literature review on quality management

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A Systematic Literature Review of Quality Management Initiatives in Dental Clinics

Emil lucian crisan.

1 Faculty of Economics and Business Administration, Department of Management, Babes-Bolyai University, 400591 Cluj-Napoca, Romania; [email protected]

Bogdan Florin Covaliu

2 Faculty of Medicine, Department of Community Medicine, Public Health and Management, Iuliu Hatieganu University of Medicine and Pharmacy Cluj-Napoca, 400337 Cluj-Napoca, Romania

Diana Maria Chis

3 Faculty of Economics and Business Administration, Department of Finance, Babes-Bolyai University, 400591 Cluj-Napoca, Romania; [email protected]

By considering the recently proposed definitions and metrics, oral healthcare quality management (OHQM) emerges as a distinct field in the wider healthcare area. The goal of this paper is to systematically review quality management initiatives (QMIs) implementation by dental clinics. The research methodology approach is a review of 72 sources that have been analyzed using the Context–Intervention–Mechanism–Outcome Framework (CIMO). The analysis identifies five mechanisms that explain how quality management initiatives are implemented by dental clinics. The simplest QMIs implementations are related to (1) overall quality. The next ones, in terms of complexity, are related to (2) patient satisfaction, (3) service quality, (4) internal processes improvement, and (5) business outcomes. This paper is the first attempt to provide a critical review of this topic and represents an important advancement by providing a theoretical framework that explains how quality management is implemented by practitioners in this field. The results can be used by scholars for advancing their studies related to this emerging research area and by healthcare managers in order to better implement their quality management initiatives.

1. Introduction

This paper has been developed considering the emergence of oral healthcare quality management (OHQM) as a distinct field of research in the wider medicine quality management area. In the next paragraphs, the theoretical background of this paper is presented, including more topics as the adoption of quality management initiatives (QMIs) in healthcare, the particularities of oral healthcare and QMIs’ implementation in this field, and the main research streams concerning OHQM. We also present our research question within the final paragraph of this section.

The implementation of quality management initiatives in general healthcare organizations has been analyzed in various papers since quality has surpassed in importance the costs of the service [ 1 ]. While initially, QMIs were observed in healthcare by considering a more general approach [ 1 ], lately, this field has diversified, and more narrow research areas have emerged. The adoption of quality management models, such as the Malcolm Baldrige Quality Award criteria, the European Foundation Quality Management Excellence Model, and the chronic care model, has initially been an important approach, especially for hospitals [ 2 ]. In these cases, adoption efforts and QMIs were extensive, and although they affected the whole system, the results of these interventions were limited [ 2 ]. Later, the adoption of total quality management (TQM) has been observed as challenging [ 3 ], while the six sigma model led to good results related to costs, satisfaction, and resource utilization [ 4 ]. In a comparison of the use and the effectiveness of quality management methodologies in surgical healthcare [ 5 ], it was revealed that the most used ones are: continuous quality improvement, six sigma, TQM, plan–do–study–act or plan–do–check–act, statistical process or quality control, lean, and lean six sigma. Additionally, in a detailed analysis of lean and six sigma adoption in healthcare, it was presented that six sigma (a detailed and consistent continuous improvement system) has been reported earlier in literature, while lean techniques have been more often found in literature (74,63%), in comparison to lean six sigma (22%), and six sigma (18,15%) [ 6 ]. Operations management techniques used in the healthcare industry, such as VSM (visual stream mapping) and standardization of work and visual management, are also recognized as widely used techniques [ 6 ]. More narrow analyses deal with the adoption of specific quality management tools in the healthcare industry. A simple Kano model is recognized as very hard to be used in healthcare since there are many variations regarding customer needs and preferences concerning different types of care provided by healthcare providers [ 7 ]. The use of SERVQUAL in healthcare services for assessing their quality has also been tested, revealing the importance of promptness of response received by patients, cleanliness and hygiene, and empathy of doctors and employees as main areas of quality perceived by patients [ 8 ].

Oral health is recognized as an important determinant for overall health and well-being, and from a statistical point of view, it can be associated with physical, mental, and general health, energy levels, work limitation, depression, and appetite [ 9 ]. It is estimated that dental diseases accounted worldwide in 2015 for USD 356.80 billion as direct costs (dental expenditure), while indirect costs associated with these diseases were estimated at USD 187.61 billion (productivity losses) [ 10 ]. Oral healthcare is different from general care, being characterized by: regular and asymptomatically participation of patients, primarily surgical nature, associations with pain and anxiety, and primarily cosmetic and secondarily disease treatment nature [ 11 ]. Moreover, dental practitioners pay their own wages by the number of patients and interventions they make and are involved in commercial activities, with the dental patient adopting customer rather than patient attitudes [ 11 ]. Though these obvious differences exist, OHQM has adopted in time practices previously used in general medicine quality management. The use of Donabedian’s structure, process, outcome system approach on quality management [ 11 , 12 , 13 , 14 , 15 ], and the use of the quality dimensions proposed by the Institute of Medicine (IoM) (safety, effectiveness, timeliness, patient-centeredness, efficiency, and equity quality dimensions) [ 12 , 13 , 16 ], similar to the dimensions proposed by Donabedian [ 17 , 18 ] and used by Campbell and Tickle [ 11 ], have also been identified for OHQM.

Much of the recent research concerning OHQM is focused on the development of concepts and defining quality. Much of the research is associated with defining quality in this field. It is recognized that quality in oral healthcare is poorly defined in comparison to quality in general medicine [ 11 , 12 , 13 , 14 ], and that the lack of a generally accepted definition and measurement of oral healthcare quality blocks its development [ 11 , 15 , 16 ]. A working definition for quality of oral healthcare has been proposed, including seven domains (patient safety, timeliness, patient-centeredness, equitability, efficiency, effectiveness, and accessibility) and 30 items [ 19 ]. Other conceptual contributions for OHQM target the introduction of adequate sets of measures [ 12 , 13 , 15 ], as well as the establishment of specific goals relevant only for OHQM (which should be generally accepted by practicians, thus providing a unified definition of quality management) [ 11 , 12 , 13 ]. A systematic literature review concerning the metrics used in OHQM reveals that they are mainly related to patients’ satisfaction, 9 out of 11 studies presenting evidence for this patient-centered quality management approach, while the rest are related to self-assessment of practice made by a dentist or a manager [ 12 ]. Efficiency (costs related aspects), and equity are poorly considered.

Secondly, besides these conceptual papers, there are papers and sources that bring evidence that quality management in oral healthcare is transposed into regional and national standards of initial education and continuing professional development of dental professionals [ 20 ]. OHQM is also presented as an activity governed by the state, multinational bodies such as the European Union, or professional associations [ 14 ], which establish policies such as the Quality in Dentistry policy proposed by the FDI World Dental Federation [ 21 ].

Finally, there are papers that analyze the context and the results of quality management practices adoption in healthcare. These results are contradictory. Though these quality management practices have been proven to positively influence healthcare organization performance [ 22 ], it is found that leaders/managers of healthcare organizations are not necessarily well trained or even the right persons for launching such quality management initiatives [ 23 ], and the adoption itself has failed in many organizations [ 24 ]. Contextual factors such as leadership, organizational culture, data infrastructure and information systems, high experience in QMI implementation [ 25 ], but also human resources involvement and their knowledge [ 26 ] are recognized as important factors affecting the success of quality management implementation in healthcare. The lack of a systemic approach and the adoption of rather microsystemic improvements have been regarded as sources for the lack of success in the case of QMIs in healthcare [ 27 ].

After considering the existing OHQM data available in the scientific literature, it is obvious that research in this field is at its beginnings, being mostly concerned with defining quality and establishing metrics. We take this one step further with this systematic literature review and answer the following question: how do dental clinics implement QMIs, as reported by the literature? In order to answer this question, we analyze empirical papers that present QMIs in dental clinics by considering a system design approach—the CIMO Framework proposed by Denyer et al. [ 28 ]. This approach is capable of explaining when and why (context—C), how (intervention—I), and with what results (outcome—O) dental clinics implement specific QMIs. Moreover, this framework targets the identification of explanatory mechanisms regarding how different dental clinics combine C, I, and O. The main result of such an analysis is a theoretical framework that aggregates and explains the QMIs already implemented in practice, this framework being an important input for further advancements in the field.

2. Research Design

The literature review follows the methodology proposed by Tranfield et al. [ 29 ], this methodology being appreciated by medical and quality management researchers due to its transparent and replicative nature [ 6 , 7 , 30 ]. This methodology is commonly used within management literature, being similar to the one detailed within the PRISMA declaration for medical research [ 31 ], since it has been developed considering previous methodologies developed in medical science [ 29 ]. Figure 1 describes the procedure we have followed, including the activities we undertook during each stage.

Research process.

2.1. Planning the Review

The first step was to establish the goal of the review, and that all articles and case studies covering dental clinics QMIs, published at all times, should be included in the review. Later, a pilot search that led to the identification of 12 articles was conducted, this search being used to establish the search strategy and to identify the search terms.

2.2. Performing the Review

Two extended searches were performed in July 2019 (in Web of Science—WoS database) and August 2020 (PubMed database). The initial WoS search included multiple terms in TOPIC (title, abstract, keywords), generating the following number of articles: “dentistry” “customer satisfaction”—7, “dentistry” “quality assessment”—112, ”dentistry” “quality improvement”—43, “dentistry” “quality assurance”—82, “dentistry” “quality management”—11, “dental” “customer satisfaction”—20, “dental” “quality improvement”—142, “dental” “quality assessment”—359, “dental” “quality assurance”—273, “dental” “quality management”—43 articles. This search led to 1092 sources, out of which 223 duplicates were removed, bringing the total to 869 unique sources. A similar PubMed search was performed, all our search terms, with the exception of “customer satisfaction”, being registered as medical subject headings terms. This search led to the identification of 1316 sources, out of which 186 duplicates were removed, bringing the total to 1130 unique sources. These sources were later compared with those from WoS sources, and after excluding duplicates, 183 unique studies were added to the WoS ones. Given the nature of the topic, which belongs both to the management and the medicine field, similar to other reviews, we have considered that the two searches in WoS and PubMed will provide the main relevant sources for our analysis. WoS was chosen due to its comprehensiveness, as it includes a wide range of academic sources in the management field [ 32 ], while PubMed is the mostly used database for medical literature [ 33 ]. Moreover, relevant articles referenced in the previously selected articles have been included in our analysis in order to also cover grey literature, as further described.

The screening of the 1052 sources’ titles and abstracts was conducted using three inclusion criteria: (I1) the articles should present cases related to dental clinics; (I2) the topics addressed in these articles are related to QMIs; (I3) all the papers are written in English. Furthermore, three exclusion criteria were considered: (E1) papers that focus only on a specific part (pathology) of dental treatment (e.g., implant); (E2) papers that focus only on a specific protocol or method related to dental treatment (e.g., radiology); (E3) papers related to national strategies. Each source was analyzed by two of the authors and, in case of doubt, the article was fully read and discussed until a common agreement was reached. The result of screening was 129 eligible sources from both searches. Three reviewers examined the content of these sources, with two reviewers evaluating each source. The same inclusion and exclusion criteria were used, 32 sources related to the WoS search and 20 related to the PubMed search being validated. After extracting the data from sources, 20 new articles, cited by initial sources, were also validated. Therefore, 72 sources were used in this systematic literature review (see Table 1 ).

Sources included in the review and main CIMO details.

All researchers were involved in extracting information from all eligible sources using an online data collection template. This template included metadata fields such as: authors, year of publication, title, publication title, item type (journal article, book chapter, conference paper, report), methodology type (qualitative, quantitative), methodology research methods, OHQM focus (primary or secondary), QMI geographical area, and relevant cited sources.

