Meet the Team

Prevalence of Otalgia in
Patients with Temporo-mandibular Disorders

Patient Satisfaction 18 months After a Two-day Quadruple Therapy for Helicobacter Pylori

The Prevalence of Hepatitis B Carrier State

Total Quality Management for Turkish Primary Care Current Status and Suggestions

Vaccination Practice in Saudi Arabia: Is it Safe?

Change in Medical Students’ Opinions and Attitudes Towards Mental Illness

First Annual International Primary Care Conference-Abu Dhabi-UAE

Announcement of the Second Course of the MEAMA

Launch of 'World CME'

Antibiotic Sensitivity Profile of Common Bacterial Pathogens in Dubai
– A study of 107 cases

Women's Health Week in Rawalpindi, Pakistan

Middle East Academey for Medicine of Aging First Course

Pan Arab Congress for Evidence Based Medicine

Childhood Emergencies


Dr Abdulrazak Abyad
Editorial office:
Abyad Medical Center & Middle East Longevity Institute
Azmi Street, Abdo Center,
PO BOX 618
Tripoli, Lebanon

Phone: (961) 6-443684
Fax:     (961) 6-443685


Lesley Pocock
medi+WORLD International
572 Burwood Road,
Hawthorn 3122
: lesleypocock


Total Quality Management for Turkish Primary Care Current Status and Suggestions


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"

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

Phone: 90 256 219 6181
Fax: 90 256 214 6495
Email: fusunersoy@mail.koc.net

This article was presented as poster during the WONCA EUROPE 2002, 9-13 June 2002, London.

Date of Submission: 01 June, 2005


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 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).

  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.


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.


1. Kavuncubasi S. Use of health services. In Management of the Hospitals and Health Services. First edition. Siyasal Publications, Ankara 2000. pg. 59-73. (In Turkish)
2. Liebow M, Bierman, AS, Fein O. The World We Live in: Health Policy from a Primary Care Perspective. J Gen Intern Med 2000;15(7):519-520.
3. Grol, R. Improving the Quality of Medical Care: Building Bridges among Professional Pride, Payer Profit, and Patient Satisfaction. JAMA.2001; 284:2578-2585.
4. Ozveren M. The improvement of Total Quality Management and basic principles. In Total Quality Management. Second edition. Alfa Publications, Istanbul 2000. pg: 52-79. (In Turkish)
5. Gann MG; Restuccia JD. Total quality management in health care: a view of current and potential research. Medical Care Research and Review 1994; 51(4):467-98.
6. Weaver CN. The effects of Total Quality Management on foundations. In The four stages of Total Quality Management. Second Edition, System Publications, Istanbul, 2000. pg. 277-293. (In Turkish)
7. Efil I. The characteristics of Total Quality Management as a management system and basic components. In Total Quality Management and ISO-9000 Quality System. Fourth edition. Alfa Publications, 1999, Istanbul. Pg. 139-185. (In Turkish)
8. Asubonteng, P, McCleary, KJ, Munchus, G. The evolution of quality in the US health care industry: an old wine in a new bottle. International Journal of Health Care Quality Assurance 1996;9(3):11.
9. Basak O, Atay E, Polatli D. The views of general practitioners on primary health care and family medicine. Turkish J Fam Med 2002; 6(1): 36-41. (In Turkish).
10. Sahin U. Suggestions for Healthcare Services. Modern Hospital Management Journal 1999; 3(4). (In Turkish) www.merih.net/wumisah01.htm (visited Feb 12, 2002)
11. Belek I, Ermis H. The Primary health care system in Turkey: the situation. Community and the Doctor 1995;10(67):35-43. (In Turkish)

12. Gorpelioglu S, Korkut F, Aytekin F. Family practice in Turkey. Fam Practice 1995; 12: 339-40.
13. Ersoy F, Sarp N. Restructuring the primary health care services and changing profile of family physicians in Turkey. Family Practice 1998; 15: 576-8.
14. Bakir B. The postgraduate expectations of students of one medical school. Community and the Doctor 1994;9(60):63-67. (In Turkish)
15. Yaris F, Topbas M, Can G, Ozoran Y. The assessment of perceptions on medical education Karadeniz Technical University School Medicine students. OMUTF J 2001;18(4):233-41. (In Turkish)
16. Acik Y, Oguzoncul F, Gungor Y, Gungor L. Perceptions of Firat University medical students on medical education and postgraduate period. Second National Medical Education Abstract Book, Izmir 2001:B3 (In Turkish)
17. Bilgel N, Bilgel H. The perceptions of last-year-medical students about medical education. Medical Educators Symposium Book, Istanbul 1996:16-21. (In Turkish)
18. Sahin U. Suggestions for our health care system. Modern Hospital Management J 1999. www.merih.com/wumisah01 (February 22, 2002) (In Turkish)
19. The situation of health sector. www.ttb.org.tr (Turkish Medical Association web site)(visited May 10, 2004) (In Turkish)
20. Hamzaoglu, O., Kiliç, B., Turkish health statistics. Turkish Medical Association publications. 2000, Ankara (In Turkish). pg. 28-29.
21. Unluoglu I. Quality in the primary care: Suggestions on the base of integrated health system. www.merih.com/wusah01 (February 22, 2002) (In Turkish)
22. Coruh M. Total quality management approach in health services. www.ato.org.tr/dergi/1999_3 (Ankara Medical Chamber web site) (February 24,2002) (In Turkish)
23. Grol R. Improving the Quality of Medical Care: Building Bridges Among Professional Pride, Payer Profit, and Patient Satisfaction. JAMA.2001;284:2578-2585.