The TQM Magazine

The evolution of TQM: An empirical analysis using the business process change
framework
Jaideep Motwani Sameer Prasad Jasmine Tata
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Jaideep Motwani Sameer Prasad Jasmine Tata, (2005),"The evolution of TQM", The TQM Magazine, Vol.
17 Iss 1 pp. 54 - 66
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TQM RESEARCH AND CONCEPTS

17,1
The evolution of TQM
An empirical analysis using the business
54 process change framework
Jaideep Motwani
Seidman School of Business, Grand Valley State University, Grand Rapids,
Michigan, USA
Sameer Prasad
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Management Department, College of Business & Economics,

University of Wisconsin-Whitewater, Whitewater, Wisconsin, USA, and
Jasmine Tata
Management Department, Loyola University Chicago, Chicago, Illinois, USA
Abstract
Purpose – Business process change (BPC) is an organizational initiative to achieve significant
improvement in performance and has been extensively reported in the information systems literature.
Total quality management (TQM) has been employed to improve the quality of processes within a
business unit. In this research an attempt is made to link BPC with TQM.
Design/methodology/approach – Using case-study methodology, an attempt is made to connect
the two fields. Specifically, examines how quality management falls within the various BPC
constructs.
Findings – Results of this study indicate that the BPC concept is generalizable to accommodate
TQM.
Originality/value – This has important ramifications for both practitioners and researchers.
Practitioners will now have a methodology that is flexible to adjust as the demands of the business
evolve from quality objectives into other needs such as mass customization and shortened lead times.
The results of this study provide a theoretical model to the evolution of quality management.
Keywords Information systems, Quality management, Business process re-engineering
Paper type Research paper

Introduction
Business process change (BPC) is an organizational initiative to achieve significant
improvement in performance (e.g. quality, responsiveness, cost, flexibility, and other
critical process measures) through changes in the relationships between management,
information technology, organizational structure, and people. According to Kettinger
and Grover (1995), any significant BPC requires a strategic initiative where top
managers act as leaders in defining and communicating a vision of change. The
organizational environment, with a ready culture, a willingness to share knowledge,
The TQM Magazine balanced network relationships, and a capacity to learn, should facilitate the
Vol. 17 No. 1, 2005
pp. 54-66 implementation of prescribed process management and change management practices.
q Emerald Group Publishing Limited
0954-478X
Process and change management practices, along with the environment change,
DOI 10.1108/09544780510573057 contribute to better business processes and help in securing improved quality of work
 life, both of which are requisite for customer success and ultimately, in achieving The evolution of
measurable and sustainable competitive performance gains. TQM
In recent years, there has been a significant interest in the application of total
quality management (TQM) in a multitude of organizations around the globe. TQM
exhibits certain characteristics that can be explained by the BPC model developed in
the information systems (IS) literature. In this research, we set out to uncover whether
TQM in fact is a unique subset of the BPC methodology using a case study of a TQM 55
program in a large hospital. This research is of value to both practitioners and
academicians. Practitioners will benefit from this study by understanding how to
manage change when the focus shifts from quality to other operational dimensions
such as mass customization or shorter lead times. Researchers can also gain by
recognizing the link between the information systems literature with that of the quality
management one.
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Business process change framework

BPC initiatives may differ in scope from process improvement to radical new process
designs depending on the extent of change undertaken in each organizational subsystem
and their respective interactions. In any examination of BPC outcomes, consideration
should be given to the environmental conditions for change and the ability of the
organization to manage change in these conditions. Kettinger and Grover (1995) have
proposed an information systems model that considers both these aspects of BPC
management. The individual components of the framework are described below and
applied to the subsequent case analysis to determine the connections with TQM.

Strategic initiatives
Process change typically begins with strategic initiatives from the senior management
team (Kotter, 1995). These could be a reaction to a need or a proactive push to leverage
potential opportunities (Earl, 1994). Evidence also exists that strategic change, and
arguably process change, are often incremental, informal, emergent, and is based on
learning through small gains (Mintzberg and Waters, 1985) as opposed to being
revolutionary and radical. According to Shrivastava (1994), strategic initiatives can be
forced on the organization through mandate (autocratic) or pushed through consensus
within existing systems of the organization (bureaucratic). Alternatively, champions of
change could emerge to seek out creative ideas and make them tangible (Tushman and
Nadler, 1986).

