Organizational democracy: A quality mandate for health care organizations

Date of Award




Degree Name

Doctor of Philosophy (Ph.D.)



First Committee Member

John W. Murphy - Committee Chair


In response to the current health care crisis, health care organizations have experimented with new management forms. Of these, Total Quality Management (TQM)/Continuous Quality Improvement (CQI) programs propose staff empowerment, democratic decision-making, and work processes to enhance care delivery outcomes. Thousands of hospitals have adopted variants of TQM/CQI at costs exceeding billions of dollars nationally. Many programs are unsuccessful, and drain resources for services to the indigent and uninsured.Investigations on quality management systems focus primarily on executive management and physician integration. These data limit evaluations to structural changes, and rarely report the effects of "totalizing" management forms on line staff, i.e., those ultimately charged with implementation of program initiatives.The purpose of this study was to examine TQM/CQI process variables at the clinical staff level, where patient care is most affected. Critical ethnography provided the research framework. This approach triangulates dialogic, empirical, and institutional process variables in data collection methods and analyses. The goal of such methodology is to explore the political economy and interpersonal dynamics that shape organizational culture and activities.Five hospitals made up the cases in this study: three academic medical centers, one non-profit community hospital (800+ beds), and one non-profit rural hospital (220+ beds). These facilities are located in New York State, North Carolina, and Florida. Open-ended interviews culminated in a sample of fifty-five participants.Analyses of case ethnographies exposed numerous limitations to the implementation of TQM/CQI ideology. Caregivers consistently reported being isolated inter-and intraprofessionally, and believed their ability to provide "safe" and "quality" care had diminished. The use of pragmatic, interpretative philosophy guided theoretical assessment of the social and interpersonal contexts reported by participants. Through examination of the culture of bureaucracy that directs care organizations, reconceptualization of the social process of alienation was proffered for pedagogic and research consideration in organizational sociology.Recommendations for the democratic restructure of care organizations are presented. Efforts for transformation must include the integration of social philosophy and theoretical praxis. These findings suggest such endeavors be redirected from management to line staff who actualize care processes, for it is at this level that theory and practice are conceptualized for application.


Sociology, Theory and Methods; Sociology, Industrial and Labor Relations; Health Sciences, Health Care Management

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