Serpil AYDIN, MD
Asst. Prof. of Family Medicine
Adnan Menderes University School of Medicine
Department of Family Medicine
(ex member of "quality management team of
Suleyman Demirel University Hospital")
Suleyman Demirel University Hospital
member of "quality management team of Suleyman
Demirel University Hospital"
Fusun ERSOY, MD
Prof. of Family Medicine
Yuzuncu Yil University School of Medicine
Department of Family Medicine
Mimar Sinan Mah
Sinan 4 Sok
No: 39, Dus Bahceleri Sitesi
09100 AYDIN, TURKEY
Phone: 90 256 219 6181
Fax: 90 256 214 6495
This article was presented as poster during
the WONCA EUROPE 2002, 9-13 June 2002, London.
Date of Submission: 01
There is a worldwide improvement
in health care and quality systems. Quality is
a very important issue for primary care, which
is the initial step in health care. Total quality
management (TQM) is one of the most common quality
systems, which can be applied in the health sector.
There is also an effort to develop Turkish primary
care. In this article, information about TQM will
be given and the current status including defects
in the Turkish primary care system and possible
solutions should be discussed.
Key Words: total quality management;
primary care; Turkey; health care
The diagnosis, therapy, rehabilitation,
and prevention of diseases and promotion of public health
can be considered as health care services (1). Health
care centres or institutions provide the health care.
Health care is a special situation which has to be given
immediately and cannot be delayed. Depending on the
caregivers' who are working and the patients, the tolerance
margin can be very low. As health requirements differ
from one person to another, the health workers' jobs
Health care services have to be not only
easy to access and use, but also must be qualified,
patient-centred, continuous, productive, professional,
and standardised. Caregivers are accepted as inner customers,
and their requirements should be regarded; they should
receive adequate payment and be managed effectively
We can consider health care as a three-step process
(1). The initial step is primary care (PC), which includes
preventive, diagnostic, and treatment properties as
well as continuous care. It is easily accessible and
cost effective. Secondary care (SC) includes diagnosis
and treatment, which is not available in PC. Tertiary
care (TC) is used for diagnosis and treatment that cannot
be performed in PC or SC. Only the patients who require
more detection should be examined in TC.
Therefore, primary care services have
to address the majority of the community needs. In a
study (2), 94% of American patients value the role of
a primary care physician (PCP) as a source of first-contact
care, and 89% value the PCP as a referral coordinator.
In that survey, considering the specific medical problem,
75% to 91% of the patients generally prefer to seek
care initially from their PCPs rather than specialists.
In Germany, patients' perceptions of the quality of
the doctor-patient relationship along with trust and
confidence in their PCP are found to be very important
There is another important point which
should not be missed in accessing the health care services--the
financial aspect. If a doctor misses the diagnosis in
the PC, the cost will be higher, or, if the patient
uses TC first, then the cost will also be higher (1).
Especially in a developing country like Turkey, the
financial aspect becomes much more important.
WHAT IS TOTAL QUALITY MANAGEMENT?
There is a real improvement in the concept
of quality all over the world, especially in health
care systems. Today, physicians are facing increased
demands to improve patient care and are forced to find
solutions for health care delivery problems. In the
last decades, the quality of health care has become
an important issue worldwide (3).
Quality has some basic principles like
proficiency, being reachable, efficiency, productivity,
continuity, reliability, and satisfaction of both the
staff and the customer (4, 5, 6). The importance given
to quality improves day-by-day, and a wide standardisation
and qualification effort is spreading around the world.
One of the most important concepts of quality is "Total
Quality Management" (TQM).
This approach began in the production
sector, and it spread quickly to other sectors. TQM
methodology is based on promoting health care quality
and minimising cost and losses (4). Top management commitment
to TQM drives participation at all levels within an
organisation to get involved in every step of the process
and to fulfil the requirements of TQM.
In health institutions, qualified service
and care requires determining the current level of quality,
continuous improvement, distributing the responsibilities
and activities, satisfying both the inner and outer
customers (staff and patients), informing society, labour
division, and continuous education in every step and
In order to be successful, the needs and expectations
of the customers would be known. Service or care must
be produced and served at minimum cost and maximum quality.
TQM focuses on the quality, customer, and process. Every
step in the TQM process has to be controlled continuously.
The TQM process is a scientific process to help develop
the people, improve society, and prevent mistakes before
they occur (7).