Learning capacity
The major goal of learning is to provide positive outcomes through effective adaptation
to environmental changes and improved efficiency in the process of learning (Guha
et al., 1997). Adaptation involves making appropriate responses to changes and
learning from other organizations that have achieved the best practices in the industry
(Freeman and Perez, 1988). Learning can come from organizational employees who
constantly review the environment for new developments and opportunities
(gatekeepers), consultants who span the boundary between the environment and the
organization (boundary spanners), and from customers.
 TQM Cultural readiness
17,1 Organizational culture facilitates (or inhibits) the integration of individual learning
with organizational learning by influencing the organization’s ability to learn, share
information, and make decisions (Kilman et al., 1986). According to Guha et al. (1997),
leadership (top management) support or change agents (e.g. BPC team) may be
considered important prerequisites for BPC. Open communication and information
56 sharing can promote a common culture and innovative behavior in the organization. So
also can cross-functional training and personnel movement within it (Guha et al., 1997).

Information leveragibility and knowledge-sharing capability

The role of information technology (IT) in the BPC project could be either dominant or
as an enabler. Evidence suggests that IT led projects often do not succeed in capturing
the business and human dimensions of processes, and are likely to fail (Markus and
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Keil, 1994). A case is frequently made for the socio-technical design approach that
suggests a mutual, bidirectional relationship between IT and the organization
(Mumford, 1994). Such an approach recommends synergy between the business,
human and IT dimensions of an organization and could be promoted through
cross-functional teams.
Communication technologies have also been proven to facilitate learning and
knowledge development through a process of coordinated interaction among
individuals. The ability to share knowledge enhances an organization’s tendency to
change (Nonaka, 1991) as transparent data access empowers individuals and
knowledge workers to reinforce one another’s expertise. Thus, IT’s communication
infrastructure and the extent of knowledge sharing can create an environment that
facilitates successful BPC.

Network relationships
Research indicates that under most circumstances cooperative, interpersonal and
group behavior results in superior performance (Johnson and Johnson, 1989). However
it is possible that competitive controversy within generally competitive groups can
result in greater openness, knowledge and understanding (Tjosvold and Deemer, 1980).
In terms of inter-organizational processes, research indicates the benefits of partnering
with external suppliers (Crosby, 1994). Consultants can also play a critical role in
introducing BPC within an organization. Organizations that could manage these
aspects of competition and cooperation continuously can benefit from employee
incentives and controls, as well as instill change more effectively (Guha et al., 1997).

Change management practice

Change management involves effectively balancing forces in favor of a change over
forces of resistance (Stebel, 1992). Organizations, groups, or individuals resist changes
that they perceive threaten them (Guha et al., 1997). It has been suggested that
corporate transformation requires a general dissatisfaction with the status quo by
employees who favor change, have vision of the future, and a well managed change
process. Revolutionary and evolutionary change theorists propose contrasting tactics
for accomplishing change (Stoddard and Jarvenpaa, 1995), which vary depending on
the type of employee involvement, communication about the change, and leadership
nature.
 Thus, the pattern of change (formal versus informal), management’s readiness to The evolution of
change (i.e. being committed to it, participative in the process, or resistant to it), scope TQM
of change (continuous improvement versus radical change), management of change
(alleviation of dissatisfaction, top management’s vision for change, well managed
process of change, and use of evolutionary versus revolutionary change tactics) are the
key dimensions in practicing change management (Kettinger and Grover, 1995).
57
Process management practice
Process management is defined as a set of concepts and practices aimed at better
stewardship of business processes (Davenport, 1995). It combines methodological
approaches with human resource management to improve the outcome of BPC (Guha
et al., 1997). Successful process management uses process measurement (application of
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process metrics, process information capture, improvement feedback loop, and process
audit), tools and techniques (e.g. quality control tools, data flow diagrams, CASE tools,
and simulation) and documentation (e.g. process flow chart analysis, fishbone and root
cause analysis). Evidence also supports the use of team-based structures both for the
implementing the project and for designing the new processes (Guha et al., 1997).
The individual components of the framework (shown in Figure 1) are applied to the
subsequent case analysis to determine if they facilitate or inhibit the success of TQM

Figure 1.
Theoretical framework for
TQM implementation
management
 TQM projects. The figure clearly shows that the first five factors are all linked together and
17,1 are critical to achieving the right change environment for achieving TQM
implementation. Once these five factors are in place, change management and
process management initiatives start occurring resulting in positive TQM outcomes.

