Implementing management tools in Turkish public hospitals: the impact of culture, politics and role status

Abstract

The government of Turkey has attempted to substantially improve the management of its public hospitals. However, an analysis of the performance of the quality certified hospitals finds only minor improvements. This study seeks to explain these disappointing results by interviewing 46 hospital managers and employees about the successes and failures of the management reform effort. The interviews suggest that traditional Turkish organisational culture often hinders attempts to decrease hierarchy, but, more positively, it also encourages the use of frontline teams and group rewards. Moreover, Turkey's hybrid system of allowing public doctors to maintain private practices has provided doctors with both the resources and the incentives to fight management reform efforts. Finally, organisational decentralisation in Turkey has evoked fierce political opposition, ironically even from many pro-modernising forces that fear it could increase the power of Islamic fundamentalists. Turkey's experience suggests a number of broader points about management reform in non-western societies. It suggests that decentralisation can often impede, rather than strengthen the other aspects of management reform; that a hybrid market organisation is often harder to move toward market efficiencies than a purely governmental one; and that national cultures should help guide the order in which reform tools are implemented. 1 ISO 9001 certification is most closely associated with 'quality management'. Although the distinctions are not always consistently followed in the literature, 'New Public Management' often connotes internal management reforms combined with a strong emphasis on market-like incentives and privatisation, while 'quality management' often connotes internal management reforms alone. The Turkish government has indicated that it hopes to eventually move its health sector toward vouchers and other forms of privatisation (i.e. toward New Public Management), but those major changes are well in the future. In the interim, it is trying to improve quality. 2 ISO certification criteria may in some cases understate the management tools that have been implemented by the certified hospitals because most of the certified hospitals have attempted to add additional management (i.e. quality) improvements beyond the ISO requirements. This would be of concern if we found major measurable efficiency and effectiveness improvements because then we would be unable to answer whether it was ISO 9001 or 'ISO 9001 plus some additional management tools' that caused the improvements. Because we do not find major improvements, any additions of yet more quality-oriented tools simply strengthen our case that implementation problems are at least a partial cause for the disappointing results. 3 The only study of the broad impact of recent management changes on Turkish hospitals is Ates (2004). However, the Ates study focuses on very different questions than does this study.

Obstacles to TQM success in health care systems

“…ISO 9001 directs managers to re-examine all their processes and identify any discrepancies between what employees are actually doing and what the documentation asks to be done. It focuses on processes rather than outcomes (Ozturk and Swiss, 2008). ISO 9001 encourages employees to demonstrate compliance with the procedures, rather than to strive for continuous improvement.…”

“…Employee IJHCQA 26,2 empowerment, commitment and involvement are key factors in the successful implementation of TQM and, were indeed included in previous TQM studies. Various studies have shown that human resources problems such as lack of employees' motivation and involvement in TQM activities, their low knowledge and experience about TQM implementation, changing employees' work habits, lack of team orientation, lack of linkages between employees' compensation and their performance and lack of time are human resource barriers in implementing TQM successfully in healthcare organisations (Alexander et al, 2007;Francois et al, 2003, Huq andMartin, 2000;Kozak et al, 2007;Mosadeghrad, 2005;Ozturk and Swiss, 2008;Withanachchi et al, 2007).…”

Experimenting with organisational development in Bhutan: A tool for reform and the achievement of multi‐level goals?

“…This audit, as opposed to change, approach to OD was also evident in the discussion of initial OD exercises in a paper co-authored by one of the SNV officers (Dorji and Schreven, 2007). This problem may be exacerbated by the requirement that OD takes place on a regular basis -imposed OD can be problematic and may, in the end, be counterproductive (although there are supporters of directive OD such as Rao and Vijayalakshmi, 2000;Ozturk and Swiss, 2008).…”

“…Evidence of such studies in a developing country context is even more elusive. Rather, both theoretical and empirical studies have been more focussed on how transferable Western management techniques are to non-Western and developing countries (Blunt and Jones, 1997;McCourt and Ramgutty-Wong, 2003;O'Donnell and Turner, 2005;Zupan and Kase, 2005;Ozturk and Swiss, 2008) and on the application of strategic human resource management and change concepts to public sector organisations (Tompkins, 2002). Such literatures provide very useful guidance on the opportunities and challenges of using Western-inspired management tools in development; however we still seem to be missing the connection between the adoption of such techniques and the complex set of multi-level goals which these tools are enacted in pursuit of.…”

Verification of a Quality Management Theory: Using a Delphi Study

“…The failure of TQM in healthcare is due to the complexity of the healthcare systems, bureaucratic and highly departmentalised structure, multiple layers of authority, professional autonomy, and tensions between managers and professionals (5)(6)(7). Insufficient motivation for professionals to participate in TQM initiatives, the difficulties involved in evaluating the processes and outcomes, and a lack of market based competition were the major obstacles to TQM implementation in the health sector (8)(9)(10). Other barriers to successful TQM implementation in health sector were authoritative leadership, lack of top managers' support, lack of employees' involvement, lack of a plan for change, inadequate resources, lack of a quality-oriented culture, insufficient education and training, poor communication, and lack of customer focus (11)(12)(13)(14).…”