP 5 3.43 0.87
FP 6 3.69 0.77
FP 7 3.63 0.79
PAMP 1 3.01 0.85 0,70
PAMP 2 3.01 0.89
PAMP 3 2.84 0.83
PAMP 4 3.08 0.86
PAMP 5 3.01 0.83
PAMP 6 2.95 0.88
FS 1 3.18 0.87 0.78
FS 2 3.15 0.86
FS 3 3.39 0.89
FS 6 3.17 0.89
FS 7 3.16 0.89
FS 8 3.34 0.88
MP 3 3.48 0.76 0.63
MP 4 3.19 0.79
MP 6 3.32 0.81
MP 9 3.37 0.84
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MP 10 3.54 0.80
MP 11 3.54 0.77
HK 1 3.64 0.81 0.60
HK 2 3.60 0.85
HK 3 3.61 0.78
HK 5 3.50 0.85
HK 7 3.38 0.77
HK 8 3.18 0.54

Table II shows that the value AVE for each variable has met the validity criteria, where the
variables of Leadership, Strategic Planning, Customer Focus, Measurement of Knowledge
Management Analysis, Staff Focus, Process Management and Performance Results with
each value AVE are 0.66, 0.70, 0.61, 0.70, 0.78, 0.63 and 0.60 have a value that is higher
than the limit value 0.5 (Hair,2019). So concluded that all variables have a good convergent
validity value. In this study, the structural model can be evaluated using the coefficient of
determination (R2) and the multicollinearity test. Here is a diagram to see the path (path
model) using PLS calculation bootstrapping.

Figure .1 Path Model PLS Algorithm

In testing the hypothesis, both direct and indirect effects, the test statistic used is the t statistic or t-
test using the provisions of the t-table value (one tail), which is 1.65 with a significant level of 0.05.
The t-table value will be used as a limit value or cut off compared to the t-statistical value in the
table Path Coefficient to accept or reject the proposed hypothesis.
 Indonesian Enterostomal Therapy Journal

Table III Path Coefficients Bootstrapping (Mean, STDEV, T-Values)
Path Coefficients Original Sample Standard T P
Sample (O) Mean (M) Deviation Statistics Values
(STDEV) (|O/STDEV|
)
KP -> PS 0.81 0.82 0.04 19.01 0.000
(X1a)
KP -> FP (X1b) 0.59 0.60 0.07 8.15 0.000
KP -> PAMP (X1c) 0.70 0.70 0.06 12.27 0.000
KP -> FS (X1d) 0.81 0.80 0.04 18.11 0.000
KP -> MP (X1e) 0.57 0.58 0.09 6.01 0.000
KP -> HK (X1f) 0.28 0.27 0.166 1.7 0.085
PS -> HK -0.23 -0.24 0.15 1.48 0.139
FP -> HK 0.11 0.11 0.13 0.85 0.393
PAMP -> HK -0.004 -0.017 0.13 0.03 0.976
FS -> HK 0.10 0.11 0.14 0.70 0.480
MP -> HK 0.57 0.60 0.11 4.89 0.000

In this research, hypothesis testing influence (direct effect) seen from the value contained in
the table path coefficient which would then be rated significance based on the value of t-
statistic Each path, here is a hypothesis testing: Leadership has a positive effect on strategic
planning, customer focus, measurement analysis and knowledge management, focus on staff
process management and performance outcomes. Strategic planning with organizational
performance results does not have a positive effect, customers focus with organizational
performance results does not have a positive effect, Measurement, Analysis and Knowledge
Management with organizational performance results do not have a positive effect, Staff Focus
with organizational performance results does not have a positive effect. However, Process
Management with performance results has a strong influence and a positive pattern. The
better Process Management will increase the results of good performance in Nursing
Independent Practice by paying attention to the quantity and quality of service and solving
problems appropriately and quickly.

