THE IMPACT OF TOTAL QUALITY MANAGEMENT (TQM) PRACTICE ON PATIENTS' SATISFACTION THROUGH OPERATIONAL by International Educational Scientific Research Journal

Research Paper

E-ISSN No : 2455-295X | Volume : 2 | Issue : 7 | July 2016

THE IMPACT OF TOTAL QUALITY MANAGEMENT (TQM) PRACTICE ON PATIENTS' SATISFACTION THROUGH OPERATIONAL FLEXIBILITY 1

Main Naser Alolayyan | AlaEldin Mohammad Hasan Awawdeh 1 2

Health Science Department, Alkhawarizmi University Collage / UAE. College of Business Administration, Al Ain University of Science and Technology/UAE.

ABSTRACT Total Quality Management (TQM) is being practiced in any organizations worldwide including healthcare services. Therefore, this paper will discuss the literature review on the basis and principles of TQM and its implementations in healthcare-related industry. From the literature, it is suggested that TQM is suitably adopted as it can improve patients‟ satisfaction, reduce cost and reduce medical errors. This study aims at studying the impacts of TQM implementation on patients‟ satisfaction level in Jordanian university hospitals through considering operational flexibility as mediating variable. The study moreover attempts to highlight the important role of TQM and operational flexibility on patients‟ satisfaction. On other hand, it plans to develop a model on activating the TQM implementations and operational flexibility to improve patient satisfaction. KEYWORDS: total quality management, health care, operation flexibility, patient satisfaction. 1.0 INTRODUCTION Quality has occupied a prominent place in Japanese industries in the late twentieth century; which was affected by complex changes such as industrial change and marketing competition. These changes come as a result of political and economic variables and the intensification of economic competition in the local, regional and global developments. These changes were followed by the technological revolution in the fields of human knowledge, information systems technology and others. The significant of quality impacts such as the emergence of the phenomenon of the total quality management (TQM) in the early twentieth century was of great importance in achieving the goals of humanitarian organizations in the production and service organizations. This paper comprises three parts aiming at providing three things, the first part is about TQM and health care services and TQM principles; the second part about satisfaction; customer satisfaction, and patient satisfaction. The third part will discuss on flexibility and operation flexibility. The major objective for this study is on the effect of cooperation and integration between TQM practices and operational flexibility on patients‟ satisfaction. 2.0 TQM AND HEALTH CARE SERVICES In healthcare sector TQM motivates the staff to increase their productivity through high and continuous performance and improvement with both staff and patients having complete satisfaction through strong strategies and effective plans. Total quality management (TQM) is an important role in all health sectors. TQM is used to improve patients‟ satisfaction, reduce cost and reduce medical errors. In recent years, attention to TQM in the healthcare industry started to rise as a major concern to achieve the overall quality. TQM depends on continued commitment and organizations works to improve the operations of the organization. It also depends on the excellence of the highest level of management to the lowest level of employee; also raw materials supplier through the supply chain to the end consumer. The requirements for the application of total quality management within the healthcare organizations depend on the organization manager to make some changes in the structure, process, system of work, and employee which with other requirements are necessary conditions for achieving the objectives of TQM. To impose all the principles of the program in all aspects of the health organization there must be a very strong commitment from the senior management (Smith & Offodile, 2008). TQM is being accepted in all sectors of business, industry and service. It has also a great impact on the level of health service in the application of tools of total quality management that will differentiate from its rival. To achieve social benefits of the TQM concept, early adaptors at TQM were motivated by vision of opportunity (Kennedy & Fiss, 2009). Basically, stakeholders‟ perspectives on healthcare quality can be explained as follows: 1. 2.

Five rights of the providers (technical quality) are right technical care to the right patient in the right time, right way, and right amount. Patients‟ quality (touch quality) of care and feeling of satisfaction including communication, coordination, compassion, respect, personalized time spent with patient.

Payers: (technical and touch quality) the timeliness, cost effectiveness and appropriateness resulting in patient satisfaction.

