JRHS 2008; 8(2): 40-50

Copyright © Journal of Research in Health Sciences

Quality Management in Health Systems of Developed and Developing Countries: Which Approaches and Models are Appropriate?

Hamidi Y (PhD)a, Zamanparvar A (MSc)b

a Department of Health Management, Hamadan University of Medical Sciences, Iran

b Department of Biostatistics & Epidemiology, Hamadan University of Medical Sciences, Iran

*Corresponding author: Dr Y Hamidi: E-mail: hamidi@umsha.ac.ir

Received: 10 September 2008; Accepted: 19 October 2008


Background: Quality Management is one of the most effective strategies for improving the health sys­tems performance in developed and developing countries. The main goal of this study was identifying the most important aspects of quality management and preparing an appropriate model for health system.

Method: This research was a comparative study on quality management models in the health systems of different countries. We have selected, as a sample, different countries in Asia, Africa, North America, Europe, and South America having a background in using various samples of total quality models in their health units. The studies also included the experiences of World Health Organization in different countries.

Results: The main goals for promoting quality in the countries are being studied includes service effi­ciency increase, promoting services delivery, promoting quality of working life, and changing  organiza­tional culture. Total approaches used for the countries studied include quality Assurance, Cultural change, ISO 9001, TQM and improving services quality. There are not generally out­comes criteria in 22 cases of the studies done in the developing countries. The most important problems revealed in estab­lishing the quality management, organizational resistance against the change, lack of senior management commitments, lack of strategic planning and lack of required resources.

Conclusion: The models for quality management should pay attention to the cultural change strategies, staff participation, strategic vision and Strategic planning. Strategic total quality man­agement is the ap­propriate model in this regard.

Keywords: Quality, Total quality management, Strategic management, Health care system


During some recent years, among all as­pects of the initiations, creations and in­novations influenced the health organiza­tions, perhaps quality revolution have been the most effec­tive and comprehen­sive one (1). Total qual­ity management, continuous quality im­prove­ment and or total quality have been the fac­tor for close relation of the rhetoricians and ex­ecutors because the total quality has sug­ges­ted a management  philosophy  and  a collec­-

tion of tools and techniques use­ful for per­formance and preserving the loy­alty and cus­tomers long term satisfaction (2).

Both in manufacturing and public health care quality allows organizations to pur­sue their own objectives. In the manu­factur­ing indus­try, where its benefits first be­came evi­dent, quality improves the per­formance of compa­nies by eliminating prod­uct defects, enhanc­ing attractiveness of pro­duct design, speed­ing service de­livery and reducing cost. In public health care, where quality medical care can be interpreted as the capacity of the ele­ments of that care to achieve legitimate medi­cal and non-medical goals (3), high quality of care allows to deliver ap­propri­ate care to pa­tients, achieve positive clinical outcomes, avoid unnecessary clinical complications and ensure that public resour­ces are effi­ciently used (4,5). In the past, the assess­ment and control of quality medical care were left exclusively to professionals, but nowa­days appropriate quality manage­ment systems are advocated widely.

Total quality investigates roots causes of pro­blems in the health processes not in the staff. Although some of the hospitals and health institutes have implemented quality programs, most of them have concentrated on special sectors instead of all organization.

The wave of quality orientation and ap­pli­cation of TQM in health systems sup­ported and encouraged by World Health Organiza­tion have been moved from de­veloped coun­tries to the developing ones. WHO has con­centrated on services con­tent quality and man­ners credits and ser­vices rendering quality by stressing on organizing, manag­ing and ex­ecuting of the affairs all the time and pub­lished pamphlets and books of spe­cialty in this regard putting developing countries on the sharp focus. In this regard De Geyndt in a report regards measurement, control and assurance of the quality of car­ing the patients and continual attempts for im­proving quality as a top activity in the de­veloping countries. For example, in Jamaica, Dominican Repub­lic, Bangla­desh, the Phil­ippines in hospitals, in Kenya, China, Ghana, Zaire, Zimbabwe in the rural clinical health centers, in new Gina, Ecuador, and Jamaica, Zaire, in ur­ban health centers and also in PHC structure (Primary Health Care), these tools have been applied. In one hand, these projects have been imple­mented called different titles such as re­forming health sector in Chili, in Yemen called fam­ily health projects, in south Ko­rea called hospitals reconstruction, in Mali called safe water provision, in Hon­duras called health and nutrition project, in Po­land called health services develop­ment and in Bangladesh called population and health pro­jects. The important point to be mentioned is that some patterns of quality used were im­perfect and limited and have had weak re­sults (6, 7).

