International Journal of Health Care Quality Assurance

Continuous quality improvement in acute health care: creating a holistic and integrated approach
Nigel Sewell

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Nigel Sewell, (1997),"Continuous quality improvement in acute health care: creating a holistic and integrated approach",
International Journal of Health Care Quality Assurance, Vol. 10 Iss 1 pp. 20 - 26
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Continuous quality improvement in acute health

care: creating a holistic and integrated approach

Downloaded by Universitas Indonesia At 20:33 09 December 2016 (PT)

Nigel Sewell
The St Helier NHS Trust, Carshalton, Surrey, UK

Reviews the range of quality

activity in a National Health
Service hospital trust, using a
staff questionnaire survey,
self-assessment against the
Baldrige Quality Award criteria, and the application of the
SERVQUAL approach to service quality assessment.
Reviews the acute health care
quality programme literature.
Finds that there are needs for
greater integration of quality
effort, to engage with
patients in a more meaningful
manner, and to achieve
greater commitment and
involvement from clinicians
and managers. Identifies lack
of time and resources as a
major barrier to greater
application of quality programmes. Explores ways of
developing a more holistic
and integrated programme of
quality improvement.
Describes the creation and
implementation of a model for
continuous improvement in
health care quality.

The St Helier NHS Trust has

been heavily involved in
quality improvement over
the last five years: it is a
national demonstration site
for TQM and patient-focused
care, a pilot site for Kings
Fund accreditation, and has
secured ISO 9000 registration for some services.

International Journal of
Health Care Quality
Assurance
10/1 [1997] 2026
MCB University Press
[ISSN 0952-6862]

[ 20 ]

National and local focus on

quality
Health care in the United Kingdom is surrounded by high individual and societal quality expectations. The National Health Service
(NHS) since its creation in 1948 has been a
central and probably the most valued part
of the social welfare infrastructure. Health,
especially the relief or cure of ill health, is
important to us individually. This places an
obligation to provide high quality services,
and the development of medicine and other
caring professions is marked with the desire
to aspire to excellence in clinical care.
In recent years there has been a growing
interest by patients and consumer groups in
quality issues within health care, highlighting an unease with prevailing arrangements.
Major external changes have made the issue
of quality and quality improvement of
increased importance over the last five to ten
years. These changes include an increase in
expectations, greater consumerist culture
and an increase in health care litigation.
In parallel, there have been major internal
changes for the NHS centred on the NHS
reforms with the formation of an internal
market in health care and the creation of NHS
trusts. With these major changes has
emerged an increasing focus on quality of
service delivery. Some of this is the result of
service specifications for provider contracts
and the need of providers to demonstrate
their quality edge within a more competitive environment.
As part of the national quality programme
there has been a greater focus and resourcing
of medical and clinical audit with the laudable desire to ensure that the professional
aspects of patient care are constantly
reviewed. This interest in quality issues did
not stop with the reforms: since 1991 there
has been the introduction of the Patients
Charter, the creation of league tables and a
growing emphasis on clinical effectiveness.
Some may question whether aspects of the
Patients Charter and league tables have
much relation to true quality of service but it
undoubtedly has created a more consumer
conscious NHS.