Policy makers: (technical and touch quality) some elements shared with payers include: Appropriateness, timeliness, cost, cost effectiveness, and resulting patient satisfaction. Care also should be accessible to meet the needs of the population and societal needs; core should be accessible to all. (Kovner & Knickman, 2008).

The researcher suggests that, medical services are intangible as it concerns immediate attention. This makes assessment operation very difficult. TQM has a strong effect on health services as follows: 1.

Improving the presentation of the types and quality of medical services.

Improving the medical service in general and at all levels of service.

Preventing mistakes which may have happened in health organization.

Reducing the cost of medical services.

Achieving a high level of satisfaction both from the patients and employees.

More than twenty years ago, developed countries implemented TQM strategies in all healthcare-related organization, because this was the best solution to improve the health status and services. Obviously, numerous studies have been conducted by good number of researchers for highlighting the process of TQM, and its effects on the medical sector. A study conducted by Mohanty et al. (1996) to the understanding of the particular nature of the health sector and to look on the relationship between TQM and health sector. The result revealed that TQM leads to better human relations, greater intimacy with customers, higher productivity and profitability and increased market share. The most appealing aspect of TQM is that it promises the opportunity to achieve better outcomes with fewer resources. TQM can be an important part of a hospital‟s competitive strategy. In TQM, we define a process as a series of operations linked together to provide an outcome which has a utility in form, place or time, etc. In the case of hospitals the process is the care service being rendered, and the output is improved quality of life. They identified a number of factors that can influence the implementation of TQM. Broadly, they may be classified as: 1.

Organizational factors;

Interpersonal factors;

Environmental factors;

Facilities factors; and

Economic factors

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3.0 TQM PRINCIPLES These eight practices are adopted by the researcher upon the results of Sila and Ebrahimpour (2003); Samat et al. (2008) and Sadikoglu and Zehir (2010). Moreover, these practices are considered as the most comprehensive practices for measuring the impact of TQM on hospital performance, thus making them suitable for the research objectives under study. This section discusses the critical successful factors of TQM in greater detail. There are eight selected factors of TQM, mentioned in the previous paragraph. These factors are closely connected to hospital performance. The researcher briefly explains these factors in the following section. Top management commitment and leadership The success of quality management implementation is a major determinant to committed to management which will act as a driver for TQM implementation that improve the organization's performance (Ahire et al. 1996). Pheng and Toe (2004) said for the success of TQM implementation it is critical for the management to support the degree of visibility. Employee management Significant contributions can come from non-managerial employees when they are empowered, so employee suggestions and participation are encouraged in a total quality setting (Sadikoglu & Zehir, 2010). This study divided the employee management to employee involvement and employee empowerment. Information analysis Samson and Terziovski (1999) said that, the philosophy of TQM stresses decision making involving analysis of information on customer needs, problems of operational problems, success of improved attempts. As suggested by TQM literature the organizations that consistently collect and analyze information will be more successful than those that do not. Employee education and training Duggirala et al. (2008b) suggested that, in a critical area such as health care employing training practices are important to ensure the employee is equipped with the right skills. In a hospital setting continuous training of the staff in patient care service is vital. Newman et al. (2002) found that to changes in nurse training will improve nurse retention and satisfaction, with increased numbers of training places and funding more posts including flexible and family working practice. Customer focus The main objectives of TQM are customers' satisfaction and focus on meeting the client needs. A long-term plan to meet or exceed the expectations of customers' satisfaction is very important (Oluwatoyin & Oluseun, 2008). Juran (1993) asserted that there are two types of customers; the external customer like clients, government bodies, and public sector and internal customer such as employees who determine the quality and service provider (Psychogios & Priporas, 2007). Continuous improvement There are five dimension of continuous improvement are process focus, customer focus, employee empowerment, data-based decision making and organization wide scope. Three elements namely executive leadership, strategic orientation and cultural change commitment are effective improving quality (Buchbinder & Shank, 2007). Continuous improvement is quality spirit; and one of the most important practices. To improve performance, top management must adopt a clear strategy to educate all employees on how to implement continuous improvement plan in both work steps and process. Continuous improvement of processes and steps to provide the service is the basic foundation in providing excellent services that meets the customer expectations. Continuous improvement is a series and a continuous cycle of continuous improvements to services to reach the highest degrees of productivity and satisfaction to customers both internal and external. Process management Implementing health care activities can be measured by the process of quality, with the speed performing of service and they can be used to pinpoint problems in the service delivery and to suggest specific solutions. Process indicators can be used by front line medical staff (nurses, physicians and managers) to monitor activities at their facility (Zineldin, 2006). Kujala et al. (2006) proposed that in the adaption of new techniques in production, improvement process plays an important role. The improvement of care processes can be attributed to the procedures, medical breakthroughs and development of new medical technologies. 4.0 SATISFACTION AND PATIENTS' SATISFACTION Satisfaction Burns and Neisner (2006) proposed that satisfaction is not a straight forward concept, it caused be fully understood without recognizing the emotional dimension. It is not pre-existing in the patient but a judgment people form over time as they reflect on their experience. Both internal and external influence can be used as a judgment including the experience they gain from their stay in hospital (Grimes 2003). In another study, Yi Sit et al. (2009) defined the satisfaction is “the level of a person‟s felt state resulting from comparing a service‟s perceived performance (or outcome) in relation to the person‟s expectations”. Badri et al. (2009) defined satisfaction as „„satisfaction is the summary psychological state when emotion surrounding the expectations and consumers prior feelings and experience.” The

