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How leadership theory can contribute in quality improvement efforts

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Tiêu đề How leadership theory can contribute in quality improvement efforts
Tác giả Nikolaos Loulas
Trường học KTH Royal Institute of Technology, Industrial Engineering and Management
Chuyên ngành Project Management and Operational Development
Thể loại Degree project
Năm xuất bản 2014
Thành phố Stockholm
Định dạng
Số trang 57
Dung lượng 0,91 MB

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Cấu trúc

  • 1.1 Background (5)
    • 1.1.1 Audience of the report (5)
    • 1.1.2 Why quality improvement? (6)
    • 1.1.3 Why leadership? (7)
    • 1.1.4 Why research of leadership theory in quality improvement? (8)
  • 1.2 Question (11)
  • 1.3 Scope (11)
    • 1.3.1 In scope (11)
    • 1.3.2 Out of scope (11)
  • 2.1 Different research methodologies (12)
  • 2.2 Why literature based (13)
  • 2.3 Data collection and analysis (13)
  • 2.4 Literature evaluation (14)
  • 3.1 Recognition and importance of Deming's theory for quality (17)
  • 3.2 Key elements (17)
    • 3.2.1 Change (18)
    • 3.2.2 Teamwork (21)
    • 3.2.3 Goal management (23)
  • 3.3 Leadership in organizations (26)
    • 3.3.1 How leadership can influence change? (30)
    • 3.3.2 How leadership can influence teamwork? (34)
    • 3.3.3 How leadership can influence goal management? (40)

Nội dung

Background

Audience of the report

This report serves as a guideline for businesses currently implementing quality programs or those looking to initiate quality improvement efforts, providing insights for leadership direction It highlights the necessity for further research on organizational leadership focused on quality improvement, as existing literature is insufficient The methodology and results presented can serve as a framework for exploring various aspects of quality Additionally, research into specific leadership practices related to quality may uncover new methods for assessing leadership effectiveness However, measuring effectiveness poses challenges due to varying criteria, some of which may negatively correlate with quality outcomes This report will also appeal to individuals interested in quality improvement and leadership strategies aimed at enhancing quality initiatives.

Why quality improvement?

Deming's consulting work in Japan significantly enhanced the quality and productivity of the Japanese industry, leading to substantial contributions to the nation's economy through his innovative philosophy and methods for quality improvement.

Quality improvement is applicable to businesses of all types and sizes, including industries, product manufacturing, food production, and services, as well as within individual company departments Deming's book "Out of Crisis" provides numerous examples of successful quality improvement practices.

Deming emphasizes that quality improvement reduces waste from human and machine work hours, leading to the creation of superior products and services A study by A.V Feigenbaum in 1977 revealed that waste in American companies accounted for 15%-40% of costs embedded in final products Implementing quality improvement initiates a chain reaction that lowers costs, enhances productivity, boosts market share and competitive positioning, increases job satisfaction, and generates new employment opportunities.

Figure 1 The chain reaction of quality improvement by Dr Deming

Deming stated in his book that it is important that a company retains stability of purpose for staying in business and create a product or service which customers need

If the situation does not improve, unemployment rates will rise, leading to a more significant decline Additionally, he noted that when customers receive low-quality products, they are likely to share their negative experiences with their social circles.

-Decrease cost through less rework -Fewer delays, mistakes, barriers -Better use of machines and materials

To capture market share, companies must offer higher quality products at lower prices, which not only helps them stay competitive but also creates more job opportunities This positive cycle can lead to significant growth; however, if a company fails to manage this effectively, it risks losing market share or even shutting down, resulting in job losses for employees.

Deming emphasized that prioritizing customer satisfaction is crucial, as a happy customer is likely to refer more clients to the company Therefore, the focus of production should be on meeting customer needs and ensuring quality.

In "Out of Crisis," Deming emphasizes that quality for employees means satisfaction with their performance, and that quality improvement enhances productivity by enabling intelligent work rather than hard labor He cites Nashua Corporation as an example, where statistical methods for quality improvement fostered creativity and innovation in process enhancement Deming also notes that while measuring productivity alone cannot improve it, such measurements provide valuable insights into activities aligned with organizational goals, allowing for targeted improvements Additionally, he highlights that poor quality leads to increased costs, as resources are wasted on defective products or necessary repairs.

Hoyle emphasized that quality must be intentionally designed rather than occurring by chance, and that mere inspection does not enhance quality He highlighted the strong connection between quality and business processes, noting that the quality of products or services is defined by the characteristics and features that meet customer needs These features are shaped by the business process, which often introduces variations and undesirable attributes Therefore, enhancing the core business process to deliver products and services with the desired features and minimal variation is essential for improving quality.

Mitra emphasizes that both organizations and individuals should prioritize quality improvement to identify and rectify various quality-related issues He asserts that enhancing quality can lead to increased profitability and efficiency while lowering costs Furthermore, Mitra advocates for adopting quality improvement as a philosophy focused on minimizing variations from established standards, thereby boosting a company's competitive edge He underscores the importance of continuous efforts in quality improvement, viewing it as an ongoing activity.

Why leadership?

Globalization, technological advancements, and shifting demographics are key trends driving organizations to focus on change management This encompasses the methods and models leaders employ to help individuals adapt to new changes Effective leadership plays a vital role during organizational transitions, as leaders must craft an inspiring vision that motivates employees to work towards shared objectives.

Leadership is a dynamic process that involves influencing others to achieve a shared goal, as highlighted by James Burns in the Encyclopedia of Leadership Gary Yukl emphasizes that effective leadership not only guides individuals towards a common purpose but also inspires them to go beyond mere compliance with organizational directives.

Leadership is a dynamic process involving interaction between leaders and their followers, where each party influences the other According to Peter Northouse, effective leadership occurs in groups of all sizes, from small teams to large organizations, with the leader's role being to inspire collaboration towards a common goal This shared objective reduces the likelihood of unethical practices, thereby enhancing teamwork Northouse emphasizes that the leadership process encompasses both leaders and followers, highlighting the leader's responsibility to foster and maintain their relationship, as well as to facilitate communication Additionally, leaders must recognize and address the needs of their followers, acknowledging their equality.

