Analyzing obstacles during the implementation of a quality management system conform HKZ norms at SMEs in the Netherlands

HKZ QUALITY MANAGEMENT SYSTEM IMPLEMENTATION

AT SMES

Analyzing obstacles during the implementation of a quality

management system conform HKZ norms at SMEs in the Netherlands

by

Yldou Brandenburgh

University of Groningen

Faculty of Economics and Business

Msc Small Business and Entrepreneurship

August 2010

in cooperation with

Thuiszorg Noord Nederland

TABLE OF CONTENTS 1. INTRODUCTION... 5 1.1 Research question ... 6 2. REVIEW OF LITERATURE... 8 2.1 ISO 9000/9001... 8 2.1.1 Explanation ISO 9000/9001………..……….8 2.1.2 TQM and ISO 9000/9001………..……….8 2.2 HKZ ... 9

2.3 Differences between large firms and SMEs ... 10

2.4 Obstacles... 11

2.5 Managerial behavior and style... 12

2.6 Financial resources ... 13 2.7 Bureaucracy ... 14 2.8 Flexibility... 14 2.9 Innovation ... 15 2.10 Resistance to change... 16 2.11 More customers ... 17 2.12 Conceptual model ... 18 3. THE CONTEXT ... 18 3.1 Sample ... 19

3.1.1 Thuiszorg Noord Nederland and HKZ……….….……19

3.1.2 SMEs in the healthcare industry………...19

3.2 Pilot studies ... 19

3.2.1 Results pilot study 1………..20

3.2.2 Results pilot study 2………..22

4.1 Research approach... 24 4.2 Data collection... 25 _{4.3 Data analysis………..26} 5. RESULTS... 26 5.1 Proposition 1... 26 5.2 Proposition 2a and 2b ... 27 5.3 Proposition 3... 28 5.4 Proposition 4... 28 5.5 Proposition 5... 29 5.6 Proposition 6a and 6b ... 30 5.7 Proposition 7... 31 6. DISCUSSION ... 31 5.1 Conclusion... 32 5.1.1 What is HKZ?...32

5.1.2 What is the definition of obstacles in this research?...32

5.1.3. What are the obstacles that large firms encounter when they apply for, and implement an ISO 9001 qualification standard according to the literature?...32

5.1.4. Do the experts in the field of certification believe the propositions to be true?...33

5.1.5. Do the obstacles found in the literature also occur in real life at small firms when they implement a quality management system according to this research?......34

5.1.6 What are the obstacles that Thuiszorg Noord Nederland encounters when they apply for, and implement a quality management system conform HKZ standards (and are those the same as the obstacles for large firms derived from literature?)………35

5.2 Recommendations ... 36

5.3 Limitations... 37

REFERENCES……….………..39

ABSTRACT

In this research, a literature review is performed to find out what the obstacles are that large firms run into when they implement a quality management system. Two pilot studies and 12 interviews at SMEs in the healthcare industry are performed to discover whether this obstacles also occur at SMEs. Implementing a quality management system is time consuming, incurs high costs, and can increase bureaucracy but also increases transparency, efficiency and clarity. Innovation is supported and resistance to change can be overcome. In the last chapter, recommendations are given for SMEs that consider implementing a quality management system.

KEYWORDS: HKZ, quality management systems, SMEs, obstacles, implementation

Supervisor: drs. Bernd W. Mintjes

2nd supervisor: Peter S. Zwart

Pages: 43

1. INTRODUCTION

Among standardized quality management systems, ISO 9000/ISO 9001 has reached a prominent position, with more than 730,000 certificates issued in almost 160 countries by December 2009 (www.iso.org). In other words, quality management is a familiar theme in business nowadays. According to Lundmark and Westelius (2006), the most apparent problem of ISO 9000/9001 standards is bureaucracy, which according to some managers can lead to reduced flexibility. Quazi et al.(2002), Docking & Dowen (1999), and Vloeberghs & Bellens (1996) all concluded that larger companies are usually more satisfied with the ISO 9000/9001 standards than smaller companies due to small and medium enterprises facing more obstacles when implementing ISO 9000/9001 standards. The requirements for quality management in the healthcare industry in the Netherlands are drawn up by Stichting HKZ (Harmonisatie Kwaliteitsbeleid Zorgsector) (Sluijs et al., 2007). The HKZ qualification has the ISO 9000 qualification as a basis and moreover embraces branch specific requirements concerning the healthcare industry. The aim of this thesis is to define and overcome those obstacles that small and medium enterprises (SMEs in further text) encounter when designing and implementing HKZ standards.

As stated above, ISO 9000/9001 has reached a prominent position worldwide in business. However, opinions about firms with an ISO 9000 qualification differ widely according to Terziovski and Guerrero-Cusumanoi (2004). There is for example a group that states that ISO 9000 certification increases bureaucracy, and reduces flexibility and innovation within firms (Corrigan, 1994; Henkoff, 1993; Johannsen, 1995; Stephens, 1994; and Terziovski et al., 1997). Nevertheless, there is also a group that is more optimistic, stating that ISO 9000 quality management system certification contributes to TQM implementation, improves customer satisfaction and productivity in firms (Henkoff, 1993; Marash and Marquardt, 1994; McQueen, 1993; Rayner and Porter, 1991; and Williams, 1997). Moreover, Han et al. (2007) discovered for example that ISO 9000 certification enhances organizational competitiveness which in turn helps to improve business performance.

Van der Wiele & Brown (1997)

Poksinska, Dahlgaard & Antoni (2002)

Johansson, Lindgren & Lissgärde (1993)

More quality awareness Improved internal procedures Improved staff motivation

Improved awareness of

problems Quality improvements Improved product quality

Improved customer service Improved corporate image Lower quality costs

Improved management control Increased customer satisfaction Increased organizational efficiency

Improved product and service quality

Increased on-time delivery to customers

Greater discipline and order Improved employee morale

Consistency across organization

Table 1. Comparison of benefits

The ultimate result of those benefits should be the attraction of more customers and retaining the customers that firms already have. However, the studies mentioned above are all

performed at large companies (>250 employees). Large companies are usually more satisfied with ISO 9000 standards than smaller companies as stated above. Why is this the case? Are the obstacles experienced by small firms different than for large firms? Are those obstacles relatively perceived larger? To formulate an answer to those questions, in the next section the research question of this thesis is described and explained.

1.1 Research question

research. Through this research, Thuiszorg Noord Nederland can take into account the obstacles found for SMEs when they implement their quality management system.

The research question related to this is:

'What are the obstacles that Thuiszorg Noord Nederland encounters when they implement a quality management system conform HKZ standards (and are those the same as the obstacles for large firms derived from literature?)’