same study determined the satisfaction as an insider perspective, where there is an evaluation of the outcome, assessing what is expected and what is actually received. In short, satisfaction is an emotional response (Badri et al. 2009; Zineldin, 2006). In addition satisfaction is associated with repurchase intentions and possible, recommendation of service or product, loyalty and profitability (Sivadas & BakerPrewitt, 2000). It is also satisfaction is a consequence of a mental evaluation of the experience and resulting outcome of the services provided )Choi et al. 2005). Satisfaction is an emotional response to the difference between what customers ultimately services receive? And what customers expect? (Zineldin, 2006). Patient satisfaction Patient satisfaction is defined as a customer‟s overall evaluation of his or her experiences with hospital services (Johnson et al. 1995; Andaleeb, 1998). A legitimate avenue to improve patient care is the examination and monitoring of customer satisfaction. The most important definition of overall patient satisfaction is when the patient‟s own expectations for treatment and care are met or exceeded (Vukmir, 2006). In addition Naidu (2008) defined patient satisfaction as “an important indicator to evaluation of distinct health care dimensions.” Vukmir (2006) defined five variables directly related to satisfaction including: 1.

Waiting before being cared for.

Degree of nurse caring.

Staff Organization.

The degree of physician caring.

The amount of information provided by nursing staff.

One of the desired outcomes and patients‟ satisfactions is the information of patient satisfaction being indispensable of the assessments of quality and management of health care systems (Andaleeb, 1998). Patient satisfaction is not a clearly defined concept. Most often satisfaction is defined differently by different individuals as a consequence of varying backgrounds and experiences (Jr et al. 1977). Although attempts were made to explain how patients become satisfied, there is not yet any one universal model explaining patient satisfaction. Also total experience of health care is the attitude of a person‟s general orientation and patient satisfaction. Satisfaction comprises both emotional and cognitive facets and relates to previous experiences, expectations and social networks (Hill & Kitchen, 2007). Over the last years, patient satisfaction has been increasingly used as one indicator of the quality of health care (Baker, 1991; Alsharif, 2008). Measurement of patient satisfaction is used to compare health care programs and to evaluate quality of care and to identify which aspects of a service need improvement (Rubin et al. 1993; Alsharif, 2008). Patient evaluations can help in education of medical staff to evaluate achievements and failure and their response to patients' needs (Al-Eisa et al. 2005; Alsharif, 2008). Alsharif (2008) suggested that patient satisfaction is an important and widely accepted measure of care efficiency. The same study found that, there are three reasons why health professionals should take patient satisfaction seriously as a measurement: 1.