Leadership as a process can lead to positive outcomes, including achieving common goals, enhancing product or service quality, and solving customer problems, while also fostering trust, morale, and respect (mindtools.com, 2014) Yukl noted that leadership significantly impacts financial performance by influencing effectiveness, environmental adaptation, and human resources, with specific leader behaviors playing a crucial role Evidence suggests that transformational leadership can enhance organizational performance and motivation (Yukl, 2008) Additionally, research indicates that the behaviors and characteristics of leaders are vital for the success of organizational changes, with charismatic and transformational leadership styles being particularly effective in driving change (Battilana et al., 2010).

Why research of leadership theory in quality improvement?

Deming emphasizes the significance of leadership in quality improvement, particularly through his 14 key principles, highlighting its crucial role for top management Extensive research on leadership has identified specific practices that enhance organizational performance Therefore, diverse perspectives on leadership research can greatly contribute to quality management and improvement initiatives.

Deming encourage managers of companies to institute leadership, which is probably necessary, and difficulties that may prevent the successful evolution and exercise of leadership have to be considered (Waldman, 1993)

Puffer and McCarthy (1996) highlight that quality management and leadership share common goals, such as enhancing employee satisfaction and performance, yet they note a significant gap in the integration of leadership theory within quality management literature Research by Waldman et al (1998) emphasizes the insufficient evidence on the effectiveness of leadership in driving organizational quality improvements and the lack of clarity regarding the leadership processes related to quality enhancement Additionally, Battilana et al (2010) point out that leadership literature often overlooks the complexities of change, while change literature assumes leaders possess the necessary skills for implementation Recent findings by Lashkman (2011) indicate that, despite some implications for quality management, there is a lack of leadership theories focused on quality, and a clear role for leadership in this area remains undefined He suggests that integrating leadership knowledge into quality management could yield significant theoretical and practical benefits.

Leadership plays a crucial role in quality management, as highlighted by the National Institute of Standards and Technology (NIST) in the Baldrige Performance Excellence Program This program emphasizes that effective leadership is essential for strategic planning and customer focus According to Deming's quality theory, customers are the most important aspect of business processes, with their demand centered on high quality at low costs, making quality a vital component of a company's strategy.

The "Encyclopedia of Leadership" emphasizes the significance of understanding quality management theories, particularly Total Quality Management (TQM) pioneered by Dr Deming, for modern leadership This knowledge can enhance collaboration within businesses, reminding leaders that teamwork is essential for effective work performance.

From a Total Quality Management (TQM) perspective, effective quality management requires the involvement of both employees and managers at all levels of a company (Lashkman, 2011) However, Lashkman points out that existing leadership literature primarily emphasizes supervisory roles, neglecting the broader organizational context, except for transformational and charismatic leadership styles He highlights the critical importance of top management commitment to quality programs, suggesting that leadership influence should extend throughout the organization Consequently, there is a need for a leadership theory that addresses quality management across various levels Additionally, Lashkman notes that essential TQM elements, such as teamwork and participation, are inadequately covered in leadership literature He advocates for a leadership framework focused on quality that enhances organizational teamwork and participation, emphasizing that quality improvement requires the engagement of all members within the organization (Lashkman, 2011).

Powell concluded that enhancements in quality performance are likely to be more effectively supported by value and behavioral factors, such as leadership and organizational culture, rather than by methods and tools like process improvement or benchmarking (Waldman et al., 1998).

Laohavichien, Fredendall, and Cantrell emphasize that effective quality management hinges on leadership and a commitment to quality, highlighting Deming's advocacy for visionary leadership as vital for quality management initiatives They also reference Juran's teachings on the importance of managers providing an inspiring vision for their organizations The authors argue that the core reason leadership is essential for quality management is that leaders can motivate and influence their team members, who in turn can enhance quality performance Furthermore, they note that merely using quality improvement as a measure of leadership effectiveness is insufficient in leadership theory and literature.

Sousa and Voss (2002) suggested that leadership theory should be integrated to enhance quality management practices However, current quality management theories do not incorporate leadership principles, which limits the assessment of leadership's role in improving quality management.

Question

This report investigates the role of leadership theories in enhancing quality improvement initiatives It specifically examines how effective leadership can impact three fundamental aspects of quality improvement: the significance of change, the dynamics of teamwork, and the management of goals.

Scope

In scope

This report examines the significance of change, teamwork, and goal management, selected through an analysis of Dr Edward Deming’s quality improvement theory and supported by further literature research Recognizing leadership as a crucial component of quality enhancement, the study explores various leadership theories to identify their connections to quality-related issues The objective is to compile insights from different leadership perspectives and correlate them with quality improvement principles, ultimately producing relationship maps that illustrate the findings.

Out of scope

This thesis focuses on Dr Deming's quality theory and Total Quality Management (TQM) issues, intentionally excluding other quality frameworks such as lean management and Six Sigma.

This chapter outlines various research methodologies, justifies the selection of a literature-based study, explains the methods of data collection and analysis, and clarifies the evaluation of the chosen literature.

Different research methodologies

Qualitative research is a scientific approach that seeks to answer questions through systematic procedures and evidence collection, often revealing previously unknown findings that may extend beyond the study's scope Common methods include in-depth interviews for individual data collection, focus groups for gathering insights from groups, and participant observation to analyze natural behaviors.

Quantitative research aims to explain phenomena through the collection and analysis of numerical data using statistical methods There are two primary types of quantitative research: experimental research, which tests known truths or examines the validity of hypotheses under controlled conditions, and non-experimental research, which observes variables as they naturally occur without manipulation.

Case studies put their attention on a particular organization or community and it arises through empirical curiosity and it has also practical use (Winch, Todd, Baker, Blain,

& Smith, 2014) A case study may include connection of the primary research with theory or empirical considerations (Winch, Todd, Baker, Blain, & Smith, 2014)

Literature-based analysis involves gathering and discussing descriptive and theoretical evidence from existing literature, while also comparing various theories regarding their applicability.

Deductive research aims to test existing theories through methods such as databases, quantitative analysis, or surveys In contrast, inductive research focuses on generating new theories, typically utilizing qualitative interviews.

Why literature based

After careful consideration, the decision was made to pursue a literature-based study due to the absence of a relevant theoretical framework for quantitative research on the positive relationships of interest This lack of theoretical foundation necessitated the creation of a literature-based study to explore specific relationships between leadership and quality theories The significance of this study lies in its ability to identify relevant relationships and potential gaps that warrant further investigation.