The sub questions related to this research question are:

1. What is HKZ?

2. What is the definition of obstacles in this research?

3. What are the obstacles that large firms encounter when they apply for, and implement an ISO 9001 qualification standard according to the literature?

4. Do the experts in the field of certification believe the propositions to be true?

5. Do the obstacles found in the literature also occur in real life at small firms when they implement a quality management system according to this research?

6. How can SMEs take those obstacles into account when they implement an ISO 9001 qualification standard?

By not only performing a literature review but also performing pilot studies at Think Too and Myron and a research at 12 SMEs in the healthcare industry about the implementation of their HKZ quality management system, obstacles are defined and tested, results are shown and recommendations made. In order to prevent problems of the implementation of the quality management system at Thuiszorg Noord Nederland, this research is performed as the quality management system will be implemented in the coming months.

This report commences by describing further the literature underlying HKZ and the differences between SMEs and large firms. From the literature, propositions will be

formulated stating which obstacles SMEs face when implementing ISO 9000/9001 standards. After that a conceptual model will be drawn on the hand of the literature review. This

necessary, the conceptual model will be modified when this is required according to the pilot studies. In order to be able to generalize the results more, 12 quality managers of SMEs in the healthcare industry that implemented a HKZ quality management system are interviewed. On that account, the propositions are tested at 12 cases. Moreover, the methodology for those case studies is described. After that, the results of the research will be analyzed. This thesis concludes by a discussion, including conclusions, recommendations and limitations of the research.

2.1 ISO 9000/9001

2.1.1 Explanation ISO 9000/9001

The International Organization for Standardization (ISO) is an international standard setting body representing different national standards organizations. ISO 9000 is a family of

standards for quality management systems. ISO 9001 is a part of this family. ISO 9000 came into existence in 1994 and ISO 9001 in 2000 as the successor of ISO 9000 (Martinez-Costa et. al 2009). The purpose of ISO 9000 was to provide a series of international standards dealing with quality management systems that could be used for external quality assurance purposes. Companies interested in demonstrating that their procedures meet international quality

standards can seek ISO 9000 certification by hiring a registration (certification) organization, accredited by ISO, to perform a quality management system audit and grant ISO 9000

certification (Stevenson and Barnes, 2002). According to Kartha (2002), ISO 9000 standards are supposed to aid companies in streamlining their operations, identifying mistakes, and being able to guarantee a consistent level of quality. When a firm is ISO 9000/9001 certified, it shows that the business processes of the company are formalized to ensure quality within the organization.

2.1.2 TQM and ISO 9000/9001

Total Quality Management (TQM) is typically defined as a system of practices with

overarching or systematic impact on company practices and performance (Martinez-Costa et al. 2008). Flynn et al. (1994) defined TQM as ‘an integrated approach to achieving and sustaining high quality output. It focuses on the maintenance and continuous improvement of processes and defect prevention at all levels and in all functions of the organization, in order to meet or exceed customer expectations.’

(Mann and Kehoe, 1994). During the second half of the nineties, ISO 9000 was the most prevalent global quality initiative (Lee and Palmer, 1999; Zhu and Scheuermann, 1999); Ismail and Hashmi, 1999; Tsiotras and Gotzamani, 1996).

Both TQM and ISO 9000 lead to improvement in performance according to Martinez-Costa et al. (2008). Further, companies with high internal motivation for ISO 9000 naturally show a high level of TQM practices. However, certified ISO companies still often fall short of

implementing a comprehensive TQM system (Gotzamani and Tsiotras, 2001; Lee et al., 1999; Reimann and Hertz, 1996; Zhu and Scheuermann, 1999). According to Hind (1996), firms attempting to implement TQM implemented some form of ISO standards, however only about one-tenth succeeds in the shift from ISO 9000 to TQM. Moreover, Taylor and Meegan (1997) concluded in their longitudinal study that 25 percent of their research companies considered their TQM to have failed. Taylor (1995) states that the reason for this is that there is no

proven theory stating that there is a clear relationship between ISO 9000 standards and TQM.

2.2 HKZ

According to Trigueros and Sansalvador (2008), the ISO 9000 standards are widely used by many firms and are perceived by many customers as synonymous of quality. In the healthcare industry the concept of quality management systems entered in 1990 (Sluijs et al., 1992). In 1996, the Kwaliteitswet Zorginstellingen (Quality act Healthcare institutions) was introduced in the Netherlands in order to guarantee the quality in the healthcare industry (Casparie et al., 2001). The requirements for quality management in the healthcare industry are drawn up by Stichting HKZ (Harmonisatie Kwaliteitsbeleid Zorgsector) (Sluijs et al., 2007). In other words, HKZ is the quality institution for the healthcare industry in the Netherlands. They draw up quality standards for a large number of branches in the healthcare industry. They work together with patient organizations, healthcare insurances and healthcare suppliers. The HKZ qualification has the ISO 9000 qualification as a basis and moreover embraces branch specific requirements concerning the healthcare industry. The HKZ qualification is a cycle and prescribes that a good organisation is aware of its processes. When organizations have a HKZ qualification their organization becomes more transparent and will work more efficient according to HKZ.

executed in practice by samples and interviews. When this is approved, the certified

institution gives the firm a HKZ certification. After the initial certification, the firm is audited yearly to see if the quality management system of the firm is preserved and improved. After three years a recertification is performed (hkz.nl).

2.3 Differences between large firms and SMEs

Small and medium enterprises (SMEs) are vital for both developed and developing economies as they are considered to be the engine of economic growth and employment (Radas and Bozic, 2008). Moreover, small firms are a significant source of innovative activity (Audretsch and Thurik, 1999) and thus important for the economy. However, small firms often lack resources and have severe limitation due to their small size compared to large firms (Carson and Gilmore, 2000). In this research, SMEs are defined as small and medium sized enterprises up to 250 employees in concurrence with the classification of firms by the European

Commission (O’Regan and Ghobadian, 2004). Firms with more than 250 employees are seen as large firms. There are more differences between large and small firms as Ghobadian and Gallear (1999) state in an article. They came up with a comparison of the differences between large companies and SMEs. A summary of those findings is shown in table 2:

Large organizations Small and medium organizations

Hierarchical with several layers of

management Flat with few layers of management

High degree of standardization and formalization

Low degree of standardization and formalization

Activities and operations governed by formal rules and procedures

Activities and operations not governed by formal rules and procedures

Mostly bureaucratic Mostly organic

Rigid organization and flows Flexible organization and flows

High degree of resistance to change Negligible resistance to change

Low incidence of innovativeness High incidence of innovativeness

Formal evaluation, control and reporting procedures

Informal evaluation, control and reporting procedures

Table 2: Differences large vs small firms

This table shows that there are many differences between small and large firms. SMEs are more flexible, informal, flat, people dominated, innovative and mostly organic. Besides, SMEs have a low degree of standardization and formalization and the evaluation, control and reporting procedures are informal. There has been done extensive research about the

differences between small and large firms. Other significant differences described by authors are for example that SME top management is often involved in day-to-day activities

