- Email: [email protected]
Total quality culture in radiotherapy departments across Ontario
Radiotherapy and Oncology 99 (2011) 90–93
Contents lists available at ScienceDirect
Radiotherapy and Oncology journal homepage: www.thegreenjournal.com
Quality of radiotherapy
Total quality culture in radiotherapy departments across Ontario Gunita Mitera a,⇑, Anthony Whitton b, Eric Gutierrez b, Sheila Robson a a
Department of Radiation Therapy, University of Toronto, Canada; b Cancer Care Ontario, Radiation Treatment Program, Canada
a r t i c l e
i n f o
Article history: Received 18 March 2010 Received in revised form 15 December 2010 Accepted 2 January 2011 Available online 28 February 2011 Keywords: Change management Organisational culture Radiation therapy Total quality culture
a b s t r a c t Purpose: To investigate the prevalence of total quality culture (TQC) within radiation therapy (RT) departments across Ontario, Canada. Methods: A prospective quantitative survey was distributed within RT departments across Ontario, Canada using the Miller Consulting Group Quality Culture survey. Findings: Ninety percent of managers (9/10) and 50% of employees (261/519) participated. There was concordance between managers and staff that overall RT departments exhibit a work culture that somewhat resembles TQC. Both groups scored 55% of the categories as somewhat agree with TQC and 9% of categories as no TQC. There was discordance in views for 36% of the categories, where managers scored a higher prevalence of TQC compared to their therapists. Larger RT departments (>50 employees) had more prevalence of discrepancy between group scores. Conclusions: This is the first study to report on the prevalence of TQC within RT departments. Strategies designed for on-going continuous improvement will benefit staff, RT managers, continuity of patient care and patient safety within RT departments. Ó 2011 Elsevier Ireland Ltd All rights reserved. Radiotherapy and Oncology 99 (2011) 90–93
A total quality culture (TQC) is a flexible organisation culture emphasizing continued excellence and quality improvement within a work environment [1–3]. A TQC is defined by top management support, process-focused rather than task-focused work, teamwork and consensus, a flat and flexible structure, commitment to customer satisfaction, and continuous improvement. Managers should strive for a TQC within the workplace if the corporate strategic goal is to implement continuous quality improvement [4–7]. A shift from device-centred staffing models i.e. staffing radiation therapists around the number of machines, to process-centred staffing models i.e. radiation therapists may be staffed around on work process [8,9] demonstrates a trend towards more patient centric core values within radiation oncology. This shift in strategy has been a recent topic of discussion within the field of radiation oncology, and an effective strategic-cultural fit will directly influence the quality of care for cancer patients. Hence, this emphasizes the importance for managers to strategically assess their organisation’s culture prior to drafting and implementing a strategic quality programme to improve both patient-focus and employee care. The purpose of this study was to investigate the level of TQC within radiation therapy (RT) departments across Ontario, Canada. The specific objectives were to determine if RT departments foster a TQC; to establish if all RT managers and radiation therapists ⇑ Corresponding author. Address: Department of Radiation Therapy, Sunnybrook Odette Cancer Centre, 2075 Bayview Avenue, Toronto, ON, Canada M4N 3M5. E-mail address: [email protected] (G. Mitera). 0167-8140/$ - see front matter Ó 2011 Elsevier Ireland Ltd All rights reserved. doi:10.1016/j.radonc.2011.01.013
(employees) collectively agree on the prevalence of TQC within RT departments across the province; to document if within each RT department each manager and his/her corresponding therapists agree on the prevalence of TQC in their workplace.
