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 become harder.

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 (1).
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 preferences (2).

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.

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 field (4).

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.

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.

- Insufficient 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 this defect.

- 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 and counselling.

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.

We acknowledge Janice Overstreet Vantrease for her grammatical review.