A quality management system in health care can be described as a structured or­ganiza­tional process that involves the staff at dif­ferent levels in planning, meas­uring and as­sessing patient care in such a way as to pro­vide optimal medical ser­vice to patients (8). These systems are similar to the ones used in other indus­tries al­though the unique na­ture of health care processes requires spe­cific adapta­tion (9).

The point is that in some of the health in­stitutes, implementation of quality man­age­ment have resulted in valuable finding as in Massachusetts General Hos­pitals Bos­ton, the amount of center debits was in­creased up to 52% and annu­ally a saving of 120000 Dollar.

Green Wood Center in the city of Likuta has annually 200,000 Dollar saving by solving the problems of non registration of the pa­tients.

Lancaster General Hospital in the U.K has used the expenses of quality for dis­covering the important opportunities for saving the expenses in the accounts re­ceivable. After the list of the cases for the expenses to be affected were provided, easily the first pri­ority for this hospital was recognized and by implementation of process promotion man­agement the level of income was increased up to 12,000,000 Dollar (10).

Totally there have been positive results for application of this model not only re­move some problems of heath systems in the world, it has been resulted in increase of the services quality, productivity and customers satisfaction and staff satisfac­tion.

So, considering totality and excellence of TQM on the other strategy for change in health systems, its application for health sys­tems are stressed. But the results show that apply­ing it in deformed types and non scien­tific and practical models and ignoring the vari­ables and main compo­nents could not meet the results and ex­pectations of planners and managers in quality manage­ment in all areas. TQM needs a strategic vi­sion and cul­tural change. The concept of TQM appears cleared, but they are hard to be imple­mented and TQM can not be imple­mented without a com­prehensive model having all important aspects.

Considering selecting TQM as a change strat­egy in the Health Ministry and on the other hand similarity of Iran Health Situa­tion with some developing countries and similar prob­lems for implementation of TQM in hospi­tals and health centers, appli­cation of total quality management in a cor­rect and com­pre­hensive form is stressed as the most im­por­tant priority for strategic planning for coun­try health sys­tem.

So, considering the mentioned issue, the re­searchers tried to do a comparative study to recognize the most important quality man­age­ment components for de­signing a com­pre­hensive model and fa­vorite for quality man­agement in health systems to be intro­duced.


This research was a comparative study in the quality management models in differ­ent coun­tries health systems aimed at dis­cover­ing the most important quality com­ponents and pro­viding appropriate mod­els for quality man­agement in health system.

This research covers different countries in Asia, Africa, North America, Europe and South America having background in ap­plying different total quality patterns in their own health system. They have been selected in a sample method which in­cluded:

  • Europe: Portugal, Spain (11), Ireland, Eng­land (12, 13), Poland (6, 7).
  • Asia: The Philippines, India, Bangla­desh, China, Malaysia, Korea, Pakistan, Yemen (6, 7, 14, 15).
  • North and South America: The United States (16, 17, 18), Canada (1), Ecuador, Brazil, Chili, Colombia, Hondu­ras, Ja­maica (6, 7).
  • Africa: Egypt, Zambia, Ghana, Papua New Guinea, Dominican Republic, An­gola, Kenya, Zimbabwe, Tanzania, Togo (6, 7, 14,19, 20).

Meanwhile the studies also included ex­peri­ences of WHO and World Bank on quality in different countries.

For examining and studying TQM in se­lected countries health systems, library and field method have been used by ap­plying valid data banks and internet and also agen­cies of WHO and World Bank in Iran. To analyze the results, the view points and opinions of experts and do­mestic and for­eign opinion makers were used for quality man­agement as well.