Methods After receiving the local research ethics board approval, the Miller Consulting Group Quality Culture survey (MCGQC) was distributed to all senior managers and their radiation therapists across Ontario, Canada. This is a published and reliable tool that uses a five-point Likert scale to document TQC in the workplace. Respondents answered each question by scoring the prevalence of TQC within their work environment. A score of 0 indicates disagreement, 5 is to somewhat agree, and a 10 is agreement with TQC. The surveys were distributed via email along with permission for consent and a letter of confidentiality, and each RT cancer centre was anonymized. The timing between initial contact with the participants and subsequent follow-ups were in accordance to Edwards et al. [10]. Non-probability sampling, specifically, convenient sampling was used and the difference in the response rate was weighted according to each group’s sample size [10,11]. Descriptive statistics were used to analyse demographic information, and an independent two-sided paired t-test compared measurement variables, such as survey categories, and nominal variables, such as manager
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G. Mitera et al. / Radiotherapy and Oncology 99 (2011) 90–93
employees scored disagree (mean = 4.4). The wealth exploiting versus wealth creating category (p = 0.015), managers results were somewhat agree (mean = 6.4) compared to employees who scored disagree (mean = 4.7). Managers consistently scored closer to a TQC (Fig. 4). Stratified by survey category, 82% of the categories between a manager and their therapists within each centre were non-congruent (p < 0.05). Stratified by the RT department, department D had the greatest number of categories (36%) that were discrepant between managers and employees. These were task versus process focus (p = 0.023), expert and labour versus experts all (p = 0.030), unstated versus shared values and vision (p = 0.036), wealth exploiting versus wealth creation (p = 0.001). Department E and I had no categories that were significantly different between managers and therapists.
versus employees. These were calculated for statistical significance at the critical level of 0.05 [12,13]. Results Of the 12 cancer centres across the province, two centres (17%) were excluded due to management turnover during the study period. Nine out of the ten centres (90%) included both manager and employee participation. There were 519 radiation therapists that were eligible to participate, of which 261 (50%) responded. Of those who participated, 84% were full-time employees and 16% were part-time, approximating the actual distribution of staff. Concordance between managers and therapists on total quality culture
Discussion
Both managers and radiation therapists agreed on 64% of categories of the survey (Fig. 1). Fifty-five percent of categories were rated as a mean of somewhat agree (score of 5–7.4) between all managers (M) and employees (E) within each category. These categories were control versus commitment (M = 6.8, E = 7.3), command versus consensus (M = 6.5, E = 5.3), individual versus teamwork (M = 5.2, E = 5.6), experts and labour versus experts all (M = 6.8, E = 5.8), one right way versus continuous improvement (M = 6.9, E = 6.5), and unstated versus shared values and vision (M = 6.8, E = 6.4). Overall, both managers and therapists across Ontario rated their RT departments as a mean of somewhat agree for the prevalence of TQC within their workplace (Fig. 2). In the category of record versus score keeping, all managers and therapists consistently scored no TQC (M = 4.1, E = 3.2) (Fig. 3).
There is a consensus amongst RT managers and radiation therapists that the prevalent work culture is somewhat compliant with a TQC (Fig. 2). Moving forward, this may have implications for RT departments on being able to successfully implement a processcentred staffing model where this strategy can incorporate on-going continuous improvement and decisions on change management embedded within safe RT work processes [13–15]. The categories of teamwork and empowerment were rated as somewhat agree in our study. In previous studies, these human resource management components may influence employee satisfaction and retention [1,16–18]. Moreover, the perception and expectations of teamwork and empowerment should be congruency between managers and employees in order for TQC to prevail within radiation oncology departments [18]. Managers consistently scored closer to TQC compared to their therapists. This may be because generally employees have been shown to have a more pessimistic view of their work environment when compared to their managers. One could hypothesize this to be related to an individual’s ranks on the organisational hierarchy and their level of involvement within their department. The more involved and committed one is in their job, the more satisfied they are with their job and department as a whole [19]. For example,
Disconcordance between managers and therapists on total quality culture Thirty-six percent of the categories differed between managers and therapists. For task versus process focus (p = 0.023), managers scored agree (mean = 7.9) whereas employees scored somewhat agree (mean = 6.8). For control/punishment versus reinforcement (p = 0.017), managers scored somewhat agree (mean = 6.2) whereas
Total Quality Culture Scale (0 - 10)
9.0 8.0 7.0 6.0 5.0 4.0 3.0 2.0 1.0
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0–4.9 = No TQC 5–7.4 = Somewhat agree there is TQC 7.5–10 = TQC * TQC = Total quality culture
Ex
s cu
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s
C Ta sk
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us
0.0
Total Quality Culture Category
Fig. 1. All managers versus all radiation therapists scoring for each TQC category.