(McCartan-Quinn and Carson, 2003). Besides, SMEs often lack financial and human

resources (Ghobadian and Gallear, 1996; Gunasekaran et al., 1996; McAdam, 2002; Achanga et al., 2006). By researching the obstacles of implementing ISO 9000/9001 standards for large firms according to the literature and compare them with the obstacles shown in small firms, one can find out if the obstacles are related to the size of a company or that they are the same for all firms. This describes what is done in this research. The obstacles found in the literature for large firms will be tested at SMEs by interviewing the quality managers at those SMEs. The obstacles found for implementing ISO 9000/9001 standards can be compared with obstacles for implementing a quality management system according to HKZ norms as the HKZ norms have the ISO 9000/9001 standards as a basis.

2.4 Obstacles

2.5 Managerial behavior and style

Meeting the requirements of the standards for quality management systems can be a major obstacle for small firms as it requires motivation by the management to appreciate, achieve and implement the necessary measures to meet those criteria (Anon 1993). As reported by Morenzo-Luzon (1993), it is necessary for the management of large firms to devote quality time to the task of implementing a quality management system successfully. However, small businesses often suffer from a lack of resources and time as the main reasons for not

implementing an ISO 9001:2000 quality management system (Aldowaisan and Youssef, 2004). The results of the research of Withers and Ebrahimpour (2000) show that the most frequently mentioned obstacle to ISO 9000 certification was top management involvement. Other researchers such as Tsiotras and Gotzamani (1996), Withers et al (1997), and Weston (1995) agree that top management commitment has an impact on the success of quality initiatives.

Moreover, according to Ghobadian and Gallaer (1999), the biggest obstacle with the introduction of Total Quality Management in SMEs is the management realization and the ability of owner managers to modify their behavior and management style. In order to devote quality time to the implementation task, the behavior and style of the management has to be altered as a proportion of their time has to be dedicated to the implementation task.

The empirical investigation of Lewis et al. (2005) of the hard and soft criteria of TQM in ISO 9001 certified small and medium sized enterprises, concluded that employees did not have complete buy in to the quality management system in their organization if the management did not spent enough time at the start of implementation. Adequate time has to be spent to totally understand what the quality management system entails. If the management is directly involved through a good working knowledge and the operational quality management system, employee acceptance could be reached.

To investigate if it is an obstacle for managers in SMEs to devote enough quality time to the implementation of the HKZ standards and thus alter their behavior, the following proposition is formulated.

Proposition 1:

2.6 Financial resources

According to Custers et al. (2001), a quality management system brings in extra costs, both the sole costs for the development of the system as well as the structural costs for maintaining the system.

The costs for implementing an ISO 9000/9001 quality management system is a large

investment for SMEs. Small businesses often suffer from a lack of resources and time which are the mains reasons for not implementing an ISO 9001:2000 quality management system for small businesses according to Aldowaisan and Youssef (2004). Other resesarchers such a Achanga et al. (2006), Ghobadian and Gallaer (1996), McAdam (2002) and Gunasekaran et al. (1996) also state that one major disadvantage of SMEs is a lack of human and financial resources. Time and costs are important issues for firms thinking about ISO 9000 certification (Atwater and Discenza, 1993; Weston, 1995; Vloeberghs and Bellens, 1996; Carlsson and Carlsson, 1996; Beattie and Sohal, 1999). The high costs can be an obstacle for SMEs in that they will choose to not implement an ISO 9000/9001 quality management system as they suffer from a lack of financial resources.

To become HKZ certified, a firm needs a quality handbook which describes all the processes in the firm. After that, the quality handbook is implemented in the firm. This means that the firm from then on works according to the processes described in the handbook. The

implementation takes time (and thus money) and the employees have to get used to the new way of working. Many small businesses can not afford to dedicate a number of their

employees during and after the ISO 9001 realization (Aldowaisan and Youssef, 2004). Moreover, these authors state that small business have problems with financing the costs of preparation and development. After the implementation of the quality management system, an independent certified institution (onafhankelijke Certifierende Instelling (CI)) has to perform an extended certificate audit (initial audit) at the firm. This audit costs between €1000 and €1200 per workday (hkz.nl). An independent certified institution needs about 2 days to audit a small firm. The prices to audit bigger firms vary from about 10 workdays for firms with 275-425 employees to about 20 workdays for firms with 5450-6800 employees.

Proposition 2a:

The costs of implementing a HKZ quality management system are relatively higher for small firms than for large firms

Proposition 2b:

2.7 Bureaucracy

According to Adlees and Borys (1996), bureaucracy in an organization means that there are high levels of formalization and/or centralization in an organization. Raub (2008) agrees with this statement as he states that standardization and centralization are bureaucratic

mechanisms. Ghobadian and Gallaer (1999) state that the planning process in SMEs is not formal and multi-functional planning occurs within individual minds. Mintzberg et al. (2003) agree with this as they state that SMEs have relatively informal structures. Moreover, as stated in table 2 in chapter 2.3, small organizations are mostly organic whereas large

organizations are mostly bureaucratic. Compared to large companies, smaller companies are unrestricted by bureaucracy and expensive existing information systems (Covin and Slevin, 1989; Douglas et al., 1982; Verity, 1994 Pelham and Wilson, 1995). According to Ballé (1999), standardisation happens through detailed procedures about how to behave in certain circumstances.

When implementing a quality management system, an organization will become more

standardized as many standards are established within the organization. In order to implement a quality management system successfully, a small organization will probably become more bureaucratic. Moreover, according to Corrigan (1994), Henkoff (1993), Johannsen (1995), Stephens (1994) and Terziovski et al. (1997), ISO 9000 certification increases bureaucracy within firms. To find out if this is true for SMEs, the following proposition is formulated.

2.8 Flexibility

According to Younger (1990), the flat structure and fewer departmental interfaces of SMEs result in a more flexible work environment. Flexibility fit is the co alignment between a firm and its environment according to Verdi-Jover et al (2006). The degree of metaflexibility (capacity to be flexible over time) can be greater among small firms than among large firms, which represents a greater information capacity, thus enabling the flexibility fit to be

constantly co aligned to changes in the environment. According to Audretsch and Thurik (2000) small entrepreneurial firms are flexible to rapidly change the product/service

specifications to meet specific demands of customers. Moreover, according to Oughton and Whittam (1997) the emergence of SMEs that are both highly responsive to changes in

Proposition 3:

consumer demand and adapt to the environment by introducing continual improvements in product/service design are essential to the production of high quality, high value-added goods/services. This literature review of flexibility shows that flexibility is an important aspect of SMEs to stay competitive.

