Total Quality Management in Healthcare: Quality Principles, Implementation and Digitalization
DOI:
https://doi.org/10.22598/pi-be/2026.1.39808Keywords:
total quality management, healthcare quality, continuous quality improvement, lean six sigma, quality 4.0Abstract
Purpose: This paper reviews and synthesizes the theoretical foundations and practical applications of Total Quality Management (TQM), highlighting current trends, organizational prerequisites, benefits, and common barriers, with emphasis on operationalizing core TQM principles and adapting them to healthcare settings. The quality of healthcare is increasingly recognized as a strategic priority due to its impact on treatment outcomes, system efficiency, and user experience. Within this context, TQM is affirmed as a comprehensive, sustainable model for systematic quality improvement.
Methodology: A narrative literature review with thematic analysis of recent literature was conducted using Web of Science, Scopus, PubMed and Google Scholar.
Findings: TQM principles are associated with improvements in safety, efficiency, patient experience, and resource use. Lean, Six Sigma, and Lean Six Sigma report measurable gains, including shorter waiting times, fewer errors, and cost reductions. Successful implementation depends on leadership commitment, open communication, a participatory culture, and staff capability, while common barriers include bureaucratization, fragmentation, limited empowerment and training, and poorly defined processes. Quality 4.0 and Healthcare 4.0 expand opportunities for predictive, data-driven, and personalized quality management.
Practical implications: Organizations should operationalize TQM with clear accountability, leadership commitment, and a participatory quality culture, leveraging Lean/Six Sigma for measurable improvements while aligning digital initiatives (Quality 4.0/Healthcare 4.0) with core TQM principles and building skills and infrastructure.
Originality/Value: The paper connects TQM with current healthcare challenges and digital transformation, highlighting how organizational and technological factors jointly shape quality outcomes and system-level improvement.
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References
Abbate, S., Centobelli, P., Cerchione, R., Oropallo, E., & Riccio, E. (2023). Investigating Healthcare 4.0 transition through a knowledge management perspective. IEEE Transactions on Engineering Management, 70(9), 3297–3310. https://doi.org/10.1109/TEM.2022.3200889
Abdallah, A., & Alkhaldi, R. (2019). Lean bundles in health care: a scoping review. Journal of Health, Organisation and Management, 33(4), 488-510. https://doi.org/10.1108/JHOM-09-2018-0263
Abdallah, A. B., Basheer, S. N., & Alkhaldi, R. Z. (2025). Unraveling the interplay between lean healthcare and patient satisfaction: The mediating roles of quality performance and process innovation. The TQM Journal. Advance online publication. https://doi.org/10.1108/TQM-07-2024-0258
Aburayya, A., Alshurideh, M., Al Marzouqi, A., Al Diabat, O., Alfarsi, A., Suson, R., Salloum, S. A., Alawadhi, D., & Alzarouni, A. (2020). Critical success factors affecting the implementation of TQM in public hospitals: A case study in UAE hospitals. Systematic Reviews in Pharmacy, 11(10), 230–242.
Aceto, G., Persico, V., & Pescapé, A. (2020). Industry 4.0 and health: Internet of Things, big data, and cloud computing for Healthcare 4.0. Journal of Industrial Information Integration, 18, 100129. https://doi.org/10.1016/j.jii.2020.100129
Aggarwal, A., Aeran, H., & Rathee, M. (2019). Quality management in healthcare: The pivotal desideratum. Journal of Oral Biology and Craniofacial Research, 9(2), 180−182. https://doi.org/10.1016/j.jobcr.2018.06.006
Ahmed, N. S. A. (2022). The role of total quality management in improving the healthcare services performance: Empirical study from hospitals in Erbil city. International Journal of Advanced Engineering, Management and Science, 8(6), 14-25. https://doi.org/10.22161/ijaems.86.3
Ahmed, S., Hawarna, S., Alqasmi, I., Mohiuddin, M., Rahman, M. K., & Ashrafi, D. M. (2024). Role of Lean Six Sigma approach for enhancing the patient safety and quality improvement in the hospitals. International Journal of Healthcare Management, 17(1), 52–62. https://doi.org/10.1080/20479700.2022.2149082
Aichouni, A. B. E., Silva, C., & Ferreira, L. M. D. F. (2024). A systematic literature review of the integration of total quality management and Industry 4.0: Enhancing sustainability performance through dynamic capabilities. Sustainability, 16(20), 9108. https://doi.org/10.3390/su16209108
Akmal, A., Podgorodnichenko, N., Foote, J., Greatbanks, R., Stokes, T., & Gauld, R. (2021). Why is quality improvement so challenging? A viable systems model perspective to understand the frustrations of healthcare quality improvement managers. Health Policy, 125(5), 658–664. https://doi.org/10.1016/j.healthpol.2021.03.015