Data collection and analysis

Data collection was conducted through prior research, encompassing both articles and books The majority of the bibliography consists of pertinent articles from reputable journals focused on quality, leadership, personnel, and performance, sourced from the KTH Primo library database A variety of methodologies were included without restrictions Keywords utilized in the search included combinations of leadership, quality, improvement, performance, teamwork, organizational change, change management, TQM, leadership competencies, effective leadership, team leadership, quality management, goal management, goal setting, and quality goals.

The initial phase involved a pre-study of 14 key principles from Dr Edward Deming’s renowned book, “Out of Crisis,” which is widely acknowledged for its contributions to quality theory This analysis identifies essential components for enhancing quality, focusing on three critical elements: the significance of organizational change, the value of teamwork, and effective goal management.

The data search and collection process begins with the selected elements to explore the relationship between leadership theory and quality theory This analysis is conducted in three distinct stages.

First data gathering comes from quality literature in order to validate the chosen elements for quality It contains relevant articles and books from different types of methodologies

This article presents a comprehensive analysis of leadership literature by evaluating the relevance of various articles through their abstracts, introductions, and results Irrelevant articles are excluded, while a systematic collection and categorization process is employed using three search combinations: leadership-change, leadership-teamwork, and leadership-goal, along with relevant variations In instances where a factor, such as leadership and participation, lacks sufficient evidence, additional research is conducted using that factor as a keyword Both qualitative and quantitative articles are meticulously examined for their results, hypotheses, and methodologies to ensure reliability The report also addresses contradictory data, such as rewards for goal achievement, and organizes the selected relationships into distinct chapters, each focusing on a specific element.

The collected data findings are synthesized into relationship maps and analyzed through observations The conclusion highlights the key observations and offers suggestions for future research.

Literature evaluation

Authority in literature-based researches requires answers to the following questions (Study & Learning Centre, 2005):

• Are the authors experts in their study fields?

• Is there evidence to support this? (Study & Learning Centre, 2005)

The theories of quality and leadership are grounded in the expertise of notable figures in their respective fields, with quality theory rooted in the work of Deming and leadership theories influenced by Burns, Bass, and Yukl Many subsequent reports and studies reference or build upon these foundational theories.

Validity in literature-based studies is concerned about the sources of the used literature research, and needs to ask certain questions (Study & Learning Centre, 2005):

• Where the research comes from? Is the source valid (eg educational institution)?

• Is the source been reviewed or passed by editorial panel (eg journal)?

• Is it from electronic source, does it include author details and publication date? (Study & Learning Centre, 2005)

This study meets the established criteria extensively, as most references were sourced from KTH University’s online library (KTH Primo) and consist of articles published in reputable journals Additionally, the electronic sources primarily originate from recognized associations or institutions, and those that are not affiliated with associations include citations from credible sources.

Accuracy in literature-based researches requires answers to the following questions (Study & Learning Centre, 2005):

• What is the subject of the literature?

• Is it accurate (does it referred to other sources)?

• Is it believable (source credibility-validity)? (Study & Learning Centre, 2005)

This report aims to address the specified requirements by focusing on references pertinent to the theories of quality and leadership, with many articles being frequently cited in other reports The validity of the findings has been confirmed in the previous section.

Objectivity in literature-based researches requires answers to the following questions (Study & Learning Centre, 2005):

• Was existing bias evidence in the articles?

• Where there match of the statistics with other articles?

• What makes data true? (Study & Learning Centre, 2005)

The selected literature does not provide evidence of bias, and while the statistics were not thoroughly examined, it is assumed that the data is derived from reliable methods.

Currency in literature-based researches requires answers to the following questions (Study & Learning Centre, 2005):

• What was the articles’ date?

• Is it probable that recent information is presented?

• Is there any recent research that doubts other findings? (Study & Learning Centre,

The report aims to explore the most recent literature, as evidenced by the references provided While some foundational theories are derived from older sources, no doubts were identified; however, numerous suggestions for further research emerged Additionally, a contradiction regarding rewards for goal achievement is highlighted.

Coverage in literature-based researches requires answers to the following questions (Study & Learning Centre, 2005):

• Is the information full? Concerning this research, is the information covering the whole area studied?

• Is the sample size adequate?

• Is there other research not mentioned or intentionally excluded from the report? (Study & Learning Centre, 2005)

Due to the time constraints of the Master Thesis, it was challenging to gather all relevant literature The broad nature of quality and leadership theories also contributed to the potential oversight of some studies Consequently, the report focused on specific, foundational, and well-established theories, leading to the exclusion of other theories Additionally, the sample size used in the research is deemed adequate.

Location in literature-based researches requires answers to the following questions (Study & Learning Centre, 2005):

• Which are the countries that the articles were written?

• Are these locations relevant or important for this study? (Study & Learning Centre, 2005):

The majority of the used books originate from the U.S.A., while the articles are authored by researchers from diverse countries, reflecting their respective universities or research institutions Additionally, the quantitative and qualitative methods employed in the studies come from various global locations This diversity in evidence enhances the objectivity of the report, as the data is not limited to specific demographic groups.

This chapter highlights the significance of Deming's quality theory and identifies key elements derived from various literature sources It also provides a concise overview of leadership within organizations and examines how leadership theory impacts these selected elements.

Recognition and importance of Deming's theory for quality

Deming's 14 key principles for quality improvement, introduced in his 1986 book "Out of the Crisis," have inspired companies worldwide to adopt his philosophies, leading to significant enhancements in quality and effectiveness Hoyle, in his "ISO 9000 Quality Systems Handbook," further explores quality improvement using ISO 9000 as a framework and emphasizes the relevance of Deming's theory by referencing many of the 14 points throughout his work.

The Deming Prize, established in 1951 to honor Dr W Edwards Deming, is a prestigious global award for Total Quality Management, highlighting the significance of his contributions to Japan's exceptional product and service quality Additionally, the Deming Medal, awarded by the American Society for Quality (ASQ), recognizes successful applications of statistical methods and management, further underscoring Deming's impact on quality improvement Furthermore, the Deming Lecturer award, initiated by the American Statistical Association (ASA) in 1995, serves as a testament to Dr Deming's enduring legacy and achievements in the field of quality management.

2014) Finally, Dr Edward Deming was one of the quality pioneers, whom theory contributed in the development of Total Quality Management (TQM) (ASQ, 2014)

Key elements

Change

Quality improvement, as emphasized by Deming, starts with the commitment of management, which is essential for implementing necessary changes within the system Management must not only identify ways to enhance processes but also effectively communicate and support these changes to employees It is crucial for management to recognize their responsibilities and take action Deming advocated for engineers and experts to translate management's intentions into actionable plans, strategies, and specifications while assessing the impact of these changes He also stressed that quality improvement should be a comprehensive commitment integrated into all company activities, from procurement and research & development to production and market research, asserting that new technology alone is not the solution.

