MASTER THESIS Total Quality Management Implementation in a Dutch Academic Hospital: the Role of the Organizational Climate

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MASTER THESIS

Total Quality Management Implementation

in a Dutch Academic Hospital:

the Role of the Organizational Climate

Yester Florian Janssen

s2155877

June 2017

MSc Business Administration

Organizational & Management Control

Faculty of Economics and Business

University of Groningen

Supervisor: Prof. dr. E.P. Jansen

Co-assessor: Dr. K. Linke

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2 Abstract

Healthcare is undergoing a fundamental transformation, caused by an aging society and the technological advancement. Healthcare cost are rising along with it. Furthermore, more emphasis is being placed on the quality of care. Because the quality of care needs to be maintained or even improved and increasing health budgets is undesirable, quality improvement methods, such as TQM, have been proposed. Organizational culture appeared to be an important factor for successful TQM implementation. However, the organizational culture is unconsciously formed and difficult to measure. Therefore, this study focuses on the part of culture that can be measured and changed: the organizational climate. The research question of this study was: how does the organizational climate influences the implementation of TQM in a Dutch academic hospital? To answer this research question, a qualitative study was conducted, in which we performed 12 semi-structured interviews with nurses from the department of surgery of the UMCG. We used another innovation, the VMS, to gain insights about TQM implementation. At the nursing department, we found a supporting climate,

shaped by the features of its surrounding context. Also, the nurse-doctor collaboration, characterized by a lack of communication and low levels of support, turned out to influence the organizational climate. We concluded that especially the soft-social aspects of TQM, like employee participation, leadership and the approachability of leaders, were bottlenecks during the VMS implementation process. This study identified five facilitators of the organizational climate for successful implementation TQM: employee involvement, teamwork, clear purpose, good information provision and high approachability of supervisors. Finally, we found that a fit between the way by which TQM is implemented and the characteristics of the organizational climate, is essential for successful TQM implementation.

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4.3.5 The changed hierarchy ... 26

4.4 VMS IMPLEMENTATION ... 27

4.4.1 Adoption phase ... 28

4.4.2 Implementation phase ... 29

4.4.3 Sustainability phase ... 31

4.4.4 TQM and implementation facilitators ... 32

5. DISCUSSION AND CONCLUSION ... 34

5.1 CONCLUSIONS ... 34

5.2 LIMITATIONS ... 36

5.3 FUTURE RESEARCH ... 37

5.4 THEORETICAL AND MANAGERIAL IMPLICATIONS ... 37

REFERENCES ... 38

APPENDICES ... 41

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5 1. Introduction

Healthcare is going through a fundamental change process. A process that, among other things, is put in motion by an aging society. In Western European countries, the percentage of older people is increasing. The Dutch CBS estimates that in the Netherlands the percentage of people older than 65 years will rise from 18.2% in 2016 to 28% in 2060. The life expectancy of the population is also rising. For example, the average age of males in the Netherlands will rise from 79.3 to 85.2 years in 2060 (Centraal bureau voor de statistiek, 2016). The combination of an increasing proportion of older people and a higher life expectancy is called ‘double societal aging’. The double societal aging, combined with the technological progress healthcare has made, inevitably leads to higher medical costs (Martín, Puerto Lopez del Amo Gonzalez, Dolores Cano Garcia, 2011; Auping, Pruyt & Kwakkel, 2015). Medical costs that are already enormous: in 2017, the Dutch government will be spending around 69 billion euros on healthcare, which is a third of the total expenditures for 2017 (Ministerie van Volksgezondheid, Welzijn en Sport, 2016).

Additional to the booming costs in healthcare another trend is noticeable, in which the focus of care shifts from a supply led system, where the healthcare system is organized around doctors, towards a patient- centered system organized around the needs of the patient (Porter & Lee, 2013). According to Porter & Lee (2013) the aim and core of this new approach is to “maximize value for the patient: achieving the best outcomes at the lowest cost” (p. 1). Key themes of this new approach are reducing medical errors and improving quality of care and patient satisfaction (Hyer, Wemmerlöv, & Morris, 2009). As quality of care is considered increasingly important by patients and healthcare organizations and because increasing healthcare budgets is not an option, many Quality Improvement (QI) methods have been developed, with the goal to increase patient satisfaction and optimize patient outcomes. One of these methods is Total Quality Management (TQM), which is defined as “an integrative management approach that aims for continuous improvement in the quality of products and services within an organization, by integrating and linking a set of core concepts related to the way an organization is expected to operate.” (van Schoten, de Blok, Spreeuwenberg, Groenewegen & Wagner, 2016, p.4; Bou-Llusar, Escrig-Tena, Roca-Puig & Beltrán-Martín, 2009). TQM aims to detect opportunities for improvement on areas such as clinical outcomes and cost-effectiveness and has the potential to reduce variation in outcomes leading to a more constant delivery of quality (van Rooyen et al., 1999, Nicolay et al., 2012).

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TQM from the hard aspects of TQM, such as tools, techniques and systems, to the softer aspects of TQM like cultural and behavioral aspects. The latter are much more difficult to measure and it is therefore not surprising that many TQM implementations have failed. (Prajogo & McDermott, 2005; Mak, 1999).

When striving towards a state of TQM, the concept of organizational culture is difficult to work with. This is mainly because a large part of the organizational culture is unconscious and difficult to measure (Schein, 2010). Therefore, one should focus on the part of organizational culture that can be measured: behavior and noticeable rituals. This is where the concept of organizational climate comes into play. We take the definition of organizational climate proposed by Litwin and Barnes (1968, p.25), who state that organizational climate is: “the relatively enduring quality of the total (organizational) environment that (a) is experienced by the occupants, (b) influences their behavior, and (c) can be described in terms of the values of a particular set of characteristics (or attributes) of the environment”. Organizational climate is subjective and often influenced directly by change initiatives (Denison, 1996). Therefore, organizational climate, in contrast to organizational culture, offers organizations the practical tools to control and improve processes and really work towards a state of TQM.

