Challenges to institutionalizing sustainable total quality management programs in healthcare systems of post-Soviet countries.

• Author: Cholewka, Patricia A.
• Position: Abstract

Abstract

Critical changes are occurring on a worldwide basis in the organization, financing, and delivery of healthcare services. A little over a decade after declaring their independence, the nations of the former Soviet Union continue to restructure their political and socioeconomic infrastructures as they move from centrally-planned to market-driven economies. In order to do this within social transition efforts, healthcare program managers realize the need to utilize more effective management methods if social services are to continue to be provided. Organization management concepts developed and used in the countries of the West, that is, the United States and the European Union are being sought for incorporation into these evolving administrative systems. Demands by practitioners and patients for advanced technology and improved healthcare services, as well as economic restraints imposed by their governments and external investors, are driving this economic sector's transformation. Economic impact studies performed by global organizations have recommended that management programs be developed for these countries at the microeconomic (organizational) level using Total Quality Management concepts. This is because, for sustainable development, the structuring and functioning of their institutions must be reformed, strengthened, and stabilized using more democratic means. In other words, implementation of decentralized, cost-effective, market-oriented management policies and practices by these nations is a crucial determinant for their continuing integration into the global community.

Introduction

This paper will be presented within an East-West perspective, i.e., post-Soviet-US/EU, regarding the sustainable development of the healthcare systems of post-Soviet nations. Its primary focus is not to propose specific economic solutions or discuss program outcomes but to share the author's insights gained from her experiences presenting healthcare management programs in the Central and Eastern European (CEE) nations and Newly Independent States (NIS) of Bulgaria, Lithuania, and Ukraine. Discussion will also include the enabling and inhibiting transcultural issues that healthcare educators, advisors, consultants, and policy makers should be aware of before attempting to design and implement Total Quality Management (TQM) programs within these healthcare systems. General policy recommendations for the development of sustainable TQM programs will be posed considering the operating environments into which these programs will be introduced.

Reforming Post-Soviet Healthcare System Management

Economic impact studies performed by the United Nations World Health Organization (WHO), the World Bank (WB), the United States Agency for International Development (USAID), and the Commission of the European Communities (CEC) have recommended that management programs be developed for post-Soviet countries using TQM concepts (Cleland, 1997; Commission of the European Communities, 1997; International Bank for Reconstruction and Development/The World Bank, 1993, 1997). In 1997 the CEC concluded that globalization and increased economic integration of these nation-states make cost-effectiveness a crucial determinant of sound economic policy for nations seeking integration into the enlarging European Union. Thus, the composition of institutions and their functioning must be reformed, strengthened, and stabilized.

This need for new management systems, and for healthcare improvement programs in particular, creates a challenge for healthcare management consultants to develop and present management training programs that are culturally sensitive, adaptable, and sustainable to the organizational and socioeconomic needs of these countries. McLaughlin and Kaluzny (1994) define Total Quality Management as a comprehensive approach to improving an organization's economic competitiveness through efficiency, effectiveness, and flexibility by involving each individual at every organizational level in the planning, organization and understanding of each activity. TQM must start at the top of the organization with a continuing demonstration of executive management commitment to quality. This commitment ensures the adoption of a strategic overview of quality with a focus on the prevention, not detection, of problems through process management. Thus, theoretically, organization management is not just implementing interventions in response to day-to-day responses to spontaneously occurring 'crises.' The core of TQM is the customer-supplier relationship. Holt (1993) defines efficiency as the result of making decisions that lead to doing things right, which helps to achieve the objectives of an enterprise with fewer resources and at lower costs. He defines effectiveness as the result of making decisions that lead to doing the right things which helps to fulfill the mission of an enterprise.

Although over ten years have elapsed since the CEE and NIS nations declared their independence from Soviet Russia in 1991, few sustained economic results have been observed although various socioeconomic transition programs have been 'instituted' by various Western countries. Why have the economic objectives of these programs not been realized? Why has socioeconomic 'progress' toward more democratic and market-oriented economies been sluggish at best? Perhaps it is because no clear, obtainable goals, or accountability for meeting these goals, consistent with cultural norms, have been factored into these externally imposed development programs. Perhaps it is because the West overestimated the collapse of failed Soviet ideology with a victory, and supposedly overwhelming acceptance, of its own democratically oriented system. Most likely, these privatization 'reforms' have been carried out in a poorly managed, uncoordinated manner within a system that had no stable base to readily incorporate democratic, market-centered tenets of a civil society.

Few in-depth, long-range studies have been undertaken to address the total healthcare system management needs of these nations, as well as the results of these programs, in a comprehensive manner. But far more importantly, the extent of dissatisfaction by the populace of these nations with the depth of political corruption and social disintegration of the Soviet system has never been effectively gauged nor fully acknowledged and addressed by the West. Issues that have effected the state of health and quality of life issues in these nations such as extant political ideology, widespread corruption, pervasive cynicism, entrenched mistrust of the West, lack of initiative and motivation, intellectual heritage of both leadership and citizenry, and the lack of components of a basic civil society have to be considered when designing any organizational change effort. In addition, acknowledgement by the West of the rebirth of a national consciousness concerning their ethnic identity and cultural heritage once suppressed by Russification will play a major part in establishing a working relationship with government and organization officials in these nations. TQM offers managerial concepts and techniques for self-governance and self-determination to post-Soviet organizations to become more effective, efficient, and more community focused. However, TQM will be sustainable only if accepted and promoted by organization leadership within a more transparent and democratic political environment (see Table 1).

The difficulties with post-Soviet socioeconomic reform efforts by these nations should touch the conscience of American (and other Western-sponsored) economists, political scientists, and other reform 'experts' who presumed to merely 're-adjust' the former 'evil empire.' Although well-meaning, these 'experts' should have been more alert to the underlying and all-encompassing political ideology that perpetrated the economic and social problems that people of the former Communist countries would face en route to the promised land of democracy and its market economy (Sims, 1999).

Social change should not be gauged in economic terms alone. It involves more of an ideological shift based on education to build human capacity and influence entrenched behavior. This is a long-term commitment on the part of the West to encourage, and accept, incremental change. The building of trust in the West by these societies can be accomplished through successful, evidence-based program implementation and outcomes realization with an observable and tangible impact on an individual's work environment and economic condition. Successful implementation of healthcare TQM programs in the post-Soviet political environment involves consideration of pre- and post-independence system environmental factors (see Table 2) as well as all of the following: 1) the political will to acknowledge that a problem exists; 2) agreement by leadership to commit resources to establishing the program; 3) managerial ability and continued strength of commitment of leadership; 4) an implementation plan; 5) active, visible involvement by leadership; and 6) policies to promote and support the establishment of an infrastructure to carry out the program. A system of accountability built into these programs is necessary to gauge progress. Current development programs should be seriously re-evaluated regarding the accountability of attaining...