Data extraction and analysis has been performed following the CIMO framework, which typically produces design propositions that encapsulate patterns of context, interventions, and outcomes to describe the examined phenomenon—in this case, QMIs’ implemented by dental clinics. In management science, it has been previously used to capture how organizational and inter-organizational phenomena occur [ 105 , 106 ]. In comparison to the PICOS criteria which are used to identify components of clinical evidence for systematic reviews in evidence based medicine [ 107 ], CIMO is mostly used for organizational design-oriented research synthesis [ 28 ]. CIMO structure provided the theoretical framework for our approach to coding, which was mostly deductive: we identified a list of codes to reflect the contexts, interventions, and outcomes of QMIs’ implementation and used these existing constructs to make sense of our data by identifying the explanatory mechanisms. For QMIs’ context, two fields have been considered: one for the nature (research/clinical purpose) of the QMI and one for the QMIs’ triggers/expected benefits. Interventions were extracted in a specific field, while for outcomes, four relevant fields have been used: one for the outcomes (similar to triggers/expected benefits identified for context), and two for the nature of the outcome (one for real outcomes versus ideas or recommendations and one for qualitative versus quantitative outcomes).

3.1. Descriptive Analysis

The 72 selected sources were published between 1974 and 2020. Almost 50% entered the literature after 2010 ( n = 35), with a peak of six articles in 2017. Furthermore, 69 of the sources are journal articles, 2 are conference papers, and 1 is a report. Concerning the country of origin, a large number of sources examine dental facilities in the USA ( n = 28), and a significant number of sources ( n = 11) looked at the UK. The majority ( n = 57) of studies refer to dental clinics in Europe and North America. Additionally, 65 sources have quality management as their primary goal, the others having quality management as a secondary one.

The most common research methods were quantitative methods, observed in 64 of sources, and implied statistical analysis of questionnaires results (45 sources) and quantitative observations from patients’ applications, dental care files, integrated electronic health records, list of patient complaints, informed consents, etc. (21 sources). The least commonly used methods were the qualitative methods (15 sources), such as summarizing, categorizing, or interpreting interviews responses (five sources), focus group discussions (three sources), and other qualitative methodologies (eight sources).

3.2. CIMO Results

3.2.1. context.

As stated by Denyer et al. [ 28 ], the context is related to the external and internal environment factors that impact behavioral change. Considering the nature of the intervention, QMIs’ context has been divided into research driven (29 studies), where the intervention was associated with a research project/initiative, and clinical driven (43 studies), where the intervention was initiated internally by the clinic without an exclusive research goal.

Five main categories regarding QMIs adoption triggers/expected benefits have emerged (see Table 2 ). The most common category of triggers of QMIs adoption is patient satisfaction, also mentioned as a more patient-centered oral healthcare, or the improvement of the patient–provider relationship (41 studies). This result confirms the increasing importance placed by the patient [ 70 ], and that patient satisfaction generally has been accepted as an important element of OHQM [ 34 ]. The second most common category of expected benefits refers to the improvement of professional practice and organizational activities (33 studies), including the improvement of professional practice and the overall practice of clinics, reshaping dentist practice patterns, increasing awareness and the level of knowledge among dentists, improving the quality of the work environment, minimizing the time-consuming and stressful patient-search process, managing the quality of products and services delivered to the customer, confidentiality and security, increased opportunities for reusing electronic data for quality assurance and research, etc. [ 52 , 84 , 88 , 96 ]. The third category, recognized in 32 studies, refers to more general triggers for dental organizations: improving the overall quality of care and health outcomes, improving access and reducing disparities in oral healthcare, etc. [ 39 , 53 , 90 ]. The fourth category of dental clinics expected benefits related to QMIs adoption, mentioned in 23 studies, is enhancing service quality of dental care, involving the improvement of the quality of delivered healthcare services, increasing the overall supply of dental services available, and encouraging utilization of dental health services, commitment to provide a high-quality service, achieving and ensuring good service quality to meet or exceed, delivering a more effective oral health service to residents, improving the service quality of care for homeless and vulnerably housed people, etc. [ 36 , 44 , 60 , 81 ]. Finally, the least mentioned category of expected benefits, appearing in only 13 studies, is related to the improvement of dental clinics business outcomes: clinic efficiency, revenue, profit, attracting new patients, enhancing dental care service providers performance and gaining customer preferences, cost containment/savings, financial stability, cost-effectiveness of the new service delivery model, etc. [ 37 , 53 , 103 ].

Context, intervention and outcomes summary.

3.2.2. Intervention

The most common category of interventions (see Table 2 ), applied in the majority of the analyzed cases (37 studies), is the evaluation of patients’ opinions/perceptions (satisfaction, complaints, factors influencing the access to oral healthcare services, criteria they use to choose a dentist, the communication they have with dentists, etc.), followed by dental care providers and other staff opinions (satisfaction, elements regarding the organizational environment, the use of information systems, etc.). The evaluated studies use various instruments (questionnaires, indicators, etc.), mainly in order to improve patient satisfaction and the delivery of high-quality dental services [ 44 , 67 , 83 ]. Another important and very common category of interventions, mentioned by 35 studies, are the ones that propose the implementation and/or the assessment of quality improvement programs, such as: implementation of a pay-for-performance incentive program for medical personnel; developing a new model of dental record; examining the effectiveness of a quality improvement and management program consisting of a set of quality indicators for external and internal dimensions; using quality improvement methods to implement an early childhood oral health program; a program to reduce the number of patients’ failed appointments; the development and implementation of an integrated model of care using oral health practitioners and tele-dentistry; assessing the implementation of an educational program related to dental care, etc. [ 14 , 53 , 97 , 102 ]. In contrast, the least common category of interventions is the adoption of technology and digitization instruments. Considered only by eight studies, this type of intervention included: the development of a prioritization system; a screening website that improves access to care for patients and assists in the matching of patients and students; use of electronic health records; evaluating the effectiveness of a pre-play communication instrument; shifting from a time-based to an item-based fee-paying system in order to improve patient satisfaction; introduction of an automated confirmation system of appointments, etc. [ 38 , 48 , 51 , 96 ].

3.2.3. Outcomes

While reviewing the outcomes for each case, we have observed that the nature of the outcomes varies from real outcomes (24/72 of sources). While real outcomes present themselves in the form of real improvements/changes related to QMIs, the nature of most outcomes are exposed in the form of proposals, including ideas and/or recommendations as a result of QMIs’ adoption. The majority of studies had presented only proposals as a result of their intervention (48/72), while seven studies (7/72) present both real results and propositions.

By considering the qualitative (e.g., improved documentation, better care) and quantitative (results which could be measured, e.g., a two-fold increase in diagnostic and treatment services capacity) nature of the presented outcomes and the research-driven or clinical-driven nature of the QMIs, we observed two patterns. Research-driven studies had qualitative outcomes (25/29 cases), and their results were mostly in the form of ideas and recommendations (27/29), while clinical-driven sources had more quantitative outcomes (17/43 compared with 5/29), and the proportion of these studies that had real outcomes was larger than the ones that had research as their main purpose (21/43 compared to 3/29).

Another analysis we made regarding the outcomes focused on the dimension to which they refer. In this analysis, the previously identified categories for triggers/expected benefits in the context section were used, and each outcome was matched with a corresponding trigger. For most studies included in our analysis, outcomes are part of multiple categories (only 10/72 studies have reported outcomes included into a single category). Overall quality and access to oral healthcare related outcomes (proposals and real outcomes) were reported in 47 cases. Outcomes related to patient satisfaction, patient-centered oral healthcare, and patient–provider relationship are present in 40/72 sources. Outcomes concerning oral healthcare service quality were revealed in 29/72 sources. Outcomes related to the improved professional practice and organizational activities have been identified in 35/72 sources. Finally, business outcomes were present in only 12/72 sources.

4. Mechanisms and Discussion

The main contribution provided by our systematic literature review, performed through the use of CIMO framework, is the highlight of the explanatory mechanisms for the phenomenon of QMIs. Regarding QMIs’ adoption (as presented by the 72 analyzed sources), these can be explained considering two perspectives: one related to the triggers of the interventions (in this case, two mechanisms being observed: research-driven and clinical-driven QMIs) and another that focuses on the nature of the intervention (in this case, five design propositions or mechanisms being observed, as further described).

4.1. Mechanisms

By considering QMIs’ nature, we have identified QMIs that cover different areas regarding quality. These areas are similar to the five-stages framework, which explains small and medium enterprises’ approaches of quality management proposed by Yang [ 108 ]: product quality (product related quality control and process inspection practices), process quality (process standardization practices), system quality (quality management system such as ISO practices), total quality (much emphasis is given to customer focus and a quality culture across the organization), and business quality (quality becomes a matter of business strategy, being related to strategic management, human resource management, or business performance). In our case, the mechanisms cover five areas: internal processes, patient satisfaction, service quality, overall quality, and business outcomes.

Internal processes improvement is the second most frequently encountered mechanism for QMIs (24 cases). The context ranges from the desire to improve the professional practice and the overall practice of dental providers, to reshape dentist practice patterns, and improve the level of knowledge among dentists. The most encountered category of interventions was the implementation and assessment of quality improvement projects, programs, and methods, due to the fact that this mechanism is more focused and specialized on clinical activities and management practices, and it included specific and unique initiatives that improve their practices [ 14 , 45 , 64 ]. The majority of outcomes in this category are qualitative and imply ideas and recommendations for improving dental quality management and professional practices. An important part of outcomes is represented by qualitative and quantitative real outcomes, such as improved documentation [ 35 ], reduced waiting list [ 48 ], improved work environment [ 89 ], enhancement of interdisciplinary collaboration [ 66 ], and reduction in number of missed appointments [ 97 ].

Patient satisfaction is the most frequently encountered mechanism (25 cases). In this case, the context categories involve the need to increase patient satisfaction, more patient-centered oral health care, and the improvement of the patient–provider relationship. The interventions involve three categories of initiatives, and some clinics propose a combination of more initiatives [ 82 , 86 ]: evaluation of patients’ satisfaction using various instruments (questionnaires, indicators, etc.), the use of quality improvement programs, and technology and digitization instruments. In this case, the majority of outcomes are qualitative, patient–customer-focused proposals, mainly emphasizing means to improve patient satisfaction and patient–provider relationship. Nevertheless, some studies present real quantitative and qualitative patient satisfaction improvements [ 63 , 65 ].

Service quality mechanism is encountered in 11 cases. The context, in this case, refers to some particular triggers: the improvement in the quality of delivered healthcare services, the increase in the overall supply of available dental services, and increasing and encouraging utilization of dental health services. The main intervention here is the evaluation of patients’ opinions, using questionnaires and other instruments, considering the importance of patients’ expectations in achieving and ensuring good service quality. The majority of outcomes are represented by qualitative outcomes in the form of proposals to enhance dental service quality. Additionally, there are some qualitative and quantitative real outcomes focused on services improvements [ 51 ].

Overall quality is the third most frequently encountered mechanism (13 cases). The context refers to some expected benefits/triggers that focus on the improvement of the overall quality of care and health outcomes, the improved access to oral healthcare, and the reduction in disparities in oral healthcare. The main intervention in this category implies quality improvement programs [ 55 , 93 , 103 ], and only a few cases refer to the evaluation of patients and dental care providers’ opinions using various instruments (questionnaires, indicators, etc.) regarding the quality of care [ 70 , 71 ]. As opposed to the above mechanisms, in this category (overall quality) the majority of outcomes are quantitative real outcomes, such as oral healthcare quality and patients’ care improvements [ 50 , 102 ].

Finally, the business outcomes represent the least frequent mechanism, recognized in nine cases. The context, in terms of the business expected benefits, vary from the desire to improve clinical efficiency, to increased revenues and profits, cost savings, financial stability, and increased number of patients. Although the most encountered type of intervention is represented by unique and specific quality improvement programs, an important role is also attributed to technology and digitization tools such as introducing an automated appointment confirmation system [ 38 ]. Similar to the previous mechanism, the most encountered category of outcomes is quantitative real outcomes, mainly increased number of patients [ 37 ], increased efficiency due to broken appointments rates reduction [ 38 , 97 ], costs savings [ 97 ], financial stability, and increased revenues [ 103 ].