Although studies on the effect of organizational climate on TQM implementation are not completely absent, they are still rare in the field of healthcare. (Emery, Summers, & Surak, 1996). And because industry type and organizational climate seem to be important determinants of successful TQM implementation, a contribution could be made to the existing literature by studying the role of organizational climate in TQM implementation in the field of healthcare. The research question this thesis will try to answer will therefore be:

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7 2. Theoretical Background

In this section, the relevant literature about the constructs being used in this study will be discussed. The constructs receiving attention are: Total Quality Management, organizational culture, organizational climate, the implementation framework, and the nurse-doctor collaboration. The sub questions of this study are formulated based on the literature about these constructs. This section will be concluded with the development of a conceptual framework.

2.1 Total Quality Management (TQM)

2.1.1 Definition

During the last decades, many definitions of total quality management (TQM) have been proposed (Bou-Llusar et al., 2009; Dean & Bowen,1994; Sitkin, Sutcliffe, & Schroeder, 1994; Hackman & Wageman, 1995; Wilkinson, Redman, Snape & Marchington, 1998; Dale, 2003; Eriksson & Garvare, 2005). What all these definitions and views have in common is that that TQM is seen as “an integrative management approach that aims for continuous improvement in the quality of products and services within an organization, by integrating and linking a set of core concepts related to the way an organization is expected to operate.” (van Schoten et al., 2016, p.4). According to Bou-Llusar et al. (2009) the basic assumptions relating the concept of TQM can be summarized in three points:

1) The core concepts can be classified as either soft- social or hard- technical. The social-soft dimension is about human resource management: leadership, teamwork, training and a focus on employee participation. The hard- technical dimension focuses more on improvement of products and services by improving the production processes (Lewis, Fai Pun & Lalla, 2006; Dotchkin & Oakland, 1992; Yong and Wilkinson, 2001; Prajogo & Sohal, 2004; Rahman, 2004; Rahman & Bullock, 2005).

2) Furthermore, the two before mentioned dimensions and their core concepts need to be considered as mutually supportive, they need to be integrated. TQM should be seen as a holistic approach and should focus on the whole organization. (Flynn, Schroeder & Sakakibara, 1994; Wruck & Jensen, 1994; Hackman & Wageman, 1995)

3) Lastly, the use of TQM has a positive significant effect on organizational performance (Powell, 1995).

2.2 Implementation of TQM in healthcare

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Brommels, 2003). Although, TQM has great promise for healthcare, reality shows that the implementation of TQM is not as easy and straightforward as theory depicts. Porter and Tanner (2004) reported that around 70% of the organizations they studied, failed to translate the theoretical concepts of TQM into successful practices. Various studies have focused on factors related to successful TQM implementation in healthcare. Contextual variables, such as industry type, appeared to have a huge impact on the successful implementation of TQM (Sousa & Voss, 2002; Hietschold et al., 2014; Jayaram et al., 2010). Talib, Rahman and Azam (2011) performed a systematic review to identify a set of best practices for the successful implementation of TQM. They identified eight TQM practices that support TQM implementation in healthcare: top-management commitment, teamwork and participation, process management, customer focus and satisfaction, resource management, organization behavior and culture, continuous improvement, and training and education. This study will focus on the construct of the organizational culture, as Prajogo and McDermott (2005) found that it is one of the most important factors for the successful implementation of TQM.

2.3 Organizational culture

2.3.1 Definition

Organizational culture is defined as “the general pattern of mindset, beliefs, and values that members of an organization hold, which shapes their behaviors, practices and other artefacts of the organization” (Prajogo & Mcdermott, 2005, p.4).

According to Schein (1990, 2010) organizational culture can be analyzed on three levels: underlying assumptions, values and beliefs, and artefacts. These three levels range from the very tangible, visible manifestations to the deepest, unconscious assumptions that are embedded in a culture. The first and deepest level is about the unconscious, taken-for-granted beliefs, thoughts and feelings that guide behavior. They form the core of the organizational culture. Many of these basic assumptions are implicit, not consciously known to employees and often nonnegotiable. Moreover, these basic assumptions are difficult to reach and change. The second level consists of the values and beliefs of the organization. This level is about social practices and specific ways of thinking. The third and last level of organizational culture is about the visible and tangible activities, such as artefacts, that are based on the underlying assumptions.

2.3.2 Organizational culture and Total Quality Management

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According to the literature in favor of the unitarist approach, certain types of culture are more supportive and suitable for TQM implementation. Shared characteristics of these cultures are that they are flexible and people- oriented. According to Tata and Prasad (1998) practices like leadership, employee involvement and empowerment, teamwork, customer focus, continuous improvement are reflections of these flexible, people- oriented cultures. Westbrook and Utley (1995) support his view by stating that a culture in which employees are valued and empowerment is associated with successful TQM implementation. However, the results of the study of Prajogo and McDermott (2005) support a more pluralist view of culture, which support the idea of multidimensional cultures. This multidimensional perspective states that TQM incorporates not only people-oriented practices, but also aspects of hierarchical or mechanistic cultures: such as rational, control types of practices (Kekale & Kekale, 1995; Morena-Luzon & Peris, 1998).

The literature has shown that organizational culture seems strongly related to successful TQM implementation. Moreover, this same literature has identified possible cultures that would lead to successful TQM implementation (Prajogo, McDermott, 2005; Tata & Prassad, 1998). Therefore, the issue of establishing a culture that would lead to successful TQM implementation should be a relatively easy one to tackle. However, applying TQM still doesn’t always lead to the expected results.

And this is where things become complicated. Because if one wants to change the culture of an organization, a change of the most deeply rooted, mostly unconscious beliefs and perceptions of the members of an organization is needed. To transform a culture, you first need to understand this culture, about which Schein (1984, p.3) said: “To really understand a culture and to ascertain more completely the group’s values and overt behavior, it is imperative to delve into the underlying, which are typically unconscious but which actually determine how group members perceive, think and feel”. The concept of culture is therefore seemingly difficult to control and direct.

2.4 Organizational climate

2.4.1 Definition organizational climate

In this study, organizational climate is defined as follows: “the relatively enduring quality of the total (organizational) environment that (a) is experienced by the occupants, (b) influences their behavior, and (c) can be described in terms of the values of a particular set of characteristics (or attributes) of the environment” (Litwin & Barnes,1968, p.25).

2.4.2 Organizational climate vs. organizational culture

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Denison (1996, p.625) brings forward is the fact that: “both are focused on the internal psychological environment of organizations and the relationship of the environment to individual meaning and organizational adaptation”. They also have in common that they consider the social context as formed by the people involved in that context.