Al-Assaf, K., Bahroun, Z., & Ahmed, V. (2024). Transforming service quality in healthcare: A comprehensive review of Healthcare 4.0 and its impact on healthcare service quality. Informatics, 11(4), 96. https://doi.org/10.3390/informatics11040096
Ali, K., & Johl, S. K. (2022). Soft and hard TQM practices: Future research agenda for Industry 4.0. Total Quality Management & Business Excellence, 33(13–14), 1625–1655. https://doi.org/10.1080/14783363.2021.1985448
Ali, K., & Waheed, A. (2025). Synergistic role of TQM 4.0 toward industry 4.0 readiness: a sociotechnical perspective of selected industries. The TQM Journal, 37(3), 853-876. https://doi.org/10.1108/TQM-08-2023-0249
Alkhaldi, R. Z., & Abdallah, A. B. (2022). The influence of soft and hard TQM on quality performance and patient satisfaction in health care: Investigating direct and indirect effects. Journal of Health Organization and Management, 36(3), 368–387. https://doi.org/10.1108/JHOM-10-2020-0416
American Society for Quality. (2025). Total Quality Management. Retrieved from https://asq.org/quality-resources/total-quality-management
Ansari, M. (2022). TQM framework for healthcare sectors: Barriers to implementation. Quality Innovation Prosperity, 26(1), 1–23. https://doi.org/10.12776/QIP.V26I1.1611
Antony, J., Kaul, A., Sony, M., Singh, N., Vij, P., Bhat, S., Yamini, S., & Laureani, A. (2025). A study into the themes of quality management: early findings from a global research project and agenda for future research. The TQM Journal, 37(8), 2260−2283. https://doi.org/10.1108/TQM-08-2024-0271
Bakotić, D., & Rogošić, A. (2017). Employee involvement as a key determinant of core quality management practices. Total Quality Management & Business Excellence, 28(11–12), 1209–1226. https://doi.org/10.1080/14783363.2015.1094369
Balasubramanian, S., Shukla, V., Islam, N., Upadhyay, A., & Duong, L. (2025). Applying artificial intelligence in healthcare: Lessons from the COVID-19 pandemic. International Journal of Production Research, 63(2), 594–627. https://doi.org/10.1080/00207543.2023.2263102
Bastani, P., Alipoori, S., Imani-Nasab, M., Jamalabadi, S., & Kavosi, Z. (2021). Evidence-based decision making among healthcare managers: Evidence from a developing country. International Journal of Healthcare Management, 14(1), 197–202. https://doi.org/10.1080/20479700.2019.1632002
Bolboceanu, M. (2025). TQM and excellence models in public sector in context of sustainability: A bibliometric analysis. Proceedings of the International Conference on Business Excellence, 19(1), 2340–2352. https://doi.org/10.2478/picbe-2025-0181
Castano, R. (2014). Towards a framework for business model innovation in health care delivery in developing countries. BMC Medicine, 12, Article 233. https://doi.org/10.1186/s12916-014-0233-z
Cavallone, M., & Palumbo, R. (2022). Delving into the soft side of TQM: An analysis of the implications of employee involvement on management practices. The TQM Journal, 34(5), 1096–1115. https://doi.org/10.1108/TQM-05-2021-0148
Chletsos, M., & Saiti, A. (2019). Strategic management and economics in health care. Springer. https://doi.org/10.1007/978-3-030-35370-4
Clauss, T. (2017). Measuring business model innovation: conceptualization, scale development, and proof of performance. R&D Management, 47(3), 385−403. https://doi.org/10.1111/radm.12186
Connor, L., Dean, J., McNett, M., Tydings, D. M., Shrout, A., Gorsuch, P. F., Hole, A., Moore, L., Brown, R., Melnyk, B. M., & Gallagher-Ford, L. (2023). Evidence-based practice improves patient outcomes and healthcare system return on investment: Findings from a scoping review. Worldviews on Evidence-Based Nursing, 20(1), 6–15. https://doi.org/10.1111/wvn.12621
Daqar, A. M., & Constantinovits, M. (2020). The role of total quality management in enhancing the quality of private healthcare services. Problems and Perspectives in Management, 18(2), 64–78. https://doi.org/10.21511/ppm.18(2).2020.07
Endalamaw, A., Khatri, R. B., Mengistu, T. S., Erku, D., Wolka, E., Zewdie, A., & Assefa, Y. (2024). A scoping review of continuous quality improvement in healthcare system: Conceptualization, models and tools, barriers and facilitators, and impact. BMC Health Services Research, 24(1), 487. https://doi.org/10.1186/s12913-024-10828-0
European Committee for Standardization. (2016). Quality management systems—EN ISO 9001:2015 for healthcare (EN 15224:2016). https://www.evs.ee/en/evs-en-15224-2016
Ferrari, R. (2015). Writing narrative style literature reviews. Medical Writing, 24(4), 230–235. https://doi.org/10.1179/2047480615Z.000000000329
Fonseca, L., Amaral, A., & Oliveira, J. (2021). Quality 4.0: The EFQM 2020 model and Industry 4.0 relationships and implications. Sustainability, 13(6), 3107. https://doi.org/10.3390/su13063107
Grossu-Leibovica, D., & Kalkis, H. (2022). Total quality management tools and techniques for improving service quality and client satisfaction in the healthcare environment: A qualitative systematic review. SHS Web of Conferences, 131, Article 02009. https://doi.org/10.1051/shsconf/202213102009.