Deming emphasized the necessity of change involving all employees, highlighting the importance of clear communication from management He advocated for the PDSA cycle, originally developed by Walter A Stewart and later refined into the PDCA cycle by Dr Edwards Deming, as an effective tool for quality improvement at every stage, including problem identification and the application of statistical methods.

When implementing changes, it is crucial to analyze the outcomes and identify opportunities for future enhancements Prediction plays a vital role in effective planning Additionally, Deming emphasized that desirable changes, along with data and observations, are essential inputs during the planning phase Completing this cycle leads to process improvements and heightened customer satisfaction (Deming, 1986)

Figure 3 Dr Deming’s PDCA cycle

Corredor and Goủi emphasize that complete organizational change is crucial for the success of quality implementation programs like Total Quality Management (TQM) (Corredor & Goủi, 2011) TQM is rooted in the theories of quality pioneers, including Deming, as highlighted by the American Society for Quality (ASQ, 2014) Puffer and McCarthy also stress the significance of organizational change with a focus on customer satisfaction, which is essential when a company's vision prioritizes quality (Puffer & McCarthy, 1996) Additionally, Waldman points out that companies must be ready to adapt their systems and processes to achieve quality improvements.

4 Act is that cultural change should be linked and proceeds in line with TQM implementation (Waldman, 1993)

In "Leadership in Organizations," Yukl (2010) emphasizes that the demand for leadership rises with increasing uncertainties and changes in the external environment, making organizational change essential These changes encompass political, technological, and economic shifts, alongside heightened customer needs, competition, and resource scarcity (Yukl, 2008) It is crucial for change to align with management's role to foster order and predictability Mutafelija and Stromberg highlight that organizations often struggle with change, particularly when employees are comfortable and secure in their roles, necessitating time and energy to enhance processes and sustain change They assert that commitment to change is vital to prevent failure, and successful implementation leads to a reluctance to revert to previous states As organizations evolve, embracing change becomes a desired practice, underscoring the importance of systematic planning for effective transformation (Mutafelija & Stromberg, 2003) Mauch (2010) further notes that thorough planning is critical when faced with significant change.

Yukl emphasized that an organization's ability to adapt to changes in the external environment is a key indicator of its effectiveness, with innovative changes being crucial for successful adaptation, especially when the strategy focuses on customer satisfaction He identified dynamic business areas such as clothing, healthcare, technology, and entertainment, where innovation is vital However, he warned that changes driven by desires rather than careful analysis of uncertainties can lead to financial disaster Additionally, high employee creativity is essential for transforming traditional work methods and fostering innovation, which is critical for achieving change goals Implementing a quality management system can further support and control these changes, creating opportunities for improvement while minimizing potential drawbacks.

Hoyle emphasizes that organizations will encounter challenges in achieving quality results if management is unwilling to adapt its principles This is evident in numerous companies that, despite being ISO 9000 certified, failed to satisfy their customers due to a lack of necessary changes He highlights the critical need for businesses to address all customer demands for enhanced services and products that offer greater value and benefits Implementing changes in a company's strategy, processes, and policies can significantly enhance overall business quality.

Teamwork

Dr Deming emphasized that consistent effort is crucial, and that teamwork and strong leadership are irreplaceable in achieving this goal He highlighted the significance of incorporating quality during the design phase, where collaboration is essential Deming pointed out that issues arise when employees concentrate solely on their departmental tasks rather than working together towards the company's objectives Moreover, he suggested that reducing the fear of taking risks can empower cross-departmental teams to enhance future designs and improve the quality of current products and services.

Teamwork is essential for the entire company, as individual weaknesses can be offset by the strengths of others It is crucial to prioritize collaboration over annual ratings to avoid fostering internal competition that hinders mutual support Everyone should feel empowered to contribute ideas and proposals, enhancing the overall performance of the team while respecting consensus and agreements Furthermore, individuals from various departments can unite to form effective teams, with a shared goal being a critical factor for success.

Teamwork is a complex social activity that requires individuals to collaborate and combine their skills, knowledge, and behaviors to achieve a common goal To enhance customer satisfaction and ensure continuous quality improvements, it is essential for teamwork and cooperation to permeate the entire organization, including interactions with suppliers and customers Effective practices to foster this environment include training in group skills, establishing shared benefits, creating diverse team types, implementing team-building strategies, and facilitating group feedback Additionally, collaboration between managers and employees can harness employee contributions, while interdepartmental teamwork and partnerships with suppliers and customers are vital for maintaining quality Ultimately, teamwork is essential for navigating challenges posed by organizational hierarchies and departmental divisions.

Cooney and Sohal emphasize the strong connection between quality management and teamwork, highlighting that teams enhance quality programs by solving problems, sharing valuable information, and increasing employee responsibility They assert that effective teamwork fosters collaboration and communication across various departments, while promoting essential dialogue between management and employees to achieve quality-related strategies Additionally, they suggest that teamwork facilitates the assignment of roles among members, which is crucial for managing new responsibilities arising from quality requirements Finally, they note the importance of considering diversity and the various skills within different types of teams.

Research by Cooney and Sohal (2004) highlights that while different companies implementing Total Quality Management (TQM) have varied team objectives, the management's goals for teamwork remain consistent, leading to standardized teamwork formation Kathuria and Davis (2001) emphasize that team building is a crucial practice for manufacturing managers, especially as the focus on quality increases Atwater and Waldman (2008) suggest that engaging in team problem-solving can be mentally stimulating for both employees and managers Additionally, Puffer and McCarthy observe that effective team building is essential for achieving TQM goals in large organizations, asserting that teamwork and empowerment are vital for addressing customer needs by enabling individuals to take on leadership roles and share information.

In the realm of Total Quality Management (TQM), Lashkman (1996) highlighted the importance of diverse teams, such as cross-functional groups, for effective quality management within organizations He referenced a case study by Rago, which illustrated the challenges organizations face when employees at various levels struggle to collaborate and engage in quality management initiatives Additionally, Waldman (1993) emphasized that active participation and teamwork among all employees are fundamental aspects of TQM.