Research methodology
58 In this section, a case study is employed at a hospital to examine how TQM fits within
the BPC methodology.

Case study unit

The hospital studied is a 250-bed, full service acute care medical center and teaching
hospital serving the community of west Michigan. Since its establishment, the hospital
has provided emergency care, particularly for patients with penetrating injuries. In
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addition, the hospital offers surgical services; cancer care; obstetrics; cardiac care; and
off-site, in patient psychiatric services. The hospital serves as the region’s only in
patient psych/med unit, and the area’s sole kidney dialysis and organ transplant
center.

Data collection
Data were collected primarily through interviews, observations, and archival sources.
Interviews were conducted, in person, with executives who were familiar with the
continuous improvement process. These included the director of operations, quality
control manager, among others. Observations were made on the shop floor in 1998
regarding tasks conducted to further the implementation progress.
Archival documentation was another major source of data used in the research.
Feasibility studies, reports, memos, minutes of meetings, proposals, newspaper
articles, and books were reviewed and its contents analyzed. These documents were
collected and analyzed to identify and/or validate data.
During the data collection, special attention was given to ascertaining whether
evidence from different sources converged on a similar set of facts. Guidelines in the
existing literature on the enhancement of retrospective data accuracy were followed.
After all the evidence had been reviewed, and after an initial case study narrative was
documented, the factual portion of the study was reviewed by the major informants in
the company. This was not only a minimal procedure for validating the data collection
process, but also a courtesy to those who had co-operated with the research.

Results
This section covers each construct of the BPC research model (Kettinger and Grover,
1995) with summative findings for the case. Wherever appropriate, respondents’
statements are quoted to illustrate the construct. Consistent with the research
objectives, specific questions were asked concerning each construct. The research
findings are summarized in Table I and are explained below.

Strategic initiatives
Leadership’s understanding and active involvement serve as the basis for
implementing TQM at this hospital. The leaders at the hospital share the vision,
model the principles, and enable others to act and promote teamwork. They have also
 Business process change The evolution of
Constructs Dimensions Hospital’s TQM approach TQM
Strategic initiatives Stimuli (proactive or reactive) Proactive
Formulation scope (incremental or Incremental
revolutionary)
Decision making (autocratic, Bureaucratic
bureaucratic, or champion emergence)
59
Strategy-led (from onset, eventually, or From onset
not)
Learning capacity Adaptation (response to technology Response to technology change
change, or learning from others) Learning from others
Improved efficiency Learning by doing
Declarative knowledge Did not develop knowledge base
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External information use (technology Boundary spanners

gatekeepers, boundary spanners, or Customers
customers)
Learning type Deutero
Cultural readiness Change agents and leadership Senior management
Change agents (teams)
Risk aversion (aggressive versus Cautious
cautious)
Open communications High
Cross-training Some
IT leveragibility and IT role (enabling, socio-technical, or Enabling
knowledge-sharing dominant factor)
Use of communication technology Medium
Network relationships Interorganizational linkages Low
Cross-functional cooperation Medium
Change management Pattern of change Formal phased process
Management readiness to change Committed
Scope of change Improvement
Management of change (alleviate Adequate
employee dissatisfaction, vision for
change, well-managed change
process, evolutionary or
revolutionary change tactics used)
Process management Process measurement Use of process metrics Table I.
Tools and techniques High Summary of findings for
Team-based No each construct