Evidence has proven that satisfaction is an important outcome measure. It may be a predictor of whether patients follow their recommended treatments, and is related to whether patients related for treatment and change their provider of health care. Evidence has also begun to emerge that satisfaction is related to improvements in health status.

Patient satisfaction is an increasingly useful measure in assessing consultations and patterns of communication (such as the reassurance, involving the patient in decisions about care, and success of giving information).

Patient feedback can be used systematically to choose between alternative methods of organizing or providing health care (such as length of consultation or arrangements for out of hours care).

Also the increasing cost of the health services and the need for better use of available resources is a concern for healthcare providers. So that there is a need to measure the efficiency of health care to determine if proper use of available resources is being made. However, satisfaction must be understood within the context in which a variety of elements may be more or less satisfying to the patient. Various dimensions of patient satisfaction of hospital care have been identified, ranging from admission to discharge services, as well as from medical care to interpersonal communication. Well-recognized criteria include responsiveness, communication, attitude, clinical skill, comforting skill, amenities, food services, etc (Alsharif 2008). In addition, the various dimensions of medical care have also supported the validity of patient ratings of satisfaction. For example, satisfaction has been established as a reliable predictor of corpulence behavior, health status, continuity of care, patient involvement in care, utilization of health services and effective patient-provider communication (Franklin, 2001; Alsharif, 2008). The patients‟ satisfaction items discussed in this study are doctor‟s care, nursing

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care, hospital infrastructure, quality communication, process of medical care and overall experience of medical care received (Vukmir, 2006; Naidu, 2008; Duggirala et al, 2008b; Andaleeb, 1998; Hill & Kitchen, 2007; Imam et al. 2007). A detailed discussion of each of the items is presented in the following section. Doctor's care Staff behavior also has an important impact on patients' satisfaction, the manner in which staff interacts with the patient and staff sensitivity to the patient's personal experience seems to be important (Andaleeb, 1998). Gilbert et al. (1992) proposed five important points on effective attributes of a physician. The most important in patient satisfaction influence were: the amount of time spent with the patient, the way the doctor provided explanations, physician friendliness, friendliness of the staff, and the amount of information provided. Ditto et al. (1995) showed that if there was a greater similarity between the physician's behaviors with the expected role, then patient satisfaction would be greater. Lovdal and Peerson (1989) found that doctors and other medical personnel‟s‟ behaviors, were central determinants of patients attitudes about a hospital as a whole. Patients look for behavior that is supportive, friendly, caring, helpful and attentive. Nursing care The most significant factor in patient evaluation associated with interpersonal relationship, is the relationship between providers and patient with a high degree of interaction, are by far the most significant in forecasting patients' assessments (Tucker and Adams, 2001). Boshoff and Gray (2004) suggested that the most significant factor that affects patient satisfaction is satisfaction with nursing staff and nursing care. “If patients experience the nursing staff as cheerful, kind, caring, courteous as well as highly skilled and prompt, they are significantly more likely to return to the same hospital”. Gilbert et al. (1992) suggested that one of the most important factors which affect patient satisfaction is staff friendliness. Nursing service is one of the most important components of hospital services; the dimension on nursing care quality evaluates the perception of the patient with respect to the quality of nursing-care provided during patient stay in the hospital (Duggirala et al. 2008b). Hospital infrastructure Zineldin (2006) defined the quality of infrastructure as “measures of the basic resources which are needed to perform the health care services, the quality of internal competence and skills experience, know how, technology, internal relationships, motivation, attitudes, internal resources and activities and how these activities are managed, co-operated and coordinated.” McFadden et al., (2006) showed that infrastructure breakdowns include power outages, shortage of water supply, and disruptions in communication system. Management should provide sufficient back up equipments so that the system is robust and staff need to be effectively trained on how to switchover if necessary. Quality communication Walston et al. (2010) proposed that the collaboration and cooperation through proper communication determines a high positive patient outcome and satisfaction. Climate can influence communication regarding patient safety. It is important to ensure that all communication channels are used in a right way to properly create a safe climate for staff and patients. A positive safe climate is founded on mutual trust through good communication. Errors occur when communication problems arise. The communication skills between medical staff and patient have received special attention as a major component of medical encounters and a key to patient compliance and satisfaction (Ishikaw et al. 2002). Gremigni et al. (2008) proposed that communication behaviors which related to patient satisfaction may include: empathy and friendliness, nonverbal affiliate expressiveness, clear and direct way to communicate, listening and other basic skills such as courtesy. The higher standards of communication skills have become requisites for healthcare providers from within the framework of patient focus. “The major problems related to patient satisfaction have been reported to be issues related to communication, lack of interest, impatient information, lack of consideration and impoliteness by medical staff” (Polluste et al. 2000). Vukmir (2006) proposed that the proactive patient communication is the basic for a positive interaction between medical providers and patient and can be accomplished by all health care staff without much extra effort. Process of medical care The process of quality, measures how well health care activities are being implemented; such as speed of performing the health care activities, waiting time, must receive more attention on process indicators in the health care industry. They can be used to pinpoint problems in service delivery and to suggest specific solution. Front line nurses, physicians, managers can use treatment process indicators to monitor activities at their facilities and to guide day to day decision making (Zineldin, 2006). The national patient safety foundations define patient safety as the “avoidance, prevention and amelioration of adverse outcomes or injuries stemming from the process of health care” (McFadden et al., 2006). Process management of health care consists of service, support, supplier and economical and financial process (Migual, 2006). Kujala et al. (2006) proposed that improvement process has an important role depending on adaptation of new technologies