All-Employees
92
Quality culture in radiotherapy
Total Quality Culture Scale (0 - 10)
8.0 7.0 6.0 5.0 4.0
All-Managers
3.0
All-Employees
2.0 1.0 0.0
Control vs Commitment
Command vs Consensus
0–4.9 = No TQC 5–7.4 = Somewhat agree there is TQC 7.5–10 = TQC * TQC = Total quality
Individual vs team work
Experts & labour vs Experts all
One right way vs continuous improvement
Unstated vs shared values & vision
Total quality culture
Total Quality Culture Category
Fig. 2. Categories where both groups have congruent mean scores of somewhat agree. 0–4.9 = no TQC; 5–7.4 = somewhat agree; there is TQC; 7.5–10 = TQC; ⁄TQC = total quality culture.
Fig. 3. Survey category where both groups have congruent mean score of no TQC. 0–4.9 = no TQC; 5–7.4 = somewhat agree there is TQC; 7.5–10 = TQC; ⁄TQC = total quality culture.
Jones et al. (2008) found that managers tend to have a more positive outlook on quality change as compared to the employees and this was mainly attributed to the level of involvement and access within the company [15]. Generally, radiation therapists are assigned to work on specific tasks, in a specific area of the department. Hence, they do not always have a high level of involvement with a patient’s overall care or with their involvement within the entire department, and this may be reflective of the organisation’s culture. In larger RT departments (>50 employees), managers and employees were more discrepant in their views of TQC within their work environment. For example, these centres had between two to four categories where the difference was statistically significant as compared to smaller departments where both groups had up to one conflicting category. These findings are similar to what Shortell
et al. [1] demonstrated after administering a quality survey across 200 hospitals, with a response rate of 72% (n = 7337). They concluded that there was a direct relationship between hospital size and level of TQC. They found that the larger the hospital size, the more bureaucratic the organisational culture. Moreover, this is usually considered to be one of the barriers to quality improvement implementation. To overcome this challenge, they recommended that an implementation approach should incorporate flexibility into their model and a flatter structure [1,17]. Our manager’s survey was congruent with this recommendation. Managers from the smaller centres did mention the ability to be more flexible with their continuous improvement and staffing needs, while also acknowledging that if their centres expand they would likely lose this aspect. However, irrespective of a company’s size, the enthusiasm to incorporate TQC existed uniformly across organisations [16]. A pocket improvement strategy is recommended to help bring the RT work environment closer to a TQC. This strategy is used to select and address particular aspects of a management issue rather than tackling all aspects of the problem simultaneously or sequentially [1]. Based on the results of this investigations, it is recommended that categories that scored as somewhat agree should be a priority for departments to improve on. For example, Boon et al. [18] suggest that teamwork and empowerment have been demonstrated to influence employees’ perceptions on the level of TQC within the workplace. Consequently, improving these areas will have a positive influence on improving other similarly identified categories. Hence, this will serve to help gain support from staff to improve the categories in the future that are distant from a TQC. Conclusions This is the first prospective survey to quantify the current work culture within RT departments. General and individual strategies to move closer towards a TQC should be considered within each department. The benefits of developing a work culture consistent with a TQC will help support a process-driven continuous improvement strategy for patient-focused care, continuity of care, patient
G. Mitera et al. / Radiotherapy and Oncology 99 (2011) 90–93
93
Fig. 4. Categories where both groups have different scores (p < 0.05). 0–4.9 = no TQC; 5–7.4 = somewhat agree there is TQC; 7.5–10 = TQC; ⁄TQC = total quality culture.
safety, and satisfaction for both patients and employees alike. Ultimately, continuity of patient care within RT departments should prevail through integration of team partnerships and cooperation. A TQC, perpetuated by the right staffing structure may help sustain all facets of patient-focused care and patient safety. Thus, a strategic investment into TQC by modifying the current staffing structure should enhance the competitive future of RT departments. Future extensions of this research may include conducting a qualitative study on the perceived level of TQC within RT departments. Managers and employees can be included for in-depth responses on their perceived work culture. Considerations into quality costing of TQC may also help managers determine the usefulness of implementing TQC within their centres [20]. Acknowledgements We would like to thank Dr. Robin Hesler, Mr. Chuck Shields, Ms. Muneerah Kassam, Ms. Anneke Kind, and Dr. Andrew Padmos for their advice and general support throughout this investigation. References [1] Shortell S, O’Brian JL, Carman JM, et al. Assessing the impact of continuous quality improvement/total quality management: concept versus implementation. Health Serv Res 1995;30:377–401. [2] Irani Z, Beskese A, Love PED. Total quality management and corporate culture: constructs of organisational excellence. Technovation 2004;24:643–50. [3] Welikala D, Sohal A. Total quality management and employees’ involvement: a case study of an Australian organisation. Total Qual Manag 2008;19:627–42. [4] Vanagas P. Management of rural business. In: Vanagas P, editor. Rural Development. Kanuas, Lithuanua: Kaunas University of Technology; 2005. p. 89–91.