According to Asubonteng et al., TQM in
health care comprises a number of strategies which are
very important to improve quality and reduce costs,
for example "customer needs, standardization, striving
for zero defect, reducing outcome variability, eliminating
the cost of poor quality, using statistical methods
to identify and monitor processes and continually working
for improved quality" (8). They suggest to apply
"top management leadership, corporate framework,
customer focus, employee education and training, benchmarking,
quality measurement, recognition and reward and integration
with the process" in order to implement TQM in
primary health care.
OF TURKISH HEALTH CARE SYSTEM
Primary care has been served by government
in PC centres in Turkey since the Socialization Law
in 1961, but day by day many problems began to occur
and the quality and efficiency problems of Turkish PC
oblige the patients to seek SC and TC initially at hospitals
(9,10,11). Although some interventions have been tried,
the Turkish primary health care system is still not
working efficiently (12, 13).
After completing the six-year-basic education
and graduating from medical school, Turkish medical
students have to pass a national examination in order
to become a specialist. Otherwise, they must deal with
patients in PC centres without any postgraduate education.
Without specialization, they are called "practitioners."
There are also PC physicians who have at least three-year-postgraduate
education -called "Family Physicians", including
about 800 family medicine specialists and 600 family
medicine residents in Turkey. They are employed to work
in PC centres and in SC and TC hospitals. A few of them
are working in the private sector, also. Other specialty
groups are working in SC or TC hospitals or the private
sector. In general, our students feel unprepared to
work in PC after graduation; many expect to enter hospital-based
specialties and are inclined to specialise in order
to work in PC (14, 15, 16, 17). We can say that both
students and patients, or the community in general,
are unwilling to participate in and do not rely on PC
in our country.
| DEFECTS AND
and inadequate use of resources, considering the efficiency
and productivity, increases the expenses. High cost,
neglecting the importance of health care, insufficient
budgets, poor resource allocation, considering health
care as a consumption sector; and inadequate policies,
damage the health care system and create a large imbalance
(18). The Turkish government should have audit responsibility.
TQM concepts need participation by the top management
in every step, so these kinds of defects can be solved
by the TQM process.
- Although they
are employed by the government, caregivers should not
be considered as government officials. Difficult and
longer working hours, hard working conditions, and a
specific mission that cannot accept any mistake or inattention,
put the caregivers into another profile (19). This can
also be solved by TQM as caregivers will be considered
as "inner customers". The "inner customer
satisfaction" is very important in TQM as it can
cause "outer customer satisfaction" (7). Professional
satisfaction can lead them to more effective and productive
working and this provides a more qualified service and
care for patient satisfaction.
- There are adequate
numbers of PC centre doctors (20). However, there is
no efficient and sufficient associate staff and equipment
in care giving and the medical education system needs
to be changed to train students for PC. TQM gives great
importance to education, and continuous education in
TQM is needed to solve this defect.
- An efficient
registry system has to be established for the entire
country. Feedback is not possible for patients who are
forwarded to SC and TC (21). Family medicine applications
also need a good registry system. TQM provides standardisation
and registration in every step, which is needed to resolve
- Patient satisfaction
can be obtained after a qualified PC has been established.
Efficient PC also has a positive effect on SC and TC
and prevents needless waiting in hospitals (18). In
our opinion, if an effective family medicine system
using TQM concepts can be established, improvements
will come spontaneously. In Cuba, for example, teams
consisting of a family physician and a nurse have reduced
hospital applications by 18% during 1985-90 (18).
- Turkish medical
education needs to be revamped, and we must diminish
the contingent of the medical schools (Every year about
5000 medical students graduate from 47 schools, it is
much more than needed (20)). The education system of
the associate staff must also be revamped (21). Education
of all staff is a necessity in TQM, so TQM concepts
would resolve this defect.
Transition to TQM will be difficult if
a new, more effective PC system cannot be properly established.
With governmental support, the transition period can
be easier (22). If TQM becomes a governmental policy,
it can be applied to all sectors. Although it would
be difficult to apply in many areas at the same time,
pilot centres and regions could be chosen in order to
improve success. It must be understood that implementing
the TQM principles will take a long time.
Although we are encouraged to know that
the TQM approach has considerable influence in many
Western countries and particularly in Western hospitals
(23), we must create our own PC system model instead
of copying other countries. Arranging the quality management
teams according to specific needs, can simplify auditing
The TQM process helps us to understand
the needs of the staff and the patients. If a quality
concept is applied in an entire area and the population
is informed, implementation will be easier. It should
not be forgotten that temporary solutions only last
for short periods; if we want permanent solutions, we
must first identify the reasons so that we can then
solve the problems. We should also keep in mind that
we need continuous education in all the areas of the
health care. If we can establish a good model for TQM
in primary health care, it can lead us to be successful
in the other steps.
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