A recent study by the Agency of Healthcare Research and Quality (AHRQ) involving 40 hospitals and 1,406 surveys revealed that quality improvement in healthcare is heavily reliant on effective teamwork Bureaucratic and hierarchical structures hinder necessary changes, making collaboration across institutions vital for enhancing quality and safety (AHRQ, 2011) Supporting this, Eric Thomas emphasizes that successful quality improvement in healthcare also hinges on strong teamwork, highlighting the importance of proper training and communication to deliver better patient services (Thomas, 2011).

Hoyle emphasizes the importance of team members viewing themselves as co-workers united by a common goal, where each individual plays a vital role in producing outputs that facilitate effective collaboration He explains that business processes are designed to yield specific outputs, necessitating defined actions from team members Additionally, Hoyle highlights that being part of a team offers psychological rewards that enhance employee motivation more than financial incentives, as recognition and respect for their contributions foster a sense of fulfillment This intrinsic motivation leads to greater employee satisfaction, aligning their efforts with quality goals and objectives.

Goal management

Deming emphasized the importance of management having a clear plan to achieve organizational goals, highlighting the need for collaboration among departments He warned that setting numerical goals without a strategy can lead to negative outcomes and suggested that management should maintain open communication with employees regarding expectations and performance improvement Additionally, he criticized the reliance on monetary rewards and ratings, stating that they often indicate poor supervision Deming advocated for stabilizing the system before implementing goal setting, asserting that a shared goal is essential for effective teamwork.

A highly effective approach for goal setting is the S.M.A.R.T method, which emphasizes that objectives should be Specific, Measurable, Accepted, Realistic, and Time-limited (Antvik & Sjöholm, 2012).

Figure 4 Requirements for goal setting using the S.M.A.R.T method (taken by Antvik

It was stated by Deming that a goal with no plan of how to achieve it, has no use (Hoyle, 2009)

Thompson and Strickland suggested these three rules in goal setting for quality improvement efforts (White, Kaighobadi, & Wharton, 1994):

1 Difficult goals create higher performance levels than easy ones

2 Specific goals also create higher performance levels than unclear ones

3 Goals have to be measurable and qualified (White, Kaighobadi, & Wharton,

To achieve quality goals, it is essential to plan and organize quality management systems, which serve as guidelines for organizations (Hoyle, 2009) These systems help in organizing resources to meet specific objectives and in analyzing factors that hinder customer satisfaction or contribute to success Consequently, a quality management system is vital for establishing various quality goals tailored to every company (www.transition-support.com, 2013).

Juran suggested a systematic approach for quality goal setting and management that affects the entire company More specifically he suggested those practices (Schneiderman, 1988):

• Establish quality strategies and goals

• Create plans of how to achieve these goals for quality

• Provide all the necessary resources to support the plan

• Control and evaluate the performance and progress of work against the goals Take necessary action

• Provide motivation to encourage employees put efforts in achieving the quality goals (Schneiderman, 1988)

Setting a goal does not guarantee its achievement, as significant improvements over previous performance may be necessary Establishing quality goals involves a level of voluntarism and negotiation, and these goals are not uniform or static; they differ across organizations and can change from year to year.

A conclusion from several reports is that if guidelines, for setting the goals for quality improvement, are followed, then the result would be performance improvement (White, Kaighobadi, & Wharton, 1994)

Latham and Locke, in their 35-year research, found that goals can affect the performance by four mechanisms (Locke & Latham, 2002):

1 Goals work for providing a directive purpose They direct individuals’ efforts and attention to certain activities that are relevant with the goals

2 Goals provide an activating effort Higher goals increase effort in comparison with easy goals

4 Goals influence activities indirectly with the use of task related knowledge, strategy, discovery and vigilance (Locke & Latham, 2002)

Latham and Locke discovered that individuals utilize their existing skills and knowledge to pursue goals, while new tasks prompt them to create plans and strategies They noted a potential delay between goal assignment and the development of these plans Additionally, they found that complex goals requiring significant effort often yield better results than challenging goals with specific performance criteria Training individuals in effective methods for achieving high-performance goals can enhance their performance in these areas (Locke & Latham, 2002).

Further in their research, Latham and Locke noted that performance will increase when individuals are committed to goals The two key factors for goal commitment are (Locke & Latham, 2002):

Achieving goals is crucial for personal and professional growth, as it fosters a sense of accomplishment and motivation Publicly committing to goals enhances accountability, while leaders play a vital role by offering an inspirational vision and supporting their team's efforts Involving subordinates in the goal-setting process encourages ownership and engagement, and providing incentives based on the difficulty of the goals can further motivate individuals Additionally, allowing team members to contribute to decision-making promotes information exchange and collaboration, ultimately leading to more successful outcomes.

Self-efficacy refers to an individual's confidence in their ability to achieve specific goals It is enhanced through adequate training aimed at improving specialization, clear assignment of roles, and persuasive support that bolsters a person's belief in their capabilities (Locke & Latham, 2002).

Latham and Locke emphasize the critical role of feedback in enhancing goal effectiveness, as individuals require insights into their efforts to ensure alignment with goal requirements Feedback serves as both a motivator and a moderator for achieving goals They also highlight that task complexity influences goal achievement, with more intricate goals necessitating advanced skills and strategic development Additionally, Latham and Locke assert that the outcomes of goal setting are highly reliable, noting that failures often stem from a misalignment between goals and performance, insufficient feedback, lack of commitment, inappropriate difficulty levels, neglecting personal goals, or setting unsuitable goals at the wrong time.

The goal setting key elements from their research can be summarized in the following diagram (Locke & Latham, 2002):

Figure 5 Goal setting key elements, taken from Locke and Latham theory and research (Locke & Latham, 2002)

Leadership in organizations

How leadership can influence change?

In "Leadership and Change," Bernard Burnes emphasizes that leadership is an evolving process characterized by adaptation and energy, distinguishing it from conventional management, which focuses on stability Instead, leadership is fundamentally about driving change (Burnes & Todmen, 2011)

Hayward highlights the 2010 Learning and Development Survey by the Chartered Institute of Personnel and Development in the UK, which identified the development of leadership competencies as the top priority for achieving future business goals The survey revealed that international organizations also prioritize leadership development, recognizing it as a crucial element for facilitating organizational change (Hayward, 2011)

Transformational leadership plays a crucial role in driving changes within organizational cultures, leading to significant quality improvements By fostering values, beliefs, and standards oriented towards quality enhancement, leaders can effectively motivate change Key factors that support this transformation include problem-solving, information sharing, system-level thinking, continuous learning, and team cooperation.