taken the responsibility for overseeing the performance improvement program to

ensure the provision and improvement of quality care and services. This is
accomplished through review and approval of the performance improvement plan at
least once a year, reappraisal of the program, and ongoing assessment of information
regarding key improvement efforts and results.
The hospital’s Health Services Board of Trustees has the ultimate authority and
accountability for the quality and appropriateness of all services and programs. The
board delegates to the chief executive officer (CEO) the responsibility and authority for
 TQM developing and implementing a quality improvement program within the hospital
17,1 division. The CEO works in consultation with the Medical Executive Committee to
develop the Clinical Quality Improvement Program of the medical staff and the clinical
quality in the hospital.
The Clinical Quality Improvement Committee (CQIC) of the medical staff reports
directly to the Medical Executive Committee (MEC). The MEC, through the CEO, has
60 the responsibility of assessing the quality improvement activities of the medical staff
and of the hospital. The CQIC is composed of physician members appointed by the
chief of staff in consultation with the Medical Executive Committee. The CEO appoints
key administrative members to serve as administrative liaison. The CEO delegates to
each departmental manager and other specified personnel the responsibility and
authority for evaluating and assuring quality within their receptive departments.
The CEO delegates to the clinical quality management department manager the
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responsibility for providing the staff support necessary for the functioning of the
quality improvement program, including data retrieval and display, preliminary
analysis of problems, and program coordination. The Medical Executive Committee
monitors and evaluates the quality and appropriateness of patient care on an ongoing
basis through the CQIC. CQIC has the authority and responsibility for recommending
and implementing corrective action when necessary. It works through the clinical
service chiefs and its other members to report quality improvement outcomes to the
Medical Executive Committee. CQIC is also responsible for determining parameters of
quality to be measured, establishing valid indicators and thresholds for evaluating
physician directed care, identifying problems or opportunities for improving care,
participating in action decisions, and evaluating the effectiveness of actions taken.
In addition to clinical service indicators, the Medical Executive Committee through
CQIC also monitors and evaluates the use of surgical invasive procedures, medications,
and blood and blood components. It conducts clinical pertinence review of medical
records and monitors pharmacy and therapeutics, infection control, utilization review,
and safety and risk management issues.
The performance improvement program is formally evaluated annually to ascertain
its progress towards achieving established purpose, goals and objectives. The program
is monitored to assure the components are comprehensive, effective and cost efficient.
Program evaluation also assures that appropriate disciplines and services are involved
in the program, that important functions and processes are included and that priorities
are addressed. The Medical Executive Committee and hospital services self-evaluate
their programs annually. The results of these evaluations are reported to the Mission
Advancement Committee, which oversees the evaluations and reports them to the
board. The board reviews the results and approves the quality management program.

Learning capacity
The management and employees at the hospital work with internal/external customers
to define needs. These needs are then met and exceeded through continuous
improvements in the design and delivery of service. The customers of the hospital
include patients, employees, physicians, insurance providers, governmental agencies,
suppliers and the community.
The management strongly believes that employees want to do the best work they
can. Therefore, the management creates an environment to enable those closest to the
 work to adapt processes to improve quality. The environment encourages innovation, The evolution of
stronger alignment of the physicians, multi-directional communication, and the TQM
celebration of accomplishments.

Cultural readiness
The hospital’s initiative for the TQM program came directly from the senior
management and the chief executive officer. The CEO commented: 61
The implementation of TQM is a key element in the long-term process improvements we have
initiated to improve customer service and reduce costs . . . while the implementation
challenges we have experienced have been at times frustrating and difficult for customer and
employees, I believe the long-range benefits the new system offers remain appealing. The
competitive advantage we gain from this sophisticated system will help us to continue to
compete successfully in the dynamic market for store brand products.
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At the hospital, everyone participates in continuous education and development

opportunities in the perspectives and tools needed for TQM. The TQM effort includes
all departments and services within the hospital. TQM improvement is considered
from various perspectives and dimensions and utilizes different types of measures. The
perspectives include: patients and families insurance providers, defined populations,
purchasers, community, and regulating agencies. The dimensions of TQM include
efficacy, appropriateness, availability, effectiveness, timeliness, safety, efficiency, and
continuity of care, respect and caring. The measures include structure, process, and
outcome. Information gained through continuous improvement activities is utilized
throughout the organization. Essential information is communicated between the
performance improvement and the safety management, risk management, and
utilization management functions. Relevant findings are utilized in the reappointment
of medical staff members and their renewal or revision of clinical privileges. Relevant
results are also taken into consideration in the staff performance evaluation of
professional performance, judgment, and clinical and/or technical skills. Information
from performance improvement activities also is utilized in staff education and
development planning and programs.