[5] Daft RL. The new era of management. China: Thomson South-Western; 2006. [6] Samadov M. Implementation of TQM: cross-cultural standpoint. Available at: http://publish.bsu.edu/msamadov/texts/Management/tqm.htm. (Accessed 15 November 2008). [7] Claver E, Gasc J, Llopis J, Gonzalez R. The strategic process of a cultural change to implement total quality management: a case study. Total Qual Manag 2001;12:469–82. [8] Anonymous. Total quality management. MN732/D edn, University of Leicester: England; 2007. [9] Varian Medical Systems. Streamlining workflow at the Tom Baker Cancer Centre. Centreline 2006; May–June: 1–24. [10] Edwards JE, Thomsd MD, Rosenfeld P, Booth-Kewley S. How to conduct organisational surveys: a step-by-step guide. United States of America: Sage publications; 1997. [11] The University of Texas at Austin. Available at: http://www.utexas.edu. (Accessed 5 May 2008). [12] Saunders M, Lewis P, Thornhill A. Research methods for business students. 4th ed. England: Pearson education limited; 2007. [13] Ahern V, Bull J, Harris J, Mattews K, Willis D. Subspecialization of radiation therapists in Australia and New Zealand. Australas Radiol 2007;51:104–5. [14] Griffiths SE, Craig A, Abraham M. Radiographer roles and risks management in radiography, and a UK survey. J Radiother Pract 2006;5:137–46. [15] Jones B, Aird E, Colyer H. United Kingdom radiation oncology 1 conference: accuracy and uncertainty in radiotherapy. Br J Radiol 2002;75:297–306. [16] Yavas B, Rezayat F. The impact of culture on managerial perceptions of quality. Int J Cross Cult Manag 2003;3:213–34. [17] Young G, Charns M, Desai K, Fonseca M, Shortell S. Implementation of total quality management: facilitators and barriers. Boston, USA: Management Decision and Research Center, Veterans Affairs, Health Services Research and Development Service; 1997. [18] Boon OK, Arumugam V, Haw TS. Does soft TQM predict employees’ attitudes? The TQM Mag 2005;17:279–89. [19] Svensson G, Wood G. Corporate ethics in TQM: management versus employee expectations and perceptions. The TQM Mag 2005;17:137–49. [20] Thiagarajan T, Zairi M. A review of total quality management in practice: understanding the fundamentals through examples of best practice applications – Part II. The TQM Mag 1997;9:414–7.