By comparing the definition of Litwin and Barnes (1968, p.25) of organizational climate with Schein’s following definition of organizational culture, the difference in perspective can be clearly demonstrated. Schein (1985, p.19) defined organizational culture as: “a pattern of shared basic assumptions that the group learned as it solved its problems of external adaptation and internal integration, that has worked well enough to be considered valid, and therefore, to be taught to new members as the correct way to perceive, think, and feel in relation to those problem”.

The definition of Litwin and Barnes of organizational climate places more emphasizes on how organizational members perceive the social environment and what the impact of this environment is, while Schein’s definition of culture focusses more on how the social environment is created. The organizational climate should therefore be seen as snapshot of the organizational environment at a particular moment. Moreover, the organizational climate can be controlled, changed and is limited to the aspects of the social environment that are consciously perceived. (Denison, 1996). Furthermore, measuring climate can tell you whether expectations or beliefs are being fulfilled (Emery et al., 1996). Because conscious behaviors, feelings, and thoughts are easier to understand and grasp, the organizational climate offers more opportunities to be manipulated or changed than the organizational culture does. According to Schwartz and Davies (1981) a climate that doesn’t fit with the intended change leads to resistance among employees and failure of the change process. Therefore, the organizational climate, contrary to organizational culture, gives as the tools to control and direct TQM implementation.

2.4.3 Organizational climate typology

De Cock, Bouwen, De Witte & De Visch (1984) developed a typology of the organizational climate, based on a thorough literature study. They state that organizations are continuously confronted with two questions:

- Do people get the chance for self-actualization within the organization (people-oriented) or are the goals of the organization leading (organization-oriented)?

- Is the organization focused on flexibility towards the environment (flexibility) or is it focused on maintaining their current status of working (control)

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maintain the status quo. This dimension is represented on the vertical axe of figure 2. Where some organizations are strongly oriented towards control, hierarchy, structure and rules, others are more oriented towards flexibility, diversity, innovation. Both types of organizations can be successful and properly functioning (De Cock et al., 1984).

Fig.2. Dimensions of the organizational climate and organizational climate typology according to De Cock et al. (1984).

According to De cock et al. (1984) an organization or department can be classified among one of the following four organizational climate types:

- Supporting climate: This climate type is characterized by its focus on employees and values.

Special attention is devoted to collaboration, tolerance, support and involvement of employees.

- Innovative climate: This climate type is characterized by concepts like change, adaption,

individual initiative, and diversity. Special attention is devoted to growth, stimulation of initiative, using the capabilities of people, using new scientific knowledge and by individual responsibility.

- Climate characterized by respecting the rules: This climate type is characterized by security,

uniformity and continuity of the current way of working. Special attention is devoted to aspects like structure, formalization, and standardization.

- Climate characterized by goal-oriented flow of information: The climate type is characterized

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2.4.4 Organizational climate and TQM implementation

Literature about the organizational climate and TQM implementation is scarce. Harber, Burgess and Barclay (1993) found that TQM implementation is more successful when the organizational climate is focused on achieving employee commitment and satisfaction. Furthermore, Emery et al. (1996) described three characteristics of an organizational climate that are supportive of TQM implementation: 1. Innovation, 2. Learning, 3. Change. This same study of Emery et al. (1996) found that the organizational climate plays a significant role in the sustainability of TQM implementations, but also that TQM implementation can lead to improved organizational climate. The study of Sommer and Merritt (1994) evaluated the impact of TQM implementation on the perceived workplace attitudes and behaviors in the context of healthcare. They found, just as Emery et al. (1996), that TQM interventions can lead to a better organizational climate, which positively influenced employee behavior on measures as attendance and turnover.

2.5 Implementation framework

Mendel, Meredith, Schoenbaum, Sherbourne and Wells (2008) developed a framework for the successful dissemination of healthcare interventions. Mendel et al. (2008) make a distinction between diffusion, dissemination and implementation. Where diffusion is simply seen as the spread of new ideas, practices, behaviors etc., dissemination is directed/targeted diffusion. Implementation is the adaption of ideas and the use in practice. The rationale behind this framework is to close the gap between research and practice. Mendel et al. (2008) distinguish a diffusion process and an evaluation process. The diffusion process consists of the context of the diffusion, the phases of diffusion and the intervention outcomes. Furthermore, three phases of diffusion are distinguished: the adoption phase (getting to know the innovation, form an opinion about it, reject/accept it), the implementation phase and the sustainability phase. In their model, the organizational climate is one of the contextual factors influencing this diffusion process. Furthermore, alongside the diffusion process an evaluation process exists. During the evaluation process, the process/implementation and outcomes are evaluated, with the aim of giving formative feedback and improving implementation and dissemination. In this study, we will look how the three phases of diffusion are influenced by the organizational climate of the nursing department. Not just the implementation phase like other studies did, but also the adoption and sustainability phase (Harber et al., 1993; Emery et al., 1996; Sommer & Merrit, 1994)

2.6 Nurse-doctor collaboration

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for the delivery of high-quality care to patients. However, because these two groups both have a distinct professional culture, inter- professional barriers can arise that prevent good collaboration (Eriksson, & Müllern, 2017; Nancarrow & Borthwick, 2005; Stein-Parbury, 2007). Eriksson and Müllern (2017) identified one of these barriers: a perceived gap in status between doctors and nurses, caused by the difference in education/training and traditions. Nurses consider this barrier as diminishing as they are better educated and trained. However, doctors are more rigid in their thinking and some of them are unwilling to give up certain rights and responsibilities. Because quality improvements often require joint efforts of the various professional groups, good collaboration between doctors and nurses is essential, (Stanton et al., 2014; Martin, Ummenhofer, Manser & Spirig, 2010). This fits with TQM implementation, where teamwork and participation also turned out to be important determinants for successful implementation. (Talib et al., 2011). However, literature on nurse-doctor collaboration and the influence of this on the organizational climate is currently lacking.

2.7 Sub questions

1. What is the organizational climate at the nursing department at a Dutch academic hospital?

2. How does the nurse-doctor collaboration influences the organizational climate at the nursing department?

3. How does the organizational climate influences the three phases of the diffusion process?

4. What are potential facilitators of the organizational climate for the implementation of TQM in a Dutch academic hospital?