The Department of Healths commitment to

quality improvement can be traced in several
activities: the creation of national demonstration sites for TQM; the Patient Perception
Booklets; the development of clinical audit,
and the encouragement of continuous quality
improvement and benchmarking.
In 1993 it became a requirement that all
NHS organizations have in place an organization-wide approach to quality[1] although
little practical advice has been provided as to
how to achieve this in the complex environment of health care. Since 1994, the St Helier
NHS Trust has been exploring the best way to
respond to this national requirement and to
establish an effective approach to creating a
holistic and integrated approach to continuous improvement in health service quality.
The Trust had taken a leading role in quality management in health care since the late
1980s when, as the Acute Services Unit of
Merton and Sutton Health Authority, it
became one of the national demonstration
sites for total quality management. This
resulted in the formulation of a detailed quality plan based on the principles and values of
TQM.
To bring principles to reality, a comprehensive training programme was initiated for the
3,500 staff within the Unit. This consisted of a
detailed programme for those in supervisory
and managerial roles and a more simplified
programme for all other staff.
This training had a demonstrable effect on
the organization as individuals and groups
applied the tools and techniques in work
settings. Reflecting this, the Trust was chosen
in 1993 for a national case study of TQM in
health care[2]. Not all was unqualified success. Problems were experienced in the form
of resistance to a management approach to
quality, difficulty in relating the approach to
the direct patient/practitioner interface, and
lack of changed management behaviours.
The focus on quality had an impact in other
ways: the Trust became an early participant
in the Kings Fund organizational audit programme; was funded as a national patientfocused care site; achieved ISO 9000 certification in some of its facilities operations and
achieved conditional clinical pathology
accreditation.

Nigel Sewell
Continuous quality improvement in acute health care:
creating a holistic and integrated approach

Downloaded by Universitas Indonesia At 20:33 09 December 2016 (PT)

International Journal of
Health Care Quality
Assurance
10/1 [1997] 2026

What emerged was a quality maze with a

range of quality activity including TQM,
Kings Fund accreditation, medical audit,
clinical audit, and other accreditation including ISO 9000. By 1994 there was a sense of
quality overload; an invitation to become a
pilot to apply the British Quality Award to
non-commercial organizations was reluctantly declined. In the face of the successes
achieved, the problems experienced and the
developing quality agenda, it was decided to
re-examine the Trusts position and formulate a more integrated approach to quality
improvement.
This was undertaken by examining the
relevant issues and undertaking an international review of approaches to quality with
local research to obtain the views of staff and
assess the Trust against stringent quality
requirements.

International review
Quality assurance, in the form of achieving
quality through systems of inspection, monitoring and review is extensive in health care
organizations. In recent years there has been
a backlash against the punitive aspects which
QA can create, and a greater interest in alternative approaches to quality where the
emphasis is on constant improvement.
One such approach is TQM which has
achieved some success in health care in
North America and to a lesser extent in the
UK. Particular problems experienced have
been the difficulty of obtaining the support
and participation of medical staff and underestimating the level of organizational and
cultural change required to implement TQM.
Where TQM has been introduced effectively,
it has resulted in demonstrable benefits. The
independent concept of achieving continuous
improvement has been used successfully by
clinicians in North America. Success in
health care requires the acquisition of new
skills, techniques and behaviours by individual staff, and resourcing and support from
management.
The most widely used form of external
review approach in health care has been
accreditation specific to health settings. The
USA, Canada, Australia and New Zealand
have well-established accreditation systems,
while the UK is only now at the point of having widely accepted schemes for organizational audit. The debate continues in the UK
about moving to a formal accreditation system but such a system is likely to become
increasingly universal as a means of providing a form of accountability and reassurance
to users and purchasers as well as an oppor-