Transformational leadership significantly influences employee psychology and behavior, playing a crucial role in organizational change By creating and communicating an inspiring vision, it boosts employees' confidence to meet high expectations This leadership style fosters a clear vision and enthusiasm among employees, motivating them to work harder and emphasizing a greater purpose that transcends individual desires and needs.

According to Battilana, Gilmartin, Sengul, Pache, and Alexander, leaders face significant challenges in executing planned organizational changes while ensuring benefits for both the organization and its members Their research highlights the impact of charismatic and transformational leadership on the success or failure of these changes While implementing change involves various activities that require diverse leadership skills, existing literature often overlooks the complexity of change and assumes that leaders possess the necessary skills for effective implementation.

Seo, Taylor, Hill, Zhang, Tesluk, and Lorinkova observed that the significant changes in the external environment over the past two decades have heightened the necessity for organizational change However, many of these change initiatives do not yield the expected results Research indicates that a primary reason for these failures is the insufficient commitment of employees to the change process.

Givens (2008) highlights that research demonstrates the positive impact of transformational leadership on employee commitment to change within organizations This leadership style is essential as it inspires employees through a compelling vision, fostering new opportunities across all levels Additionally, Givens emphasizes the importance of building trust, a fundamental trait that transformational leaders cultivate in their relationships with followers By empowering employees and enhancing their motivation, transformational leaders create a participative environment that enables quick and flexible responses to organizational change.

Transformational leaders play a vital role in facilitating organizational change by crafting and sharing an inspiring vision, which contrasts with the approach of transactional leaders This leadership style enhances morale and motivates followers to strive for higher achievements (Cavazotte, Moreno, & Hickmann, 2012) According to Bass, essential leadership traits such as charisma, individualized consideration, and intellectual stimulation are particularly important for leaders in organizations undergoing change (Bass, 1990).

Leonard, Lewis, Freedman, and Passmore (2013) highlight that significant organizational changes can induce stress among employees due to increased work targets, job security concerns, shifts in responsibilities, and alterations in authority balance, all of which can diminish their commitment to change Negative reactions to change are often linked to lower job satisfaction and commitment To address these challenges, it is essential for managers to engage in effective communication through change-related practices, demonstrating their own commitment and fostering a supportive environment for employees.

3 gaining participation and commitment (Leonard, Lewis, Freedman, & Passmore,

Timely feedback on changes can alleviate role conflict uncertainty, as noted by Leonard, Lewis, Freedman, and Passmore They emphasize that commitment to change is crucial for aligning employees with organizational goals For successful change implementation, organizations must possess the knowledge and earn the respect of their employees Research indicates that acceptance of change, positive attitudes, and perspectives towards change foster greater organizational commitment.

Seo et al (2012) found that transformational leadership from managers significantly influences both the positive and negative affect of employees, impacting their normative and affective change commitment during organizational change Their research indicates that effective leadership fosters greater change commitment, leading to increased creativity, supportiveness, and reduced resistance to change among employees They emphasize the necessity of incorporating leadership roles at various organizational levels in change models and advocate for practices that promote positive affect, such as communicating a clear change vision and providing employee support Training managers to understand the role of affect in influencing employees is essential, as developing transformational leadership skills can help mitigate emotional distress The study also highlights the importance of cultivating normative change commitment through positive social relations before organizational change, while affective commitment can be nurtured during ongoing changes when employees anticipate positive outcomes Ultimately, the findings suggest that fostering normative commitment early in the change process can predict employees' supportive, creative, and resistant behaviors, whereas affective commitment primarily forecasts supportive responses.

Waldman and Bass emphasize that innovation is a crucial factor for the success of organizations in rapidly changing environments, involving the generation and application of new ideas, whether administrative or technological They propose that certain social and organizational phenomena, particularly leadership, can foster innovation Drawing from prior research, they predict how leadership characteristics can support innovation across various phases.

1 Inspirational motivation and intellectual stimulation may be related with idea generation phase

2 Individualized consideration, inspirational motivation, and intellectual stimulation, may be related with progression of the idea from generation to realization phase

3 Charisma and contingent reward may be related with the progression of the idea from realization to diffusion of innovative phases (Waldman & Bass, 1991)

Figure 7 Leadership and innovation processes according to Waldman and Bass (Waldman & Bass, 1991)

A study by García-Morales, Jiménez-Barrionuevo, and Gutiérrez-Gutiérrez demonstrates a positive relationship between innovation and transformational leadership, both directly and indirectly, by fostering skills that reduce internal change costs Their findings highlight the significance of transformational leadership in driving innovation generation.

Change-oriented leadership behaviors, as outlined by Yukl, focus on fostering innovation, adapting to external environments, and promoting collective learning Key components include envisioning and advocating for change, which emphasize leaders' roles in initiating and supporting change efforts Additionally, encouraging innovation and facilitating collective learning reflect leaders' support for emerging change processes (Yukl, 2012).

• Advocating change by: communicating change importance, influence people and increase awareness

• Envisioning change by: creating an inspiring vision and communicating vision

• Encouraging innovation by: assisting creative ideas, stimulating thinking and promoting creativity

• Facilitating collective learning by: promoting new knowledge through internal or external sources, guiding learning and learning from mistakes (Yukl, 2012)

In their book, Leonard, Lewis, Freedman, and Passmore highlight various studies on trust, revealing that followers who view their managers as transformational leaders exhibit increased trust and positive attitudes towards management, particularly during organizational change The research indicates that high trust in senior leadership correlates with a greater willingness among employees to embrace change Additionally, a study involving 194 employees from an R&D department in a multinational automotive company found a positive relationship between trust in top management and charismatic leadership with the successful implementation of innovation Trust is shown to enhance leadership effectiveness, and other scholars have noted that trust in supervision and perceived control over change processes can boost employee commitment, even in low-control situations Seyranian & Bligh emphasize that leaders who use inclusive language and foster a sense of similarity can build trust with employees, aligning their social values towards change.

How leadership can influence teamwork?

Hauschildt and Konradt highlight that teamwork introduces an additional role for personnel, requiring them to coordinate and synchronize their efforts with others while also embracing their responsibilities as team members after completing individual tasks They observe that while collaborative behaviors are typically analyzed at the team level, there is an increasing focus on individual contributions within team settings Task-related cooperative behaviors, including cooperation, coordination, and information exchange, play a crucial role in achieving team success.