4.2. Discussion

QMIs adoption by dental clinics is performed in the context of research projects or is clinically driven. By considering the 72 sources included in the current review, the existence of these two approaches, with research-driven interventions in 29 studies and clinical-driven interventions in 43 studies, explains the variation observed especially when we consider real outcomes and proposed outcomes that derive from these interventions. However, the proposed mechanisms that explain QMIs’ adoption are similar to maturity models presented by the literature [ 108 ]. Based on our analysis, it can be observed that QMIs can have narrow internal focus, such as improvement of processes, but are mainly externally driven (patient satisfaction and service improvements). Larger focuses, such as overall quality and business outcome mechanisms, have been also identified. The five mechanisms explain the evolutionary nature of quality adoption in any organization, which usually starts from simple internal processes improvements and later develops a customer focus (patient satisfaction and service quality in our case), followed by a quality management system focus, and finally, a business impact focus, similar to the self-assessment tool for SMEs created by Sturkenboom et al. [ 109 ]. The main reasons for not passing to the more evolved stages are the lack of knowledge and resources [ 110 ], or in the case of dental clinics, the lack of a generally accepted definition and measurement tools for oral healthcare quality management [ 11 , 15 , 16 ].

While comparing the initial triggers and expected benefits when adopting QMIs, it can be observed that the number of outcomes exceeds the number of triggers, especially while considering the proposals associated with QMIs. Supplementary outcomes were identified in relation to the initial proposed context (based on our counting a 14% increase was observed), which can suggest either insufficient planning of the intervention, or external factors driving to other results related to specific QMIs.

Additionally, considering the two areas—research and clinical-driven cases—the most encountered category of clinical-driven studies outcomes is qualitative and involves proposals for future overall quality of dental care improvements, while the research-driven cases mainly provide proposals for patient satisfaction and patient–provider relationship improvements, as well as proposals for improving the overall quality of dental care. Moreover, besides the service quality mechanism, the rest of our mechanisms were observed mostly in clinical-driven studies, probably because the clinical real interests are mainly related to internal processes, patient satisfaction, overall quality improvements, and obtaining better business outcomes. Almost a third of interventions had a research purpose only, without impacting the actual quality of the system. However, the majority of studies were initiated internally based on real needs.

5. Conclusions

We have reviewed 72 papers in order to observe how quality management initiatives are implemented by dental clinics. Five design propositions or mechanisms were observed, ranging from overall quality to patient satisfaction, service quality, internal processes improvement, and business outcomes. The main focus of quality management in this field is related to patients’ satisfaction, followed by process improvements, a balance between internal and external-driven quality management initiatives being observed. It is obvious that more systemic approaches are required [ 14 ], business outcomes being targeted at a low level. Dental clinics’ organizational capabilities, as quality management is also defined, should be considered towards the technical capabilities as an important area of oral healthcare. Although about twenty years have passed, the four core properties of successful quality-improvement work proposed by Ferlie and Shortell [ 1 ] (leadership, culture, teams, and technologies) are still insufficiently implemented in the field of dental care.

Considering the five mechanisms identified in our study, it has become clear that dental clinics managers should perform a detailed analysis on the fitness of a specific QMI for their organizational context. Depending on internal needs, proper QMIs should be selected. Similar to the initiatives implemented in healthcare in general (ex. [ 24 ]), the implementation of different quality management initiatives should be well planned and communicated across the organization, otherwise the results of the initiatives could be different than the ones initially targeted. The development of more complex quality management initiatives that have, as a goal, the improvement of business outcomes should also be considered by dental clinic managers, since patient satisfaction and process improvements are important as long as they are linked to more customers and increased financial benefits.

Acknowledgments

This work was supported by the grant Partnership for the transfer of knowledge in biogenomics applications in oncology and related fields–BIOGENONCO, Project co-financed by FEDR through Competitiveness Operational Programme 2014–2020, contract No. 10/01.09.2016.

Author Contributions

Conceptualization, E.L.C.; methodology, E.L.C. and D.M.C.; validation, E.L.C., B.F.C., and D.M.C.; formal analysis, E.L.C. and D.M.C.; investigation, E.L.C., B.F.C., and D.M.C.; resources, E.L.C., B.F.C., and D.M.C.; data curation, E.L.C.; writing—original draft preparation, E.L.C.; writing—review and editing, E.L.C., B.F.C., and D.M.C.; visualization, D.M.C.; supervision, E.L.C.; project administration, E.L.C.; funding acquisition, E.L.C., B.F.C., and D.M.C. All authors have read and agreed to the published version of the manuscript.

This research received no external funding.

Institutional Review Board Statement

Not applicable.

Informed Consent Statement

Conflicts of interest.

The authors declare no conflict of interest.

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A Systematic Literature Review of Quality Management Initiatives in Dental Clinics

Affiliations.

• 1 Faculty of Economics and Business Administration, Department of Management, Babes-Bolyai University, 400591 Cluj-Napoca, Romania.
• 2 Faculty of Medicine, Department of Community Medicine, Public Health and Management, Iuliu Hatieganu University of Medicine and Pharmacy Cluj-Napoca, 400337 Cluj-Napoca, Romania.
• 3 Faculty of Economics and Business Administration, Department of Finance, Babes-Bolyai University, 400591 Cluj-Napoca, Romania.
• PMID: 34769604
• PMCID: PMC8582852
• DOI: 10.3390/ijerph182111084

By considering the recently proposed definitions and metrics, oral healthcare quality management (OHQM) emerges as a distinct field in the wider healthcare area. The goal of this paper is to systematically review quality management initiatives (QMIs) implementation by dental clinics. The research methodology approach is a review of 72 sources that have been analyzed using the Context-Intervention-Mechanism-Outcome Framework (CIMO). The analysis identifies five mechanisms that explain how quality management initiatives are implemented by dental clinics. The simplest QMIs implementations are related to (1) overall quality. The next ones, in terms of complexity, are related to (2) patient satisfaction, (3) service quality, (4) internal processes improvement, and (5) business outcomes. This paper is the first attempt to provide a critical review of this topic and represents an important advancement by providing a theoretical framework that explains how quality management is implemented by practitioners in this field. The results can be used by scholars for advancing their studies related to this emerging research area and by healthcare managers in order to better implement their quality management initiatives.

Keywords: CIMO framework; dental clinics; oral healthcare quality management; quality management initiative; systematic literature review.

Publication types

• Research Support, Non-U.S. Gov't
• Systematic Review
• Delivery of Health Care
• Dental Clinics*
• Health Facilities
• Quality of Health Care*

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Please note you do not have access to teaching notes, total quality management: a critical literature review using pareto analysis.

International Journal of Productivity and Performance Management

ISSN : 1741-0401

Article publication date: 8 January 2018

Due to its impact on business performance total quality management (TQM) has gained a lot of importance by businessmen, managers, practitioners, and research scholars over the last 20 years. Therefore, the purpose of this paper is to critically assess the literature on TQM and find out the areas where future research is required.

Design/methodology/approach

To achieve this purpose the articles published in the last 20 years were studied in a systematic way and a snapshot of the same was prepared in the tabular format with points such as year and journal of publication, application and country, statistical method used, and findings of the study such as practices and impact of TQM. After identifying the practices and impact of TQM a quality tool “Pareto Analysis” was applied on them for development of the model.

The findings provide the practices of TQM and its impact on the performance of a business. The gaps from the literature have been identified and areas for future research have been suggested. On the basis of the findings a generalized framework of TQM has been suggested which can be applicable irrespective of the sector.

Practical implications

The research will help academicians and future researchers to have a clear understanding of TQM in different rosters.

Originality/value

Ample literature is available on TQM but in the best knowledge of authors no study has taken place to integrate the reviews and findings of 102 research papers of the last two decades.

• Total quality management
• Organizational performance
• Pareto analysis

Bajaj, S. , Garg, R. and Sethi, M. (2018), "Total quality management: a critical literature review using Pareto analysis", International Journal of Productivity and Performance Management , Vol. 67 No. 1, pp. 128-154. https://doi.org/10.1108/IJPPM-07-2016-0146

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IS 2020: Proceedings on 18th International Conference on Industrial Systems – IS’20 pp 1–8 Cite as

Quality Management and Innovation Performance: A Short Literature Review

• Stana Vasic   ORCID: orcid.org/0000-0001-8176-8422 6 ,
• Marina Zizakov   ORCID: orcid.org/0000-0003-0519-197X 6 ,
• Milan Delic   ORCID: orcid.org/0000-0002-3307-8942 6 ,
• Dusko Cuckovic   ORCID: orcid.org/0000-0003-4835-2075 6 &
• Ilija Cosic   ORCID: orcid.org/0000-0001-9796-4452 6  
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Part of the Lecture Notes on Multidisciplinary Industrial Engineering book series (LNMUINEN)

The purpose of this study is to examine the relationship, and its nature, between quality management and innovation performance. Needless to say, quality management and innovation have the same purpose in the organization; they both provide continual improvement and sustainable development. A literature review was done, discussing the relationship between these two organizational aspects. The results suggest that the academic community is divided, concerning the positive nature of this relationship. However, the results of this study speak in favor of the positive findings, providing empirical evidence in supporting fostering power of quality management towards the development of innovation performance.

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Vasic, S., Zizakov, M., Delic, M., Cuckovic, D., Cosic, I. (2022). Quality Management and Innovation Performance: A Short Literature Review. In: Lalic, B., Gracanin, D., Tasic, N., Simeunović, N. (eds) Proceedings on 18th International Conference on Industrial Systems – IS’20. IS 2020. Lecture Notes on Multidisciplinary Industrial Engineering. Springer, Cham. https://doi.org/10.1007/978-3-030-97947-8_1

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A literature review on total quality management (models, frameworks, and tools and techniques) in higher education

PurposeThe purpose of this paper is to analyze the evolution of total quality management (TQM) models, frameworks, and tools and techniques in higher education (HE) over the last thirty years from 1991 till 2020, based on a literature reviewDesign/methodology/approach30 articles from 52 journals were used to perform this detailed literature review. For the detailed analysis, the focus was only on articles related to TQM in higher education and specifically related to models, frameworks and tools and techniques. The study has investigated the growth of research articles, research streams, research methodologies, models and frameworks in the higher education sector and tools and techniques related to those.FindingsThis review addresses the progress and gaps in the application of TQM in HE, including the shift in global research in this area from the USA and Europe to Asia in recent years. The articles have been classified into four research methodologies and two research streams which have been reviewed in detail. The findings include reasons for multiple models/frameworks in HE proposed by researchers over the years and the importance of tools and techniques used in TQM implementation.Originality/valueThis study, which tries to bring a perspective to the main trends in TQM application to higher education wrt models, frameworks, tools and techniques over the last thirty years, is expected to add to the body of knowledge in this area and help future researchers to focus on the relevant areas identified in this paper.

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Total Quality Management in higher education: a literature review on barriers, customers and accreditation

PurposeThe purpose of this paper is to analyze the evolution of Total Quality Management (TQM) in terms of barriers, customers and accreditation in higher education (HE) over the last three decades (1991–2020) using literature review to establish the current state.Design/methodology/approachA total of 137 articles across 55 journals were consolidated for this review specifically focused on TQM (barriers, customers and accreditation) in HE. The investigations were carried out to identify the chronological growth of articles, research streams and methodologies. The articles were classified based on four research approaches and three research streams which have been reviewed in detail.FindingsConsidering the rapid growth in the HE sector and the concerns over reduction in quality of education especially in developing countries, the importance of TQM in HE is immense. The findings include identification of the barriers to successful TQM implementation, the need for alignment of TQM objectives of higher educational institutions (HEIs) and identified target customer(s) with the selected model/framework and the impact of accreditation/certification in the attainment of TQM.Originality/valueThis study which tries to bring a perspective to the main trends in TQM application to HE with respect to barriers, customers and accreditation over the last three decades is expected to add to the body of knowledge in this area and help future researchers to focus on the relevant areas identified in this paper.