tunity to providers to demonstrate their

worth. The ISO 9000 approach of external
accreditation has not been widely used in
health care although there are some examples within the NHS and private health care.
Accreditation is often viewed as a necessary evil rather than a central part of the
particular organizations quality strategy.
The criticisms of accreditation are major: it
fails to capture the performance of the organization over time; develops into a paperchase exercise; is no guarantee of quality;
concentrates on rigid standards and criteria;
and fails to focus on the service outcome to
patients. The North American approaches to
accreditation are now embracing aspects of
continuous improvement and entail a greater
consideration of outcomes assessment.
Quality reviews within clinical professions
have existed for many years. Medical audit
can cover a wide range of medically related
activity but in essence should be reviewing
the exercise of professional judgement and
this requires a degree of confidentiality in the
process. Criticisms of medical audit have
been expressed including the failure to
ensure that improvement is achieved. Professional quality assurance has traditionally
been undertaken on a uniprofessional basis
but the NHS is now moving towards multiprofessional clinical audit.
A wide range of different approaches to
quality in health care exists, each with a
particular emphasis and all having varying
advantages and disadvantages. This creates a
quality maze and there are few accounts of
approaches and attempts which integrate
some or all of the different approaches to
quality improvement in health care. Those
which do exist vary in nature and are not
usually developed as organization-wide
approaches.
Many, if not all, developed health care systems are facing similar problems today: how
to respond to increasing patient and professional quality expectations with increased
governmental pressure to contain the costs of
service delivery. In facing these challenges,
there are particular issues which come to the
fore when looking at quality in the health
care setting.
One of these issues is that of being clear as
to what constitutes quality in health care. It
can be very tempting to search for an allembracing definition of quality in health
care. This is inappropriate. There can be no
fixed definition of quality for universal application, because what constitutes quality is
linked to individual values and expectations.
These values and expectations belong to the
community, the patient and the professional
staff involved. Therefore, quality can be

[ 21 ]

Nigel Sewell
Continuous quality improvement in acute health care:
creating a holistic and integrated approach

Downloaded by Universitas Indonesia At 20:33 09 December 2016 (PT)

International Journal of
Health Care Quality
Assurance
10/1 [1997] 2026

defined only by explicitly exploring these

values and expectations in any particular
setting.
Linked to defining quality is the place
which standards have in any quality programme. The use of standards within health
care quality systems is widespread but there
are dangers of standards being set as minimal
levels which become the accepted norm, or
being seen as fixed statements rather than
used in a dynamic fashion. Nationally
derived standards do not necessarily accord
with local users preferences and priorities
and wherever possible, standards should
represent users views, expectations and
requirements.
A particular risk is to overlook the importance of processes (rather than standards) in
the delivery of services to patients. Processes
in health care are of vital importance in quality improvement and if neglected can have
grave consequences. Processes are relevant
in any area of activity, including health care,
and therefore relevant in the direct
patient/practitioner interface. The provision
of health care presents an extremely complex
matrix of processes with the particular feature that patients are not external to the key
processes but an essential part of them.
Despite the importance and complexity of
processes in health care, the emphasis should
not overlook the vital part which staff play in
designing, operating and improving
processes.
Another issue is the need for chief executives and medical directors to understand the
crucial role which they must play in developing and sustaining a quality programme.
Medical commitment and leadership to quality improvement activity are essential but
difficult to achieve, possibly because medical
staff are faced with a complexity of quality
activity. Senior managers have a key role to
play and need to provide persistence and
maintain a long term perspective of the quality programme. Quality improvement must
be seen as a major organizational change
exercise.

Research findings
In order to examine the issues in greater
depth, the Trust undertook three distinct
pieces of research during 1994 to take stock
and ascertain where change was required
and how that change might best be made.
This research consisted of:
a questionnaire survey of staff within the
Trust;

[ 22 ]

an assessment of the Trust against the

requirements of the Baldrige Quality
Award;
a survey to ascertain the importance which
patients and staff attach to quality criteria
and how they perceived the Trust when it
was measured against those criteria.
The staff questionnaire was designed to
ascertain the extent to which staff were
aware of the various aspects of the Trusts
quality programme; whether they had
received training in the particular
approaches and the extent of usage of the
approaches. Questions were also asked to
identify the causes which prevented staff
from using the approaches more effectively in
their working environment.
The results of this questionnaire survey
indicated a high familiarization of the Trusts
prime quality programme based on the principles of TQM. A training programme had
achieved a high penetration within the organization and most respondents indicated that
they had made beneficial usage of the tools
and techniques contained within the training
programme. However, of those applying the
approach, 70 per cent identified lack of time
and lack of resources as major hindrances to
greater application of the approach.
Other key results of the staff survey were a
high familiarization with the Kings Fund
organizational audit programme and a belief
that it has resulted in benefits to the organization. Questions relating to the understanding
and usage of medical and clinical audit highlighted the strength of medical audit within
the Trust but a lower appreciation and application in the other clinical professions.
The second major piece of research was an
assessment of the Trust against the stringent
requirements of the Baldrige Quality Award.
(The Malcolm Baldrige National Quality
Award is named after Malcolm Baldrige who
was US Secretary of Commerce from 1981 to
1987. The Award was created by public law in
August 1987).
The Award is structured around seven
categories of corporate activity: leadership;
information and analysis; strategic quality
planning; human resource development and
management; management of process quality; quality and operational results; and customer focus and satisfaction. A system of
scoring is applied to each of these areas with
a total maximum score of 1,000 and any organization achieving a score of over 875 is considered to be world class.
This assessment within the Trust was
undertaken by experienced Baldrige surveyors in conjunction with two groups of staff
within the Trust. Each group independently