Contents lists available at ScienceDirect
Radiotherapy and Oncology journal homepage: www.thegreenjournal.com
Quality of radiotherapy
Total quality culture in radiotherapy departments across Ontario Gunita Mitera a,⇑, Anthony Whitton b, Eric Gutierrez b, Sheila Robson a a
Department of Radiation Therapy, University of Toronto, Canada; b Cancer Care Ontario, Radiation Treatment Program, Canada
a r t i c l e
i n f o
Article history: Received 18 March 2010 Received in revised form 15 December 2010 Accepted 2 January 2011 Available online 28 February 2011 Keywords: Change management Organisational culture Radiation therapy Total quality culture
a b s t r a c t Purpose: To investigate the prevalence of total quality culture (TQC) within radiation therapy (RT) departments across Ontario, Canada. Methods: A prospective quantitative survey was distributed within RT departments across Ontario, Canada using the Miller Consulting Group Quality Culture survey. Findings: Ninety percent of managers (9/10) and 50% of employees (261/519) participated. There was concordance between managers and staff that overall RT departments exhibit a work culture that somewhat resembles TQC. Both groups scored 55% of the categories as somewhat agree with TQC and 9% of categories as no TQC. There was discordance in views for 36% of the categories, where managers scored a higher prevalence of TQC compared to their therapists. Larger RT departments (>50 employees) had more prevalence of discrepancy between group scores. Conclusions: This is the first study to report on the prevalence of TQC within RT departments. Strategies designed for on-going continuous improvement will benefit staff, RT managers, continuity of patient care and patient safety within RT departments. Ó 2011 Elsevier Ireland Ltd All rights reserved. Radiotherapy and Oncology 99 (2011) 90–93
A total quality culture (TQC) is a flexible organisation culture emphasizing continued excellence and quality improvement within a work environment [1–3]. A TQC is defined by top management support, process-focused rather than task-focused work, teamwork and consensus, a flat and flexible structure, commitment to customer satisfaction, and continuous improvement. Managers should strive for a TQC within the workplace if the corporate strategic goal is to implement continuous quality improvement [4–7]. A shift from device-centred staffing models i.e. staffing radiation therapists around the number of machines, to process-centred staffing models i.e. radiation therapists may be staffed around on work process [8,9] demonstrates a trend towards more patient centric core values within radiation oncology. This shift in strategy has been a recent topic of discussion within the field of radiation oncology, and an effective strategic-cultural fit will directly influence the quality of care for cancer patients. Hence, this emphasizes the importance for managers to strategically assess their organisation’s culture prior to drafting and implementing a strategic quality programme to improve both patient-focus and employee care. The purpose of this study was to investigate the level of TQC within radiation therapy (RT) departments across Ontario, Canada. The specific objectives were to determine if RT departments foster a TQC; to establish if all RT managers and radiation therapists ⇑ Corresponding author. Address: Department of Radiation Therapy, Sunnybrook Odette Cancer Centre, 2075 Bayview Avenue, Toronto, ON, Canada M4N 3M5. E-mail address: [email protected] (G. Mitera). 0167-8140/$ - see front matter Ó 2011 Elsevier Ireland Ltd All rights reserved. doi:10.1016/j.radonc.2011.01.013
(employees) collectively agree on the prevalence of TQC within RT departments across the province; to document if within each RT department each manager and his/her corresponding therapists agree on the prevalence of TQC in their workplace.
Methods After receiving the local research ethics board approval, the Miller Consulting Group Quality Culture survey (MCGQC) was distributed to all senior managers and their radiation therapists across Ontario, Canada. This is a published and reliable tool that uses a five-point Likert scale to document TQC in the workplace. Respondents answered each question by scoring the prevalence of TQC within their work environment. A score of 0 indicates disagreement, 5 is to somewhat agree, and a 10 is agreement with TQC. The surveys were distributed via email along with permission for consent and a letter of confidentiality, and each RT cancer centre was anonymized. The timing between initial contact with the participants and subsequent follow-ups were in accordance to Edwards et al. [10]. Non-probability sampling, specifically, convenient sampling was used and the difference in the response rate was weighted according to each group’s sample size [10,11]. Descriptive statistics were used to analyse demographic information, and an independent two-sided paired t-test compared measurement variables, such as survey categories, and nominal variables, such as manager
91
G. Mitera et al. / Radiotherapy and Oncology 99 (2011) 90–93
employees scored disagree (mean = 4.4). The wealth exploiting versus wealth creating category (p = 0.015), managers results were somewhat agree (mean = 6.4) compared to employees who scored disagree (mean = 4.7). Managers consistently scored closer to a TQC (Fig. 4). Stratified by survey category, 82% of the categories between a manager and their therapists within each centre were non-congruent (p < 0.05). Stratified by the RT department, department D had the greatest number of categories (36%) that were discrepant between managers and employees. These were task versus process focus (p = 0.023), expert and labour versus experts all (p = 0.030), unstated versus shared values and vision (p = 0.036), wealth exploiting versus wealth creation (p = 0.001). Department E and I had no categories that were significantly different between managers and therapists.