The researcher studied different resources aimed at models and criteria of quality in different countries health systems and found the information for applying com­prehen­sively different total quality mod­els (in Asia, Europe, America, Africa). These samples in­clude: Health centers, urban and rural clin­ics, hospitals, and in some other sam­ples, in a Ministry level. Studying the TQM in dif­ferent countries health systems was com­pared in the fol­lowing items.


A: Goals

The main goals for promoting quality in these countries include increase of ser­vices effectiveness, promoting services efficiency, promoting work life quality, decreasing ex­penses, removing wastes, correct use of re­sources and reforming organizational cul­ture. In North America and Europe, decrease of expenses, stan­dardization and increase of services effi­ciencies and also work life qual­ity pro­motion and behavioral change were mostly stressed. It is the case that in most de­veloping countries, promotion of proc­esses and increase of services efficien­cies were the main goals. For example, in Ghana, im­proving services processes and in Do­mini­can Repub­lic, decrease of ex­penses and pro­moting the performance were con­sidered and the point to be men­tioned is that before years of 1995-96, in developing countries, work life quality improvement, promoting the em­ployees em­powerment and total par­ticipa­tion were not considered. In­stead of the re­cent change and tendencies for quality as­sur­ance, total quality for culture change and par­ticipation has been consid­ered more and more.

B: The Approaches to be used

Total approaches used in the countries stud­ied include quality assurance, cultural change ISO9002 standards, TQM, Re-engi­neering of the process and projects for ser­vices quality promotion. The most applied approach were in the developing countries as of quality as­surance and various projects were also im­plemented for increasing ser­vices quality im­prove­ment based on the hospital commit­tees, health accounting. For example, in Ghana, the method of tracer, in Brazil the hospital com­mittees and in Zam­bia qual­ity assurance meth­ods were used. Recent studies in these coun­tries refer to TQM and quality improvement. In Malay­sia, moving from quality assurance to total quality is the most important chal­lenge of the recent years in this country. On the other hand application of ISO 9000 stan­dards was applied in a limited for in these areas which of lack of resources can be an important factor for lack of obtain­ing these credits documents in most of the organiza­tions.

In Europe and North America, consider­able attention were paid to total quality manage­ment as of late 80s and in most hos­pitals merge of TQM and reengineer­ing processes were mentioned. For ex­ample, in Ireland, 33% of TQM are used and 27% of the hospitals are developing cultural change method and obtaining ISO certifi­cate. The important point is that in these countries, traditional quality assurance is totally abol­ished and no report on appli­cation of quality assur­ance in hospitals has been seen in the re­cent years.

C: Criteria and quality assessment in­dexes

The studies showed that the attempts made for assessing and promoting the quality in developing countries were con­centrated on structure, process and finally the re­sults were also concentrated before 1995. the findings of the recent years show that in 22 cases of the studies done in de­vel­oping countries generally there is not re­sults crite­ria, 7 studies on structure in­dexes and 12 studies on proc­esses in­dexes and 3 studies on both indexes and structure for assessment of quality of care were applied. A review in Europe and Amer­ica shows an attention to the proc­ess and results. In the United States, death rate in the hospital was used as an in­dex for quality of ser­vices. The studies werent focused on long term result in­dexes and plans impacts. Table 1 shows quality improvement in­dexes in different countries.

Table 1: Quality improvement projects with indexes and unit of analysis in selected countries




Unit of Analysis


Amonoo- Lartson


Rural Clinics

Papua New Guinea



Health Center

United state








United state




Papua New Guinea



Health Center

8 Countries



PHC Facilitates

Dominican Republic




Papua New Guinea




Zimbabwe/ Zaire



Rural & Urban Clinics


Begum& Salahuddin





Structure/ Process

Rural Clinics


Peters & Becker

Structure/ Process


12 Countries



PHC Facilitates


Bjorck& Johansson


Health Center


World Bank



Bangladesh/ Egypt



PHC Facilitates

United State





Loevinshn / Mwabu

Structure/ Process

Rural Centers




Health Centers/ Hospital

United State



Health Institutes



Structure/ Process


United State

De Geyndt



Portugal/ Spain



Health Centers

United State

Weiner& Shortell




Wager & Rondeau



United State

Batalden & Smith




Ennis &Harrington



D: The factors influencing quality pro­grams implementation

Quality management and quality man­age­ment systems are widely advocated in health care.  Some of the main reasons for

this de­velopment are: the increasing com­ple­xity of health institutions and systems, the focus on efficiency and ef­fectiveness, the pre­ssure on cost-reduc­tion, the ongoing proc­ess of (sub-) spe­cialization and individu­aliza­tion and strengthening of the position of the client.