DISCUSSION

The discussion of the results of hypothesis testing concluded that leadership has a positive
and significant effect on the strategic planning variable. This hypothesis proves that
leadership's role will influence strategic planning (Wilson & Collier, 2000). Leadership has a
role in strategic planning so that it has the ability to face an uncertain environment (Kiptoo &
Mugambi Mwirigi, 2014). In terms of leaders designing plans, it can see from the results of
interviews with informants:

…So that's our common goal Because I need to compile now an example of organizational
goals or vision and mission like that Can not be done If physical is more towards service
products meaning the main goal of establishing practice independent nursing which focuses
on the wound care model caring for wounds wholeheartedly according to the dream of building
this practice (Informant 2)

Dyah (2013), stated that customer satisfaction and loyalty would increase if a company can
handle complaints effectively on the first contact. Information from customers can be done by
 Indonesian Enterostomal Therapy Journal

conducting regular satisfaction surveys or placing a suggestion box in the service room. The
expectations and desires of customers can be read by the leaders compiled. This is done in
addition to being able to identify the desires, expectations, and level of acceptance of
patients/customers for health services in independent nursing practice, as well as to give a
positive signal that in independent nursing practice has great attention and concern for
patients/customers and creates a strong partnership relationship. Both with
patients/customers to improve service processes. In the interview with the informant, it was
stated:

... the form of service services, how do we create optimal wound care services and not
targeted, then how do we create targets according to the patient's needs which occur optimally
...(Informant 2)

In research, it's an influencing leadership towards a staff focus. In line with the study results
by Rad (2005), it is stated that for all hospital employees to be able to commit to their
organization, the hospital organization must first be committed to its employees. In connection
with what was conveyed by the informant during the interview:

…. In my independent practise leadership with my team who I consider my friend. a leader in

our practice has an automatic perception of the purpose of the independent practice to build
this together, so we assume they are friends so that it does not differentiate that we are
leaders, but both have and eventually have the same goals with the same perception so that
independent practice can move forward together (Informant 5)

Leaders who motivate - mobilize - increase human resources' ability to be more effective in
carrying out their duties and responsibilities as an activity implementer. The problem is not
easy (Informant 6)

.... the highest decision is with me, but yes for anything, the decision is up to me, but I don't
make my own decisions based on what I decide myself I continue to discuss with the team
Back again with my decision this is following what is called with comfort … (Informant 3)

According to Fellisa (2010), in the Malcolm Baldrige Assessment, leadership is how senior
leaders can guide and sustain the organization and set its vision, values, and expectations
performance. Leadership is a dimension of quality management practices to improve
operational performance, and overall organizational performance is not doubted. Almost all
quality management studies have shown that leadership is one of the main quality
management practices. It proves it a critical factor that influences and plays an important role
in successfully implementing quality management in an organization, including in independent
nursing practice.

The results of interviews with informants showed that by setting the vision and mission of the
hospital, it is hoped that it can serve as a guide for all employees in carrying out their duties
because a clear, logical (logical) vision and mission that has inspirational values are a source
of fundamental strength in achieving goals organization (Boidoun, 2018). However, some
informants have not yet disseminated the vision and mission of practising self-employment to
all employees as the goal of an organization. The results of the interview can see in the
following quote:
 Indonesian Enterostomal Therapy Journal

….. in compiling this vision and mission, there were obstacles in compiling. The beginning was
mastery of vision and mission because it used to be like that. So now you have to make your
own for a practice place, so the challenge is you have to understand the vision. mission Then
the second one saw my capacity as well, so my capacity to be able to manage later What is it
like then the next thing is parakeets are indeed targets that must be achieved… .. (Informant
5)

As a form of commitment in implementing quality management, hospital leaders are also must
be able to create a good (two-way) communication system with all employees where the flow
of information is applied top-down and bottom-up (Allolayan, Ali, & Idris, 2011; Kaluarachchi,
2010)

In connection with service process standards, especially in the midst of a pandemic COVID-
19 must have compiled and developed a standard service document (SPO) (health protocol)
as a guideline n in carrying out actions/services for patients in the midst of the COVID-19
pandemic, as well as establishing a service process flow so that it can be more efficient so as
not to violate health protocols. Following the results of the interview with the following
information:
... well, that's already really about the performance we did, and it's not right, so it really has to
be studied really, especially if the family really wants to know about treating wounds during a
pandemic This is then the patient will have more confidence, can also be obtained. So that's
really an effect, sir, you have to understand us. If we are sure to determine everything, we
have to consider the patient's point of view that the quality of service must maintain or improve
the quality that already exists. … (Informant 6)

