After applying the search criteria, we retrieved a total of 326 articles. The number of publications has increased since 1991, with 2 publications, and reached 24 publications in 2018 (Fig. 2a). It can be referred from the graph that there was a period of publication stagnation between 1993 and 2014.

According to Fig. 2b, it can be observed that the curve does not fit the data well; when using a logarithmic curve fit, resulting y = 7-16exp (0.0185x) to describe the relation between publication number by year, the R-squared value is only 0.1003.

Mainly, the development of this research field is characterized by a wave-like progression. This research field progressed since 1990, rising from 2 to 8–14 publications annually, maintaining a high level from 1993 to 2002. A downturn occurred from 2003 to 2005, with fewer than 8 publications annually. From 2006 to 2018, a second wave of rapid growth emerged, peaking at around 10 publications annually from 2011 to 2019 (excluding the outlier of 4 in 2016), with 2018 witnessing a high of 24 publications. Despite a low of 5 publications in 2020, the significant increase to 16 papers in 2022 indicates sustained interest in TQM research within healthcare management.

(a) The number of publications on healthcare TQM by years; (b) The annual publication volume and trend prediction on healthcare TQM; (c) Distribution map of the top 10 countries or regions with the most publications on healthcare TQM; (d) The top 10 countries or regions with the highest publication number on healthcare TQM. (1991–2022)

A total of 51 countries and regions have published publications in the field of research. The top contributors in this field are shown in Fig. 2b and c. The United States has made the most significant contribution with 131 publications; followed by Germany with 42 publications; the United Kingdom with 20 publications; and Netherlands and Canada with 19 publications, respectively. (Figure 2c and d)

The USA leads significantly in publication output in this field, followed by other major publishing countries, which are primarily European nations and China.

The United States has the highest total number of citations (5,134) among all included publications, while England ranks second (967), followed by the Netherlands (933), Italy (828), and Australia (584) (Fig. 3a).Publications from Italy have the highest average number of citations (55.2), followed by the Netherlands (49.11), Australia (48.67), England (48.35), and the US (39.19) (Fig. 3b).The US outranks other countries and regions with the highest H-index of 33, followed by the Netherlands (n = 11), England (n = 11), Italy (n = 10), and Germany (n = 10) (Fig. 3c).

The USA leads significantly in total citation counts and H-index rankings, ahead of other countries. The H-index indicates both a large scale and strong quality. However, in terms of average citations per paper, Italy, the Netherlands, and Australia rank in the top three, reflecting a higher quality in terms of citations.

(a) Top 10 countries or regions with the highest total number of citations on healthcare TQM; (b) Top 10 countries or regions with the highest average number of citations per publication on healthcare TQM; (c) Top 10 countries or regions with the highest H index on healthcare TQM. (1991–2022)

Figure 4a shows the top ten journals with the highest number of publications.

The Journal of Applied Clinical Medical Physics published the most articles/reviews (14 publications), surpassing other journals in this field. The second highest number of publications came from Clinical Chemistry and Laboratory Medicine, Accreditation and Quality Assurance, Journal of Continuing Education in The Health Professions, with a total of 10 articles/reviews. Additionally, there were 9 publications in Journal of Operations Management, 7 in Biochemia Medica, and 7 in Military Medicine.

(a) The top 10 journals in terms of publication quantity on healthcare TQM; (b) The top 10 research topics and orientations on healthcare TQM; (c) The top 10 authors in terms of publication quantity on healthcare TQM; (d) The top 10 institutions in terms of publication quantity on healthcare TQM. (1991–2022)

Figure 4b shows the top 10 research topics related to TQM in healthcare services. The most common areas of research were Health Care Sciences Services (69 publications), General Internal Medicine (41 publications), Public Environmental Occupational Health (29 publications), Medical Laboratory Technology (27 publications), and Radiology Nuclear Medicine Medical Imaging (25 publications).

This reflects research papers focusing primarily TQM in services management, followed by studies in fields such as internal medicine, occupational health, and medical experimental technologies. It highlights that management topics constitute the predominant focus of TQM research.

Figure 4c shows the top ten authors with the most publications in this field. Among them, Libeer JC ranked first with four articles/reviews, and Bissonnette JP, Cohen DJ, Ehrmeyer SS, Freniere N, Goldschmidt HMJ, Laessig RH, Lippi G, Pomer-Leau-Dalcourt N, Villarreal-Barajas JE, Vogt W followed with three published articles/reviews.