In most of the related researches in America on deduction of expenses and increase of income were stressed. In the developing coun­tries, the pressure of de­crease expenses of limited resources and waste were impor­tant factor for promot­ing quality. In Malay­sia, domestic pres­sure by the government for in­creasing efficiency was an important fac­tor, in other countries such as Zambia and Egypt the internal forces especially the gov­ern­ment in commissioning quality programs were effective. On the other hand, global process for supporting TQM programs re­sulted from WHO attempts in devel­oping quality in the world especially in the devel­oping countries were consid­ered.

In Europe and developed countries, some other factors such as staff and managers zeal and tendencies for implementing qual­ity pro­grams were referred in addi­tion to foreign pressure.

E- Quality programs implementation methods

In Spain and Portugal, some methods such as team working, quality promotion projects, workshop training as a basic element and strategic factors were men­tioned. In Amer­ica, the tools and various techniques such as research on custom­ers, educational stan­dardi­zation, team working and process reen­gi­ne­ering were used for implementation of TQM and the important note was prize of quality Baldrige in this country. In Ireland, cus­tom­ers satisfaction, quality improve­ment pro­jects and determining the mission and stan­dards were mostly stressed.

In developing countries such as Malaysia, training to the managers and staffs and pro­jects for quality promotion and also vi­sion determination of used methods was applied and in Zambia and Egypt training workshop, standards determina­tion and holding confer­ences were used.

Totally the methods used can be specified as: quality promotion projects, determi­na­tion of mission and vision, research on cus­tom­ers, establishing standards, man­agers training, staff training, team work­ing, clini­cal assess­ment, tools and tech­niques of total quality training, reengi­neering of the proc­esses, prize and award of quality, facilitation skills, benchmark­ing and improving proc­esses quality.

F: problems and barriers for imple­ment­ing total quality

The studies done in different countries men­tioned lack of senior and middle man­age­ment commitment as a most im­portant bar­rier for implementing TQM. In Cana­dian health sys­tem a meaningful statisti­cal rela­tions was found between senior man­agement commit­ment and quality pro­grams accom­plishment and it has been stressed that with­out manage­ment com­mit­ment and creating appropri­ate and sup­port­ing organizational culture, can not ex­pect any progress. An­other im­portant fac­tor is lack of participa­tion and involve­ment of the staff in pro­grams and lack of cul­ture change.

In developing countries, like developed coun­tries, lack of senior management com­mitment was important factor for fail­ures reports. Other reported items in­cluded lack of technical skills and team working, lack of appropriate information system and lack of appropriate organiza­tional structure. The most important problems present in Ta­ble 2.

Table 2: The most important problems for implementing total quality in selected countries

  • Organizational resistance against change
  • Resistance of Experts and staffs against the changes
  • Resistance of middle managers against the changes
  • Lack of encouragement and zeal in managers
  • Lack of encouragement and zeal in staff
  • Lack of unity in organization
  • Lack of senior expert management commit­ment
  • Lack of required resources
  • Lack of skills and staff participation
  • Barriers in the sectors and units
  • Lack of strategic planning
  • Lack of health information system

G: Impacts and results of programs im­ple­mentations

In this study, the results of developing and developed countries had the maxi­mum re­peti­tion level, includes: improve­ment of proc­ess quality, decrease of ex­penses, in­crease of ser­vice efficiency, satisfaction of customers and staff job satisfaction. In developed coun­tries, de­crease of ex­penses, increase of in­come were stressed mostly but in develop­ing coun­tries, work proc­esses improvement, processes stan­dards improvement, health services pro­mo­tion were mostly stressed. In both groups, the long term results and final impacts of TQM programs imple­mentation were not referred. Results of quality plans imple­men­tation shows in Table 3:

Processes Improvement Approaches

In studying the models for TQM applica­tion in the health systems and other mod­els used for other sectors, it has been ob­served that various models for improving process or proc-­

ess management were ap­plied, ap­proach of FADE, America hos­pital institute prob­lem solving approach or FOCUS- PDCA, prob­lem solving process, process contin­ual im­prove­ment cycle, 8 steps for proc­ess im­provement cycle in Malaysia and other models of which all are collection of re­peat­able processes which a team or per­son can learn them or follow up are pre­sented. Proc­ess management, through guide­lines, proto­cols and preventive in­spec­tions, is instru­mental to quality im­prove­ment be­cause health-care activities are sets of interlinked processes. Totally it can be con­cluded that all methods for improving qual­ity benefits from four basic process: These processes  include Plan, Do, Check and Act (PDCA cycle).

 Table 3: Impacts and results of quality programs implementation in selected countries

- Increase of customers / patients satisfaction

- Increase of effectiveness

- Change in Organization Culture

- Better Communication in Organization

- Increase of process quality

- Increase of information on quality

- increase of efficiency

- Decrease of expenses

- Decrease of customers claims

- Employees empowerment


During the studies, positive results of TQM application in different countries health in­sti­tutes were repeatedly ob­served. Though the few existing studies show a positive re­la­tion­ship between the implementation of quality management systems and organiza­tional per­formance (21- 23). Most TQM pat­terns have stressed necessity of senior man­agement com­mitments and increasing in­formation and man­agement knowledge for accept­ing change (1). Also based on the studies in various coun­tries, there has been a meaningful statistical relation between sen­ior management com­mit­ment and quality programs accomplish­ment and it has been stressed that without health management commitment for quality and cre­ating favor­ite and supporting man­agement culture, can not expect any suc­cess (1). It is seen that most opinion mak­ers and re­searches in health organizations reveals importance of management com­mitment and their full scale supporting of TQM. Through com­mit­ment to quality, management implements the commu­nity desires for quality of care and make and address the organizational culture. Man­age­ment leadership and com­mitment to quality is expected to build, maintain and en­courage an organizational context that leads to high organizational per­formance, individ­ual de­velopment, and or­ganiza­tional learning.

As mentioned, implementation of contin­ual training programs for managers and staffs for increasing their ability in tech­niques and total quality tools are another important factor for effective TQM ac­complishment and should be paid atten­tion in quality man­agement.

In this study it has been stressed that train­ing should not be for one time and cross-sectional but it should be continual for the subjects such as quality concept under­stand­ing, techniques and quality tools, par­ticipation, process and method for quality improvement and also the skills of leader­ship should be taught to the managers. By studying theo­retical research principles and examining quality opinion makers' com­ments, the as­pects with most emphasis are: Leader­ship, Team working, customer ori­entation, con­tinuous im­provement and qual­ity training. On the other hand, by studying and ex­am­ining the manag­ers, most im­por­tant re­sponsibilities, most skills are allocated for TQM programs ef­ficiencies. So, it is nec­essary that in sug­gested qual­ity man­age­ment model the con­tinual trainings are stre­ssed for continual train­ing of organ­iza­tional leadership skills, prob­lem solv­ing, teams learning, training educa­tional coaches.

Certainly, team working, participation, con­flict management, development of inno­va­tion and creativity are the most impor­tant aspects of effective leadership in the total quality or­ganization (1). Quality ex­perts be­lieve that leadership should de­veloped a culture in which all the staff from top man­ager to the mini­mum level should have commitment for continuous improvement as a part of their daily work appeared. TQM has a clear man­agement method dealing with trans­ferring respon­sibility and quality culture develop­ment which each person has commitment for continuous improvement and customers satisfaction (24).

In Ireland, 27% of the hospitals have re­peatedly used culture change method and 50% declared that the relations were better as the result of pro­grams imple­men­ta­tion (12).