2.8 conceptual framework

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14 3. Methodology

This section describes how the previously stated research questions will be answered. First the research design will be discussed and we will explain why this is the appropriate way to answer our research questions. After this the data collection method will be explained, with special attention for the case description, the selection of interviewees and the development of the questionnaire used. Finally, we will describe how the data will be analyzed. The concepts of controllability, validity and reliability are discussed throughout this section.

3.1 Research design

This study aims to describe ‘how’ the organization climate in a Dutch academic hospital influences the implementation of TQM. Because not much is known about the characteristics of the organizational climate in Dutch academic hospitals and its influence on the implementation of new innovations/systems like TQM, a qualitative research approach is appropriate. According to Hennink, Hutter, and Bailey (2011): “Qualitative research is an approach that allows to examine experiences in detail, by using a specific set of research methods, such as in depth interviews, focus group discussions, observation, content analysis, visual methods, and life histories or biographies” (p. 8). The qualitative research method we chose in this study is the case study method. According to Yin (1994) case studies are a tool for exploratory research. However, they can also be used for other purposes, such as discovery and description, theory validation and theory extension/refinement (Handfield & Melnyk, 1998). With this approach, we will try to come up with answers to the ‘how’ and ‘what’ questions that this study poses.

3.2 Data collection

3.2.1 Case description

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department and the rest of the hospital. Under each head nurse are one or several director nurses (regieverpleegkundige), who function as the link between the management of the department (head nurse) and the employees (normal nurses). They are responsible for the daily operational management of the department. Lastly, you have the normal nurses, which can get the function of ‘senior nurse’ after two/three years.

Table 2. Interview details

3.2.2 Interviews and interviewee selection

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3.2.3 Questionnaire development

To get insights into the organizational climate of the nursing departments, we developed an interview guide based on a validated climate questionnaire developed by de Cock et al. (1984). De Cock et al. (1984) developed two validated questionnaires to measure the organizational climate of an organization: one short questionnaire, the OKIPO, and an extended questionnaire, the VOKIPO. We used the constructs/scales applicable to our study setting to come up with an interview guide with a validated scientific grounding.

Furthermore, to be able to make comments about the relationship between the organizational climate and the implementation of an innovation/system, we also added questions that connected these 2 concepts. Because the concept of TQM has not been implemented yet in academic hospitals in the Netherlands it was impossible to study this concept retrospectively and ask respondents about the process of implementation. However, what we could do is ask the respondents about the adoption of other new innovations in recent years and translate the outcomes to the context of TQM. The innovation we used for this, is the VMS (veiligheidsmanagementsysteem). The aim of the VMS is to reduce avoidable health damage and deaths in the Dutch healthcare setting. The VMS pays attention to policy, culture, risk inventory and patient participation, but also to 10 medical themes such as ‘pain’ and ‘vulnerable elderly’. These 10 themes are based on previously detected health damage. In the UMCG the 10 themes were implemented before the end of 2012 (Weijling, 2014). By looking at the implementation of the VMS, we can: 1) identify the concepts that play a role in the implementation of innovations in a Dutch academic hospital and 2) determine how the organizational climate of a nursing department influences this implementation process. We can ultimately translate these findings to the context of TQM. The interview guide used for the interviews can be found in appendix A.

3.3 Data analysis

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17 4. Results

4.1 Introduction: A complex and dynamic working environment

Furthermore, the complexity of care and the administrative burden have increased tremendously… Sometimes it’s difficult to tell people they must register things twice. (head nurse, dep. B)

The high turnover of nurses has also influenced the workload. New nurses who step into this place whom are used to relatively quiet nursing departments, don’t know what they get themselves into. (dir. nurse, dep. B)

The work we must do is getting more demanding and more complex. A few years back, people with ankle fractures lay at our department for around 5 days. Nowadays, such a patient is discharged 1 day after surgery (dir. nurse, dep. C)

These quotes slightly reveal how dynamic and complex the environment of the nursing department is. This environment hugely influences the organizational climate at the nursing department, the collaboration with attending doctors and medical specialists, and the implementation of new innovations. In the subsequent section, we will answer our main research question by answering the four sub questions we formulated. We will start with describing the key characteristics of the organizational climate and the context in which it is embedded. After this we will describe the collaboration between nurses and doctors and how this relates to the organizational climate. The last major part of this section is about the implementation of the VMS: how did people experience the adoption, the implementation and sustainability of the VMS. We try to link our findings to the context of TQM implementation and we will ultimately describe the facilitators for TQM implementation.

4.2 Key characteristics organizational climate

4.2.1 Type of organizational climate

To be able to say something about how the organizational climate influences the VMS implementation, one first must describe this climate. This corresponds to the first sub question we formulated: What is the organizational climate at the nursing department at a Dutch academic hospital?

fig.4. Conceptual framework, highlighting the first sub question, the organizational climate.

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climate types, each with its own characteristics. The organizational climate at the nursing departments tends to a people oriented climate, with a preference for flexibility, which fits most with a ‘supporting climate’, see figure 5.

In the next paragraphs, a justification will be given why this is the most appropriate type of climate for the nursing department. We do this by describing the primary characteristics of the ‘supporting climate’ and other secondary characteristics, present in the case. The following primary characteristics of a ‘supporting climate’ will receive attention: high support colleagues, relation-focused leadership, limited approachability supervisor, oral and personal communication, uncritical attitude nurses, and false openness.

Fig.5. Positioning the climate of the nursing department according organizational climate typology by De Cock et al. (1984).

4.2.1.1 Primary characteristics

On the nursing departments collaboration between nurses and head/director nurse is very important. This indispensable collaboration, is reflected in the high support of nurses towards each other. As one of the nurses describes it:

If your planning is very busy, it is so important that you can rely on the colleagues with whom you have to work. Without this support, my work would be impossible to do. (Dir. nurse, dep. E)

Another feature that fits with a supporting climate is a personal and relation-focused way of

leadership, which is often practiced through informal contacts, and an informal organizational

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The head nurse feels like a normal colleague, as an equal. … Of course, she is the head nurse, but we can always come to her with questions. (Normal nurse, dep. A)

This personal and relation-focused way of leadership thrives by a high approachability of the head and director nurses. In the case investigated, this is partially true. Although head nurses say that their door is always open for their employees, still some sort of threshold is being experienced by the nurses. A threshold which is based on hierarchical inequality.

