Table Of Content

Can Total Quality Management Improve the Quality of Care in Saudi Arabian Hospitals? A Patient and Service Provider Perspective Ibrahim Alqasimi Submitted in Partial Fulfilment of the Requirements of The Degree of Doctor of Philosophy University of Salford, Manchester United Kingdom School of Nursing, Midwifery, Social Work and Social Sciences August 2017 i Table of Contents Thanks and Acknowledgments……………………………………………………………………………………… Abstract ……………………………………………………………………………………………………………... CHAPTER ONE: INTRODUCTION Introduction………………………………………………………………………………………………………….. Section One: Context of the Kingdom of Saudi Arabia…………………………………………………………….. Population and economic overview…………………………………………………………………………………. Economic overview…………………………………………………………………………………………………. Religion, culture and Language……………………………………………………………………………………... Social and literacy rates……………………………………………………………………………………………... Patient safety………………………………………………………………………………………………………… Patient rights………………………………………………………………………………………………………… Patients’ Rights in Saudi Arabia…………………………………………………………………………………….. Healthcare services provided by the MOH………………………………………………………………………….. Primary Care………………………………………………………………………………………………………… Secondary Care……………………………………………………………………………………………………… Tertiary Care………………………………………………………………………………………………………… Section Two: Healthcare system challenges………………………………………………………………………… Patient satisfaction in Saudi hospitals through quality of care……………………………………………………… Care from Doctors…………………………………………………………………………………………………... ii Care in Nursing……………………………………………………………………………………………………… Hospital infrastructure………………………………………………………………………………………………. Potential challenges in Saudi Arabia regarding the implementation of TQM………………………………………. Personal inspiration and experiences………………………………………………………………………………... Section summary……………………………………………………………………………………………………. Section Three: Research module……………………………………………………………………………………. Background and rationale…………………………………………………………………………………………… Research significance……………………………………………………………………………………………….. Research Gap………………………………………………………………………………………………………... Research Problem…………………………………………………………………………………………………… Aim and objectives………………………………………………………………………………………………….. Research focus………………………………………………………………………………………………………. The study location…………………………………………………………………………………………………… Overview of the thesis………………………………………………………………………………………………. Chapter Summary…………………………………………………………………………………………………… CHAPTER TWO: TQM REVIEW AND BACKGROUND Chapter Introduction………………………………………………………………………………………………… Definitions…………………………………………………………………………………………………………... The concept and philosophy of TQM……………………………………………………………………………….. Edward Deming’s Philosophy………………………………………………………………………………………. iii TQM failures ……………………………………………………………………………………………………….. TQM and the Saudi healthcare industry…………………………………………………………………………….. TQM in the global context…………………………………………………………………………………………... Middle Eastern quality………………………………………………………………………………………………. TQM in Saudi Arabia……………………………………………………………………………………………….. Global TQM key elements for successful implementation………………………………………………………… Management commitment and leadership………………………………………………………………………….. Teamwork…………………………………………………………………………………………………………… Training and education……………………………………………………………………………………………… Communication ……………………………………………………………………………………………………... Customer focus……………………………………………………………………………………………………… Employee involvement and participation …………………………………………………………………………… Culture………………………………………………………………………………………………………………. TQM critical success factors (CSFs) in Arabic countries and Saudi Arabia………………………………………... Background to the MOH’s plans to enhance health promotion and TQM………………………………………….. Current standard of TQM in Saudi government hospitals…………………………………………………………... Overall design of TQM in Saudi Hospitals………………………………………………………………….. ……... Patient journey into the secondary care environment……………………………………………………………….. Quality points………………………………………………………………………………………………………... Summary…………………………………………………………………………………………………………….. iv CHAPTER THREE: LITERATURE REVIEW Introduction………………………………………………………………………………………………………….. Search strategy and process…………………………………………………………………………………………. Literature review findings…………………………………………………………………………………………… Appraisal and quality of the review including studies………………………………………………………………. Description of studies in the review………………………………………………………………………………… Study aims…………………………………………………………………………………………………………... Participants………………………………………………………………………………………………………….. Methods……………………………………………………………………………………………………………… Quantitative methods………………………………………………………………………………………………... Qualitative approaches………………………………………………………………………………………………. Mixed methods approaches………………………………………………………………………………………….. Review studies approach analysis…………………………………………………………………………………… Main retrieved themes from the review……………………………………………………………………………... Implementation of TQM……………………………………………………………………………………............... The impact of TQM…………………………………………………………………………………………………. Challenges and solutions to TQM implementation………………………………………………………………….. Cultural perspective on total quality………………………………………………………………………………… Performance of nurses in Saudi Arabia……………………………………………………………………………... Nurses’ expectations surrounding the development of TQM……………………………………………………….. v Quality management implementation outcomes…………………………………………………………………….. Quality of Care………………………………………………………………………………………………………. Summary of TQM constructs in the literature………………………………………………………………………. TQM constructs……………………………………………………………………………………………………... CHAPTER FOUR: METHODOLOGY Introduction………………………………………………………………………………………………………….. Philosophical Foundation and Paradigms…………………………………………………………………………… Ontology……………………………………………………………………………………………………………... Objectivism…………………………………………………………………………………………………............... Subjectivism…………………………………………………………………………………………………………. Epistemology: Pragmatism…………………………………………………………………………………………... Approach……………………………………………………………………………………………………………... Methodological