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and production techniques. The improvement of care processes in the healthcare sector can be mainly attributed to the procedures, medical breakthroughs and development of new medical technology. Operation management techniques such as the optimization and the assumption of processes have been used to analyze different parts of the hospital system. Lean management principles have been applied to facilitate healthcare production processes. Process reengineering has been applicable in improving patient processes. Overall, Experience of medical care received Polluste et al. (2000) found that patients‟ opinion is an important tool in the evaluation health care systems. Patient assessment of physician competence, comprehensiveness of the explanations given by the doctor, and cleanliness and comfort in the clinic were the factors that significantly affected the degree of satisfaction. Thus, the dimension of the overall experience with providing health care services should include different elements from the experience of the patient for treatment. The patient‟s view of the overall experience of medical care he or she received at this hospital is very important in evaluate of health care quality. Consumer perceptions of healthcare quality are important for several reasons: 1. Evaluations of higher quality are related to satisfaction, 2.

Intention to use a service again in the future if necessary,

Compliance with advice and treatment regimens,

Choice of provider or plan,

Decreased turnover and malpractice law suits,

Possibly better health outcomes.

Positively related to financial performance in healthcare organizations.

Strong relationship between overall service-quality perception and patient satisfaction (Duggirala et al. 2008b)

Patient satisfaction with medical care is a multi-dimensional construct reflecting patients‟ expectations, values and experiences (Baker & Streatfield, 1995). The dimension on overall experience with healthcare delivery encompasses different elements of the patient‟s experience of the treatment (Duggirala et al. 2008b). 5.0 FLEXIBILITY AND OPERATION FLEXIBILITY Galther and Frazier (2002) proposed factors affecting operation management that is: Reality of global competition and quality of customer service, cost challenges, rapid expansion of advanced technology and continued growth of the service sector, scarcity of operation resources and finally social responsibilities. TQM also has the same affecting factors which have a major impact, where TQM plays a major role in operational management. Thus, the relationship between TQM and operational management is strong and positive. If there is any weakness or wrong application of TQM, there will be a negative reaction in the organizational and operational management including quality level both internally and externally. The main objective of TQM is a high level of customer satisfaction, and when we relate this to the strong and positive relationship between operational management and TQM, we also find that the main objective of operational management is internal and external customer satisfaction. The researcher suggests a positive relationship between TQM and customer satisfaction through operational management will achieve the highest level of customer satisfaction. Chan (2004) proposed that the flexibility manufacturing system covers spectrum of manufacturing activities, which includes machining, welding, fabricating, assembly and a number of other applications. From this definition it shows, flexibility covers all aspects of manufacturing, from the raw materials suppliers to the after sales services. The changes in market competition, and customer wants, needs on efficient, good quality, and highly flexible production and services. Flexibility is important to meet the many unexpected changes in consumer requirements. Flexibility is able to manage rapid changes in an efficient and effective manner. Strategies is based on reducing the number of workers, improving the utilization of machines, improving the operation control, and reducing both the work in process inventory and the final products inventory. All flexibility strategies have positive attitudes in all the production stages but reducing the number of workers will create social problems, by increasing the number of unemployed people which relate unfavorably on the society. Correa and Gianesia (1994) adopted two important ways for flexibility which are related to organization manufacturing strategy. The first is response to an increasing turbulent environment. Second, flexibility can be very pervasive and can influence the performance of other organization completive criteria, such as delivery speed and dependability. The same authors defined flexibility as being able to vary and adopt the operation either, because the needs of customer alter, or because of changes in the production process, or perhaps because of changes in the supply of resources. So flexibility covers all organization services process, especially when these changes relates to the customer. The objective is to meet all changes which have an effect on customer satisfaction level.