Nigel Sewell
Continuous quality improvement in acute health care:
creating a holistic and integrated approach

Downloaded by Universitas Indonesia At 20:33 09 December 2016 (PT)

International Journal of
Health Care Quality
Assurance
10/1 [1997] 2026

assessed the Trust against the specific criteria within each of the Baldrige categories and
arrived at an overall assessment or score for
the Trust. Although one staff group consisted
primarily of senior managers while the other
comprised more junior staff, both groups
placed the Trust in the same banding within
the Baldrige scheme.
This banding described the state of quality
development as being at a formative position
where there is some evidence of effort in few
categories, but not outstanding in any. Poor
integration of efforts. Largely based on reaction to problems, with little preventive
effort. This was seen as a fair description of
the Trusts progress at that time. While this
was against the Baldrige requirements of
being a world-class quality organization, it
demonstrated how much progress was yet to
be made despite the demonstrable commitment and progress to quality improvement
over a period of four years.
The particular areas requiring greater
attention were the need for greater integration of activity across the whole organization
and involving all activities, whether clinical
or managerial. A major area of improvement
was the need to involve service users in the
quality design and evaluation processes.
The third piece of research asked patients
to identify what quality characteristics or
dimensions they considered to be important
in assessing the Trust. This was achieved by
using the SERVQUAL questionnaire developed by Zeithaml et al. in the USA[3]. It is
based on extensive discussions with users of
service organizations regarding the features
of service which are of importance to them.
These features are grouped into five categories and adapted to health care to represent
the following:
1 Tangibles: the appearance of the hospitals
physical facilities, buildings, equipment,
personnel and communication materials;
2 Reliability: the hospitals ability to perform the promised service dependably and
accurately;
3 Responsiveness: the hospitals willingness
to help patients and provide prompt service;
4 Assurance: the knowledge and courtesy the
hospitals staff and their ability to convey
trust and confidence:
5 Empathy: the caring, individualized attention the hospital provides its patients.

of service quality identified by patients

was reliability and the importance attached
to each of the dimensions is shown in
Figure 1.
The actual performance of the hospital
against these measures indicated that there
was scope for improvement on all five dimensions and especially reliability. This indicates
the importance being attached to issues such
as appointments and admissions taking place
at the time scheduled.
An analysis of responses by age and social
group indicated that those over 65 years
scored the hospital more highly on responsiveness and assurance. This suggests that
older people may be more easily pleased with
services. Alternatively, younger patients may
have higher expectations which, if
maintained through to old age, will create a
greater need to meet rising expectations.
From these pieces of survey research, the
following key conclusions were drawn:
Varied degree of usage of the various
aspects of the Trusts quality programme;
Lack of time and resources were frequently
identified by staff as hindrances to utilizing
the approaches and tools within the quality
programme;
An assessment of the Trust against the
stringent requirements of the Baldrige
Quality Award indicated that, while
progress had been made, there was poor
integration of efforts and activity.
the Baldrige approach indicated the need to
have a greater customer focus and involve
customers more in the quality process;
Clinicians, especially doctors, were faced
with a complexity of quality effort which
becomes counterproductive;
The overall results of the SERVQUAL survey highlight the need to understand with