However, when implementing a quality management system conform the HKZ norms, all the processes in a firm have to be described and the organization has to work according to

protocols which probably reduces flexibility. The responsiveness to changes in the

environment will be lower as the flexibility is less. Moreover, according to Corrigan (1994), Henkoff (1993), Johannsen (1995), Stephens (1994) and Terziovski et al. (1997), ISO 9000 certification reduces flexibility within firms. If this is true, HKZ certification includes a negative aspect for SMEs that can be seen as an obstacle, as flexibility is a positive aspect of SMEs as concluded above.

2.9 Innovation

Small firms are a significant source of innovative activity (Audretsch and Thurik 1999). Innovativeness is among the most important means through which SMEs contribute to economic growth (Radas and Bozic 2008). According to the research of Rosenbusch et al. (2009), innovation has a positive effect on the performance of SMEs. They concluded this after analyzing 42 empirical studies on 21,270 firms. Moreover, SMEs are frequently the first to commercialise and are thus more innovative than large firms given the limited resources they devote to R&D (Oughton and Whittam, 1997). Innovation may be even more important for SMEs than for large firms (Radas and Bozic 2008). Besides, some authors (Fritz, 1989; Sweeney, 1983) believe that SMEs use product innovations as a means to become more competitive than large organizations.

When implementing a quality management system conform the HKZ norms, almost all processes of a firm have to be described. In order to get the certification, the organization has to prove the audits that the organization is working conform those prescribed processes. Those processes leave less room for spontaneity and probably also for innovativeness. Besides, bureaucracy has often been characterized as a negative phenomenon limiting

innovation (Adler and Borys,1996). Moreover, according to Corrigan (1994), Henkoff (1993), Proposition 4:

Proposition 6a

SMEs have a negligible resistance to the changes in the organization due to the implementation of the quality management system due to their small size

Proposition 6b

Implementing a HKZ quality management system in an SME will only succeed if there is no resistance to change within the organization

Johannsen (1995), Stephens (1994) and Terziovski et al. (1997), ISO 9000 certification reduces innovation within firms. To see if this is true, proposition 5 is developed.

2.10 Resistance to change

Change is a situation that interrupts normal patterns of organization and calls for participants to enact new patterns, involving an interplay of deliberate and emergent processes that can be highly ambiguous (Mintzberg and Waters, 1985).When a quality management system is implemented, there will occur some changes in the organization as described earlier. One of these changes is that the organization has to work according to prescribed processes and protocols which were not present to the full extent before the implementation of the quality standards. According to Kotter and Schlesinger (2008), most organizational change efforts encounter problems, they often take longer than expected and desired, they sometimes kill morale, and they often cost a great deal in terms of managerial time. The most common reason why people resist change are a misunderstanding of the change and its implications, a desire not to lose something of value (parochial self-interest), a low tolerance for change, and a belief that the change does not make sense for the organization (Kotter and Schlesinger 2008).

On the other hand, table 2 in chapter 2.2 is stated that in small organizations there is a negligible resistance to change whereas in large organization there is often a high degree of resistance to change. If employees of an organization resist to changes in the organization, the implementation of the change will be more difficult than when there is no resistance to the change. To find out if resistance to change is negligible in small firms when implementing a quality management system, the following propositions have been formulated.

Proposition 5

2.11 More customers

It will be interesting to find out why organizations incorporate a quality management system within their organization. The reason for implementing a quality management system will be the desired result of the implementation. In this section will be described why organizations implement a quality management system according to the literature. This reason will also be researched in the pilot study and in the interviews with the participating organizations.

The reason why SMEs implement a quality management system is often to demonstrate others that their organization is sound. Consumers and businesses demand high quality products (Withers and Ebrahimpour, 2000). The ISO 9000/9001 quality standards are designed to show to customers that an organization has accomplished a certain level of quality assurance by the formalization and documentation of their quality management system (Beattie and Sohal, 1999; Docking and Dowen 1999). According to Jacobson and Aaker (1987), ‘customers seem to place a premium on quality and are willing to reward those firms perceived as offering a quality product.’

One of the most important goals of implementing a quality management system is to assure the quality of products and decrease risks. Besides when having a quality management system, the processes of an organization are monitored and in that way, mistakes are prevented instead of recovered when they already occurred (De Dreu, 2006).

The question is if this all eventually results in the attraction and preservation of more customers. According to Babicz (2000), when an organization is ISO 9000 certified,

customers will be more loyal to the organization. The HKZ foundation stimulates working on quality from the perspective of the customer (hkz.nl). The view of working from the

perspective of the customer could imply that organizations apply for an ISO 9000/9001 certification to attract more customers. Thus by having a sound and efficient way of working, organizations hope to convince their customers to buy more of their products or services. This would be a positive result of implementing a quality management system in an SME. To find out if it is the case that through a HKZ certificate an SME will attract and preserve more customers, the following proposition is formulated.

Proposition 7

2.12 Conceptual model

The conclusion of the literature review is the conceptual model. All the propositions formulated in the literature review are implemented in the conceptual model as is shown in Figure 3.

Figure 3: Conceptual model

3. THE CONTEXT

In this section the context of the performed research is described. To gain more insight in the implementation of quality management systems in small firms in the North of the

Netherlands, two experts in the field of implementing ISO 9000/9001 quality management systems were interviewed. Those pilot studies at Think Too and Myron were executed to test the conceptual model. The companies Think Too and Myron agreed to participate in this research as both being companies supporting small- and medium sized firms with

healthcare industry to test the propositions found in the literature. As an intern at Uni2all marketresearch, a small organization in the North of the Netherlands, I wrote the HKZ quality handbook for Thuiszorg Noord Nederland, another small organization in the North of the Netherlands, and closely follow the implementation of the quality management system. As an intern, I had the chance to monitor the implementation and interview key persons in the organization. In the next subsection Thuiszorg Noord Nederland is more thoroughly described as well as their reasons for applying for a HKZ certification. After that the sample of the 12 other SMEs is described. Furthermore, the pilot studies executed at Think Too and Myron are described and the results of the pilot studies are shown.