• Coordination: Integration of team members’ contributions and activities for synchronizing the tasks accomplishment into the time frame

• Cooperation: creation of common assistance In other words, work all together for the duration of the task of goal implementation

• Information exchange: Communication and share of task-related information among the team members (Hauschildt & Konradt, 2012):

Those three behaviors show the degree to which an employee can satisfy his role and contribute as a team member, else known as team member proficiency (Hauschildt & Konradt, 2012)

Effective leadership fosters positive relationships between leaders and followers, which enhances teamwork and supports Total Quality Management (TQM) practices According to Atwater and Waldman, leadership is crucial for motivating individuals and transforming groups into cohesive teams, while also articulating a clear vision for the organization's strategic direction Therefore, communication emerges as a vital component for effective leadership and overall organizational performance.

The team perspective highlights the dual influence of leaders on team dynamics, focusing on aspects such as role clarity, commitment to goals, skill development, and resource allocation Leaders play a crucial role in organizing work, coordinating activities, establishing team priorities, fostering trust, and enhancing cooperation among members Additionally, recognition of individual contributions and confidence in the team's capabilities are essential for achieving objectives Research by Yukl (1999) emphasizes the impact of both formal and informal leaders on problem-solving, creativity, collective learning, and decision-making within teams.

Lashkman (2011) emphasizes that teamwork and participation are essential leadership values linked to behaviors such as team development and structuring He argues that for effective quality management, these values should be embraced organization-wide rather than limited to specific decisions Leadership behaviors that support participation and implement team-related processes—such as team arrangement, careful hiring, training, and time management—are crucial for fostering successful teamwork and participation.

According to Yukl, effective leaders foster participation by establishing clear objectives, enhancing problem-solving skills, promoting self-efficacy, ensuring access to information, and building trust among team members He emphasizes the importance of integrating various leadership behaviors, such as inspiring, supporting, coaching, team building, leading meetings, informing, and managing conflicts, tailored to the specific situation at hand.

Relations-oriented leadership behaviors prioritize enhancing the quality of human resources by improving member skills, fostering leader-member relationships, and strengthening commitment to the mission (Yukl, 2012) This category encompasses team-related behaviors, including promoting teamwork and cooperation, building mutual trust, facilitating collective learning within teams and organizations, and supporting the performance of both teams and individuals (Yukl, 2008) Specifically, all four component behaviors in this category significantly contribute to effective teamwork (Yukl, 2008).

• Supporting by: concerning of team members’ feelings and needs, listening to team members’ worries, encouraging and increasing confidence when there are difficult tasks

• Developing by: aiding members to enhance their skills, promoting collaboration between new and old members, coaching and training

• Recognizing by: appreciating and praising high performance, significant contributions and important achievement of teams

• Empowering by: giving authority to teams or members for decision making (delegation) (Yukl, 2012)

Extensive research, including experiments, observations, and surveys, indicates that task-oriented behaviors significantly enhance the performance of individuals and small teams (Yukl, 2008) Key components of this approach involve effective planning for task assignment and resource allocation, clear communication of job expectations and performance standards, diligent monitoring of work execution, and proactive problem-solving (Yukl, 2012).

Recent research by Yukl highlights the importance of external behaviors, known as boundary spanning, for effective team performance Key objectives in this area include acquiring essential resources and information, as well as advocating for the interests of the organization and the team External monitoring can enhance teamwork, especially when team performance relies on outside factors, and leaders play a crucial role in representing their teams to external stakeholders like customers and suppliers Additionally, Zaccaro, Rittman, and Marks suggest that in teams with significant experience and knowledge, leadership activities can be shared among members, while official leaders maintain boundary spanning responsibilities.

Yammarino, Spangler, and Bass indicate that greater performance of leadership, transformational leadership, is perceived when leaders:

• expand and uplift their subordinates’ interests,

• develop acceptance and awareness among employees for the mission and purpose and of the team,

• motivate subordinates to get ahead their self-interests, for the benefit of the team (Yammarino, Spangler, & Bass, 1993)

Transformational leaders foster employee commitment to organizational values and goals, as well as team cohesion (Givens, 2008) This leadership style emphasizes team building, providing guidance, energy, and support for change processes and organizational learning It enhances awareness and acceptance of the organization's mission, promotes a shared vision, and focuses on the training and development of teams (García-Morales, Jiménez-Barrionuevo, & Gutiérrez-Gutiérrez, 2012) Additionally, many characteristics of transformational leadership are linked to business innovation, as these leaders prioritize effective communication, share core values, and create an environment conducive to team innovation (García-Morales, Jiménez-Barrionuevo, & Gutiérrez-Gutiérrez, 2012).

Yukl noted some of the ways that leadership improves organizational learning by teams, and these are:

• Support and encourage the obtaining of necessary skills of teams and individuals for collective learning

• Help individuals grow shared models for cause-effect relationships, as well as performance factors for teams and organization

• Help individuals realize when significant learning has happened and recognize the effects on the organization and team

• Encourage teams in making reviews, when activities are over, to detect ineffective, as well as effective, processes (Yukl, 2009)

To enhance job satisfaction, improve team relationships, and support employee retention, leaders must recognize generational differences and individual strengths among team members Research by Klein et al (2010) indicates that in teams with members aged 17-25, high diversity in values, ethics, and traditions necessitates effective leadership, emphasizing the importance of task-oriented practices.

Jaques and Jacobs, defined two basic mechanisms for reducing uncertainty for top management teams, since their environment is more complex (Zaccaro, Rittman, & Marks, 2001):

Weak authority relationships can empower subordinates to identify crucial patterns within the organization's environment Conversely, strong authority may lead subordinates to accept management's proposed patterns, even when they are incorrect.

A diverse top management team, composed of members with varying expertise, possesses greater resources and knowledge, enabling them to effectively navigate and demonstrate the complexities of the business operating environment.

Hauschildt and Konradt's study highlights the positive relationship between team members' self-leadership and team-oriented behaviors, including expertise, adaptability, and foresight They reference Andressen's findings, which indicate that transformational leadership enhances self-leadership by fostering employee commitment through a shared vision, values, and purpose.

In the context of team leadership, Zaccaro, Rittman, and Marks introduced a model that outlines the influence of leadership on team effectiveness This model comprises four fundamental processes, as illustrated in Figure 8 (Zaccaro, Rittman, & Marks, 2001).