Hedayatipour, M., Etemadi, S., Hekmat, S. N., & Moosavi, A. (2024). Challenges of using evidence in managerial decision-making of the primary health care system. BMC Health Services Research, 24(1), 38. https://doi.org/10.1186/s12913-023-10409-7
Hidayah, N., Arbianingsih, R., & Ilham, L. (2022). The impact of integrated quality management-based health services on general hospital quality. Frontiers in Public Health, 10, 1011396. https://doi.org/10.3389/fpubh.2022.1011396
Hu, Z., Wang, R. S., Qin, X., Huang, Y.-N., Li, L., Chiu, H.-C., Liu, Y., & Wang, B.-L. (2024). The global research landscape and future trends in healthcare total quality management. Archives of Public Health, 82(1), 193. https://doi.org/10.1186/s13690-024-01420-3
Ilangakoon, T. S., Weerabahu, S. K., Samaranayake, P., & Wickramarachchi, R. (2022). Adoption of Industry 4.0 and lean concepts in hospitals for healthcare operational performance improvement. International Journal of Productivity and Performance Management, 71(6), 2188–2213. https://doi.org/10.1108/IJPPM-12-2020-0654
International Organization for Standardization. (2015). Quality management systems—Fundamentals and vocabulary (ISO 9000:2015). https://www.iso.org/standard/45481.html
Kavukoğlu, T., & İşci, E. (2024). The mediating role of strategic planning awareness in the impact of organizational innovation on business excellence in hospitals. The TQM Journal, 36(8), 2527−2550. https://doi.org/10.1108/TQM-05-2023-0155
Kruk, M. E., Gage, A. D., Arsenault, C., Jordan, K., Leslie, H. H., Roder-DeWan, S., Adeyi, O., Barker, P., Daelmans, B., Doubova, S. V., English, M., García-Elorrio, E., Guanais, F., Gureje, O., Hirschhorn, L. R., Jiang, L., Kelley, E., Lemango, E. T., Liljestrand, J., … Pate, M. (2018). High-quality health systems in the Sustainable Development Goals era: Time for a revolution. The Lancet Global Health, 6(11), e1196–e1252. https://doi.org/10.1016/S2214-109X(18)30386-3
Laureani, A., Antony, J., Ramadan, M., Al Dhaheri, M. K., Fundin, A., & Sörqvist, L. (2024). Leadership characteristics for implementation and sustainability of quality: An exploratory study and directions for further research. The TQM Journal, 36(8), 2599–2617. https://doi.org/10.1108/TQM-06-2023-0185
Lazibat, T., Baković, T., & Dužević, I. (2023). Upravljanje kvalitetom. Znanstvena knjiga.
Lillrank, P. (2015). Small and big quality in health care. International Journal of Health Care Quality Assurance, 28(4), 356–366. https://doi.org/10.1108/IJHCQA-05-2014-0068
Mahin, M., Kadasah, N., Alsabban, A., & Albliwi, S. (2024). Exploring the landscape of quality 4.0: A comprehensive review of its benefits, challenges, and critical success factors. Production & Manufacturing Research, 12(1), Article 2373739. https://doi.org/10.1080/21693277.2024.2373739
Mandel, K., & Cady, S. (2022). Quality improvement as a primary approach to change in healthcare: A precarious, self-limiting choice? BMJ Quality & Safety, 31(11), 860–866. https://doi.org/10.1136/bmjqs-2021-014447
Marbouh, D., Swarnakar, V., Simsekler, M. C. E., Antony, J., Lizarelli, F. L., Jayaraman, R., Garza-Reyes, J. A., Shokri, A., Cudney, E., & Ellahham, S. (2023). Healthcare 4.0 digital technologies impact on quality of care: A systematic literature review. Total Quality Management & Business Excellence, 34(15–16), 2157–2182. https://doi.org/10.1080/14783363.2023.2238629
Melnyk, B. M., & Fineout-Overholt, E. (2023). Evidence-based practice in nursing & healthcare: A guide to best practice (5th ed.). Wolters Kluwer.