The proposed quality management model should be stressed on the culture change strategies in practical process and regular basis and establishment of participation techniques of first and second level such as: survey feedback, dividing informa­tion, sug­gestion system and also forming a team for solving problems for strength­ening par­tici­pation should be used.

For accomplishment and reaching TQM goals, is required for quality to be recog­nized as an organization's strategic goal (25, 26). Con­sidering quality as an inte­gral part of the over­all business planning allows health-care or­gani­zations to de­termine their strengths, weak­nesses and opportunities in the quality ser­vice area, optimize the use of resources and ensure that the deployment will be effective. Re­cently, two major changes have emerged in government health policy: (a) a shift from an internal approach to performance (e.g., internal efficiency, productivity) to an exter­nal one (e.g., patient satisfaction, account­ability), and (b) a shift from a fo­cus on struc­ture to a focus on proc­ess. These changes have placed a renewed emphasis on service quality and its rela­tion­ship with health-care providers or­ganiza­tional performance in or­der to cre­ate a mechanism for internal feed­back and exter­nal accountability.

Thus TQM should be implemented in a com­prehensive and total form in the or­gani­zation not in a unit and sector form, TQM is a total and horizontal process which include all levels of organization and is searching for the answers to needs and expectations of all stakeholders of all health organization such as the people, government, services receivers, staff and other economical social organiza­tions in a long term. So, it is neces­sary that TQM implemented in strategic form. Madu also stressed on this quality strategic view point (27). It has been re­vealed that 60% of the organizations using TQM in America had strategic plan­ning, de­signing manage­ment and informa­tion analysis. Before imple­mentation of TQM appropriate planning should be ap­plied, and without having a plan, es­tablish­ment of TQM will not be applied and after a while it will be mitigated. Most of the fail­ures in TQM implementation are due to lack of action plan (23). Of course, the plan can be implemented in a coordinated and inter related forms for common vi­sion when they are regulated in a strate­gic manage­ment framework.

By studding the health system process man­agement models and other industrial and service organizations in different coun­tries in four steps; Plan, Do, Check and Act are common which are in accor­dance with qual­ity improvement cycle of Show­hart and Deming (28). The re­searcher have stressed in the suggested model in team working, value and im­portance of staff par­ticipation in dis­cov­ering the problems, documentation, rela­tion with customers, statistical process con­trol, process ca­pa­bility analysis, pre­senting solution and implementation of re­forming solution.

Measuring full impacts of TQM in health sector within the framework for a com­pre­hensive pattern including all structure, proc­ess, short term results, long term re­sults and final impacts indexes. This means having strategic vision for health sector.

Proposed model

For success in TQM implementation in health organizations, the most important fac­tors are as following:

  1. A manager who has active and con­siderable role in encouragement of team work­ing, development of participa­tion and creativity, creating organiza­tional useful com­mu­nication, expanding common vision and training.
  2. Manpower of capable and active staff whose goals are doing the right things and doing things right and improving it in later times by customers satisfaction
  3. Organizational culture stressing on con­tinues change, accepting conflict, team work­ing, multi aspect communica­tion, total par­ticipation and continual learning.
  4. Strategic management considering spe­ci­fying the mission, vision, long term goals continuous improvement, strategic think­ing and total comprehensiveness in the or­gani­zation interacting with external environ­ment.

The researcher proposed models for quality management having mention component title strategic total quality management and define it as follows:

Strategic Total Quality Management

(STQM) is a strategic approach toward em­ployees, the organization and society and fo­cuses on empowering the employ­ees at all levels and ensures their partici­pation in the permanent quest for the im­provement of the quality of processes and health planning, cre­ating added values, changing organiza­tions culture, and pre­serving the resources. The final objective of STQM is to improve of the societys health, fulfillment of social respon­sibili­ties and focusing on the needs of all stakeholders. The element of STQM model shows in Fig. 1.

Figure 1: Final Model of Strategic Total Quality Management


The authors would like to acknowledge Hama­dan University of Medical Sciences for pro­vid­ing support and encouragement for this study.


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