Figure 8 Zaccaro, Rittman and Marks model for leadership performance processes that contribute to effectiveness of teams (Zaccaro, Rittman, & Marks, 2001)

Each of the four team processes is analyzed more in the below figures, taken from Zaccaro, Rittman, & Marks’ research:

Figure 9 Leadership influence in team cognitive processes (Zaccaro, Rittman, & Marks, 2001)

Figure 10 Leadership influence in team motivational processes (Zaccaro, Rittman, & Marks, 2001)

Figure 11 Leadership influence in team affective processes (Zaccaro, Rittman, & Marks, 2001)

Figure 12 Leadership influence in team coordination (Zaccaro, Rittman, & Marks,

How leadership can influence goal management?

Transformational leadership and goal management

Research by Bronkhorst, Steijn, and Vermeeren (2013) in the Dutch public sector, involving surveys of 958 municipal employees, reveals that transformational leadership enhances work motivation by establishing specific and challenging goals This leadership style also reduces employees' perceptions of obstacles that hinder goal setting The study emphasizes that goal setting is the primary theory for boosting employee motivation, with Latham highlighting motivation as a crucial leadership skill Additionally, the characteristics of transformational leadership positively influence employee motivation by encouraging dedication and persistence towards specific goals and tasks.

Yee, Lee, Yeung, and Cheng (2013) emphasize the significance of both transformational and transactional leadership styles in shaping the goal orientation of service employees Effective leaders who can blend these styles are better equipped to communicate essential goals to their teams The study highlights that a clear understanding of job goals allows employees to align their activities accordingly Additionally, fostering organizational commitment is crucial for employees to connect their knowledge with the assigned job objectives.

Research indicates that transformational leaders who actively listen to their employees' concerns and assist them with their challenges foster a sense of obligation among employees to reciprocate this positive behavior As a result, employees are more likely to support the organization's goals (Seo et al., 2012).

Transformational leaders significantly impact employees by elevating their values, goals, and ambitions, encouraging them to prioritize organizational objectives over mere job intentions Intellectual stimulation fosters a willingness to embrace new challenges and motivates employees to innovate in response to uncertain customer needs Additionally, individualized consideration helps employees overcome their fears associated with these challenges Research by Locke and Latham further supports the notion that transformational leadership enhances employee efficacy through inspired communication and intellectual engagement.

Whittington, Goodwin, and Murray highlight that transformational leaders use inspirational motivation to foster a positive future, providing both purpose and challenges for employees They emphasize that leadership can translate visions into achievable contributions through effective goal-setting, which encourages employee engagement Additionally, challenging goals can stimulate intellectual growth among employees, and when leaders address their needs, it enhances focus on improving performance levels.

According to Leonard, Lewis, Freedman, and Passmore, employee commitment to a goal significantly increases the likelihood of achieving it This is because employees perceive the goal as aligned with their self-image, leading them to maintain their commitment even in the absence of initial motivation.

Research indicates that organizations with shared values and goals between leaders and employees are more effective Scholars have highlighted the positive relationships among leadership behavior, goal achievement, value alignment, and employee commitment Therefore, management should focus on enhancing employee commitment as a strategy to boost participation.

Yee, Lee, Yeung, and Cheng (2013) define organizational affective commitment as the psychological bond between employees and their organization, where committed employees embrace the organization's values and goals and are motivated to exert greater effort to achieve them Their research indicates a significant relationship between organizational commitment and transformational leadership, revealing that transformational leaders have a more profound impact on fostering affective commitment in service companies compared to transactional leaders.

Whittington, Goodwin, and Murray (2004) argue that relying solely on transformational leadership, goal setting, or job enrichment can hinder overall effectiveness They highlight that transformational leaders who set challenging goals can enhance affective commitment and performance Additionally, job enrichment can help maintain an employee's connection to the organization, especially in the absence of transformational leadership.

Various leadership styles, such as transactional and transformational, play a crucial role in enhancing employee motivation and commitment Research indicates that the transformational leadership style directly influences employee commitment, whereas the transactional style has an indirect effect (Yee, Lee, Yeung, & Cheng, 2013)

Regarding rewards, it is proposed that adjusting rewards, by transactional leaders, to highlight quality management would create be beneficial (Laohavichien, Fredendall,

Transactional leadership plays a crucial role at lower staff levels by ensuring that quality goals and activities are effectively communicated, monitored, and rewarded.

In Yukl’s book “Leadership in Organizations,” it is emphasized that participative leadership enhances decision-making delegation by providing employees with feedback on their assigned tasks This approach enables better monitoring of work progress, ultimately leading to improved performance (Yukl, 2010)

Kathuria and Davis (2001) found that in quality-focused industries, effective leadership behaviors—such as inspiring, consulting, supporting, planning, recognizing, clarifying, informing, and mentoring—are essential for successfully achieving organizational goals.

Task-oriented leadership behaviors focus on efficiently managing company resources to achieve organizational goals and fulfill the mission Key leadership practices associated with goal attainment include effective planning, clear communication, and performance monitoring.

• Planning though decision making about objectives, assignment of responsibilities, allocation of resources, activity scheduling,

• Clarifying through clearly explaining and communicating objectives, deadlines and priorities, and setting challenging, specific and realistic goals

• Monitoring through checking if the work is proceeds as planned (Yukl, 2012)

Finally, relationship-oriented leadership behaviors can also influence in achieving goals using (Yukl, 2012):

• Supporting: encouragement in difficult tasks, confidence increase for implementing tasks

• Developing: level of skills improvement, training

• Recognizing: Appreciation of employee performance and achievements, awarding (Yukl, 2012)

4 Results and analysis: Gathered information and graphical representation

This study presents three distinct relationship maps, each corresponding to the key elements of importance: change, teamwork, and goal management These elements are essential for enhancing customer satisfaction and driving quality improvement, as highlighted by Deming (1986) and Dean & Bowen (1994) The maps are numbered accordingly—Map 1 for change, Map 2 for teamwork, and Map 3 for goal management—and each map is divided into three dimensions.

• The central (light grey) which includes all the factors that affect the related element (eg change factors) based on the literature findings

• The external (dark grey), which represents the style or behavior of leadership that have a positive relationship (influence), according to literature findings, with the factors

• The customer satisfaction, which is the desired outcome in quality improvement

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