Some of the nurses really see the head nurse as the boss and therefore experience a threshold. […] Some of the nurses find it difficult to ask question. (Head nurse, dep. B)

During a normal working day, there are many moments at which supervisors ask their employees if they need help. Communication is mostly oral and there is much attention for individual problems and questions. This form of oral and personal communication suits a ‘supporting climate’ (De cock et al., 1984)

Every morning we have a consultation moment. …during which dir. and head nurse check if there are problems, if there are people who need help and people who can offer this help. People are always willing to help each other. (Head nurse, dep. D)

However, as De Cock et al. (1984) stated, in a supportive climate there is a tendency to prefer relationships above the tasks needed to be performed. The narratives show that the high support sometimes goes at the cost being critical. We can even say that in general that nurses have adopted an

uncritical attitude towards their colleagues.

There is a culture of caring for each other, in which people tend to avoid address problems/mistakes (normal nurse, dep. B)

We should be more critical towards each other. Giving feedback is something that happens very little. It is because of the culture. People are afraid of getting a reaction back. (normal nurse, dep. B)

In a climate where good relationships are the most important determinant for good collaboration and performance, openness is a must. However, there seems to be a false sense of

openness present at the nursing department. Various interviewees state that it is an illusion that people

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It looks like an open team, but we aren’t. […] People just don’t speak up when they have something on their mind. Perhaps they tell it to their direct colleague, but not to the one with whom they have the problem. (Senior nurse, dep. C)

This false openness again adds to the uncritical attitude of the nurses. Giving feedback and being critical happens more in the hall ways then in direct contact with the ones involved. Moreover, this lack of openness is reflected in the way nurses handle conflicts. There are not many conflicts or fights between nurses, mainly because there is tendency to avoid conflicts.

I do think that they (nurses) conflict too little. This is probably because they are a very social and close group and they don’t want to make a point of everything (Head nurse, dep. D)

I don’t think people conflict often, probably because they don’t dare to speak up to each other. (Dir. nurse, dep. C)

4.2.1.2 Secondary characteristics

Besides the supporting climate, the nursing department also shows some secondary characteristics: features of the other 3 climate types. One of these characteristics is the lack of use of the feedback/input.

What can be seen at the nursing department, which is in favor of an innovative climate, is the fact that individual employees are stimulated to give input and feedback to their supervisors. Nurses get their own topic/theme, for which they are responsible. Head nurses expect nurses to become experts on that particular topic and elevate the quality of care on that specific theme.

I tell my employees to which point on the horizon we need to go, but the way to get there is being shaped and created by the people. […] As a head nurse, you are constantly trying to enable people to reach that point. (Head nurse, dep. E)

But signaling a problem or coming with a proposal for improvement is one thing, really doing something with this feedback is another. There seems to be a lack of use of the feedback/input employees deliver. Some nurses have the feeling that the input they deliver, is not used or translated into new practices.

The first steps are being made, like the collection of ideas of asking people how they think about certain matters, but the next step is often missing. This really frustrates the team. (Dir. nurse, dep. C)

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to be limited and a false sense of openness is present, which is accompanied by an uncritical attitude of nurses. Furthermore, the use of feedback/input seems to be limited.

4.2.2 Context surrounding the organizational climate

Describing the organizational climate at the nursing department is the first step. The second step is describing the context surrounding and influencing this climate. Alteration of the organizational climate can only take place once you know the surrounding context that shapes the organizational climate. Therefore, we will continue with describing some key aspects of the surrounding context. The following four aspects of the context will be discussed in the next section: 1) the dynamic nature of the department of surgery, 2) high working pressure, 3) high (employee) turnover, and 4) the unnecessary repetition of actions,

4.2.2.1 the dynamic nature of the department of surgery

The nursing departments are characterized by having a very unpredictable nature. The reason for this Is strikingly simple, as one of the interviewees states:

Here we have to deal with patients, not machines. Sometimes things can be done more efficient, or we set out a plan in the morning which is already altered after 2 hours.

And because nursing departments are working with patients, many variables, such as the duration of consults, are unpredictable. Nurses also describe the department of surgery as more hectic than other departments. Especially at the department of surgery, flexible employees are a must:

If you can’t handle change and new things, you can’t work here. The only thing you know at the beginning of the day, is that the day won’t go as you have planned. If you just want to do your job and don’t want to develop, you are at the wrong place. (Head nurse, dep. D)

4.2.2.2 High working pressure

One of the biggest challenges the department of surgery faces, is the high working pressure. This high working pressure has many causes: high employee turnover (next paragraph), high patient turnover, an increased complexity of care, and unexperienced attending doctors.

The complexity of care has increased a lot and that is also what the UMCG wants. … We have a group of patients with much comorbidity, which makes the care for these patients more difficult. (Dir. nurse, dep. D)

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ill than before. People are more tired and unhappy because of the high working pressure. When the working pressure rises, the mental resilience of nurses is being tested.

We did a professionality scan… from which became apparent that around 40% of the nurses has an increased risk of a burn-out. (Head nurse, dep. E)

Another negative effect of the higher working pressure, is the fact the quality of care decreases. Especially themes like psychosocial care, the fragile elderly, mobilization of the patient, and registration of quality measures are being skipped when people have a shortage of time. Skipping psychosocial care, special attention for fragile elderly, and mobilization of the patient, can have a detrimental effect on the health outcomes of the patient.

.. Because you structurally can’t do things: psychosocial care, registration, proper supervision of new nurses. […] You notice that more mistakes arise, like forgetting to do a double check with medication. (Head nurse, dep. E)

A high working pressure also leads to decreased collaboration between nurses. Where nurses described the collaboration between them as good, with high levels of support, it also became apparent that when the working pressure rises, the collaboration suffers. In these situations, nurses tend to focus primarily on their own work and are much less willing to help colleagues.

The working pressure is high sometimes. […] Collaboration is very important, especially when the working pressure rises. But at the same time, it is very vulnerable. I have seen many occasions where people tend to go for themselves when it is getting busy. When people go for themselves, it only gets busier. (Head nurse, dep. B)

4.2.2.3 high employee turnover

A high employee turnover is something the nursing department must deal with. Many nurses leave the department of surgery after a few years to go to more dynamic departments like the ER (emergency room) and the IC (intensive care). This employee turnover results in many younger nurses with little experience. Because of the high turnover, the quality of the workforce and the patient satisfaction decreases.