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The flexibility objective, the ability to deal effectively with effects, through unplanned changes control methods thus work as a filter to restrict the amount of change effects the system has to deal with. Emphasis on developing operation flexibility to deal with the unplanned changes effects once they have occurred, in the same study, the author proposed several dimensions for control filter; such as monitoring, forecasting, standardizing, maintaining, booking, queuing and promoting, substituting, delegating and sub contracting, focusing and coordination and integration. If unplanned changes which for some reasons, can enter through control filter, the operation flexibility must deal with it, through types of service operation. There are seven types of service operation flexibility: 1.

Design flexibility, the ability to introduce new service.

Package flexibility, the ability to offer varied services within a period of time.

Delivery location services, the ability to offer the service in a variety of places.

Delivery time flexibility, the ability to anticipate the services delivery to requirement.

Volume flexibility, the ability to change services output levels.

System robustness flexibility, the ability to remain operation effectively despite changes affecting inputs and process.

Customer recovery flexibility, the ability to recover the customer after some things goes wrong. The effect of unplanned changes goes in tow way, affecting the organization only, and affecting the whole market (Correa & Gianesia, 1994).

with offensive behavior or defensive and respectively in organization. 6.0 RESEARCH MODEL Proposed conceptual model to determine the relationship between TQM, operational flexibility and patient satisfaction Figure 1

Harvey et al. (1997) proposed the specificity of services and service delivery process as follows: 1. Services generally involve customer contact of one kind or another. 2.

Customers demand increasingly that all the services required to produce a given result be bunched together and delivered in harmony with their activity cycle.

Services are generally consumed as they are produced.

In the same study the authors determine the source of variability, both internally and externally. External variability come from market and driven by competition, internal variability comes from aspects of the organization, such as product or process design, organization structure or administrative procedures. Verdu and Gomez-Gras (2009) suggested that organization flexibility is the main capability that enables companies to face environmental fluctuations, as it makes the organization more responsive to change. In this century the organization must become most sensitive to changes in the environment to have a strategic organizational capability that enables them to change easily and thus to continue to maintain acceptable results without incurring high reorganization costs. Four types of managerial flexibility adopted: 1. Strategic flexibility. This type have the potential of a company to transform itself, and propose to deal with hypercompetitive environment, and economic crises, flexibility strategy give the organization new state from engendering learning, adaptation, renewal and enhanced longevity. 2.