In a previous study conducted by (Boidoun, 2018), customers' reluctance to directly their

hopes and desires to officers could be caused by worry, the possibility that they might get a
sour face from the officers. In solving organizational problems, finding the root of the problem
and not solving the problem according to its root should be solved. Therefore, in this case, a
management system in wound care unit is needed for improvement and monitoring of
services. The results of patients or customers' response for improvement continue to be
considered in quality for better service in the future optimal.

CONCLUSION

The application of TQM can improve performance results into evaluation materials to
implement continuous improvement CEO's wound care unit to formulate an appropriate vision,
mission and strategic planning and disseminate information to all employees and
stakeholders. Create work instruction standards as a guide for staff at work. This guide is an
instrument that can be used to measure staff performance. Providing media information
services that are easily accessible to patients or stakeholders. This information service media
contains the organization and services provided and the space for conveying expectations,
suggestions and complaints of patients or stakeholders so that the data entered is used as an
evaluation material for the implementation of continuous (improvement continuity
improvement).
 Indonesian Enterostomal Therapy Journal

Creating quality documents following the duties and functions of Nursing Private Practices so
that staff who provide services have standards and the results of the services provided can
measure. To improve the wound care unit performance, you can apply the Baldrige Criteria,
while to assess the current performance conditions using the Baldrige Assessment. 
As a
Ministry of Health supervisor, compiling service quality instruments in wound care unit is a
standard in Indonesia. The Director-General of Health Care, Ministry of Health, conducts
supervision or service assessors in Nursing Independent Practices to assess service
conditions at the primary.

REFERENCES

Alolayyan, M.N., Mohd Ali, K.A., & Idris, F., 2011. The Influence of Total Quality Management
(TQM) on Operational Flexibility in Jordanian Hospitals: Medical Workers’ Perspectives.
The Asian Journal on Quality. Vol. 12 No. 2, pp. 204-222

Baidoun, S.D., Salem, M.Z. and Omran, O.A. (2018), "Assessment of TQM implementation
level in Palestinian healthcare organizations: The case of Gaza Strip hospitals", The
TQM Journal, Vol. 30 No. 2, pp. 98-115. https://doi.org/10.1108/TQM-03-2017-0034

Baldrige National Quality Program 2019/2020. Criteria For Performance

Excellence.(http://www.quality.nist.gov/PDF_files/2019_2020_Business_Non
profit_Criteria.pdf

Fellisa, R., 2010. 7 Kriteria dari Malcolm Baldrige National Quality Award.
http://vibizmanagement.com.

Hair, J.F., Risher, J.J., Sarstedt, M. and Ringle, C.M. (2019), "When to use and how to report
the results of PLS-SEM", European Business Review, Vol. 31 No. 1, pp. 2-
24. https://doi.org/10.1108/EBR-11-2018-0203

Kaluarachchi, K.A.S.P., 2010. Organizational Culture and Total Quality Management

Practices: A Sri Lankan Case. The TQM Journal, Vol. 22 No. 1, pp. 41-55

Kiptoo, J. K., & Mugambi Mwirigi, F. (2014). Factors That Influence Effective Strategic
Planning Process In Organizations. IOSR Journal of Business and Management Ver. II,
16(6), 2319–7668.

Oakland, J., S., 2003. Total Quality Management Text With Cases (Third Edition), Butterworth-
Heinemann, Oxford, Burlington

Rad, A.M.M., 2005. A Survey of Total Quality Management in Iran: Barriers to Successful
implementation in Health Care Organizations. International Journal of Health Care
Quality Assurance, Vol. 18 No. 4, pp. xii-xxxiv.

Wilson, D. D., & Collier, D. a. (2000). An Empirical Investigation of the Malcolm Baldrige
National Quality Award Causal Model. Decision Sciences, 31(2), 361–383.
https://doi.org/10.1111/j.1540- 5915.2000.tb01627.x