We are in the middle of a period in which 8 nurses will leave on a group of 30 nurses. […] You want to build on quality… Right now, we must do a step back and start over. We have this cycle every few years. The quality of the nurses decreases. People are less capable on some aspects. You also notice that patients are less satisfied. Young, unexperienced nurses miss the antennas to notice when things go the wrong way. (Dir. nurse, dep. B)

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replacement of the nurses who left, leads to frustration among the experienced nurses who stay. In their opinion, they lose valuable time explaining the basics.

We have to deal with a high working pressure and a group consisting of many new colleagues. This is something that doesn’t always goes without friction. The new colleagues need to be trained, which costs time. (Dir. nurse, dep. C)

In the previous section the uncritical attitude of nurses was being described. According to the interviewees this has to do with a lack of experience among new nurses. Because they are new, speaking up is not something you do very quickly. As one of the interviewees states:

Most of them just come from school and only have temporary contract. They find it all very exciting and frightening. You won’t hear them say straight away what could be better and what is badly organized around here. (Dir. nurse, dep. B)

4.2.2.4 the unnecessary repetition of actions

Lastly, a trend is noticeable in the Dutch healthcare setting, where nurses but also medical specialist are faced with an increasing administrative burden. An increasing number of indicators needs to be registered, so that outcomes can be measured and compared with standards/ other departments. However, because the UMCG no central patient record, this administrative burden leads to situation in which nurses have to register things multiple times at different places. This unnecessary repetition leads too much frustration.

What could be much more efficient, is the fact that you have ask a patient 3 times for his/her weight during a single hospital visit. […] Now, many things are unnecessary repeated, because the information is scattered and we need to get information from all sorts of different places. (normal nurse, dep. A)

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24 4.3 Nurse-doctor collaboration

In this section, the collaboration between nurse and doctor is being discussed and how this influences the organizational climate at the nursing department. This follows from our second sub question: How does the nurse-doctor collaboration influences the organizational climate at the nursing department?

fig.6. Conceptual framework, highlighting the second sub question, the nurse-doctor collaboration

When describing the nurse-doctor collaboration the distinction needs to be made between the attending doctor, who is responsible for the ward and mainly works at the nursing department, and the medical specialist, who is end responsible for the care process of the patient and less bound to a specific department. Furthermore, in this section we will look at this collaboration by highlighting 6 aspects: 1) the lack of a common cause, 2) lack of communication, 3) variety in support, 4) the ‘drowning’ attending doctor, 5) and the changed hierarchy.

4.3.1 The lack of a common cause

One of the most striking observations from the interviews, was that doctors and nurses still look at things from their discipline/profession. A gap seems to exist between the medical and nursing profession, resulting in a lack of common goal that is being chased. More fine tuning seems to be needed.

You notice that specialists and nurses still look too much at their own domain. […] .. medical specialists and nurses should think more from a common perspective. (Head nurse, dep. B)

4.3.2 Lack of communication

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… I miss results. We are the ones standing next to the bed of the patient that askes us things that we don’t know anything about. […] It would be nice if doctors just keep us up to date about the various tests and results. (senior nurse, dep. D)

An important reason for this lack of communication, is the lack of contact between nurses and specialists. Because of this lack of contact moments, mistakes are easily made and not always corrected:

What sometimes happens is that the other party (specialist) is being asked to adjust a policy, but this policy is not communicated back to the attending doctor or the nurse. It happens that I check the patient file after 3 days and see a policy with which nothing is done in the past 3 days. (senior nurse, dep. C)

4.3.3 Variety in support

Another important aspect of the collaboration between doctors and nurses is the extent to which nurses feel supported by attending doctors and medical specialists. This support is very diverse, ranging from doctors who are willing to help, answering questions and are easily approachable, to doctors who come by ‘like a tornado’ and don’t like questions. The high turnover of nurses is also becoming visible in the collaboration with doctors. Often, good collaborating with doctors is something that nurses need to learn. They need to get experience, before they can make the collaboration fruitful. This remains difficult, because the turnover is so high.

4.3.4 The ‘drowning’ attending doctor

Most of the attending doctors have just finished their medical education and running the ward is their real first job as a doctor. Starting attending doctors have a difficult time in the beginning. Everything is new and they have to get used the way of working. However, what is typical for the department of surgery is the tendency of attending doctors not to ask for help. Asking for help in the world of surgery is seen a weakness:

Some of the attending nurses don’t dare to ask for help. If you don’t dot this you will have a hard time. […] ultimately you want to become a resident, so you won’t complain. (Head nurse, dep. B)

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If I have an unexperienced attending doctor, I demand of the specialists that one of them supervises him. If I don’t do that, the whole planning turns sideways. (Head nurse, dep. D)

4.3.5 The changed hierarchy

The last years, a trend is noticeable towards the ‘modern’ medical specialist. Many of the older medical specialists, who enjoyed much authority, have retired. They have been replaced by younger medical specialists who are willing to try new things, place more emphasis on collaboration and are much less fixed on their authority.

That also had to do with the older generation of doctors. … They have a different view of their job and status. […] I noticed this when one of the staff members, whom I had known for 6/7 years, became a professor. […] When I saw him, he said to me: I think things will become different now between us. […] He really thought he would get another status once he became professor. For the older generation, that really is a big thing. (Head nurse, dep. D)

The younger generation of doctors don’t want to be treated solely on their authority. Most of all, they want to collaborate. (Head nurse, dep. D)

Nurses also notice this shift in the relationship and especially behavior based on hierarchy is much less accepted than before:

If you had asked me this question 10 years ago, I would have said that the relationship is unequal. However, nowadays this clear difference hierarchy is almost unrecognizable. I always tell this to my nurses: you don’t have to accept that anti-social behavior anymore. (Head nurse, dep. A)

This change in roles also becomes apparent from increased responsibility given to nurses: doing the anamnesis, doing physical tests, being mainly responsible for wound care, and performing punctures. Years ago, this would have been unthinkable. Nowadays, doctors stimulate it that nurses take over some tasks, because it reduces their workload.