Information leveragibility and knowledge-sharing

Gathering and using information to analyze and monitor processes and outcomes, and
making decisions and measuring improvement over time is another important
principle of the hospital’s TQM efforts. The hospital employs a systematic process to
assess collected data. Data are assessed using computers to determine: meeting of
design specifications, performance and stability of important existing processes,
priorities for improvement, actions for improvement and whether changes in the
processes really resulted in improvement.
This process includes using statistical quality control techniques as appropriate
and comparing data about processes and outcomes over time. Performance of
processes are also compared to relevant scientific, clinical and management literature
and to relevant practice guidelines/parameters, as appropriate.
The program ensures intensive assessment when undesirable variation in
performance occurs. Such an intensive assessment is initiated by important single
events and by absolute levels and/or patterns/trends that significantly and undesirably
vary from those expected based on appropriate statistical analysis: i.e. when
 TQM performance significantly varies from that of other organizations, from recognized
17,1 standards or when there is a desire to further improve already good performance.

Network relationships
In order to facilitate the teaching of TQM principles and techniques, the corporation,
hired an expert in TQM to assist its various hospitals. The TQM consultant acted more
62 as a facilitator than a formal consultant. This expert would spend time teaching about
TQM technique after which the focus team would immediately apply the concepts to
the data that they had. The expert not only helped the group how to use TQM tools and
techniques, but also established a common vocabulary throughout the whole
organization. One key aspect of this approach was that the tools and techniques were
not taught in the abstract with canned examples but directly applied to the issues at
hand.
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Change management
The hospital followed a structured methodology recommended by the consultant for
implementing TQM. The management of the hospital was committed to the change
process and had taken into consideration that problems would occur in the process.
The hospital’s management was not prepared to make any radical changes in the
organization and quickly found out that the best way to succeed was through
incremental change. Credibility established with these small successes eventually
paved the way for larger-scale changes. This way the management was able to take
most employees in its line of thinking. Employees were agreeable to allocate a
substantial amount of their time to the project. They were aided by training sessions
that were conducted both during day and at night. The open communication
encouraged by management gave users a sense of ownership of the system.

Process management
The hospital has adopted the FOCUS-PDCA methodology for its continuous
improvement process (see Figure 2). FOCUS-PDCA is utilized for identifying processes
and outcomes to improve, testing the strategy for change, assessing the data from the
test and implementing the improvement strategy. New services are designed, product
lines are extended, and functions or processes are modified based on the mission,
vision and strategic plan and inputs of the community, patients and staff and other
stakeholders. New processes and services are developed utilizing up-to-date resources
such as practice guidelines, parameters and benchmarks. Those closest to the design or
improvement activity are involved in the planning and implementation phases.
Priorities for improvements are determined based on organizational priorities,
which are established by leadership. There is a systematic improvement of existing
processes. Decisions considered when determining processes to improve include
important functions, measurement data, resources required, and organization’s
mission and priorities. As new processes and services are designed, mechanisms to
evaluate them are also planned. Expectations are set and measures of performance are
adopted, adapted and/or created. Both internal and external customers participate in
the evaluation process.
There is a systematic measurement process used at the hospital. Performance of
processes in patient care and organizational functions are measured according to
 The evolution of
TQM

63
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Figure 2.
Overview of the
focus-PDCA approach
used at the case study
company

priorities determined by organizational leadership on the basis of input from internal

and external customers. A department, unit or service area may choose to measure
other functional areas not specifically identified by leadership as organizational
priorities.
Certain processes are assessed on a continuing basis. These ones affect a large
percentage of patients and/or place patients at serious risk if not performed well or
undertaken when not indicated; and/or have been or are likely to be problem prone.
Processes measured include those related to the use of surgical and other invasive
procedures, use of medication, use of blood and blood components, and the
appropriateness of admissions and continued hospitalization. These indicators are
reviewed and considered when process and outcome indicators are designed and
selected.
Data are collected about the needs and expectations of patients, and the degree to
which they have been met. Staff’s views regarding current performance and
opportunities for improvement are also collected. Data are also collected about autopsy
results, risk management activities and quality control activities. Quality control
activities include, at a minimum, clinical laboratory, diagnostic radiology, dietetic,
nuclear medicine and radiation oncology services.