Figure 1
Importance attached by patients to SERVQUAL
dimensions

This survey was carried out in association

with Kingston University, Surrey. The random sample size was 478 and 235 usable
replies were received, representing a
response rate of 49 per cent. The results
indicated that the most important dimension

[ 23 ]

Nigel Sewell
Continuous quality improvement in acute health care:
creating a holistic and integrated approach

Downloaded by Universitas Indonesia At 20:33 09 December 2016 (PT)

International Journal of
Health Care Quality
Assurance
10/1 [1997] 2026

greater clarity what constitutes quality for

patients.

The new model

A range of options was considered with the
purpose of developing a holistic and integrated approach to quality improvement.
Seven criteria were adopted to assess each
option:
1 support of clinicians;
2 facilitates patient involvement;
3 minimal time demands;
4 simplicity;
5 achievability;
6 cost of implementation;
7 ease of implementation.
Six options were selected:
1 maintain the status quo;
2 exclusively adopt one existing approach in
use;
3 blend the existing approaches together;
4 create an entirely new approach and
model;
5 adopt a laissez-faire approach;
6 adopt an alternative available approach.
An assessment of these options against the
criteria resulted in the identification of a
preferred option which was the blending
together of existing approaches in use within
the Trust. The development of such an integrated approach was achieved by focusing on
key principles appropriate for quality and
quality improvement in health care and differentiating between the different quality
approaches adopted. This enabled the identification of those aspects of each programme
which should be retained or used in a
reduced or modified form.
This enabled the Trust to develop an
approach with a high degree of consistency
throughout all aspects of its application and
to have a constant theme of continuous
improvement. This new framework, the
model for continuous improvement in
health care quality is built on the principles
of being:
Process based: a process-based approach is
considered essential if greater improvements are to be achieved across a wide
range of activities. Processes are vital as all
activity is part of a wider process and the
delivery of care and services to individual
patients normally requires a complicated
mix of different processes across a wide
range of services and departments. An
emphasis on processes also assists in avoiding the creation of an organizational culture where people are seen as the cause of
quality problems.

[ 24 ]

Designed to achieve continuous

improvement: in a constantly changing
environment, it is vital that any health care
organization has the capacity and ability to
respond rapidly to those changes. It is a
prerequisite that any model for service
quality improvement is able to encourage
and support continuous improvement in all
the activities of the organization. Continuous improvement is a simple concept which
few would disparage, but its creation
requires a supportive organization with
appropriate values and behaviours.
Focused on client/patient: any attempt to
achieve quality without a full understanding of the requirements and expectations of
customers is likely to have serious deficiencies. Such an understanding requires constant attention to developing a clarity
regarding users expectations and the measures or features which they use to formulate a view on service quality.
Supportive rather than punitive: staffs
perceptions of quality programmes are
significant. If the approach to quality is
predominantly through inspection,
imposed targets or standards, or monitoring by full-time quality professionals, the
result is likely to be resistance to quality
issues, attempts to thwart the inspectors
and a generally negative view of quality.
What is preferred is an approach which
encourages staff to identify quality problems, identify causes, and gives them the
authority to take corrective action. In an
environment such as health care, where
service quality is largely dependent on the
exercise of personal skills, a supportive
approach is more appropriate.
Capable of organization-wide application:
this requires the approach to be capable of
implementation and application across the
whole organization; usable in clinical and
non-clinical settings and within any type of
service or function.
Supportive of the organizational values of
both continuous professional training and
R&D: as an organization with a commitment to undergraduate medical education,
and the development of all professional and
other staff, together with a developing academic and research agenda, it is important
that any major corporate approach to quality improvement supports these aims.
The model proposed has the following features to integrate the different aspects of
quality improvement into a single approach:
continuous quality improvement is the lead
or generic approach being consistent with
the values of health care staff;