versus employees. These were calculated for statistical significance at the critical level of 0.05 [12,13]. Results Of the 12 cancer centres across the province, two centres (17%) were excluded due to management turnover during the study period. Nine out of the ten centres (90%) included both manager and employee participation. There were 519 radiation therapists that were eligible to participate, of which 261 (50%) responded. Of those who participated, 84% were full-time employees and 16% were part-time, approximating the actual distribution of staff. Concordance between managers and therapists on total quality culture
Discussion
Both managers and radiation therapists agreed on 64% of categories of the survey (Fig. 1). Fifty-five percent of categories were rated as a mean of somewhat agree (score of 5–7.4) between all managers (M) and employees (E) within each category. These categories were control versus commitment (M = 6.8, E = 7.3), command versus consensus (M = 6.5, E = 5.3), individual versus teamwork (M = 5.2, E = 5.6), experts and labour versus experts all (M = 6.8, E = 5.8), one right way versus continuous improvement (M = 6.9, E = 6.5), and unstated versus shared values and vision (M = 6.8, E = 6.4). Overall, both managers and therapists across Ontario rated their RT departments as a mean of somewhat agree for the prevalence of TQC within their workplace (Fig. 2). In the category of record versus score keeping, all managers and therapists consistently scored no TQC (M = 4.1, E = 3.2) (Fig. 3).
There is a consensus amongst RT managers and radiation therapists that the prevalent work culture is somewhat compliant with a TQC (Fig. 2). Moving forward, this may have implications for RT departments on being able to successfully implement a processcentred staffing model where this strategy can incorporate on-going continuous improvement and decisions on change management embedded within safe RT work processes [13–15]. The categories of teamwork and empowerment were rated as somewhat agree in our study. In previous studies, these human resource management components may influence employee satisfaction and retention [1,16–18]. Moreover, the perception and expectations of teamwork and empowerment should be congruency between managers and employees in order for TQC to prevail within radiation oncology departments [18]. Managers consistently scored closer to TQC compared to their therapists. This may be because generally employees have been shown to have a more pessimistic view of their work environment when compared to their managers. One could hypothesize this to be related to an individual’s ranks on the organisational hierarchy and their level of involvement within their department. The more involved and committed one is in their job, the more satisfied they are with their job and department as a whole [19]. For example,
Disconcordance between managers and therapists on total quality culture Thirty-six percent of the categories differed between managers and therapists. For task versus process focus (p = 0.023), managers scored agree (mean = 7.9) whereas employees scored somewhat agree (mean = 6.8). For control/punishment versus reinforcement (p = 0.017), managers scored somewhat agree (mean = 6.2) whereas
Total Quality Culture Scale (0 - 10)
9.0 8.0 7.0 6.0 5.0 4.0 3.0 2.0 1.0
re
n
ltu y
cr
lq ua lit
ea To
ta
w vs g tin
oi pl
ex lth ea W
ne O
cu
ea
tio
si on lth
&
le ed sh ar
d te ta
lu es va
vs id rig
ll-
vs
Ta ns U
vi
xi bl e
g in
e or
sc vs
d or
vs ay w
All-Managers
rig
ht
fla t-f
ke
ve m pr o im
us uo
ec R
in nt co
ep
en t
en t em rc fo
en t m sh
pu ni ia
tro lv on
C
in re vs
ur bo la &
pe rts Ex
al rts
vs
vs al du vi
di In
l
k or pe
am te
on vs d
an m om C
w
ns se
fo C
oc Pr vs
0–4.9 = No TQC 5–7.4 = Somewhat agree there is TQC 7.5–10 = TQC * TQC = Total quality culture
Ex
s cu
t en
es s
itm m om lv
s
C Ta sk
ro on t C
us
0.0
Total Quality Culture Category
Fig. 1. All managers versus all radiation therapists scoring for each TQC category.
All-Employees
92
Quality culture in radiotherapy
Total Quality Culture Scale (0 - 10)
8.0 7.0 6.0 5.0 4.0
All-Managers
3.0
All-Employees
2.0 1.0 0.0
Control vs Commitment
Command vs Consensus
0–4.9 = No TQC 5–7.4 = Somewhat agree there is TQC 7.5–10 = TQC * TQC = Total quality
Individual vs team work
Experts & labour vs Experts all
One right way vs continuous improvement
Unstated vs shared values & vision
Total quality culture
Total Quality Culture Category
Fig. 2. Categories where both groups have congruent mean scores of somewhat agree. 0–4.9 = no TQC; 5–7.4 = somewhat agree; there is TQC; 7.5–10 = TQC; ⁄TQC = total quality culture.