3.1 Sample

3.1.1 Thuiszorg Noord Nederland and HKZ

Thuiszorg Noord Nederland is small organization based in Groningen that offers home care in and around Groningen. The services they offer at the moment are help with housework, personal care, supportive accompaniment and active accompaniment. In the coming years Thuiszorg Noord Nederland would like to expand and offer a more broad range of services. However, before expanding, Thuiszorg Noord Nederland is applying for a HKZ certification. In that way, the organization will become more transparent for outsiders. The HKZ

certification will show that Thuiszorg Noord Nederland works according to prescribed quality requirements and thus offers services with quality.

3.1.2 SMEs in the healthcare industry

In order to be able to generalize the results of this research, 12 SMEs in the healthcare

industry are included in the research. The organizations all have less than 250 employees and have a HKZ certificate. By interviewing key persons of the HKZ quality management systems in those organizations the obstacles found in the literature are tested.

3.2 Pilot studies

Think Too is an advising company that supports companies with the improvement of their business. One of the main services they offer is advising and helping to design a quality handbook conform the HKZ norms. Moreover, they can help to implement the quality management system within the company. Furthermore, they are a partner of the HKZ

foundation. Think Too was approached for this research due to their experience with SMEs in the healthcare industry and because they are a partner of HKZ.

their wide range of experience in the ISO 9000/9001 scene. Myron not only aids SMEs in the healthcare industry but also in other industries.

By interviewing those experts in the field of certification of small firms, the initial conceptual model was tested. The experts were asked whether they agree with the concepts in the

conceptual model as being obstacles for the implementation of HKZ quality management systems. This was done by interviewing the experts.

3.2.1 Results pilot study 1

The first interview was done with Teun Rozenveld from Think Too. Think Too aids SMEs in designing and implementing quality handbooks conform HKZ norms. First of all he was asked what kind of obstacles he runs in to when aiding companies with HKZ. He came up with the following obstacles:

- Companies often have little knowhow about their own business. Therefore it takes a lot of time to develop a quality management system because the business processes first have to be discovered;

- Making the management (and thus the employees) aware of the impact of a quality management system on the whole organization takes a lot of time;

- Through the increased bureaucracy due to the quality management system, the organization becomes less flexible;

- Organizations often let the HKZ advisor establish the whole quality management system. Therefore they are not independent and there is little initiative.

To find out if the obstacles found in the literature also occur in real time cases, mr Rozenveld was asked what he thinks about the found obstacles from the literature. The results are shown after every proposition.

1. Devoting enough quality time to the implementation of the quality management system conform HKZ norms and thus alter the behavior of the management is an obstacle for the implementation of HKZ in SMEs

He agrees with the first proposition as can also be deducted from the obstacles he named by himself.

2. a: The costs of implementing a HKZ quality management system are relatively higher for small firms than for large firms

few employees costs in total about €2000,-. Relatively seen is a quality management system more expensive for a small organization than for a large one.

b: Those high costs are an obstacle for SMEs in that SMEs will decide not to implement a HKZ quality management system

This is not the case with HKZ mostly. The health office in the Netherlands requires organizations to have a HKZ certificate in order to do business with them. If

organizations would like to go into business with them, they need the HKZ certificate.

3. Implementing a quality management system based on HKZ norms increases bureaucracy for SMEs

Due to the quality management system, there are more protocols and procedures where the firms have to work according to. However, if there were first five different

procedures at different levels, there will be only one after the implementation of the quality management system. This means that the organization will work more efficient.

4. Implementing a quality management system conform HKZ norms reduces flexibility for SMEs through a higher degree of bureaucracy

Through the increased bureaucracy due to the quality management system, the organization becomes less flexible. The basis of quality management system is to document and measure business processes. The organization thus has to work according to prescribed processes which reduces flexibility.

5. Implementing a HKZ quality management system reduces innovation for SMEs through the prescribed processes that have to be followed

Due to increased cohesion between different processes between the organization, the total can be easier overlooked. On that account the innovative capacity of the

organization increases through increased insight in processes.

6. a. SMEs have a negligible resistance to the changes in the organization due to the implementation of the quality management system due to their small size

There can be resistant to change in SMEs when employees do not acknowledge the value of the quality management system within their organization. This is often the case because they are not properly informed about the quality management system by the management of the organization.

As long as the employees do not acknowledge the value of the quality management system, and there consequently is resistance, the quality management system will not work optimally. In other words, there should be no resistance to change within the organization to successfully implement the quality management system.

7. By acquiring a HKZ certification, SMEs’ goal is to attract and preserve more customers than without such a certificate

Eventually this is the goal for organizations to implement a quality management system. The quality of an organization is on the surface when they have a HKZ certificate. Through a high quality of the delivered healthcare, the organization will acquire and preserve more customers.

The results of the first pilot study show that the found obstacles in the literature can occur at SMEs as well when implementing a quality management system. Only proposition 2b and 6a are not relevant according to mr Rozenveld. To reach a higher reliability of the results, a second pilot study was conducted at Myron.

3.2.2 Results pilot study 2

The second interview was held with Henk Jan Roos, the CEO of Myron. Myron is also an advising company that aids companies in designing, implementing and maintaining ISO 9000/9001 quality management systems. Mr Roos was asked more questions than mr

Rozenveld in order to achieve a more in-depth answers. First mr Roos was asked to name the obstacles of implementing a quality management system. He named the following obstacles:

- Little or no support of the (top) management when implementing the system; - Lack of time and money;

- The key persons within the organization who have to implement the quality management system often do not have enough knowledge about HKZ; - Resistance to changes within the organization.

Mr Roos was also asked how he thinks about the found obstacles in the literature. His opinion is shown after every proposition.

1. Devoting enough quality time to the implementation of the quality management system conform HKZ norms and thus alter the behavior of the management is an obstacle for the implementation of HKZ in SMEs

implementation of the quality management system which causes delay. It takes time and effort to implement a management quality management system.

2. a: The costs of implementing a HKZ quality management system are relatively higher for small firms than for large firms

This is true if there is a limit of 100 employees. Above a 100 employees the costs are relatively similar.

b: Those high costs are an obstacle for SMEs in that SMEs will decide not to implement a HKZ quality management system

This is often not the case in the Netherlands as organizations are required to have a HKZ certificate. If organizations do not have a HKZ certificate, the health office will not go into business with them.

3. Implementing a quality management system based on HKZ norms increases bureaucracy for SMEs

HKZ requires that all the processes are documented in detail which reduces the workability of the system.

4. Implementing a quality management system conform HKZ norms reduces flexibility for SMEs through a higher degree of bureaucracy

Through all the documented processes where the organization has to work according to, the system is too extended to be flexible.

5. Implementing a HKZ quality management system reduces innovation for SMEs through the prescribed processes that have to be followed

Due to the capaciousness of a quality management system conform HZK norms, the organization becomes less flexible. This results in slowing down of the enactment of innovative activities.