Structural flexibility. This type from flexibility focus more on people, and tend to be less formalize, and decentralize, so that this type focus on human resource management in firms, especially some managerial practices which can affect directly on structural flexibility such as compensation system, personal selection, participation, team work, training, job design and authority system, the workers have main effect on performance especially who have polyvalence and can work different tasks and functions in a firms. Labor flexible practices like timework have a positive effect in organizational performance. Operational flexibility. This type has the capability to meet the unexpected changes depend on ordinary capacities based on the organizationâ&#x20AC;&#x;s structures or current objectives, so that the changes in the environment. Do not involve changes in the relationship between the company and the environment. Operation flexibility can affect on cost and speed of the company operational response, and the changes as general reversible to short-term changes, these changes involve day to day or hour to hour operations. Internal and external scopes, internal flexibility is the capability for organizations to adapt to the environment, and external flexibility refers to effect the environment, and thus to reduce their vulnerability. Flexible also means

changing the organizational environment through actions like communication, innovation and advertisement. Internal and external flexibility are associated

7.0 MATERIAL AND METHODS This part describes the methodology which will be employed in conducting this study. It includes study population, study variables, method of data collection, study questionnaire, study instrument, and statistical analysis. Study population This study will adopt a random stratified sample, from medical staff who works in university hospitals in Jordan. The population is divided into the doctors, nurses, and medical technicians. Study variables The study consists of three variables as follow: 1. Independent variables (total quality management). 2.

Mediating variables (operation flexibility).

Dependant variables (patient satisfaction).

Method of data collection Data collection is simply the way information is gathered, secondary data and primary data collection are two ways of collecting information. Both quantitative and qualitative data collection will be used in this study to investigate the relationship between (TQM) principles, operation flexibility and patient satisfaction. The study respondents are the medical staff (Doctors, Nurses, and medical technician) in hospitals. Questionnaire of the Study Questionnaire will be used as an instrument in this study, to collect information and data from medical staff in hospitals. This questionnaire consists of three parts, the first one (TQM) consists of 8 items, the second operation flexibility consists of 2 items, and the third is patient satisfaction consists of 6 items. Webb (2007) found that through asked staff about their views on patient and visitor needs and expectations around the areas of care, staff showed a good understanding of patient expectations. The two groups (medical staff and patients) agreed on a number of key problem areas, for example, cleanliness, waiting times for tests and poor communication. Study instrument A questionnaire has been developed by the researcher to measure and apply the principles of total quality management; patientsâ&#x20AC;&#x; satisfaction and operation flexibility depending on the literature review and following the authorsâ&#x20AC;&#x; names (Sadikoglu and Zehir (2010), Imam et al., 2007, and Idris, 2006). Questions which have a definite set of answers will be used to collect data from respon-

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dents. The Likert scales 7 points will be used from 1- strongly disagree to 7strongly agree to collect the questionnaire answers. Statistical analysis Various statistical techniques will be used such as factor analysis, correlation analysis, multiple regression and Structural Equation Modeling (SEM) which supported by analysis structures 16.0, software. 8.0 EXPECTED RESULTS AND DISCUSSION This study will clarify the direct relationship between total quality management and patient satisfaction, the indirect relationship between TQM and patient satisfaction through operational flexibility and the impact of operational flexibility on patient satisfaction. This study will work to identify the failure and weakness points in the application of total quality management principles and effectiveness of operational flexibility plans in hospitals. To stimulate the production and increase patients' satisfaction, the researcher will determine the default or negligence in application of total quality management principles and operational flexibility strategy. The researcher will propose recommendations to improve the hospital productivity and patients‟ satisfaction, this recommendation will depend on the study results. The study idea comes from the importance of TQM on patients‟ satisfaction and the major impact of operational flexibility on patient satisfaction. The researcher proposes that to improve hospital productivity and patients‟ satisfaction, there is a need to measure and improve operational flexibility plans and TQM practice in all organizations types. The integration and cooperation between TQM principles and operation flexibility is the solution for every successful organization. 9.0 CONCLUSION Patients‟ satisfaction nowadays is considered as a significant indicator for the quality level on the service organizations especially the big hospitals. Therefore, this study tries to shed light on the level of TQM and operation flexibility implementation since they play a major role on patient satisfaction level. Through reviewing the effective and ineffective TQM criteria in the university hospitals and after deciding the internal and external operation flexibility level in these hospitals, we can study the effects of TQM and operation flexibility through comparing them with the patients‟ satisfaction level. REFERENCES

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