Nigel Sewell
Continuous quality improvement in acute health care:
creating a holistic and integrated approach

Downloaded by Universitas Indonesia At 20:33 09 December 2016 (PT)

International Journal of
Health Care Quality
Assurance
10/1 [1997] 2026

medical audit and clinical audit are supported as part of the continuous quality
improvement approach and to ensure confidential review of issues of professional
judgement;
Kings Fund accreditation has a limited
role of providing standards and criteria for
local adaptation and use in process review;
ISO 9000 is preferred as the external verifier of quality performance because of its
greater emphasis on processes than accreditation. However, it is recognized that this is
not an immediate option for full application
in a large acute Trust;
one of the Baldrige models should be used
as a tool for management teams to assess
the extent of organizational achievement of
total quality.
This approach can be shown in simple diagrammatic form (Figure 2) but it is also necessary to be clear regarding how the patient
input is achieved within this approach. This
is outlined in Figure 3, demonstrating how
effective input is required at each stage of the
quality design, review and improvement
process.
Particularly useful is clarity regarding how
different aspects of health care and clinical
activity can contribute within a new
approach, especially in the design, monitoring and improving of processes, as shown in
Table I.

Figure 2
Model for continuous improvement in health care quality

Figure 3
Patient input into model

Implementation
To support this development of a holistic
approach to quality improvement a detailed
programme of implementation is required.
This needs to take account of identified significant issues which can affect the degree of
success and effectiveness. Among those
issues are:
the need for clear clinical leadership and
active participation;
the needs for supporting behaviours and
action from managers;
the need for demonstrable leadership from
the top of the organization;
the need for internal consistency of purpose through a supporting quality structure.
A detailed action plan was devised which
covered a number of areas includes training;
clinical leadership; support and facilitation;
focusing on processes; and ensuring patients
input into the quality activity. Training is
particularly important if there is to be a
greater integration of quality improvement
effort and the creation of a basic core of quality improvement skills applicable to clinical
and non-clinical issues.
Closely allied to training is the provision of
facilitation and support to individuals and
teams as they seek to apply the new model in
live situations and problem areas. The intention is to trial the new approach in one or two
clinical areas and to use the experience to
modify the implementation programme
before total implementation is commenced.
Although it is too early to say, it is felt that
the new model will result in a more coherent

[ 25 ]

Nigel Sewell
Continuous quality improvement in acute health care:
creating a holistic and integrated approach

Downloaded by Universitas Indonesia At 20:33 09 December 2016 (PT)

International Journal of
Health Care Quality
Assurance
10/1 [1997] 2026

Table I
Processes within the new model
Designing processes:
designing in quality by
incorporating:
Clearly defined patient
expectations
Good practice from general
risk management
Good practice from clinical
risk management
Standards and criteria of
Kings Fund organizational
audit where appropriate as
process requirements
Requirements of ISO 9000
Results from benchmarking
Control of infection preventive
practice
Outcomes expectations
Clinical protocols and
guidelines
Results of R&D

Improving processes:
continuous improvement
by using:
Tools of continuous quality
improvement
Results of clinical audit
Results of medical audit
Patient feedback
Other client feedback

approach to quality and quality improvement

within the trust and will result in greater
integration of effort, and commitment to
improvement by all involved. It is equally felt
that this model is transferable to other NHS
organizations and, indeed, to other health
care settings.
The sobering aspect is the realization that
although the journey to total quality started
five years ago, there are many years to follow
before the Trust achieves status as a world
class total quality health care organization.