The University of California System, and the University of Wisconsin System have the highest number of publications, with 11 publications each. The US Department of Veterans Affairs has ten publications, followed by VHA (Veterans Health Administration) with nine publications. The top 10 institutions with the highest number of publications are presented in Fig. 4d. This reflects that university research still has the highest publication volume in this area, followed by various other types of research institutions.

Co-authorship analysis demonstrates the correlation between items based on the number of co-authored documents [33], which is a potent instrument for evaluating collaboration patterns and identifying leading scientists, countries, and organizations [34].

In Fig. 5a, VOSviewer was used to analyze 61 authors with at least two publications. The top 11 authors with the highest TLS scores are shown in the red cluster on the right side of the figure, represented by Freniere, Normand (citation count = 19), Bissonnette, Jean-Pierre (citation count = 18), and others. VOSviewer also shows three authors with the highest citations (citation count = 479): Friedman, Susan M., Kates, Stephen L., Mendelson, and Daniel A. (all three TLS = 4). They are in the light blue cluster on the upper part of the image.

According to the Fig. 5a, we can observe that the red group forms the largest collaborative authorship cluster, they come from various research institutions and medical centers across Canada, forming the most prominent research group with evident connectivity strength in this field.

(a) Co-authorship analysis on healthcare TQM (n = 61); (b) Co-authorship analysis of countries and regions on healthcare TQM (n = 25); (c) Co-authorship analysis of institutions on healthcare TQM (n = 79). (1991-2022)

A total of 25 countries and regions with a minimum limitation of at least three publications were identified and analyzed using VOSviewer (in Fig. 5b). The top five countries and regions with the highest TLS scores are presented as follows: the Netherlands (TLS = 30 times), the United States (TLS = 30 times), Germany (TLS = 29 times), Sweden (TLS = 22 times) and Italy (TLS = 19 times).

This finding aligns with the analysis of publications where the USA dominates in terms of the highest publication volume. Institutions and authors from the USA are the most frequent collaborators in multinational research articles.

As shown in Fig. 5c, a total of 79 institutions had at least two publications included in the study and were analyzed using VOSviewer. In addition, University of Calgary (TLS = 30 times), Tom Baker Cancer Clinic (TLS = 29 times), University of Toronto (TLS = 29 times), Juravinski Hospital and Cancer Centre (TLS = 28 times) and Princess Margaret Cancer Centre (TLS = 28 times) were the top five institutions with the highest TLS scores.

These highly collaborative research institutions are from Canada, and the largest red institutional collaboration network in the Fig. 5c indicates that these conditions are consistent with the observation of the largest clustering in the authorship collaboration map originating from Canada.

Co-citation analysis of journals based on VOSviewer establishes the relationship between items by examining how often they are cited together. Co-citation analysis identifies the connection between two references by counting the number of times they are jointly cited in another article, thereby creating a network of all references within a research area, known as the “intellectual structure [25]. " This approach is useful for identifying key literature that can help support cross-disciplinary ideas. In the co-citation visualization figures, the size of the circles in the image represents the corresponding TLS values of each entry. Specifically, larger circle sizes indicate higher TLS values [33].

A total of 78 journal with a minimum number of citations greater than 20 times data points are included in the visualization Fig. 6. The top five journals with the highest TLS scores are illustrated as follows: JAMA-Journal of The American Medical Association (TLS = 10,969 times), Critical Care Medicine (TLS = 8606 times), New England Journal of Medicine (TLS = 6845 times), Medical Care (TLS = 5010 times) and Annals of Internal Medicine (TLS = 4950 times).

Co-citation analysis of journals on healthcare TQM (n = 78,1991–2022)

In the green cluster, JAMA and NEJM are the two core publishing medicine journals occupying the most central position, with academic journals on general medicine as the main content of the green cluster, including journals on medical biology and experimental biochemistry.

The blue cluster includes The LANCET and some specific field medicine journals in the small cluster on the right side, as well as journals on healthcare quality and safety and healthcare quality improvement in the upper left corner of the blue cluster.

In the red cluster, the core journals include the Journal of Operation Management, Health Service Research, and Management Science, which focus mainly on the researches on managerial studies and healthcare organizational management.