Discussion
In this research, the implementation of TQM program at a Midwest hospital using the
BPC framework is examined. The analysis is a result of a two-year study designed to
 TQM identify and assess the ingredients that led to the successful implementation of TQM
17,1 program at the hospital.
Evidence of the success of TQM efforts have been reported hospital-wide. For
example, it was applied in the emergency department to identify and address the key
causes for delays in processing patients in and out of the hospital. Four key causes for
delays were identified by the TQM teams:
64 (1) transportation of obstetrics (OB) patients to the OB floor;
(2) registering of patients and getting them into the Emergency Care Center (ECC);
(3) availability of supplies and equipment in the emergency department; and
(4) the patient admitting process from the ECC to the hospital.
Using the Focus-PDCA approach and TQM tools, the teams were able to design
procedures that resulted in significant improvements. They were also able to influence
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the way emergency care was delivered by focusing on developing critical pathways for
these processes. Specific benefits that the teams were able to achieve included:
.
reduction in the average time from decision to admit until admission from 90
minutes to less than 45 minutes;
.
decrease of lab draw order times from an average of 14 minutes to nine minutes
and the actual draw time from eight to six minutes;
.
enhanced customer satisfaction and staff morale;
.
improvement in the working relationship between the units; and
.
eliminated some sutures as well as lowered the inventory levels of the remaining
sutures, thus saving over $8,000 the first year.
Similar benefits were also reported in other departments.

Conclusions
The information theory of business process change suggests a range of approaches for
organizations to adapt to a changing environment. In this research, the TQM
methodology is examined relative to this model. The connection between TQM and
BPC has important ramifications to the academic community in that it provides a link
between the information systems literature and the TQM one. In addition, it provides
generalizable model for TQM applications. Practitioners can benefit from this research
in that, the application of the BPC model provides indication on the aspects of TQM
that need to be focused more on and how they should evolve. Next, the links between
TQM and BPC will be explored.
Table I, provides a listing of the various BPC constructs and their dimensions. In
addition, the TQM values are reported for the respective various dimensions. The
dimensions for the strategic initiatives constructs include: stimuli, formulation scope,
decision making and strategy leadership. In Table I, it is apparent that TQM approach
adopts a proactive, incremental, bureaucratic approach from the onset.
In terms of the learning capacity construct the dimensions include adaptation,
improved efficiency, declarative knowledge, external information use, and learning
type. The TQM approach involved a response to technological change, learning from
others, learning by doing and connections of information across boundaries including
customers. However, the TQM program did not develop a knowledge base.
 The cultural readiness construct includes dimensions of change agents and The evolution of
leadership, risk aversion, open communications and cross-training. The TQM program TQM
included senior management and change agents, the approach was cautious, with high
level of communication and some cross-training.
In terms of the IT leverageability and knowledge-sharing construct, the dimensions
include the role of IT, and the use of communications technology. In the TQM program,
IT had an enabling role with a moderate use of communications technology. 65
For the network relationship, the interorganizational linkages for the TQM program
were relatively low, but the cross-functional cooperation was moderate. In the change
management construct, the pattern of change was found to be a commitment formal
phased approach. The process was managed adequately.
Finally, in the construct for process management, the TQM program utilized
process metrics, with a high use of tool and techniques. However, this was limited at an
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individual basis.
By classifying a TQM program within the BPC framework, specific
recommendations to practitioner can be made. For example, this TQM program
would benefit from developing a knowledge base, greater interorganizational links,
and the use of teams for process management. This study also established that the BPC
is an acceptable framework that provides a generalizable model for change
management to incorporate TQM implementation. This has important ramifications
in that as the industry’s focus evolves from quality to flexibility and mass
customization, an adaptable model is available to guide practitioners. Finally, this
research also provides a basis for a theoretical model for TQM.

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