6. a. SMEs have a negligible resistance to the changes in the organization due to the implementation of the quality management system due to their small size

There can also be resistance to change in SMEs. However if the management is not resisting the change, the employees often also do not resist the change.

b. Implementing a HKZ quality management system in an SME will only succeed if there is no resistance to change within the organization

7. By acquiring a HKZ certification, SMEs’ goal is to attract and preserve more customers than without such a certificate

The most common reason for designing and implementing a quality management system is due to the demand of the health office. The proposition is indirect true as this should lead to the attraction and preservation of more customers as the health office will only go into business with organizations with a HKZ certificate.

The second pilot study shows that the found obstacles in the literature also occur in SMEs. Propositions 2b and 6 are not totally underlined by the second pilot study. By analyzing the results of the two pilot studies, it can be concluded that proposition 2b and 6 might not be relevant for SMEs. Further research will show if more organizations have the same opinions about the above mentioned propositions.

4. METHODOLOGY

This section covers the methodology underlying the research performed at the SMEs in the healthcare industry with a HKZ certificate. The pilot studies have shown that the found obstacles in the literature can occur in real life. That is why the initial conceptual model was used to design the interviews. To discover how the management and employees of Thuiszorg Noord Nederland experienced the design and implementation of the quality management system within the company, the quality manager was interviewed. Besides, interviews were conducted at 12 other SMEs in the healthcare industry with a HKZ certificate. Multiple case studies aid to increase generalizability well beyond drawing conclusions from a single case (Hilllebrand et al. 2001).

In that case, the results can be generalized. The goal of those interviews was to discover which obstacles the organizations encountered when designing and implementing their quality management system.

4.1 Research approach

time consuming (Snider et al. 2008). That is why the sample size is limited in this research consisting out of two pilot studies and 12 actual case studies. By carrying out 12 case studies, a deeper understanding of outcomes of the cases is reached and there is the chance to test hypothesis (Miles and Huberman 1994).

4.2 Data collection

Each participating organization in this research was required to: - be located in the Northern part of the Netherlands;

- be a small or medium sized organization (up to 250 employees); - operate in the healthcare industry;

- have a HKZ certificate and thus;

- implemented a quality management system.

A total of 35 companies were contacted by telephone and e-mail. After reminder e-mails and calls, 12 organizations agreed to participate in the research. According to Eisenhardt (1989), a minimum number of four cases is required for multi-case research which is thus exceeded in this research. At all the companies, the quality manager was interviewed which resulted in 12 separate interviews.

The interview questions were based on the results of the literature review, the there from emerged obstacles, and the pilot study. First of all, obstacles were defined in the interviews as changes in the organization due to the designing and implementation of the quality

4.3 Data analysis

The results of the interviews were analyzed individually as Miles and Huberman (1994) and Eisenhardt (1989) prescribe. A summary was made of the provided answers. This analysis showed whether the organizations agreed with the propositions or not and why. After that, the results per question for all the cases were ordered into one document. In that way, the answers and explanations per proposition could be analyzed.

5. RESULTS

In this chapter the results of the performed research are shown per proposition. Moreover, in this chapter is shown whether the propositions derived from the literature are underlined by the case studies.

5.1 Proposition 1

Proposition 1: Devoting enough quality time to the implementation of the quality management system conform HKZ norms and thus alter the behavior of the management is an obstacle for the implementation of HKZ in SMEs

The results show that all the companies agree that implementing a quality management system takes a lot of time. The documentation of all the processes is especially time consuming. In small organizations time is already scarce. Most of the interviewed

organizations misjudged the amount of time necessary to implement a quality management system. The managers did not have a good vision of what should be done in order to implement the quality management system. Through the prescribed procedures, business in general is altered. Moreover, after the implementation of the quality management system, the enactment of the prescribed procedures also takes time which is a consequence of the

implementation. The smaller organizations up to 15 employees that participated in the research (25%) had less problems with modifying the behavior of the management as the managers had a clear overview of the organization and there is almost no hierarchy within the organization. As a consequence, the communication between the managers and employees is effective and everyone has a clear task within the organization. However, those small

In conclusion, this proposition is underlined by this research. Enough quality time should be devoted to the implementation of the quality management system conform HKZ norms which is scarce in small firms and thus an obstacle. The behavior of the management should be altered by making time free for activities related to the implementation of the quality management system. This is an obstacle as the behavior has to be altered in order to implement the quality management system successfully.

5.2 Proposition 2a and 2b

Proposition 2a: The costs of implementing a HKZ quality management system are relatively higher for small firms than for large firms.

According to the participating organizations, the costs of implementing a HKZ quality management system for small organizations are relatively high. One of the participating organizations with 80 employees acquired a HKZ certificate in 2005. The organization set up a foundation with two other organizations in the healthcare industry last year. One of the reasons for the cooperation was that the costs for HKZ would be relatively lower. The costs for the audits could be shared in this way and documents as policy and procedures shared which increased efficiency time- and moneywise.

The results show that proposition 2a is underlined by the conducted research. This means that the costs of implementing a HKZ quality management system are relatively higher for small firms than for large firms.

Proposition 2b: Those high costs are an obstacle for SMEs in that SMEs will decide not to implement a HKZ quality management system

None of the participating organizations have considered not to implement a quality management system conform HKZ norms due to the high costs. The most frequent reason mentioned why the high costs were not seen as an obstacle is that the health office in the Netherlands requires a HKZ certificate. If the organizations do not have a HKZ certificate, the health office will not go into business with them.

5.3 Proposition 3

Proposition 3: Implementing a quality management system based on HKZ norms increases bureaucracy for SMEs

The opinions about this proposition were divided. 42% of the participants experienced that the bureaucracy within the organization did not increase after the implementation of the quality management system. Those organizations did not experience an increase in bureaucracy however they deem that the quality management system provides oversight and clarity which increases efficiency. 58% of the respondents agree with this proposition in that the

management quality management system increases bureaucracy within their organization. Nevertheless, the organizations do not see the increased bureaucracy as a negative aspect of the quality management system. This is the case due to the increased clarity, transparency, and efficiency provided by the quality management system. However, one participating organization mentioned that due to the increased bureaucracy the patient care had under gone some pressure as the organization has to work according to prescribed processes. This leaves less space for spontaneity which is sometimes required in the healthcare industry.

As can be concluded from the above results, 58% of the participating organizations

experienced an increase in bureaucracy while 42% of the participating organizations did not experience an increase in bureaucracy. Nevertheless, all organizations agreed that through the implementation of the quality management system, the clarity, transparency, and efficiency of the organization increased. Proposition 3 is not underlined by the research but the efficiency and clarity within an organization will be improved as a consequence of the implementation of a quality management system.