Total quality management elements and results in higher education institutions

Purpose The purpose of this paper is to determine the main total quality management (TQM) elements adopted and the respective results achieved by higher education institutions (HEIs) in Greece. Design/methodology/approach A research study was designed and carried out in private sector Greek HEIs. Fifteen HEIs were approached through interviews based on a structured questionnaire. The measured variables of the TQM elements and results identified in the literature were used as the questionnaire items. Descriptive statistics were applied to determine the TQM elements mostly adopted and the results achieved by the HEIs. Findings According to the findings, the TQM elements mostly adopted by the Greek HEIs concern the following: student focus, leadership and top management commitment, strategic quality planning, process management and teaching staff and employee involvement. On the other hand, the most significant results achieved by the sample HEIs concern quality performance improvement, teaching staff and employee satisfaction, operational performance improvement and the positive impact on society. Research limitations/implications The subjective data collection involved chief executive officers of a small sample of HEIs operating in a European Union country. Thus, no advanced statistical methods could be applied. Based on these limitations, future research studies are recommended. Practical implications By focusing on specific TQM elements, an HEI can develop a robust TQM model, approach business excellence, which can, in turn, help the HEI apply for appropriate quality awards, and finally derive significant benefits. In doing so, an HEI can lay the foundations for being competitive in the current global context that is characterised by an economic downturn. Originality/value This study contributes to the literature by empirically determining the TQM elements mostly adopted as well as the respective results achieved by Greek HEIs in a period of economic downturn. This is the first research study in the field of TQM in higher education that has been carried out in Greece in a period where many service organisations, whether private or public, are making significant efforts to withstand the current downturn and achieve a sustainable growth.

A systematic literature review on total quality management critical success factors and the identification of new avenues of research

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Purpose The purpose of this paper is to present a systematic literature review to identify new avenues of research in line with the ongoing changes in quality and management required to firms, especially regarding customers. Design/methodology/approach This study uses a systematic review of the literature contained in the three databases Ebsco, JSTOR, and Springerlink and on the search engine Google Scholar. Findings An analysis of the literature identifies three different clusters of papers: “identification” papers, which show that customer focus has gained importance in recent times; “implementation” papers, which highlight that a general or shared model or scale to successfully implement total quality management (TQM) does not yet exist; and “impact-on-performance” papers, which show that few studies have considered the relationship between TQM and the issues of both marketing and performance, underlining the most significant gap in the TQM literature. Research limitations/implications This study is limited by the small number of databases and search engines used and by the restricted number of keywords used in searching these sources. Practical implications This work highlights a gap in the existing research and thus an incomplete consideration of the interplay between management, marketing, and quality issues, all centered on customers and other stakeholders. Researchers and firms are thus advised to adopt a wider view that considers the role of the quality process to support the firm’s engagement of customers in activities that enhance both the customer role and customer satisfaction. Originality/value This study uses a systematic literature review to review all critical factors of TQM and identifies new research avenues and different approaches to implementing TQM, focusing on the central role that customers play in achieving firm success.

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Emergence in tqm, a concept analysis.

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Twenty years of research on total quality management in higher education: a systematic literature review, twenty-first century total quality management: the emergence paradigm.

Purpose The purpose of this paper is to present the framework of a fourth paradigm since the existing three paradigms in quality management are not sufficient anymore to understand what happened in the past and surely fail to understand what is happening at the moment and needed in future. Design/methodology/approach A literature review has been undertaken on different visions on quality management that are used. The underlying principles have led to three quality paradigms. Literature on quadrant models is studied to place the three existing paradigms and identify the possible characteristics of the fourth. Findings One can discern four quality paradigms in quality management: the Empirical Paradigm, the Reference Paradigm, the Reflective Paradigm and the Emergence Paradigm. The use of these paradigms differs according to the context. Together they form a concept of Total Quality Management. At the moment the Emergence Paradigm has not had enough attention although it might be the best equipped to find new ways of working for the organisations in the current context. Research limitations/implications In the literature review the authors selected seven journals in the Business Source Premier database: Total Quality Management (Total Quality Management & Business Excellence); the Academy of Management Review; Product and Operations Management; Organisational Dynamics; the Harvard Business Review; the Sloan Management Review and Organisational Behavior and Performance. In the advanced search mode the authors entered two subjects: “quality management” and “paradigm”. The selected results (in total 289 articles) were examined for its fitness for answering the questions above. That resulted in a selection of 26 articles that are being used in the literature review. Practical implications The Emergence Paradigm can be further investigated on its use for quality management in organisations in times of emergent change. Some first insights have been presented here. Social implications The Emergence Paradigm can have impact beyond the field of quality management. Originality/value The paper provides new insights in the essence of quality management in times of change and clarity on the usability of the thoughts and tools of four different paradigms in the twenty-first century.

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Home » Research Literature Reviews » Literature Review – Quality Management Systems

Literature Review – Quality Management Systems

According to various authors, quality improvement and management has become a subject of great importance in organisations. Quality Management focuses on the overall process of a system rather than just concentrating on results, it is the determination and implementation of the quality policy with regard to the organisation. Many organisations throughout the world have started to realize the potential it holds for them and have therefore adopted new philosophies focused on quality management rather than just being focused on the end results. Some organisations already implementing the ISO 9001 Quality Management System are wondering is it worth maintaining and what significance does it hold for the company? Empirical studies have shown that Quality Management does indeed have a positive effect on the various business functions (Piskar & Dolinsek, 2006) and therefore calls for a deeper look. The empirical studies were undertaken through questionnaires during 2002 in Slovenia. 212 Companies that were already implementing the ISO 9001 system were asked to participate in this study. The results obtained from this study were analysed and compared by the various authors. In conclusion all the authors were in favor of the Quality Management System (Piskar & Dolinsek, 2006).

A Quality Management System guarantees that all activities regarding to quality are planned. What is a management system? It is the matter of organizing elements to   achieve a specific goal. A Quality Management System consists basically of an organizational structure , responsibilities, procedures, processes and resources for implementing quality management. More focus will be given on processes and procedures later on in this study. The objective of a Quality Management System is for the continuous improvement of quality in an organization and therefore it is implied that a Quality Management System reaches all parts of an organisation, it is not just isolated to one area of the business. A good Quality Management System can provide the following benefits: greater efficiency, reduced cost, better performance, less unplanned work, fewer disputes, improved visibility, reduced risk, problems show up earlier, better quality, improved customer confidence, portable and reusable products and better control over contracted products. Currently there are two different ways to define a Quality Management System. One can either choose the home grown approach or choose from an existing model such as ISO 9000, SEI-CMM and MB-NQA, these models can then be adapted to fit the organisation (Kelkar, 2008). Some of the advantages in having a documented Quality Management System are: it is reviewable, it can be revisited for improvement, serves as training material, serves as reference material, it enables repeatability and uniformity across instances/locations. The level of detail to which a particular practice should be documented depends on the practice itself. A quality policy forms part of a Quality Management System and is usually the main focus around which the rest of the Quality Management System is formed. Prior to certification, audits are performed on the Quality Management System to ensure that implementation is satisfactory and that it complies with the contracted requirements. Audits can be performed by first, second or third party auditors. First party audits are basically performed in house by people working for the organisation, but not on that particular project. Second party audits are performed by the customer, this way the customer can evaluate your organisation in order to see if it meets their specific requirements. This shifts the power to the customer. Third party audits are conducted by certification agencies for example if the organisation is doing the ISO 9000 certification. A Quality Management System has several uses namely: a means to communicate the vision, values, mission, policies and objectives of the organisation, a means of showing how the system has been designed, a means of showing linkages between processes, a means of showing who is responsible for what, an aid to training new people, a tool in the analysis of potential improvements and a means of demonstrating compliance with external standards and regulations.

Plenty of research and studies have been conducted on the growth of quality management and standards throughout the world. Over the past 10 years the number of companies becoming ISO 9001 certified has increased dramatically (Siazarbitoria, 2006). It should be noted that for these quality standards, although globally spread, the initial growth started in the European Union, which was the focus of the ISO   reports in 2003. To compare the results obtained from the ISO (2003) reports a certification intensity has been compiled, which illustrates the “percentage of ISO 9000 certificates from each country and its percentage of contribution to the European GDP” as stated in (Siazarbitoria, 2006). Figure 1 illustrates the certification intensity distribution over Europe.

Once a Quality Management System is implemented successfully, it is monitored closely and improved over time. This is all part of the continuous improvement process which in turn leads to the another objective for an organisation: Total Quality Management . According to Deming Total Quality Management is not possible, since reaching it means that everything is perfect, which will never be the case, but it is rather meant as a philosophy which to employ in an organisation. Never the less, organisations strive for Total Quality Management through a philosophy which focuses on customer satisfaction, problem prevention rather than detection, teamwork, leadership, management responsibility, continuous improvement, control of business processes. Quality Management Systems and Total Quality Management can be combined, but they are not dependant on each other and therefore a company can implement a Quality Management System without adopting the whole Total Quality Management philosophy. From here on out the reference to Total Quality Management refers to the philosophy an organisation adopts and not the impossible objective of TQM as stated by Deming. A full consensus is yet to be reached on the exact content and definition of a Total Quality Management System (Yong & Wilkinson, 2001), although it is agreed that Total Quality Management   is not possible within an organisation without a commitment from the top management (Kelkar, 2008).

Business Process Re-engineering is often compared with Total Quality Management where the difference lies in that Total Quality Management is a more gradual change and improve on what is already there. In the case of   Business Process Re-Engineering the company seek a major and rapid break-through. Many authors describe Total Quality Management as a dying management philosophy (Yong & Wilkinson, 2001), but is still holds some merit according to other authors. Today (2010) Total Quality Management is rather broken up into smaller parts and companies adopt whichever part applies to them such as ISO 9000 Quality Management systems, TPM, JIT , Deming’s Cycle (PDCA) , etc. One of the main reasons for Total Quality Management being criticized is because many people try and fail to implement a Quality Management philosophy. It is not something that can be entered into lightly, since its implementation will ask a lot of hard work and patience.

Processes and procedures are ever present in our everyday life and many of us don’t even realize it. Sometimes it is more noticeable, like when you follow instructions the bake a cake, and other times it has become such a habit, like brushing your teeth, you don’t even notice it. So what exactly is a process and a procedure? A process describes what we do in what sequence (Cunat & Graig, 2000), for instance when baking a cake the process would be to mix the dry ingredients, then to mix the wet ingredients, then to mix the dry and wet together, then scoop it into a cake pan and finally place it in the oven. A procedure on the other hand explain to one how to do a task (Cunat & Graig, 2000), for instance when baking a cake one of the procedures would be to sift the dry ingredients together and to use a whisk rather than a spoon to mix the wet ingredients with the dry ingredients to ensure the batch is smooth throughout. A Quality Management System consists of different areas, including processes and procedures.

A process consists of a sequence of actions that transforms an input into value-added output. A process map is the visual representation of a process in such a way that the flow of work/activities can be clearly seen. According to Anjard 1996, processes were not usually documented, continually improved, standardized or managed in the 1990’s, but today (2010) with the increased popularity in Quality Management Systems process mapping has started to become more customary and even required in some organisations. A process map gives a better idea of the bigger picture and assists in the identification of areas requiring improvement. It highlights the main steps to achieve a desired output and facilitates process improvement where necessary to achieve higher quality. Several advantages can result from process improvement , such as: less rework, increased productivity, improved quality and decreased costs. According to Gitlow 2005, it is important that processes should have feedback loops. A feedback loop relates information back to another stage in the process with the intention that decisions are made based on the analysis of the information. A process without a feedback loop is destined to decline and crumble, since there is no feedback data from which the process can be improved or even reinvented over time. Every process can be studied, classified, documented, standardized, improved and innovated (Gitlow, Oppenheim, Oppenheim, & Levine, 2005).