Fig. 3. Survey category where both groups have congruent mean score of no TQC. 0–4.9 = no TQC; 5–7.4 = somewhat agree there is TQC; 7.5–10 = TQC; ⁄TQC = total quality culture.
Jones et al. (2008) found that managers tend to have a more positive outlook on quality change as compared to the employees and this was mainly attributed to the level of involvement and access within the company [15]. Generally, radiation therapists are assigned to work on specific tasks, in a specific area of the department. Hence, they do not always have a high level of involvement with a patient’s overall care or with their involvement within the entire department, and this may be reflective of the organisation’s culture. In larger RT departments (>50 employees), managers and employees were more discrepant in their views of TQC within their work environment. For example, these centres had between two to four categories where the difference was statistically significant as compared to smaller departments where both groups had up to one conflicting category. These findings are similar to what Shortell
et al. [1] demonstrated after administering a quality survey across 200 hospitals, with a response rate of 72% (n = 7337). They concluded that there was a direct relationship between hospital size and level of TQC. They found that the larger the hospital size, the more bureaucratic the organisational culture. Moreover, this is usually considered to be one of the barriers to quality improvement implementation. To overcome this challenge, they recommended that an implementation approach should incorporate flexibility into their model and a flatter structure [1,17]. Our manager’s survey was congruent with this recommendation. Managers from the smaller centres did mention the ability to be more flexible with their continuous improvement and staffing needs, while also acknowledging that if their centres expand they would likely lose this aspect. However, irrespective of a company’s size, the enthusiasm to incorporate TQC existed uniformly across organisations [16]. A pocket improvement strategy is recommended to help bring the RT work environment closer to a TQC. This strategy is used to select and address particular aspects of a management issue rather than tackling all aspects of the problem simultaneously or sequentially [1]. Based on the results of this investigations, it is recommended that categories that scored as somewhat agree should be a priority for departments to improve on. For example, Boon et al. [18] suggest that teamwork and empowerment have been demonstrated to influence employees’ perceptions on the level of TQC within the workplace. Consequently, improving these areas will have a positive influence on improving other similarly identified categories. Hence, this will serve to help gain support from staff to improve the categories in the future that are distant from a TQC. Conclusions This is the first prospective survey to quantify the current work culture within RT departments. General and individual strategies to move closer towards a TQC should be considered within each department. The benefits of developing a work culture consistent with a TQC will help support a process-driven continuous improvement strategy for patient-focused care, continuity of care, patient
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93
Fig. 4. Categories where both groups have different scores (p < 0.05). 0–4.9 = no TQC; 5–7.4 = somewhat agree there is TQC; 7.5–10 = TQC; ⁄TQC = total quality culture.
safety, and satisfaction for both patients and employees alike. Ultimately, continuity of patient care within RT departments should prevail through integration of team partnerships and cooperation. A TQC, perpetuated by the right staffing structure may help sustain all facets of patient-focused care and patient safety. Thus, a strategic investment into TQC by modifying the current staffing structure should enhance the competitive future of RT departments. Future extensions of this research may include conducting a qualitative study on the perceived level of TQC within RT departments. Managers and employees can be included for in-depth responses on their perceived work culture. Considerations into quality costing of TQC may also help managers determine the usefulness of implementing TQC within their centres [20]. Acknowledgements We would like to thank Dr. Robin Hesler, Mr. Chuck Shields, Ms. Muneerah Kassam, Ms. Anneke Kind, and Dr. Andrew Padmos for their advice and general support throughout this investigation. References [1] Shortell S, O’Brian JL, Carman JM, et al. Assessing the impact of continuous quality improvement/total quality management: concept versus implementation. Health Serv Res 1995;30:377–401. [2] Irani Z, Beskese A, Love PED. Total quality management and corporate culture: constructs of organisational excellence. Technovation 2004;24:643–50. [3] Welikala D, Sohal A. Total quality management and employees’ involvement: a case study of an Australian organisation. Total Qual Manag 2008;19:627–42. [4] Vanagas P. Management of rural business. In: Vanagas P, editor. Rural Development. Kanuas, Lithuanua: Kaunas University of Technology; 2005. p. 89–91.
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