A total of 55 publications were included in the study with each reference had a minimum number of citations greater than 5 times, and were analyzed using VOSviewer (Fig. 7). The top five publications with the highest TLS scores are presented as follows: Shortell SM, 1995, Health Services Research, v30, p377 (TSL = 167 times, cited 37 times), Shortell SM, 2000, Medical Care, v38, p207 (TSL = 104 times, cited 17 times), Berwick DM, 1989, New England Journal of Medicine, v320, p53 (TSL = 64 times, cited 21 times), Deming W.E., 1994, Out Crisis, MIT Press (TSL = 64 times, cited 17times) and Meterko M, 2004, Medical Care, v42, p492 (TSL = 62 times, cited 7 times).Table 1. below shows the detail of the five highest co-cited publications, including the full titles and corresponding references.

Among the publications, the top one cited, and top one TLS publication was published in 1995, Assessing the impact of continuous quality improvement/total quality management: Concept versus implementation [35], in which the researchers found that a participative, flexible, risk-taking organizational culture was related to quality improvement implementation. Quality improvement implementation was associated with better patient outcomes and human resource development. Larger hospitals had lower clinical efficiency due to bureaucratic and hierarchical cultures hindering quality improvement. According to the figure, the article most highly co-cited is situated in the central part of the graph, connecting with various clusters, clearly indicating its top position in this field.

Co-cited analysis of reference publications on healthcare TQM (n = 55,1991–2022)

Keywords are an essential part of a research publication and contain the vital information [40]. Co-occurrence analysis effectively uncovers relationships between research items, especially keywords based on their co-appearance in publications [33].

A keyword map of TQM in healthcare is presented, where node size signifies frequency and lines between nodes represent co-occurrence [22].

A total of 1433 keywords were included, and 49 met the criteria of over five occurrences. All keywords were grouped into five clusters (Fig. 8): total quality management (in yellow color), quality assurance (in red color), healthcare and performance (in green color), implementation (in blue color), and models (in purple color). The keywords-clustering processing provide insights into the most prominent topics and trending keywords related to total quality management in modern medical services management.

Keywords clustering co-occurrence analysis on healthcare TQM (n = 49,1991–2022)

In the “total quality management” cluster, other important keywords are “quality improvement”, “quality of healthcare”, and “six sigma”. In the " quality assurance " cluster, other main keywords are “quality”, “patient safety”, “management” and “quality indicators”. The main keywords in “implementation” cluster, others are “impact”, “outcomes”, and “interventions”. The cluster centering keyword “healthcare and performance”, other keywords are “quality management”, “accreditation”, “systems”. The cluster of “models” as its main word, other keywords are “program”, and “EFQM” in purple cluster is an acronym that stands for: European Foundation for Quality Management and its homologous EFQM model, the model is of great importance in the evolvement of quality management theoretical field [41].

The study will analyze and discuss these different clusters shown in different colors, revealing the distribution of key terms in healthcare TQM research field and the interrelationships among several categories of research focus.

VOSviewer assigns a continuous gradient of colors to each keyword based on their chronological appearance in the included publications [33]. Keywords that appear earlier are assigned darker colors, while keywords that appear later are marked with green, light green, and yellow colors and this research marked the average occurrence year in the development process of this field.

Keyword evolution analysis by year on healthcare TQM (n = 49,1990–2022)

Figure 9 revealed the development trend of keywords in over the near decades. Prior to the year of 2005, academic research topics and keywords focused mainly on continuous quality improvement, practice guidelines, and assurance.

From 2005 to 2015, research keywords shifted to quality management, quality assurance, healthcare, implementation, impact and a term efqm. And the year of 2010 witnessed the transformation of healthcare TQM from traditional industry TQM concept like six sigma, intervention, etc. to a new concept more suited to the healthcare industry, such as measures of clinical outcomes, patient safety, and safety indicators.

After 2015 and until nowadays, keywords in this field of research changed to organizational performance, efficiency, services safety, systems, and errors. In the recent years, keywords of efficiency and safety climate are trending, takes important places in the field of quality management for a healthcare organization, and they are hotspots in the current studies and academic research [42, 43].

These changes in research keywords over time indicate trends and processes of changing directions in this research field at different periods. Meanwhile, recent trends shown in light color suggest that research trends in the other clusters are diversifying, indicating that these research objects’ keywords are changing to varying degrees and have different research priorities.