Processes should be used when the responsible person in a process knows how to do the activities, but want to achieve a desired result.

Process maps should be developed from the top down, in other words the highest level tasks should be mapped first to give a better idea of the scope of the process within the system (Anjard, 1996). Different flowcharts are available for process mapping such as system flowcharts and layout flowcharts. Some of the benefits of flowcharts are: it assists in communication between departments and people, since it is an universal form of communication, helps with the planning phase of projects, gives one the bigger picture of a system, gets rid of clatter, which can shift ones focus in the wrong direction, defines responsibilities, reveals the relationships between different processes, improves the logical layout and sequencing of a process, helps to identify errors in the system and it documents the process.

Procedures is more of a how to guide and is mostly utilised by people new to the process and the tasks thereof. Procedures does illustrate how the described task fits into to bigger picture.

References:

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• Open Access
• Published: 23 August 2023

Successes and challenges towards improving quality of primary health care services: a scoping review

• Aklilu Endalamaw   ORCID: orcid.org/0000-0002-9121-6549 1 , 2 ,
• Resham B Khatri   ORCID: orcid.org/0000-0001-5216-606X 1 , 3 ,
• Daniel Erku   ORCID: orcid.org/0000-0002-8878-0317 1 , 4 , 5 ,
• Frehiwot Nigatu 6 ,
• Anteneh Zewdie 6 ,
• Eskinder Wolka 6 &
• Yibeltal Assefa   ORCID: orcid.org/0000-0003-2393-1492 1  

BMC Health Services Research volume  23 , Article number:  893 ( 2023 ) Cite this article

158 Accesses

Metrics details

Quality health services build communities’ and patients’ trust in health care. It enhances the acceptability of services and increases health service coverage. Quality primary health care is imperative for universal health coverage through expanding health institutions and increasing skilled health professionals to deliver services near to people. Evidence on the quality of health system inputs, interactions between health personnel and clients, and outcomes of health care interventions is necessary. This review summarised indicators, successes, and challenges of the quality of primary health care services.

We used the preferred reporting items for systematic reviews and meta-analysis extensions for scoping reviews to guide the article selection process. A systematic search of literature from PubMed, Web of Science, Excerpta Medica dataBASE (EMBASE), Scopus, and Google Scholar was conducted on August 23, 2022, but the preliminary search was begun on July 5, 2022. The Donabedian’s quality of care framework, consisting of structure, process and outcomes, was used to operationalise and synthesise the findings on the quality of primary health care.

Human resources for health, law and policy, infrastructure and facilities, and resources were the common structure indicators. Diagnosis (health assessment and/or laboratory tests) and management (health information, education, and treatment) procedures were the process indicators. Clinical outcomes (cure, mortality, treatment completion), behaviour change, and satisfaction were the common indicators of outcome. Lower cause-specific mortality and a lower rate of hospitalisation in high-income countries were successes, while high mortality due to tuberculosis and the geographical disparity in quality care were challenges in developing countries. There also exist challenges in developed countries (e.g., poor quality mental health care due to a high admission rate). Shortage of health workers was a challenge both in developed and developing countries.

Conclusions

Quality of care indicators varied according to the health care problems, which resulted in a disparity in the successes and challenges across countries around the world. Initiatives to improve the quality of primary health care services should ensure the availability of adequate health care providers, equipped health care facilities, appropriate financing mechanisms, enhance compliance with health policy and laws, as well as community and client participation. Additionally, each country should be proactive in monitoring and evaluation of performance indicators in each dimension (structure, process, and outcome) of quality of primary health care services.

Peer Review reports

Introduction

Quality of care is the extent to which the health care system can achieve the desired health care goals, such as effective recovery, preventing premature mortality, halting disease progression from being complicated, and maximising clients’ satisfaction with the care they received [ 1 ]. With efficient, integrated, equitable, timely, people-centred, and safe health services, preventive and promotive, treatment, palliative, and rehabilitative quality care could be achieved [ 2 ]. These services are provided in primary health care (PHC) [ 3 ], for which quality is an attribute in the first-contact care of several health conditions [ 4 ]. Because PHC is planned to deliver essential health services as close to home as possible, it serves as a roadmap to universal health care coverage (UHC), which must be of high quality to achieve the health system’s vision.

Quality is currently on the agenda of sustainable development goals that target UHC [ 5 ]. The World Health Organisation (WHO), the Organisation for Economic Co-operation and Development, and the World Bank emphasised that ensured quality is a fundamental component of UHC [ 6 ]. To streamline policy and PHC quality implementation, a series of national strategic directions have been adopted [ 7 ]. Notable quality and safety standards or strategies have been established in some countries, for example, Australia [ 8 , 9 ], European [ 10 ] and African countries [ 11 ]. Good health governance and administration [ 12 ], quality improvement programmes [ 13 ], financial and non-financial support, community empowerment and engagement, competent health care providers, and monitoring and evaluation [ 14 ] are some of the quality improvement strategies. These schemes have a vital role in improving the patient experience in PHC, including quality of care, satisfaction, and the health of populations [ 15 ].

Despite these strategies, poor-quality care is a continuing public health debate. This could be explained by safety problems, a large percentage of hospital-acquired infections, a high burden of amenable mortality, and excess health care expenditure. Globally, the estimated annual cost due to medication errors is 42 billion United States dollars (US$) [ 16 ]. Similarly, more than 10% of hospital expenditure in high-income countries is due to medical errors or hospital-acquired infections [ 17 ], where 1 in 10 patients experience medical errors while receiving hospital care, and 7 out of 100 hospitalised patients (1 in 10 in developing countries) acquire a health care-associated infections [ 17 , 18 ]. This situation is recorded much more unacceptable, especially in less developed countries. A systematic analysis of preventable deaths in 137 low- and middle-income countries (LMICs) revealed that 5.0 million deaths are attributed to poor-quality care annually [ 19 ], which imposes costs of US$ 1.4 to 1.6 trillion each year in lost productivity [ 20 ].

The health system could prevent many deaths if high-quality care were implemented. The Lancet Global Health Commission estimated that high-quality health systems could prevent 8 million deaths yearly in LMICs [ 5 ]. This requires systematic and coherent evidence-based actions that give emphasis quality [ 21 ] that pragmatic framework can measure.

Donabedian’s quality of care measurement model is considered a logical quality measurement framework to produce evidence on quality care based on the structure, process, and outcome dimensions [ 22 ]. This framework indicates what systems, policies, and infrastructure should be in place to ensure the delivery of high-quality PHC services towards the most desired health care outcome. This helps to identify challenges that need improvement, including commenting on the presence of policy documents or workable guidelines and the interaction between clients and health care providers. Experts advise that it is crucial to measure quality of care with a focus on the interaction between structure, process, and outcome dimensions because outcome status reflects the structure and process indicators [ 23 ]. The WHO’s ‘Network for Improving Quality of Care Programme’ has identified four measures for improving quality of health care. These are patient outcome measures, patient process measures, facility input or structure-related measures, and programme performance measures [ 24 ]. Identifying crucial quality indicators in health care provision is also suggested [ 25 ].

Previous reviews focused on either individual countries or specific diseases only. For example, a review on depression [ 26 ] and outpatient practise of primary care in the United States of America (USA) and the United Kingdom (UK) [ 27 ] did not address the successes and challenges in providing quality care in the PHC system. Another review focused on the quality indicators of PHC and also did not address the successes and challenges of quality of care [ 28 ]. Therefore, scoping all available evidence, including original articles, reviews, professional discussions, or arguments, will provide information for researchers and highlight areas for policy and decision makers to take corrective action on the identified gaps. This scoping review summarised indicators, successes, and challenges in delivering quality PHC services.

Search strategy

This review is guided by the preferred reporting items for systematic reviews and the meta-analysis extension for scoping reviews (PRISMA-ScR) to adhere to procedural activities starting from search strategy to reporting findings [ 29 ]. A systematic search of literature from databases was conducted between 05 July 2022 and 23 August 2022 with no date restriction to access articles from inception to the final search date. Then, the screening process proceeded after fully-exported all articles into EndNote x9 reference manager software. The databases we accessed to identify articles were PubMed, Web of Science, Excerpta Medica dataBASE (EMBASE), and Scopus. We also searched Google Scholar to find additional literature. We operationalised the concept of quality of care in this study using Donabedian’s model [ 22 ]. The Donabedian model addresses structure (availability of inputs and resources, appropriateness of facilities and administration), process (indicators streamlined from patient and health worker interaction), and outcome (interventions’ health effects). Search terms were “primary health care”, “primary healthcare”, “primary care”, “quality of care”, quality, “quality care”, “quality of health care”, “quality of healthcare”, Donabedian, “Donabedian’s model”, “Donabedian model”, “Donabedian’s structure process outcome”, “Donabedian’s structure-process-outcome”, “Donabedian structure process outcome” and “structure process outcome”. Different Boolean operators were used. These are: “AND” and “OR” to expand or narrow the search parameters, quotation marks (“”) to get results with the exact phrases; and parentheses to group search terms. The search strategy fitted in PubMed was (((((“primary health care” [All Fields] OR “primary healthcare”[All Fields] OR “primary care”[All Fields]) AND “quality of care”[All Fields]) OR “quality”[All Fields] OR “quality care”[All Fields] OR “quality of health care”[All Fields] OR “quality of healthcare”[All Fields]) AND “Donabedian”[All Fields]) OR “Donabedian’s model”[All Fields] OR “Donabedian’s structure process outcome”[All Fields] OR “Donabedian model”[All Fields]) OR “Donabedian structure process outcome”[All Fields] OR “Donabedian’s structure-process-outcome”[All Fields] OR “Donabedian structure-process-outcome”[All Fields] OR “structure-process-outcome”[All Fields]. The search strategy for Scopus, Web of Science and EMBASE is available in the supplementary file 1 .

Selection criteria and data extraction

Searches were limited to articles published in English. We used ‘population’, ‘concept’ and ‘context’ frameworks to establish a search strategy and include articles [ 30 ]. The population was any participants, PHC personnel (general practitioners, nurses, pharmacies, midwives, dentists, etc.), or clients who participated in the study. The ‘concept’ was the quality of PHC, which approached Donabedian’s structure-process-outcome model. The ‘context’ was any study setting, including urban or rural institutions (district hospitals, health centres), community care, nursing homes, family care, or if articles mentioned PHC settings in any country. When articles did not mention PHC, we reviewed keywords, and included the article if it fulfilled other criteria. The search was tailored to any document type, such as an article, review, perspective, opinion, letter, commentator, etc. However, we only found opinions, professional discussion, reviews, and articles. Previous reviews have reported the synthesis from different original studies, which may not be necessarily conducted by the Donabedian input-process-output framework, but the reviews should summarise the findings into this framework context to be included in the current review. The reference lists of previous reviews were assessed to check whether original studies included in the review were conducted based on Donabedian framework. Primary studies included in the review articles were in different contexts, dimensions, types of cases, functions, and domains except one review for from 2005 [ 31 ], which is included in another from 2010 [ 32 ]. Therefore, we could not directly include the primary studies that were included in the former reviews except these two reviews 2005 and 2010 [ 31 , 32 ]. We decided to include both reviews because only part of information from the 2005’s review [ 31 ] included in the 2010 [ 32 ]. Additionally, one of the purposes of a scoping review is to include any type of article, including previous reviews, to map the available literature besides summarising results [ 33 ]. Therefore, the steps before data extraction were article search, exporting all accessed articles into EndNote x9 reference manager, duplication check, screening articles for title, screening articles for abstract, and full-text assessment. Author, publication year, country discussed, type of study or study design, PHC setting, study participant, and main findings of included documents were extracted.

Data synthesis

The main findings for structure, process, and outcome dimensions were synthesised using a narrative approach. Success was defined as high-quality care or improved quality of care. Any observed gap in the quality of PHC or barriers that affected the provision of quality of PHC were narrated as challenges. The search and characteristics of results, PHC quality indicators, successes, and challenges of quality in PHC were described sequentially in the result section. Summary of professional discussion: neither success nor challenges were described in the PHC quality indicators section of the result.