When I arrived here at the department there were staff members here who said: where is my coffee and my biscuit? […] On that area, we have made huge progression the last few years, partly by giving nurses a more prominent role during consultations. (Head nurse, dep. A)

But nurses don’t only get extra responsibilities, they are also more involved in the decision-making process by doctors. Nurses have their own areas of expertise. When speaking about these areas, doctors are willing to listen to nurses and give them the power to make decisions.

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Concluding, we can say that the collaboration between doctors is not optimal: communication is poor and support is too often lacking. This suboptimal communication results in conflicts between doctors and nurses. With the arrival of the ‘modern’ specialist, collaboration seems to have improved, hierarchy seems to have diminished and nurses get more responsibility. However, doctors and nurses still consider things too much from their discipline/profession, something that is strengthened by a lack of contact between the two professions. This hasn’t changed with the new role of the doctor.

The organizational climate at the nursing department was characterized as a ‘supporting climate’, where support towards colleagues and good, personal communication were essential. The collaboration between nurses and doctors doesn’t seem to fit into this type of climate. Quality improvement like TQM implementation require the involvement and collaboration of the relevant professional groups. (Stanton et al., 2014; Martin et al., 2010). This is supported by prior research of Talib et al. (2011) who found that teamwork and participation are important factors in the successful implementation of TQM. In the collaboration between doctors and nurses, the ingredients for successful TQM implementation, teamwork, and involvement of all the relevant groups, currently do not seem to be present. However, one could also reason the other way around, where the aspects of the context, such as a high working pressure and a high employee turnover, force the collaboration in the previously described direction. The relationship between the organizational climate and the doctor-nurse collaboration could therefore be seen as a reciprocal one.

4.4 VMS implementation

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fig.7. Conceptual framework, highlighting the third and fourth sub question about VMS and TQM implementation.

4.4.1 Adoption phase

During the adoption phase of the VMS implementation at the department of surgery, ambassadors were appointed. A team of 2 ambassadors, consisting of the head nurse and a doctor, was responsible for the promotion, implementation and the incorporation of VMS in daily practice of a particular theme.

That is because at the department of surgery we worked with ambassadors. Every theme had a few ambassadors who were responsible for the implementation. […] The goal was to implement it properly and make it part of the daily work. […] You need people pulling the cart and taking responsibility. (Dir. nurse, dep. E)

During the introduction period of the VMS, the provision of information was limited. There were PowerPoint presentations about the different themes, a few clinical lessons and working groups. However, not all nurses could attend these working groups because of their different schedules.

We barely had an introduction period about the VMS. Only for the specific theme of elderly care we had a three-day course. The information about the other themes was limited. (Dir. nurse, dep. C)

What made the lack of information even worse, was the fact that the introduction of the VMS did not happen centrally. The UMCG did not communicate properly what needed to happen and how it was going to be done. The responsibility to implement the innovation (VMS) was distributed to all the individual sectors in the hospital. These sectors needed to shape and implement this innovation themselves, which made the whole process very inefficient.

… Not every department has to reinvent the wheel. You can do this together and share ideas. […] You should do this UMCG wide. (Dir. nurse, dep. C)

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because people did not see the purpose, they were only concerned with the increased administrative burden coming with the VMS system.

… Nowadays we are busier with doing administrative work than the patient. That is very frustrating. It felt like it (VMS) only led to more work. […] You really have to give good arguments why you want to do something. You shouldn’t just drop it with the message: we are going to do it, just figure it out. You have to motivate employees and let them see the purpose of it. If you can’t do this, you can try as hard as you can, but it will fail. (Dir. nurse, dep. B)

Furthermore, besides the lack of a clear purpose, the VMS wasn’t easy to embed in the current way of working. It didn’t fit with the systems being used.

I told the board that I’m aware of the fact that it is a quality claim, but that it just wasn’t supported by the ICT and other tools. And because of that nurses had to register things twice. (Head nurse, dep. D)

Conclusion: during the adoption phase it appeared that, although there were ambassadors appointed for the introduction of VMS, the information provision was limited, a clear explanation of the purpose was missing and the VMS was not embedded in current working practices. The use of direct colleagues as ambassadors is a technique that fits with a supporting climate, where informal contacts and support are very important. However, this technique did not seem to have the expected effect. Two aspects of the organizational context, the high working pressure and unnecessary repetition of actions, seemed to be responsible for this. Because a clear explanation of the purpose and workings of the VMS was missing, employees were only concerned with the rising working pressure and increase in administrative work, as this was something they were already struggling with. This negatively influenced their opinion of the VMS. Therefore, the context surrounding the organizational climate seemed to have a huge influence on the adoption of the VMS.

4.4.2 Implementation phase

The fact that the purpose wasn’t clear and that the VMS was difficult to embed in the existing systems, led to resistance among employees during the implementation phase. They were reluctant to start using the new system, mainly because they just didn’t have the time and willingness to register things twice.

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This resistance was made even higher because of the lack of good implementation plan. This was for example reflected in the fact that there was no coordination between the medical and nursing department. Also, a clear structure for the implementation of the VMS themes is missing.

It began with the fact that they came quite suddenly with all the VMS themes. […] Furthermore, we couldn’t adhere to all the things that were asked. One moment, the attention was being focused on one particular theme and the next moment the attention was being focused on another theme. […] You don’t motivate your employees by constantly changing the emphasis. (Dir. nurse, dep. C)

Because the information provision was very limited in the adoption phase, many nurses had difficulties with working with the new system. Therefore, support from colleagues was also key in this setting. When the VMS had just been implemented, colleagues helped each other. Support was also given by the ambassadors, who were mainly responsible for answering questions and keeping the focus on the VMS. Nurses liked the fact that their direct colleagues had a promoting role in the whole process.

I think it’s very powerful if a colleague of yours functions as the point of contact, instead of an outsider who tells us what to do. (Dir. nurse, dep. E)

Besides the ambassadors, normal nurses without a specific function were not involved during the implementation process. According to the head nurse of dep. B, only the nurses in the working groups delivered input. A topic very much related to this low involvement of employees is the extent to which feedback of employees is used for improvement of the system. The usage of feedback of employees was low during the implementation process. Many nurses felt unheard: they gave feedback, but nothing was done with it.

In the beginning we gave much feedback, but we didn’t see this back in later versions of the system. (normal nurse, dep. A)

What is surprising is that the opinions about this topic are very different between the normal nurses, the employees and the supervisors. The latter really believed that the feedback employees gave was used for improvement. However, none the normal employees confirmed this. There seems to be a big difference in perception between these 2 groups.