5.4 Proposition 4

Proposition 4: Implementing a quality management system conform HKZ norms reduces flexibility for SMEs through a higher degree of bureaucracy

Only 17% of the participants agreed with this proposition. Due to the prescribed processes and all the paperwork, there is less time for patient care and flexibility within the

procedure is not flexible enough for the organization, the procedure can be altered in a way that the organization becomes more flexible. Besides, if the rules and agreements within the organization are clear, an organization can easier and faster react to changes due to everyone knowing via which ways decisions are made. Moreover, through the registration of everything that happens within the company within the quality management system, an organization has a better insight in the developments within the organization and is it possible to react flexible at those changes.

This proposition is not underlined by the performed research. As can be concluded from the above analysis, implementing a quality management system conform HKZ norms does not reduce flexibility for SMEs due to a higher degree of bureaucracy. The chance that flexibility is increased within the organization after the implementation of a quality management system is bigger than that it will reduce according to the research.

5.5 Proposition 5

Proposition 5: Implementing a HKZ quality management system reduces innovation for SMEs through the prescribed processes that have to be followed

Only one participant agreed with this proposition. According to this participant, since the organization has a quality management system there is less time for the development of new ideas. Remarkably, all other organizations did not agree with this proposition. The main reason mentioned for the disagreement is that there have to be procedures within the quality management system that support innovation within the organization. This is a part of the quality management system which is also audited by the auditor. In other words, a part of the quality management system requires innovation within the organization. The described quality management system asks for critic maintenance (through intern and extern audits) to improve the quality within the organization. Moreover, through the transparency of

procedures, there is space to search for improvement of the procedures. Through the transparency, an organization has appropriate information to develop new services. The research shows that this proposition is not underlined when it comes to SMEs.

5.6 Proposition 6a and 6b

Proposition 6a: SMEs have a negligible resistance to the changes in the organization due to the implementation of the quality management system due to their small size

During the interviews, the interviewees were asked whether they experienced resistance to change during the implementation of the quality management system within their

organization. 58% of the participants experienced resistance to the change by one or more employees or managers. The reason for the resistance most frequently mentioned was that the resisters were afraid the implementation required too much time. They were afraid that the invested time would not compensate for the returns of the implementation. Another reason mentioned is the fear for too much administrative activity in the healthcare which reduces time available for actual care for patients. Healthcare should be about people not about paperwork. One participant mentioned that resistance to change can be good for the organization to stimulate creativity within the organization to overcome the resistance. Although there was some resistance to change within those organizations, the resistance was negligible as all the organizations implemented their quality management system successfully. 42% of the participants did not experience resistance to change during the implementation of their quality management system. Those organizations all had less than 50 employees. Through there small size and effective communication, the organizations did not experience resistance to change.

This proposition is primarily underlined for firms under 50 employees. Those organizations did not experience resistance to change. The resistance to change experienced by the other 58% of the participating organizations was also negligible as the resistance was only

experienced during the first stage of the implementation of the quality management system. The resistance to the change was overcome when the resisters experienced that the quality management system was successful for the organization.

Proposition 6b: Implementing a HKZ quality management system in an SME will only succeed if there is no resistance to change within the organization

successfully. Their enthusiasm can inspire the resisters. Another advise given by one of the participants is to show and communicate the first positive effects of the quality management system immediately. The resistance will vanish automatically in that way.

5.7 Proposition 7

Proposition 7: By acquiring a HKZ certification, SMEs’ goal is to attract and preserve more customers than without such a certificate

50% of the participants did not agree with this proposition. 67% of those participants acquired a HKZ certificate due to the health office in the Netherlands requiring such a certificate in order to do business with other organizations. The remaining 33% acquired a HKZ certificate to gain a better insight in their processes and to improve the overall quality of the

organization. The other 50% of the participants agreed with the proposition. Eventually their goal of the HKZ certificate is to attract and preserve more customers. However, this is not the only goal of the implementation of the quality management system. Besides attracting and preserving more customers, the organizations desired to improve the quality of their organization and work more efficiently. When an organization has a quality management system, there is continuously attention for improvement, which is also a goal of many organizations.

Attracting and preserving more customers is thus often one of the goals of acquiring a HKZ certificate. However this is not necessarily the main goal of acquiring a HKZ certificate. If the proposition would be changed in: ‘One of the goals of SMEs is to attract and preserve more customers with a HKZ certificate than without a certificate’, the proposition would be underlined by this research.

6. DISCUSSION

The goal of this research was to find out if SMEs in the Netherlands in real life encounter the same obstacles as large firms when implementing a quality management system. A literature review was conducted to formulate the obstacles encountered by large firms when

the interviews. The opinions of the participants on those propositions were asked, formulated and analyzed. The second goal was to give recommendations for SMEs that consider

implementing a quality management system.

First the conclusions of this research will be shown. In that section, the first five sub questions and the research question are restated and answered. Secondly the recommendations emerged from this research will be presented. In this section, the final sub question will be answered. By giving recommendations, SMEs that consider implementing a quality management system should keep in mind those findings. Finally, the limitations of this study are presented in this chapter.

5.1 Conclusion

In this section, the sub questions and research question are restated and answered which together form the conclusion of this research.

5.1.1. What is HKZ?

HKZ is the quality institution for the healthcare industry in the Netherlands. They draw up quality standards for a large number of branches in the healthcare industry. The HKZ

qualification has the ISO 9000 qualification as a basis and moreover embraces branch specific requirements concerning the healthcare industry. The HKZ qualification is a cycle and

prescribes that a good organisation is aware of its processes. After the implementation of a quality management system, an independent certified institution (Certiferende Instelling) performs an initial audit at the firm. When this is approved, the certified institution gives the firm a HKZ certification. After the initial certification, the firm is audited yearly to see if the quality management system of the firm is preserved and improved.

5.1.2. What is the definition of obstacles in this research?

In this research, obstacles are found obstacles from literature. Those obstacles should be taken into account when implementing a quality management system as they incur change. The obstacles are not necessarily insurmountable but can be a bump in the road towards the implementation of a quality management system. In other words obstacles are changes in the organization due to the designing and implementation of a quality management system which should be taken into account when implementing a quality management system.

5.1.3. What are the obstacles that large firms encounter when they apply for, and implement an ISO 9001 qualification standard according to the literature?

SMEs in the healthcare industry. This resulted in the following propositions:

- Proposition 1: Devoting enough quality time to the implementation of the quality

management system conform HKZ norms and thus alter the behavior of the management is an obstacle for the implementation of HKZ in SMEs

- Proposition 2a: The costs of implementing a HKZ quality management system are relatively higher for small firms than for large firms.