Search results

A total of 1,055 documents were available. These articles were accessed using the final search strategy of Web of Science (84 articles), Scopus (66 articles), and PubMed (722 articles), as well as searching of articles by topic in Google Scholar (105). The final articles (1,055) were exported in EndNote X9 and checked for duplication. After we removed duplication (272 were excluded), 783 were eligible for title screening. A total of 528 were excluded by title screening. Then, 255 were eligible for abstract screening, and 196 were excluded due to the abstract not having information related to the objectives. Then, 59 articles were eligible for full text screening, and 37 were excluded. Finally, 22 were eligible for the current result synthesis (Fig.  1 ).

PRISMA article selection process adapted from PRISMA 2020 for new systematic reviews which included searches of databases

Characteristics of articles

Three articles were from Japan [ 34 , 35 , 36 ], two each from the USA [ 32 , 37 ], South Africa [ 38 , 39 ], Ethiopia [ 40 , 41 ], and Iran [ 42 , 43 ]. Brazil [ 44 ], Canada [ 31 ], Nigeria [ 45 ], Uganda [ 46 ], LMICs [ 47 ], and upper-middle- and high-income countries [ 28 ] each had one. Others were from two or more high-income countries [ 26 , 27 , 48 ]. One author published an opinion article on the structure, process, and outcome dimensions of primary dental care, which was not specific to any country [ 25 ]. Another author discussed the definition and framework based on the context of the UK, New Zealand, and Germany [ 23 ]. Overall, ten articles were from high-income countries [ 23 , 26 , 27 , 31 , 32 , 34 , 35 , 36 , 37 , 48 ], three articles were from upper-middle-income countries [ 38 , 39 , 44 ], four articles were from LMICs [ 42 , 43 , 45 , 47 ], three were from low-income countries [ 40 , 41 , 46 ], and one each upper-middle- and high-income countries [ 28 ] and not-specific [ 25 ].

Regarding article type, seven were different types of reviews [ 26 , 27 , 28 , 31 , 32 , 47 , 48 ], and five were cross-sectional studies [ 38 , 41 , 42 , 43 , 46 ]. Others were qualitative studies [ 34 , 36 , 39 ], mixed-method studies [ 40 , 45 ], Delphi study [ 35 ], evaluation study [ 44 ], retrospective cohort study [ 37 ], opinion [ 25 ], and an operational discussion [ 23 ].

The included articles focused on several health problems. Eight articles focused on the overall PHC settings [ 26 , 27 , 28 , 35 , 41 , 44 , 47 , 48 ]. Four articles were on nursing home care [ 31 , 32 , 36 , 42 ], three studies were conducted each in rural health care settings [ 37 , 38 , 39 ], and health care centres [ 43 , 45 , 46 ], and one each in district public health facilities [ 40 ], and community pharmacy [ 34 ].

Four articles were focused on chronic diseases [ 38 , 39 ], including mental health problems [ 26 , 32 ] and diabetes [ 42 ]. One article on both chronic and communicable diseases [ 37 ]. Three articles focused on women’s health: early abortion care [ 47 ], antenatal care/ANC/ [ 41 ], and preconception care [ 43 ]. The other three articles were on pharmaceutical services [ 34 , 35 , 36 ]. The remainders were on tuberculosis [ 46 ], oral health care [ 44 ], youth-friendly health services [ 40 ], osteoarthritis [ 48 ], dental care [ 25 ], and not specific diseases [ 23 , 27 , 28 , 31 , 45 ].

PHC quality indicators

Several indicators were identified in the structure, process, and outcome dimensions of PHC quality.

Byrne and Tickle argue in their opinion article that six domains of health care quality—safety, effectiveness, timeliness, patient-centredness, efficiency, and equitability—have to be measured for structure, process, and outcome to assess the quality of primary dental care [ 25 ]. Gardner and Mazza, who explored implementing of the quality framework in general practise settings in New Zealand, the UK, Germany, and Australia, concluded that the application of the Donabedian framework varies across countries [ 23 ]. An umbrella review identified 727 PHC quality indicators: 74.5% were process indicators, 19.2% were outcome indicators, and the remainder (6.3%) were structure indicators, and these indicators were related to safety, effectiveness, timeliness, patient-centredness, efficiency, and equitability [ 28 ].

Other reviews identified quality indicators, which were 134 on geriatric pharmacotherapy [ 35 ], 53 on depression [ 26 ], 21 on early abortion care [ 47 ], and 20 on osteoarthritis [ 48 ]. The types or numbers of indicators depend on the nature of the disease. For example, 80% and 38% of indicators were related to treatment safety and causes of drug selection in geriatric pharmacotherapy, respectively [ 35 ], and the majority (82%) of quality indicators were process indicators in this therapy [ 35 ]. There was no structured indicator for the quality measurement of geriatric pharmacotherapy delivered by community pharmacists [ 35 ]. From 53 quality indicators, 16 structure, 33 process, and 4 outcome indicators were identified in depression care; a “do not do” process indicator for some selected antidepressant drugs was identified [ 26 ]. As an additional example, the 20 quality indicators (2 structure, 16 process, and 2 outcome domains) in osteoarthritis care are further grouped into two structures, nine processes, and two outcome indicators [ 48 ]. According to the home health care professional’s perspective, home pharmaceutical care were established with 9 themes and 27 subthemes [ 36 ]. One study discussed the Donabedian care model as a mediation pathway; structure indicators can directly affect outcome indicators [ 38 ].

In few studies, some process determinants were grouped into structural indicators. To illustrate, waiting time [ 48 ], teamwork [ 34 , 36 ], and professionalism [ 34 , 36 ] were reported in the structure domain, but they are also involved in the process domain.

The common structure indicators were human resources for health, law and policy, infrastructure, facilities, and resources. Diagnosis (health assessment and/or laboratory tests) and management (health information, education, and treatment) were some of the process indicators. Clinical outcomes (cure, mortality, defaulter, treatment completion, recovery from pain) and satisfaction were the common measurement indicators of the outcome dimension. The main indicators based on the Donabedian quality care model are summarised in Fig.  2 .

PHC quality indicators with their interaction based on Donabedian model

The details of each indicator with a citation are also shown in the supplementary file (supplementary file 2 ).

Successes and challenges of quality of PHC

In addition to the identification of several indicators as determinants for the quality measure of PHC, the absence or presence of structure indicators, the appropriateness of process indicators, and the status of health service outcomes guide whether PHC is on a successful road map or struggling with challenges in the delivery of quality service. A similar level of perception between managers and clients on health care providers’ competency and professional conduct and a similar perception of clients and health care providers on structural factors (e.g., Nigeria) [ 45 ], high-quality structure indicators in some countries (e.g., Iran) [ 43 ], lower cause-specific mortality, and a lower rate of hospitalisation due to chronic disease and pneumonia in high-income countries (e.g., the USA) [ 37 ] were achievements. Challenges to quality PHC include high mortality due to tuberculosis in low-income countries (e.g., Uganda) [ 46 ], geographical disparity of quality care (e.g., Ethiopia and Iran) [ 40 , 43 ], shortage of health care providers both in developed and developing countries, client and community engagement problems, lack of guidelines and providers’ poor adherence to guidelines [ 40 ], provision of inadequate information to clients [ 46 ], and poor quality due to a high admission rate (e.g., a mental disorder in the rural USA) [ 32 ] (Table  1 ). Table  1 shows the successes and challenges of quality of care in PHC based on the World Bank country categories.

This review summarised indicators, successes, and challenges of quality of care in PHC settings. Quality of PHC consists of an interaction of several quality indicators related to structure, process, and outcome, denoting physical and organisational characteristics where health care occurs and focusing on the care delivered to clients and the effect of health care on the status of patients and the population. The structure domain comprises health care resources, human resources, infrastructure, governance, law, policy, and guidelines. Providing preventive, professional, and ancillary services accompanied by professionalism was the common process indicator. Outcome indicators include mortality, cure rate, and treatment completion, behavioural change, and client satisfaction.

Quality of care indicators were identified. Some studies recruited quality indicators based on experts’ and health care providers’ perspectives [ 34 , 35 , 36 ] without community engagement. This may face feasibility, applicability, acceptability, implementation challenges, and a lack of comprehensiveness. For example, there was no structure indicator for geriatric pharmacotherapy [ 35 ]. This could be solved when perspectives from clients, families, health care providers, and administrators are considered. It is known that community engagement, continuous feedback, government support, and active community involvement play pivotal roles in the quality issues of PHC [ 49 , 50 ], while a lesser client engagement decreased the quality of health care services [ 40 ]. Additionally, only one review assessed all quality elements (efficiency, effectiveness, safety, people-centredness, timeliness, equity, and integration) using structure, process, and outcome components [ 28 ] despite the importance of assessing the six domains of health care quality [ 25 ]. The Institute of Medicine has developed six domains of health care quality: safe, effective, patient-centred, timely, efficient, and equitable care [ 51 ]. The current review relies on previous studies, which did not present all domain of quality. Therefore, assessing the full domain of quality of PHC services under structure-process-outcome will give critical evidence.

The relationship between structure, process, and outcome indicators was a mediation process [ 38 ]. This was the direct and indirect relationship between structure, process, and outcome that worked when the outcome indicators were client satisfaction, coherence of integrated care, competence of nurses, and patients’ confidence in nurses. Clients were satisfied when they attended health institutions during convenient time, waited a short time to receive care, and attended a clean and suitable health institutions (e.g., waiting areas and other infrastructure). This means that clients were satisfied before interacting with health care providers, which indicates the need for critical attention during rating the status of the quality of care in the absence of process through which the real services are provided to clients. Studies investigated structure factors as the direct determinants of client satisfaction [ 52 , 53 ]. Similarly, outcomes such as coherence of care and patient confidence in health care providers were affected by interpersonal aspects, shared decision-making procedures, and clients own problems and feelings [ 54 ].

Challenges persist in improving the quality of PHC services. Disparity of quality care between different health centres [ 40 , 43 ] and a lack of structural inputs were reasons for the poor-quality care in low-income countries. There was also a low and varied quality of care between regions in middle-income countries due to the absence of support mechanisms, lack of coordination, problems in comprehensiveness and continuity of care [ 55 , 56 , 57 ], a lack of privacy and respect, an unsatisfactory pace of quality system development, and staff shortages [ 39 , 58 , 59 ]. Most countries have national quality care initiative strategies towards UHC [ 6 ], but they are not equally proactive in implementing the strategies. They also have different quality implementation approaches. For example, Donabedian’s system-based framework implementation is top-down in New Zealand and the UK, and bottom-up in Germany [ 23 ] though further research is indicated whether the top-down or bottom-up approach resulted in better quality of care. Countries may also have varied levels and extents of adapting PHC to different models of care, which the included articles did not address. Some are a ‘client circle of support’ [ 60 ], a ‘person-centred’ approach [ 61 , 62 ], a ‘conversation approach’ [ 63 ], and ‘making or using action plans’ for PHC services [ 64 ].

Inadequate health workforces were understood challenge for poor quality care in low-income countries (e.g., Uganda) [ 46 , 65 ]. For instance, the quality of ANC, adolescent, and youth-friendly service was low due to a shortage of adequate and trained health care providers. On the other hand, staff shortage was handled in such a way to do not interrupt the quality of care in high-income countries though workforce shortage was a challenge in developed countries. For example, the absence of physicians did not lower the quality of care in the USA [ 37 ]. The availability of other structure indicators and the substitution of the deficient personnel by other health care professionals could maintain high-quality care. For instance, a nurse-led PHC provided care equivalent to that of care by physician in chronic disease management [ 66 ], improved clinical outcomes and quality of life, and enhanced patient satisfaction [ 67 , 68 ]. The health workforce shortage between developed and developing countries might vary based on the width and depth of health care. For example, the chiropractic workforce is unknown in some developing countries, and its shortage is sometimes underreported due to a poorly organised and unavailable written job description. In most developed countries, it is in practise, people demand the services, and the shortage can be reported [ 69 ]. Therefore, the health workforce shortage should be interpreted in light of the context.