[ 26 ]

Monitoring processes:
overseeing effectiveness
of processes by:
Comparative benchmarking
Control of infection monitoring
Review of key organizational
processes
Outcomes measurement
BS/ISO certification

References
1

NHS Management Executive, Achieving an

Organisation-wide Approach to Quality, NHSE
Bulletin EL(93)116, NHSE, 1993.
NHS Management Executive, Quality in
Action: The St Helier NHS Trust a Case Study,
NHS Training Directorate, 1993.
Zeithaml, V.A., Parasuraman, A., and Berry,
L.L., Delivering Quality Services Balancing
Customer Perceptions and Expectations, The
Free Press, New York, NY, 1990.

Downloaded by Universitas Indonesia At 20:33 09 December 2016 (PT)

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International Islamic University Malaysia, Kuala Lumpur, Malaysia. 2012. Inpatient satisfaction: an analysis of Malaysian
public hospitals. International Journal of Public Sector Management 25:1, 6-16. [Abstract] [Full Text] [PDF]
9. Andreas P. Kakouris, Elina Meliou. 2011. New Public Management: Promote the Public Sector Modernization Through
Service Quality. Current Experiences and Future Challenges. Public Organization Review 11:4, 351-369. [CrossRef]
10. Marci K. Campbell, Irene Tessaro, Mindy Gellin, Carmina G. Valle, Shannon Golden, Leanne Kaye, Patricia A. Ganz,
Mary S. McCabe, Linda A. Jacobs, Karen Syrjala, Barbara Anderson, Alison F. Jones, Kenneth Miller. 2011. Adult cancer
survivorship care: experiences from the LIVESTRONG centers of excellence network. Journal of Cancer Survivorship 5:3,
271-282. [CrossRef]
11. Ramzi NasserQatar University, Doha, Qatar Jacqueline DoumitNotre Dame University, Zouk Mikael, Lebanon. 2011.
Developing criteria for elderly nursing homes: the case of Lebanon. International Journal of Health Care Quality Assurance
24:3, 211-222. [Abstract] [Full Text] [PDF]
12. Liz GillUniversity of Sydney, Australia Lesley WhiteUniversity of Sydney, Australia Ian CameronRoyal Rehabilitation Centre
Sydney, University of Sydney and Director of Medical Services, Australia. 2010. Transitional aged care and the patient's view
of quality. Quality in Ageing and Older Adults 11:2, 5-18. [Abstract] [PDF]
13. Jacqueline DoumitFaculty of Natural and Applied Sciences, Notre Dame University, Zouk Mosbeh, Lebanon Ramzi
NasserCenter of Educational Development and Research, Qatar University, Doha, Qatar. 2010. Quality of life and wellbeing
of the elderly in Lebanese nursing homes. International Journal of Health Care Quality Assurance 23:1, 72-93. [Abstract]
[Full Text] [PDF]
14. Wan Edura Wan RashidFaculty of Office Management and Technology, Universiti Teknologi MARA, Shah Alam, Selangor,
Malaysia Hj. Kamaruzaman JusoffSchool of Forestry & Environmental Studies, Yale University, New Haven, Connecticut,
USA. 2009. Service quality in health care setting. International Journal of Health Care Quality Assurance 22:5, 471-482.
[Abstract] [Full Text] [PDF]
15. 2009. Erratum. Asian Journal on Quality 10:1, 77-87. [Abstract] [PDF]
16. Su Mi DahlgaardParkEleonora KarassavidouBased in the Department of Economics, Division of Business Administration,
Aristotle University of Thessaloniki, Thessaloniki, Greece , Niki GlaveliBased in the Department of Economics, Division of
Business Administration, Aristotle University of Thessaloniki, Thessaloniki, Greece and Chrissoleon T. PapadopoulosBased
in the Department of Economics, Division of Business Administration, Aristotle University of Thessaloniki, Thessaloniki,
Greece. 2009. Quality in NHS hospitals: no one knows better than patients. Measuring Business Excellence 13:1, 34-46.
[Abstract] [Full Text] [PDF]
17. Ali Asghar Anvary Rostamy. 2009. Toward understanding conflicts between customers and employees perceptions and
expectations: Evidence of Iranian bank. Journal of Business Economics and Management 10:3, 241-254. [CrossRef]

