Degree Name

Doctor of Philosophy


Graduate School of Public Health - Faculty of Health & Behavioural Sciences


In 1997, Thailand suffered a severe economic downturn. The government was obliged to control health spending whilst also attempting to maintain the quality of hospital services. In the same year, the Thailand Hospital Accreditation Program (HA-Thai) was established. This built on earlier accreditation schemes, and an initial group of thirty-five public and private hospitals joined the program. This study explores the strategies the managers of these 35 hospitals used to maintain the quality of their services since the economic downturn. It also investigated the managers’ perception and understanding of the Hospital Accreditation Program. Little is currently known about the use of quality management within Thai hospitals. The aim of this study was to provide evidence of how hospital quality management was being implemented and how its practices were affected by the economic crisis.

The study used a mixed method approach. This was felt to be appropriate given the little that was known about quality management in Thai hospitals. Baseline data were collected by a survey questionnaire. This collected data on which components of Total Quality Management (TQM) were used by the thirty-five hospitals. The hospitals were also requested to provide their strategic plans (or other planning documentation) and their financial reports or annual budgets between 1996-1999. Finally, interviews were conducted with thirty-two top and middle managers from four public hospitals in different provinces and of different size. Public hospitals were selected because they had less access to alternative means of funding than private hospitals and, therefore, their quality programs may have been affected more by the economic downturn.

The survey questionnaire was returned by 28 hospitals (80%) in the HA Thai program. Statistical analyses were conducted to assess whether quality management activity was related to public/private status, hospital size, location and whether the hospital was fully or partially accredited. The small sample size lacked sufficient power to identify any statistically significant relationships. Nonetheless, various features were noticeable in the responses of the hospitals. Many had adopted core aspects of TQM, including the communication of the quality management principles, extensive training for various categories of staff, a customer focus, and a broad involvement of staff in hospital decision making. Fewer had strategic plans that included quality, and over half of those hospitals responding thought TQM was an adjunct to management practices rather than being fully integrated. Few hospitals used quality costing, or appeared to understand the concept.

All respondents reported collecting data on quality performance from either patient and staff surveys (or both), as well as using customer complaints. These data were primarily used to improve performance in specific areas, but none seemed to use widespread statistical monitoring. Eight hospitals reported benchmarking their services. Nursing and administrative tasks were most involved in implementing quality programs. But despite this, the perceived success of the TQM initiatives was limited. No hospital reported a decline in costs, average length of stay, customer complaints, or number of re-admissions. This may have been linked to barriers that the hospitals reported to TQM implementation. Some hospitals reported that it was too expensive, did not have support of key personnel, or had found that information was either not available or too difficult to obtain. These were consistent with problems reported in other studies but may also reflect the difficult financial circumstances that the hospitals were operating under.

The 32 interviewed managers provided greater insight into their approach to quality management. They revealed that each of the four hospitals implemented quality strategies, including joining the HA-Thai program as a way to maintain quality during the economic downturn. The strategies increased the public recognition of the hospitals and were regarded as helping the hospitals cut costs while maintaining quality. The CEOs were regarded as being the main quality instigator. Nonetheless, there were many uncertainties for hospital staff, notably job security. Increased workloads from new quality related administration and increased patient demand, fewer resources and decreased training opportunities were common experiences. The clinical managers had some concerns about the appropriateness of the HA-Thai program for clinical services, and doctors were reported to be apprehensive, feeling they had not been consulted. Doctors also believed they were already providing a quality service. Overall, the managers thought the benefits outweighed the difficulties involved in setting up the program.

The analysis of strategic plans was fairly limited. The survey responses suggested that 16 hospitals had strategic plans, and nine hospitals submitted planning documents. Not all documents were complete and many did not contain an internal/external analysis of the hospital’s operating environment. Yet, all plans were produced in 1997 or after, demonstrating their importance to senior management. Moreover, several contained objectives that directly related to the economic crisis.

All hospitals made some mention of quality in their plans, but it is quite limited for several hospitals. All but two hospitals mentioned training, although it is unclear whether there was more or less than before the crisis. This seems to show a commitment to quality improvement as the direct effect of training is difficult to quantify. Another common quality initiative was to apply for ISO9002 accreditation. This also indicated a strong quality focus because the ISO9002 scheme involves extensive documentation and its implementation is likely to increase costs.

What the plans did not contain was also interesting. None of the plans reflected a complete “customer focus”. This was demonstrated by a lack of commitment to consulting with the local community and only a few plans contained strategies to involve customers or staff. Other aspects of TQM that were not mentioned included quality costing, and benchmarking.

Unfortunately, the final aspect of the analysis provided little insight. Few hospitals supplied financial reports, possibly for commercial/privacy reasons. Moreover, the information in the supplied documents was not sufficiently consistent nor detailed to determine how the economic crisis affected individual hospitals.

In conclusion, the study findings suggest that these 35 Thai hospitals maintained a commitment to quality management during the economic crisis. Managers appear to be convinced of the long term benefits, and are prepared to work through the difficulties of implementation, including some staff dissatisfaction and an apparent lack of measurable benefits. Despite the economic downturn, the hospitals continued to adopt various quality initiatives, involving mainly nursing and administrative staff. They also continued to provide quality training. In other areas, the use of TQM principles seemed less developed. The study did not identify examples of statistical monitoring, or the use of quality costing. In relation to the HA-Thai accreditation program, the managers were convinced that external accreditation was required to ensure the reputation of their organisation in the community. The managers did not view it uncritically, however, and suggested that it needed to increase transparency and clarity of instructions.

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