Rate of admission was identified as a challenge for quality of PHC service delivery in rural area. For example, mental health care in rural settings was poor due to a lower chance of accessing appropriate care and an increasing admission rate in the USA [ 32 ]. This might be due to clients wait longer until they are seen by a health professional, and they might suffer from pain of disease progression if timely intervention is not provided.

Another challenge was a debate on electronic health records as one review reported that electronic health records have no impact on clinical outcomes [ 27 ]. However, another argument concluded that ‘electronic medical records improved quality of care, patient outcome and safety by improving management, preventing medical errors, reducing unnecessary investigations, and improving therapeutic interaction among primary care providers and patients [ 70 ]. Other studies also confirmed the importance of electronic medical records on quality of care improvement [ 71 , 72 ] though there is a suggestion for a future prospective study [ 73 ].

This review has some limitations. Articles included in this review were conducted based on Donabedian’s quality framework. There may several articles have reported about quality of care. For example, there are factors that the current review did not address such as non-compassionate and unrespectful care can contribute to the low quality care because only 60% and 64% of health care providers provided compassionate and respectful care, for example, in Ethiopia despite caring, respectful, compassionate health care workers and quality included in the health care agenda [ 74 , 75 ]. Similarly, in Uganda, a case study revealed that the national health system, overall working environment, national budgetary allocation to the health sector, and limited collaboration between health centres and hospitals are factors affecting the quality of health care [ 76 ]. Additionally, the articles included in this review were published only in English. There are articles published in non-English languages; including those articles may allow us to see the quality of PHC care in other countries contexts. Furthermore, the search was conducted only in four databases (Web of Science, Scopus, EMBASE, and PubMed) and Google Scholar. Other databases (e.g., Cochrane Library) may have related articles.

Quality of care indicators varied according to the health care problems, which resulted in a disparity in the successes and challenges between developing and developed countries. Disparity in service coverage due to daily living conditions and mortality due to infectious diseases were more common in developing countries. On the other hand, quality of care problems due to chronic diseases were recorded in developed countries. Inadequate health workforce was a challenge in developing and developed countries as a structure component of quality care provision. The PHC system should ensure the presence of adequate health care providers, equipped health care facilities, compliance with health policy and laws, adequate financing, and enhanced community and client participation. Additionally, each country should implement national quality initiative strategies with appropriate monitoring and evaluation of performance in each structure, process, and outcome indicator. PHC quality improvement needs appropriate resources and infrastructure, and an adequate PHC workforce with skill mix.

Data availability

The data set is available within this manuscript.

Abbreviations

Community Health Workers

Primary Health Care

United Kingdom

Universal Health Coverage

United Nations

United States of America

World Health Organisation

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Aklilu Endalamaw, Resham B Khatri, Daniel Erku & Yibeltal Assefa

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AE and YA conceptualised the study design, retrieved relevant articles, screening and data extraction, analysed, interpreted the results, and drafted the manuscript. RBK and DE contributed to the research aim and manuscript draft and critically revised the drafted manuscript. AZ, EW, and FN contributed to critically revising the drafted manuscript. All authors read and approved the final manuscript.

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Endalamaw, A., Khatri, R.B., Erku, D. et al. Successes and challenges towards improving quality of primary health care services: a scoping review. BMC Health Serv Res 23 , 893 (2023). https://doi.org/10.1186/s12913-023-09917-3

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A systematic review and meta-analysis of hernia sac management in laparoscopic groin hernia mesh repair: reduction or transection?

• Mohamed Ali Chaouch 1 ,
• Mohammed Iqbal Hussain 2 ,
• Amine Gouader 3 ,
• Abdallah Amine Lahdhiri 4 ,
• Alessandro Mazzotta 5 ,
• Adriano Carneiro da Costa 5 ,
• Bassem Krimi 3 ,
• Faouzi Noomen 1 &
• Hani Oweira 6  

BMC Surgery volume  23 , Article number:  249 ( 2023 ) Cite this article

134 Accesses

Metrics details

There is no consensus regarding hernia sac management during laparoscopic hernia repair, and this systematic review and meta-analysis aimed to compare the postoperative outcomes of sac reduction (RS) and sac transection (TS) during laparoscopic mesh hernia repair.

We conducted a systematic review and meta-analysis according to the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) 2020 and AMSTAR 2 (Assessing the Methodological Quality of Systematic Reviews) guidelines. We used the RevMan 5.4 statistical package from the Cochrane collaboration for meta-analysis. A random effects model was used.

The literature search yielded six eligible studies including 2941 patients: 821 patients in the TS group and 2120 patients in the RS group. In the pooled analysis, the TS group was associated with a lower incidence of seroma (OR = 1.71; 95% CI [1.22, 2.39], p = 0.002) and shorter hospital stay (MD = -0.07; 95% CI [-0.12, -0.02], p = 0.008). There was no significant difference between the two groups in terms of morbidity (OR = 0.87; 95% CI [0.34, 2.19], p = 0.76), operative time (MD = -4.39; 95% CI [-13.62, 4.84], p = 0.35), recurrence (OR = 2.70; 95% CI [0.50, 14.50], p = 0.25), and Postoperative pain.

Conclusions

This meta-analysis showed that hernia sac transection is associated with a lower seroma rate and shorter hospital stay with similar morbidity, operative time, recurrence, and postoperative pain compared to the reduction of the hernia sac.

The protocol was registered in PROSPERO with ID CRD42023391730.

Peer Review reports

Introduction

Groin hernia repair is one of the most commonly performed surgical procedures. However, the optimal surgical procedure remains controversial [ 1 ]. Moreover, each procedure includes some technical variations: surgical approach [ 2 ], mesh types [ 3 ], mesh fixation modalities [ 4 ], mesh no fixation [ 5 ], and attitude regarding the hernia sac [ 6 ]. These varieties were developed to reduce postoperative complications, pain, recurrence, return the patient to normal activities quickly, improve quality of life, and minimize postsurgical discomfort as well as the adverse effects of surgery. It is widely accepted that the laparoscopic approach is safe, reproducible, and associated with enhanced recovery and less postoperative pain [ 1 ]. However, many studies have highlighted the limitation of a longer operative time, particularly due to hernia sac manipulation and reduction [ 7 ]. This dissection is performed in a larger preperitoneal plan than in the open approach, which requires the dissection of the hernia sac from the spermatic cord without separating the preperitoneal space. It is sometimes difficult to achieve total reduction with sac transection and distal splitting, especially in large indirect inguinal sacs and inguinoscrotal sacs. However, prolonged and extensive laparoscopic dissection of the herniated sac increases the risk of damage to the testicular vascular supply or the vas. We postulated that laparoscopic sac transection can potentially simplify the procedure and shorten the operative time. However, the residual sac tissue may increase the risk of postoperative seroma formation. Several studies have investigated Postoperative outcomes, with controversial results [ 8 ]. Therefore, we conducted a systematic review and meta-analysis to present a higher level of evidence concerning the management of the hernia sac in laparoscopic hernia repair using TEP or TAPP.

This systematic review and meta-analysis aimed to compare the postoperative outcomes of sac reduction and sac transection during laparoscopic mesh hernia repair.

We conducted a meta-analysis according to the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) 2020 [ 9 ] and the AMSTAR 2 (Assessing the Methodological Quality of Systematic Reviews) guidelines [ 10 ]. The study protocol was registered in PROSPERO under the number ID: CRD42023391730.

Electronic database searches

An extensive electronic search of relevant literature until December 10, 2022, with no language restrictions, was performed using the following databases: Cochrane Library’s Controlled Trials Registry and Database of Systematic Reviews, PubMed/MEDLINE of the United States National Library of Medicine, Google Scholar, Excerpta Medica Database (Embase), and Scopus. The keywords used were “Randomized Controlled Trials,” “Clinical Controlled Trials,” “inguinal hernia,” “hernia repair,” “hernioplasty,” “herniorrhaphy,” “laparoscopic hernioplasty,” “reduction,” “transection,” “dissection,” and “ligation” “total extraperitoneal,” “transabdominal preperitoneal,” “seroma,” and “morbidity.” We manually checked the reference lists of articles obtained for eligible clinical trials.

Eligibility criteria

All randomized and controlled clinical trials reported comparisons between sac transaction and sac resection during laparoscopic mesh hernia repair. Non-comparative studies, editorials, letters to editors, review articles, and case series or papers were not considered in this study. We excluded clinical trials that compared sac transection and sac resection during open surgery or treatment without mesh repair.

Populations

Adults (aged ≥ 18 years) of either sex undergoing laparoscopic groin hernia repair using a mesh were included.

Intervention

Laparoscopic hernia repair with transection of the hernia sac (TS group).

Laparoscopic hernia repair with resection of the hernia sac (RS group).

Outcomes measures

The main outcome measure was seroma formation. A seroma was defined in the original studies as a collection of fluid or swelling at the surgical site or in the scrotum. The secondary outcomes were morbidity, bleeding, operative time, postoperative pain, bleeding, reoperation, hospital stay, and recurrence.

Data collection and analysis

Study selection.

After independent literature research by two authors. The two authors independently reviewed all the abstracts. RCTs and CCTs were considered. The full texts of all the studies that met the inclusion criteria were retrieved. After consulting a third review team member, the discussion resolved any disagreements.

Assessment of studies quality and risk of bias assessment

Two authors independently appraised all studies that met the selection criteria. Concerning quality assessment, CCTs and RCTs were assessed according to the methodological index of non-randomized studies (MINORS) [ 11 ] and the Consolidated Standards of Reporting Trials (CONSORT) statement [ 12 ], respectively. We excluded all studies with a MINORS or CONSORT statement inferior to 13. For the risk of bias in the RCTs, we used the Cochrane tool for bias assessment to assess the risk of bias in randomized trials (RoB2) [ 13 ]. For the risk of bias in CCTs, we used the Newcastle Ottawa Scale (NOS) [ 14 ].

Data extraction

Two authors independently extracted data from the retained studies. Disparities were settled after a discussion with a third author. If studies presented the results as the median and interquartile range (IQR) or range, we converted the values to mean and SD according to Cochrane Handbook 7.7.3.5 [ 15 ] or Hozo et al. [ 16 ]., as appropriate.

Evaluation of effect size

We used the RevMan 5.4 statistical package from the Cochrane Collaboration for meta-analysis [ 17 ]. We selected the mean difference (MD) as an effective measure of continuous data. Odds ratios (OR) with 95% confidence intervals (95% CI) were calculated for dichotomous variables. A random effects model was used. The threshold of significance was set at p < 0.05.

Assessment of heterogeneity

We used the Cochrane Chi² test (Q-test), I² statistic, and variance TAU² to estimate the degree of heterogeneity [ 18 ]. Funnel plots were used to identify studies responsible for heterogeneity. A subgroup analysis was performed when all the included studies reported outcomes.

Summary of findings

Two authors independently assessed the evidence of the primary outcomes. We used The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) [ 19 ]. We considered the study limitations in terms of the constancy of effect, imprecision, indirectness, and publication bias. We assessed the certainty of the evidence as high, moderate, low, or very low. We used GRADEpro GDT software to prepare a summary of the findings tables.