Choice………………………………………………………………………………………………. Qualitative…………………………………………………………………………………………………………… Quantitative………………………………………………………………………………………………………….. Mixed Methods……………………………………………………………………………………………………….. Research Strategies…………………………………………………………………………………………………... Sampling……………………………………………………………………………………………………………... Using mixed methods for the current study design………………………………………………………………….. Data collection tools…………………………………………………………………………………………………. vi The use and value of mixed methods………………………………………………………………………………… The rationality for sequentially………………………………………………………………………………………. Phase one: qualitative method……………………………………………………………………………………….. Advantages and disadvantages of qualitative methods……………………………………………………………… Semi-structured interviews…………………………………………………………………………………………... Interview guide protocol……………………………………………………………………………………………... Piloting the interview protocol………………………………………………………………………………………. Target population and sample size for stage one……………………………………………………………………. The Qualitative and quality of research ……………………………………………………………………………... Ensuring the trustworthiness and Credibility………………………………………………………………………... Interview analysis……………………………………………………………………………………………………. Framework Analysis…………………………………………………………………………………………………. Framework analysis adoption for this study…………………………………………………………………………. Data familiarisation………………………………………………………………………………………………….. Developing initial codes……………………………………………………………………………………………... Searching for themes………………………………………………………………………………………………… Reviewing themes……………………………………………………………………………………………………. Defining and naming themes………………………………………………………………………………………… Producing a report……………………………………………………………………………………………………. Phase two: quantitative methods…………………………………………………………………………………….. vii Advantages and disadvantages of quantitative methods…………………………………………………………….. Sources influencing the questionnaire design………………………………………………………………………... Target population and sample size for stage two…………………………………………………………………….. Using the Likert scale………………………………………………………………………………………………... Five-point Likert scale……………………………………………………………………………………………….. Reverse panel back-translation………………………………………………………………………………………. Instrument validity…………………………………………………………………………………………………… Pre-piloting test phase………………………………………………………………………………………………... Language together with non-English speakers………………………………………………………………………. Content validity report……………………………………………………………………………………………….. Reliability of the scales………………………………………………………………………………………………. Questionnaire data analysis………………………………………………………………………………………….. Ethical approval……………………………………………………………………………………………………… Ethical considerations………………………………………………………………………………………………... Questionnaire data collection………………………………………………………………………………………... Integration of quantitative and qualitative analysis………………………………………………………………….. Mixed methods analysis……………………………………………………………………………………………... Conclusion…………………………………………………………………………………………………………… CHAPTER FIVE: DATA ANALYSIS AND FINDINGS Introduction…………………………………………………………………………………………………………... viii Demographic profiles of the participants……………………………………………………………………………. Approach of the selection codes……………………………………………………………………………………... Manual data coding…………………………………………………………………………………………………... Sensitising concepts………………………………………………………………………………………………….. Theoretical sensitivity………………………………………………………………………………………………... Saturation of data…………………………………………………………………………………………………….. Definition of the terms……………………………………………………………………………………………….. Journey of coding……………………………………………………………………………………………………. Development of themes……………………………………………………………………………………………… Results and analysis………………………………………………………………………………………………….. Identified Key themes………………………………………………………………………………………………... Theme 1: Understanding TQM practice……………………………………………………………………………... Theme 2: Important of communication and strategies………………………………………………………………. Theme 3: Important of training………………………………………………………………………………………. Theme 4: Management and Leadership……………………………………………………………………………… Theme 5: Barriers to quality improving…………………………………………………………………………….. Qualitative data findings about barriers to improving the quality of care…………………………………………… Nursing and the nature barriers………………………………………………………………………………………. Barriers of Language/Communication………………………………………………………………………………. Psychologically-related barriers to nurses…………………………………………………………………………… ix Patient-related barriers……………………………………………………………………………………………….. Administration-related barriers………………………………………………………………………………………. Conclusion…………………………………………………………………………………………………………… TQM Practice in Saudi Arabia: A Quantitative Nursing Study Introduction………………………………………………………………………………………………………….. Nurse demographics…………………………………………………………………………………………………. Nurses’ perceptions of TQM practice……………………………………………………………………………….. Implementation of a TQM programme in Saudi Arabian hospitals…………………………………………………. Quality of care within hospitals in Saudi Arabia…………………………………………………………………….. Barriers to improving quality of care………………………………………………………………………………… The role of organisational communication in TQM…………………………………………………………………. Competency development and staff training………………………………………………………………………… Patients’ Perceptions of Service Quality…………………………………………………………………………….. Patient demographics………………………………………………………………………………………………… Patients’ perceptions of organisational communication……………………………………………………………... Patients’ satisfaction with services provided………………………………………………………………………… Patients’ perceptions of TQM practice………………………………………………………………………………. Role of staff training from the patients’ perspective………………………………………………………………… Related barriers to improving the quality of care……………………………………………………………………. Conclusion…………………………………………………………………………………………………………… x

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Patient co-operation and quality improvement… .. Saudi Nursing Procedure Manual and Policy. WHO. World Health Organization . is to explore the existing state of total quality management (TQM) practice in healthcare in Encyclopedia of survey research methods: Sage Publications. Lee, P.-M.

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