- Proposition 2b: Those high costs are an obstacle for SMEs in that SMEs will decide not to implement a HKZ quality management system

- Proposition 3: Implementing a quality management system based on HKZ norms increases bureaucracy for SMEs

- Proposition 4: Implementing a quality management system conform HKZ norms reduces flexibility for SMEs through a higher degree of bureaucracy

- Proposition 5: Implementing a HKZ quality management system reduces innovation for SMEs through the prescribed processes that have to be followed

- Proposition 6a: SMEs have a negligible resistance to the changes in the organization due to the implementation of the quality management system due to their small size

- Proposition 6b: Implementing a HKZ quality management system in an SME will only succeed if there is no resistance to change within the organization

5.1.4. Do the experts in the field of certification believe the propositions to be true?

During the interview with the experts in the field of certification, they were asked what kind of obstacles they encounter when they aid small firm with the implementation of a quality management system. The experts came up with obstacles resembling the obstacles found in the literature such as resistance to change within the organization and reduced flexibility due to the increased bureaucracy when implementing a quality management system conform HKZ norms. Besides, it takes a lot of time to develop and implement a quality management system according to the experts. One of the reasons for this is that organizations often have little knowledge about their own business or/and about HKZ and its impact. The opinion of the experts about the propositions was asked. The pilot studies showed that the experts agreed with most of the propositions. Only proposition 2b and 6b might not be relevant for SMEs according to the experts. This means that high costs would not be an obstacle for SMEs in that SMEs will decide not to implement a HKZ quality management system. Moreover,

5.1.5. Do the obstacles found in the literature also occur in real life at small firms when they implement a quality management system according to this research?

By conducting interviews at 12 SMEs in the healthcare industry, the propositions as stated in chapter 5.1.3 were tested. The results show that enough quality time should devoted to the implementation of the quality management system conform HKZ norms which is scarce in small firms and thus an obstacle. The behavior of the management should be altered by making time free for activities related to the implementation of the quality management system. This is an obstacle as the behavior has to be altered in order to implement the quality management system successfully. Organizations with less than 15 employees had less

problems with modifying the behavior of the management than organizations with 15 employees or more, as the managers in the smaller organizations had a clear overview of the organization and there is almost no hierarchy within the organization. This results underline the first proposition.

Proposition 2a is also underlined which means that the costs of implementing a HKZ quality management system are relatively higher for small firms than for large firms. Proposition 2b was not underlined by the performed research which yields the same result as the pilot studies showed. High costs are thus not an obstacle for SMEs in that SMEs will decide not to

implement a HKZ quality management system. The most frequent reason mentioned why the high costs were not seen as an obstacle is that the health office in the Netherlands requires a HKZ certificate.

The third proposition of this research is not underlined by the research. 58% of the participating organizations experienced an increase in bureaucracy while 42% of the participating organizations did not experience an increase in bureaucracy. However, all organizations agreed that through the implementation of the quality management system, the clarity, transparency, and efficiency of the organization increased.

As the results showed, implementing a quality management system conform HKZ norms does not reduce flexibility for SMEs due to a higher degree of bureaucracy. The chance that

flexibility is increased within the organization after the implementation of a quality management system is bigger than that it will reduce according to the research. As can be concluded from this results, proposition 4 is not underlined by this research.

The research shows that proposition 5 is also not underlined when it comes to SMEs.

procedures within the quality management system that support innovation within the organization.

Proposition 6a is primarily underlined for firms under 50 employees. Those organizations did not experience resistance to change. The resistance to change experienced by the other 58% of the participating organizations was also negligible as the resistance was only experienced during the first stage of the implementation of the quality management system. The resistance to the change was overcome when the resisters experienced that the quality management system was successful for the organization. In conclusion, some organizations did experience resistance to change but the resistance was negligible. Proposition 6b was not underlined by the research as the pilot studies already predicted. This means that implementing a HKZ quality management system in an SME will also succeed if there is some resistance to change within the organization.

Attracting and preserving more customers is often one of the goals of acquiring a HKZ certificate. However this is not necessarily the main goal of acquiring a HKZ certificate.

5.1.6 What are the obstacles that Thuiszorg Noord Nederland encounters when they apply for, and implement a quality management system conform HKZ standards (and are those the same as the obstacles for large firms derived from literature?)

As Thuiszorg Noord Nederland is a small organization operating in the healthcare industry, the results from the performed research can be taken into account when implementing their quality management system.

First of all, Thuiszorg Noord Nederland should take into account that implementing a quality management system takes a lot of time. The documentation of all the processes is especially time consuming.

Moreover, Thuiszorg Noord Nederland should consider the costs of implementing a quality management system conform HKZ norms. However, the health office requires a HKZ certificate in order to do business with them so Thuiszorg Noord Nederland needs a HKZ certificate.

The bureaucracy within the organization could be increased. However, this does not

automatically has to be a result of the implementation of a quality management system. The increasing bureaucracy does not have to be a negative aspect of the quality management system as this increases clarity, transparency and efficiency.

The innovative activity within Thuiszorg Noord Nederland will probably not reduce but increase. A part of the quality management system requires innovation within the

organization. The described quality management system asks for critic maintenance (through intern and extern audits) to improve the quality within the organization. Moreover, through the transparency of procedures, there is space to search for improvement of the procedures. When implementing the quality management system, there can be resistance to the changes within the organization.

The propositions tested in the research were derived from the literature review. The literature review was based on obstacles for large firms. Some obstacles that Thuiszorg Noord

Nederland can run into are similar to the obstacles large firms run into when implementing a quality management system as described in the above text. The recommendations formulated to overcome the obstacles are described in the next section.

5.2 Recommendations

In this section, recommendations are given by answering the final sub question. The final sub question asks: How can SMEs take those obstacles into account when they implement an ISO

9001 qualification standard? This sub question is answered by presenting the

recommendations emerged from the research. By giving recommendations, SMEs that

consider implementing a quality management system should keep in mind those findings. The following recommendations emerged from the obstacles found in the literature that are

underlined by the performed research.

- Enough quality time should devoted to the implementation of the quality management system conform HKZ norms which is scarce in small firms and thus an obstacle. The management should have a good vision on what should be done in order to implement the quality management system within their organization. Through the prescribed procedures, business in general is altered. The behavior of the management should be altered by making time free for activities related to the implementation of the quality management system.

- The costs of implementing a HKZ quality management system are relatively higher for small firms than for large firms. The costs of implementing a quality management system should be taken into account by SMEs that would like to implement such a system.