Literature search results

The literature search yielded six eligible studies [ 6 , 20 , 21 , 22 , 23 , 24 ] (Fig.  1 ). Four studies were included in the previous version of the review [ 6 , 20 , 21 , 24 ]. Two studies were RCTs [ 6 , 24 ] and four studies were CCTs [ 20 , 21 , 22 , 23 ]. Four studies were excluded: one systematic review with a meta-analysis of this subject [ 8 ], one systematic review [ 25 ], one narrative review [ 26 ], and one CCT comparing hernia remnant sac fixation with no fixation [ 27 ]. The number of involved patients was 2941 patients:821 patients in the TS group and 2120 patients in the RS group, respectively. The list of the retained studies, NOS and RoB 2 scores of the included patients were presented in Table  1 . The demographic data of the retained studies were presented in Table  2 . Several studies have been published between 2002 and 2022. Five studies were conducted in China, and one study was conducted in Korea. The mean age of the patients ranged from 49 to 64 years. The sex ratio was six, with a large male predominance. Regarding laparoscopic hernia repair, three studies performed TEP hernia repair, two studies performed TAPP hernia repair, and one study performed TEP and TAPP. The follow-up ranged from one to 40.8 months.

PRISMA 2020 flow diagram of the included studies

Outcome measures

All retained studies assessed seroma [ 6 , 20 , 21 , 22 , 23 , 24 ]. I was reported in 118 of the 821 patients in the TS group and 235 of the 2120 patients in the RS group. There was a significantly lower seroma rate in the RS group than that in the TS group (OR = 1.71; 95% CI [1.22, 2.39], p = 0.002). There was low heterogeneity among the studies ( Fig.  2 . A) .

Forest plot of the different outcomes

The morbidity rate was assessed in five studies [ 20 , 21 , 22 , 24 ]. It was reported in eight of 510 patients in the TS group and 18 of 668 patients in the RS group. The difference between the two groups in terms of morbidity was not statistically significant (OR = 0.87; 95% CI [0.34, 2.19], p = 0.76). No heterogeneity was observed among the studies ( Fig.  2 . B) .

Operative time

The operative time was reported in five studies [ 20 , 21 , 22 , 24 ]. It was assessed in 510 and 668 patients in the TS and RS groups, respectively. There was no statistically significant difference between the two groups in terms of operative time (MD = -4.39; 95% CI [-13.62, 4.84], p = 0.35). There was high heterogeneity among the studies Tau2 = 107.67 (I²=99%) ( Fig.  2 . C) .

Hospital stay

Hospital stay was reported in five studies [ 20 , 21 , 22 , 24 ]. It was assessed in 510 and 668 patients in the TS and RS groups, respectively. There was a significantly shorter hospital stay in the TS group (MD = -0.07; 95% CI [-0.12, -0.02], p = 0.008). No heterogeneity was observed among the studies ( Fig.  2 . D) .

The recurrence rate was assessed in five studies [ 20 , 21 , 22 , 24 ]. It was reported in three of 510 patients in the TS group and two in 668 patients in the RS group. The difference in recurrence between the two groups was not statistically significant (OR = 2.70; 95% CI [0.50, 14.50], p = 0.25). No heterogeneity was observed among the studies ( Fig.  2 . E) .

Postoperative pain

Postoperative pain was assessed in four studies [ 20 , 21 , 24 , 28 ]. Different measurement features were used in these studies, and a pooled analysis was not feasible for performing a meta-analysis. All the studies concluded that there was no difference between the two groups. The results are summarized in Table  3 .

Reporting of the effects of transection of hernia sac during laparoscopic hernia repair

A Summary of the evidence is presented in Table  4 . This review shows that when the hernia sac is transected:

This may have reduced the seroma rate with a shorter hospital stay.

We do not know if it leads to additional morbidity, recurrence, operative time, or postoperative pain because the evidence regarding these outcomes is very uncertain.

This systematic review and meta-analysis showed that hernia sac transection is associated with a lower seroma rate and shorter hospital stay with similar morbidity, operative time, recurrence, and postoperative pain compared to the reduction of the hernia sac.

The proper management of the hernia sac during laparoscopic repair is crucial, and cutting it could simplify the procedure by eliminating the challenging dissection of the sac from the spermatic cord. Our research found both techniques to be safe and feasible, with comparable rates of complications. Nevertheless, previous studies have identified a higher incidence of postoperative seroma [ 8 , 24 ]. This complication was defined as fluid exudation and accumulation in the surgical field. It is the most common postoperative complication after laparoscopic inguinal hernia repair, with various reported rates ranging from 1.9 to 11.7% [ 21 ]. The variation in reported incidence rates of seroma among studies can be attributed to the fact that most cases of seroma are asymptomatic and resolve spontaneously without treatment. Susmallian et al. [ 29 ] suggested that seroma was diagnosed clinically in only 35% of cases, whereas ultrasound examination revealed the presence of seroma in 100% of patients, and the amount of fluid collection increased until the 7th day after surgery and decreased after laparoscopic repair of the incisional hernia. Morales-Conde et al. [ 30 ] created a seroma classification system in which they defined seroma as a complication only if they were symptomatic, persisted for longer than six months, or were infected (types III and IV). Clinically relevant seroma that disappeared in less than six months (types I and II) were classified as incidental findings, reflecting that these were considered normal sequelae of the operation. Type III seroma persists for longer than six months or becomes symptomatic but does not require intervention, while type IV seroma is symptomatic and requires intervention. In this classification, only seroma types III and IV should be considered as real complications as they affect the clinical progression of the patient. Several reasons have been attributed to the development of seroma formation after laparoscopic inguinal hernia repair, including dissection of the preperitoneal space for mesh placement, the existence of dead space after hernia sac reduction, and irrigation of prosthetic materials implanted in the preperitoneal space [ 31 ]. According to our study, the management of the distal sac, reduction, or transection of the hernia sac in inguinal hernia repair affects the occurrence of postoperative seroma. This is in agreement with the International Endohernia Society guidelines published in 2015 [ 32 ], which reported that the complete reduction of the hernia sac may eliminate the occurrence of chronic seroma or pseudo-hydrocele. In addition, in a recent systematic review of the literature, Li et al. [ 25 ] reviewed of literature how enrolled four studies that compared the results of indirect hernia sac transection and complete sac reduction. The pooled results indicated that indirect hernia sac transection was associated with an increased seroma rate. A meta-analysis performed by Chai et al. [ 8 ], which included 848 patients, concluded that sac transection may increase the risk of seroma formation. Several therapeutic modalities have been reported to prevent seroma formation. We thought that even the heterogeneity among the different included studies in our review was due to a non-standardized diagnostic criterion of Postoperative seroma or if they had used any surgical features to reduce the seroma rate. A systemic review published by Li et al. [ 28 ] mentioned six adjunctive techniques to reduce seroma formation: transversalis fascia inversion with tacking, the endoloop technique, barbed suture closure of the transversalis fascia, surgical drains, and fibrin sealant. This systematic review concluded that seroma formation is a natural process that cannot be completely prevented following laparoscopic inguinal hernioplasty, particularly in patients with direct and large indirect inguinal hernias. Some intraoperative adjunctive techniques are effective in reducing clinically palpable seroma formation in selected patients. The way a hernia sac is managed during laparoscopic inguinal hernia surgery can impact the duration of hospitalization. Hospital stay duration is commonly used as an indicator of efficiency, and there have been numerous studies investigating this topic with conflicting outcomes. In a systematic review of the literature, Li et al. [ 25 ] found no statistically significant difference in the length of hospital stay between the two procedures. However, these findings were consistent with those of Chai et al. [ 8 ], who reported a significantly shorter hospital stay after sac transection than after sac reduction. Although advances in surgical techniques and the use of meshes have improved outcomes for inguinal hernia repair, recurrence rates remain a significant concern, ranging from 1 to 7.9% [ 33 , 34 ]. Recurrence of inguinal hernia is a possibility at any point following surgery. Various risk factors, both modifiable and non-modifiable, are responsible for its occurrence, such as factors related to the patient and surgical techniques. SiddaiahSubramanya et al. [ 35 ] concluded that higher BMI, smoking, diabetes, and postoperative surgical site infections increase the risk of recurrence and can be modified accordingly. In addition to surgical techniques such as using a larger mesh with better tissue overlap, reducing recurrence rates after inguinal hernia surgery can also depend on the surgeon’s experience. The way the hernia sac is managed during surgery can also have an impact on recurrence rates. The Swedish Hernia Register found that the 5-year cumulative incidence of reoperation for recurrence after open inguinal hernia repair was 1.7% for hernia sac excision, 1.7% for division, and 2.7% for invagination. For indirect hernia repair, sac excision and sac division were associated with a lower relative risk of reoperation for recurrence compared to sac invagination. Lichtenstein repair with hernia sac excision had a 5-year cumulative reoperation incidence for a recurrence rate of only 1%. The authors concluded that excision of the indirect hernia sac in inguinal hernia repair is associated with a lower risk of hernia recurrence than division or invagination [ 36 ]. Chai et al. [ 8 ] concluded that there was no difference in terms of recurrence between the sac transaction and sac reduction groups, which is similar to our findings. Regarding postoperative pain, Othman et al. [ 37 ] compared the effect of invagination excision of the hernia sac without ligation with the traditional method of high ligation of the hernia sac on postoperative pain and recurrence. The authors found that invagination and excision of the hernia sac were safe and suitable for repairing sliding hernias without any adverse effects. They recommend against ligating the hernia sac in inguinal hernia surgery, as it is unnecessary, time-consuming, and associated with increased postoperative pain. Choi et al. [ 20 ] recorded the frequency at which patients required more than two analgesic doses. Lau et al. [ 21 ] evaluated pain scores at rest and on daily coughing for the first four postoperative days. Li et al. [ 28 ] defined a visual analogue scale pain score > 5 as significant pain. Ruze et al. [ 24 ] assessed pain scores on the seventh postoperative day, at one and three months following surgery. No significant differences were observed between the two groups.

Compared with the previous version of this systematic review and meta-analysis published by Choi et al. [ 20 ], we have included two additional recent studies with the highest number of patients: 2941 patients versus 848 patients. We have assessed additional outcomes like hospital stay and recurrence. In addition in our study, we have found a significant difference between the two groups in terms of hospital stay which is novel and interesting. Furthermore, we have used the most updated methodology of systematic review and meta-analysis and we have performed a GRADE assessment for suitable conclusions. On the other side, this study presented several limitations. Owing to the small number of RCTs, lack of some outcomes, and lack of long-term follow-up, we included additional CCTs. The quality of the included studies was limited by their retrospective nature, and the certainty of the evidence was very low for some outcomes. Therefore, further prospective and larger studies are required to confirm these findings. We did not assess other outcomes such as postoperative pain, time of return to activities, chronic pain, and long-term discomfort. The risk of bias assessment using NOS and Cochrane RoB-2 was performed, and there was no high risk of bias in the retained studies. It is interesting to note that five out of six studies came from China and only one from Korea. None from European countries, Africa, or the United States. Therefore, we cannot speculate on the generalizability of the results of hernia sac resection or reduction in laparoscopic hernia repair. The number of included patients in our study was 2941 patients. A larger number of patients included was in 1763 patients by Pan et al. [ 23 ], which allowed us to reach statistical significance in some parameters. The systematic review and meta-analysis by Chai et al. [ 8 ] included only four studies. In addition, there was no summary of the findings table, and the study was not conducted according to the PRISMA guidelines 2020.

In conclusion, our study showed that hernia sac transection is associated with lower seroma and shorter hospital stay with similar morbidity, operative time, recurrence, and postoperative pain compared to the reduction of the hernia sac. For better placement of the best modality for hernia sac management during laparoscopic hernia repair, additional multicenter RCTs with larger sample sizes are required.

Data Availability

All data generated or analyzed during this study are included in this published article.

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MAC, FN and MIH collected the data. AG and AL performed the data analysis. AM and AC performed the literature research and risk of bias assessment. BK and HO participate in the summary of findings and English revision. All the authors contributed and validated the final version of the article.

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Chaouch, M.A., Hussain, M.I., Gouader, A. et al. A systematic review and meta-analysis of hernia sac management in laparoscopic groin hernia mesh repair: reduction or transection?. BMC Surg 23 , 249 (2023). https://doi.org/10.1186/s12893-023-02147-8

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Received : 27 March 2023

Accepted : 09 August 2023

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DOI : https://doi.org/10.1186/s12893-023-02147-8

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