Osama, M., Ateya, A. A., Sayed, M. S., Hammad, M., Pławiak, P., Abd El-Latif, A. A., & Elsayed, R. A. (2023). Internet of Medical Things and Healthcare 4.0: Trends, requirements, challenges, and research directions. Sensors, 23(17), 7435. https://doi.org/10.3390/s23177435
Ramasamy, G., & Avadaiyar, P. (2024). Total quality management (TQM) for sustainable growth performance in the private healthcare sector. Problems and Perspectives in Management, 22(4), 229–242. https://doi.org/10.21511/ppm.22(4).2024.18
Rosa, A., Romeo, E., Capolupo, N., & Schiavone, F. (2025). Redefining value creation innovation in healthcare organizations: The catalytic role of Lean Management, Six Sigma and patient safety. European Journal of Innovation Management, 28(10), 5277–5300. https://doi.org/10.1108/EJIM-10-2024-1155
Sader, S., Husti, I., & Daróczi, M. (2022). A review of quality 4.0: Definitions, features, technologies, applications, and challenges. Total Quality Management & Business Excellence, 33(9–10), 1164–1182. https://doi.org/10.1080/14783363.2021.1944082
Samanta, A., Varaprasad, G., & Gurumurthy, A. (2023). Implementing Lean Six Sigma in health care: A review of case studies. International Journal of Lean Six Sigma, 14(1), 158–189. https://doi.org/10.1108/IJLSS-08-2021-0133
Shrout, A., & Gallagher-Ford, L. (2021). Use of toolkits to facilitate evidence-based practice implementation. Worldviews on Evidence-Based Nursing, 18(4), 241–242. https://doi.org/10.1111/wvn.12527
Silvestri, C., Piccarozzi, M., Ruggieri, A., & Pacchera, F. (2024). A new holistic definition of TQM towards sustainability. Total Quality Management & Business Excellence, 35(3–4), 465–502. https://doi.org/10.1080/14783363.2024.2312370
Singh, M., & Rathi, R. (2019). A structured review of Lean Six Sigma in various industrial sectors. International Journal of Lean Six Sigma, 10(2), 622−664. https://doi.org/10.1108/IJLSS-03-2018-0018
Sony, M., Antony, J., & Douglas, J. A. (2020). Essential ingredients for the implementation of Quality 4.0: A narrative review of literature and future directions for research. The TQM Journal, 32(4), 779–793. https://doi.org/10.1108/TQM-12-2019-0275
Sony, M., Antony, J., & McDermott, O. (2023). The impact of Healthcare 4.0 on the healthcare service quality: A systematic literature review. Hospital Topics, 101(4), 288–304. https://doi.org/10.1080/00185868.2022.2048220
Tabish, S. A. (2024). Total quality management. In S. A. Tabish, Health care management: Principles and practice (pp. 505–519). Springer. https://doi.org/10.1007/978-981-97-3879-3_25
Tortorella, G. L., Fogliatto, F. S., Sunder, M. V., Cawley Vergara, A. M., & Vassolo, R. (2021). Assessment and prioritisation of Healthcare 4.0 implementation in hospitals using Quality Function Deployment. International Journal of Production Research, 60(10), 3147–3169. https://doi.org/10.1080/00207543.2021.1912429
van Schoten, S. M., de Blok, C., Spreeuwenberg, P., Groenewegen, P., & Wagner, C. (2016). The EFQM model as a framework for total quality management in healthcare: Results of a longitudinal quantitative study. International Journal of Operations & Production Management, 36(8), 901–922. https://doi.org/10.1108/IJOPM-03-2015-0139
WHO Regional Office for Europe. (2024). Taking the pulse of quality of care and patient safety in the WHO European Region: Multidimensional analysis and future prospects. https://iris.who.int/items/a6dbfc8b-58a3-4087-a7eb-d147e8b21729
World Health Organization. (2006). Quality of care: A process for making strategic choices in health systems. https://www.who.int/publications/b/40340
World Health Organization. (2025). Quality health services. https://www.who.int/news-room/fact-sheets/detail/quality-health-services
Zehir, S., & Zehir, C. (2023). Effects of total quality management practices on financial and operational performance of hospitals. Sustainability, 15(21), 15430. https://doi.org/10.3390/su152115430
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