We got many comments about the amount of work the VMS brought with it. We really used this feedback to improve the system. (Head nurse, dep. E)

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That is something in which the department of surgery is bad. We don’t evaluate here. […] We are very good in trying new things and innovating, but there is never a formal moment for evaluation. Things on which we can improve are never written down. […] That is just the culture around here. (Head nurse, dep. A)

Concluding, one can say that during the implementation phase resistance arose among employees, because of the earlier described unclear purpose and lack of embeddedness in existing systems. This resistance was strengthened by the lack of a clear implementation plan, something that became apparent from the poor coordination between the medical and nursing department. This is in line with the previous section, where it was argued that the collaboration and communication between doctors and nurses is poor. In a setting where there is resistance among and no clear implementation plan, support from colleagues becomes vital. This support seemed to be present, as colleagues and ambassadors helped and supported each other where possible. Here the role of the supporting climate really becomes visible. Also, other aspects of the organizational climate became visible during the implementation phase. One of these aspects is the limited use of feedback/input of employees. Employees were not involved during the implementation process of the VMS and their input was barely used. Moreover, the low approachability of supervisors became apparent, as supervisors and employees had very different views on the extent to which feedback was being used for improvement.

4.4.3 Sustainability phase

During the sustainability phase, not much support came from the management to continue using the VMS. Attention was primarily paid to the process of implementation, after which the departments were expected to figure it out themselves.

Now, it is more an initiative from the department itself. I think the framework is clear, so the only thing we have to do is work with it and solve occurring problems. (Head nurse, dep. E)

As a result, the maintenance and improvement of the VMS appears to be difficult, especially with a high employee turnover.

You notice that during the course of years, you have a continual change of personnel. Therefore, good maintenance of the system is essential. […] However, this maintenance has been let go. […] It is almost impossible to do this without support. (Head nurse, dep. E)

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maintaining and improving the VMS, experience and knowledge of this system is needed. Because of the high employee turnover, this is hard to achieve.

4.4.4 TQM and implementation facilitators

This section will be ended with establishing the link with TQM and describing facilitators for successful implementation of TQM. TQM aims to improve the quality of services or products by bringing together and linking a set of key competences that are relevant for the operational process of the organization (van Schoten et al., 2016). These key competences can be divided in hard-technical and soft-social competences. (Bou-Llusar et al., 2009). Especially these soft-social competences are relevant when speaking about organizational climate, because these are about leadership, teamwork, and employee participation. In the previous sections, we described the organizational climate to be of a supporting type with high levels of support, a relation-based leadership style, false openness, an uncritical attitude of nurses. What became apparent when studying the VMS implementation, was that soft-social competences like employee participation, leadership and the approachability of leaders, were bottlenecks during the implementation process. The same applied for teamwork: the collaboration between nurses- doctors seemed to be struggling, which led to poor coordination between the two professions and lack of a clear implementation plan. Support and help from nurses to each other appeared to be good, but this support appeared to be fragile. The contextual factors surrounding the organizational climate showed that, once the working pressure starts to rise, people tend to focus more on their own work.

Based on our analysis, we identified five facilitators of the organizational climate for successful implementation TQM:

1) Employee involvement:

You have to involve your employees, people from the work floor, in the change process. If you manage to do this, then you are already half way. […] Stimulate them to be critical and don’t tell them exactly how it should be. (Head nurse, dep. A)

2) Teamwork:

If things don’t go as planned, the group should be able to say that it doesn’t work and they should support each other in this statement. (Head nurse, dep. C)

3) Clear purpose:

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4) Good information provision:

Something I find frustrating is the fact that we are continuously implementing things, but that we don’t get anything back from it. This ultimately leads to a lower willingness of nurses to do it again. (Senior nurse, dep. D)

5) High approachability supervisors:

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34 5. Discussion and conclusion

In this section, the most important empirical findings will be presented and discussed. These findings form the basis of the revised conceptual framework and are used to answer the research question of this study. Furthermore, some of the major limitations of this study will be discussed, followed by possible future research that could be conducted. We will end this section with the managerial and theoretical implications of our findings.

5.1 Conclusions

The research question this study aimed to answer was: how does the organizational climate influences the implementation of TQM in a Dutch academic hospital setting? We tried to answer this question by studying the organizational climate and VMS implementation. We found a ‘supporting climate’, characterized by high levels of collegial support, a relation-based leadership style, limited approachability of supervisors, a false sense of openness, an uncritical attitude of nurses, and limited use of employees’ feedback/input. This organizational climate is embedded and shaped by the unique features of its surrounding context. Also, the nurse-doctor collaboration, characterized by a lack of communication and low levels of support, turned out to have an impact on the organizational climate. Furthermore, when studying the VMS implementation, we found that the organizational climate and its surrounding context played a huge role during the three phases of diffusion. When matching these findings with TQM characteristics, we concluded that especially the soft-social aspects of TQM, like employee participation, leadership and the approachability of leaders, were bottlenecks during the VMS implementation. The same applied for teamwork: the collaboration between nurses- doctors seemed to be struggling. Moreover, support and help from nurses to each other appeared to be good, but fragile. Lastly, this study identified five facilitators of the organizational climate for successful implementation TQM: employee involvement, teamwork, clear purpose, good information provision and high approachability of supervisors.

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fig.8. Adjusted conceptual framework about the organizational climate and TQM implementation

We described the organizational climate as a ‘supporting climate’, characterized by an orientation on people and flexibility. This is in line with the unitarist approach described by Bright and Cooper (1993). Tata and Prasad (1998) found that TQM thrives in a culture that is people-oriented and flexible. Characteristics of that culture are employee involvement, empowerment, teamwork, continuous improvement, and leadership. We also found that employee involvement, teamwork and leadership are extremely important if you want to implement TQM in a healthcare setting. The study of Westbrook and Utley (1995) adds to this, that a culture in which employees are valued is associated with successful TQM implementation. This longing for being valued for what you do is reflected by the fact that people want heard when giving input. This again corresponds with a climate type that is people-oriented. Talib et al. (20110 identified a set of best practices for successful implementation for TQM. Although this study only focused on the one particular concept influencing TQM implementation, we still identified the practices of top management commitment, teamwork and participation in our study.