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18. Mayuri DuggiralaDepartment of Management Studies, Indian Institute of Technology Madras, Chennai, India
Chandrasekharan RajendranDepartment of Management Studies, Indian Institute of Technology Madras, Chennai, India
R.N. AnantharamanDepartment of Management Studies, Indian Institute of Technology Madras, Chennai, India. 2008.
Patientperceived dimensions of total quality service in healthcare. Benchmarking: An International Journal 15:5, 560-583.
[Abstract] [Full Text] [PDF]
19. Noor Hazilah Abd ManafInternational Islamic University Malaysia Phang Siew NooiUniversity Malaya. 2007. Patient
Satisfaction as An Indicator of Service Quality In Malaysian Public Hospitals. Asian Journal on Quality 8:3, 113-122. [Abstract]
[PDF]
20. Gareth SmithUniversity of Loughborough, Loughborough, UK Alison SmithUniversity of Loughborough, Loughborough,
UK Alison ClarkeUniversity of Nottingham, Nottingham, UK. 2007. Evaluating service quality in universities: a service
department perspective. Quality Assurance in Education 15:3, 334-351. [Abstract] [Full Text] [PDF]
21. Ram HersteinBusiness Management Department, Ruppin Academic Center, Emek Hefer, Israel Eyal GamlielBehavioral
Sciences Department, Ruppin Academic Center, Emek Hefer, Israel. 2006. The role of private branding in improving service
quality. Managing Service Quality: An International Journal 16:3, 306-319. [Abstract] [Full Text] [PDF]
22. Naceur JabnounDepartment of Business Administration, University of Sharjah, Sharjah, United Arab Emirates Aisha
Juma AL RasasiMedical Records Department, AlThaid Hospital, Sharjah, United Arab Emirates. 2005. Transformational
leadership and service quality in UAE hospitals. Managing Service Quality: An International Journal 15:1, 70-81. [Abstract]
[Full Text] [PDF]
23. Raduan Che RoseAssociate Professor, Graduate School of Management, at the University Putra Malaysia, Serdang, Selangor,
Malaysia Jegak UliAssociate Professor, Department of Professional Development and Extension Education, at the University
Putra Malaysia, Serdang, Selangor, Malaysia Mohani AbdulLecturer in the Faculty of Economics and Administration, at
the University Putra Malaysia, Serdang, Selangor, Malaysia Kim Looi NgDirector of Clinical Nursing at the King Khalid
National Guard Hospital, Jeddah, Saudi Arabia. 2004. Hospital service quality: a managerial challenge. International Journal
of Health Care Quality Assurance 17:3, 146-159. [Abstract] [Full Text] [PDF]
24. Naceur JabnounAssociate Professor, University of Sharjah, Sharjah, United Arab Emirates.Mohammed ChakerAssistant
Professor, University of Sharjah, Sharjah, United Arab Emirates.. 2003. Comparing the quality of private and public hospitals.
Managing Service Quality: An International Journal 13:4, 290-299. [Abstract] [Full Text] [PDF]
25. Adrienne CurryUniversity of Stirling, Stirling, UK Emma SinclairUniversity of Stirling, Stirling, UK. 2002. Assessing
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[Abstract] [Full Text] [PDF]
26. Amy E. Bonomi, Edward H. Wagner, Russell E. Glasgow, Michael VonKorff. 2002. Assessment of Chronic Illness Care
(ACIC): A Practical Tool to Measure Quality Improvement. Health Services Research 37:3, 791-820. [CrossRef]
27. Cludio Reis Gonalo, Edison Jacques JacquesBest Practices of Knowledge Strategy in Hospitals 180-202. [CrossRef]
28. A.N. Dwivedi, R.K. Bali, R.N.G. Naguib, V. Baskaran, N.S. NassarTracking the healthcare management landscape:
implications for integrated healthcare management and practice 1240-1243. [CrossRef]