An Empirical Case for Culture Change in Healthcare Delivery

Quality of healthcare delivery is a long-standing issue that concerns every individual member or group in society. The purpose of this paper is to identify problems with HRD functions in healthcare delivery and to suggest ways to improve and sustain quality healthcare delivery in Ghana. Using the FOCOS Orthopedic Hospital as a case study, data were collected using a qualitative research design. The following HRD functions: Program effectiveness, operating efficiency, service quality, financial stability, long versus short–term impact, tangible impact, client satisfaction, community support, publicity, employee satisfaction and commitment to the organization, trust in leadership, and altruism assessed as core indicators of high performance at the organization level, as well as the epitome of quality healthcare delivery. The results indicated that these factors presented different levels of importance to employees of FOCOS. However, there is universal agreement that the composite of these HRD functions and contextual performance indicators enhance quality healthcare delivery. FOCOS’ adherence to best practices in healthcare delivery presents a case for future research to adopt the culture espoused by FOCOS to help bridge gaps in healthcare delivery in Ghana. Unlike the traditional sectoral reforms that characterize healthcare delivery in Ghana, this paper proposes a holistic approach to culture change in healthcare delivery.

Quality of healthcare delivery is a long-standing issue that concerns every individual member or group in society. This inevitable phenomenon has attracted research interest spanning a broad range of disciplines, including the health sector and the social sciences. Hall (2013) reiterated the importance of healthcare to humans by stating that, "from the macro perspective an individual only leaves the healthcare system at the end of life because, he or she is constantly making decisions and engaging in activities that affect his or her health, whether or not under the direct care of a healthcare provider" (p. 6). Even though there has been significant improvement in healthcare delivery over the years, people continue to encounter problems mainly related to delays and scarcity of healthcare services in some parts of the world (Hall, 2013).
Despite numerous efforts to improve healthcare delivery, many problems continue to persist that need further attention. Chassin & Galvin (1998) classified problems in healthcare delivery into three main categories: "Underuse, the failure to provide a healthcare service when it would have produced a favorable outcome for a patient; overuse', providing healthcare service under circumstances that present more harms than benefits to a patient; and misuse, when an appropriate service has been selected but a preventable complication occurs and the patient does not receive the full potential benefit of the service" (p. 1002). Chassin and Galvin (1998) suggested a complete systematic overhaul in healthcare delivery that encompasses a conclusive definition of what quality of care means, educating and training clinicians, and continuous assessment of healthcare programs to ensure effectiveness.
Other researchers have identified problems such as variations in access to healthcare (Kim, Sinco, & Kieffer, 2007;O Connor, Llewellyn-Thomas, & Flood, 2004;Wennberg, 2002); cultural and linguistic problems (Cioffi, 2003;Goode, Dunne, & Bronheim, 2006); discrimination in healthcare delivery (Shavers, Fagan, Jones, Klein, Boyington, Moten, & Rorie, 2012;Stuber, Meyer, & Link, 2008); perceptions of bias (Johnson, Saha, Arbelaez, Beach, & Cooper, 2004); and differences in beliefs and attitudes about healthcare, as some of the issues that need attention. Bishop, Foster, Thomas, and Hay (2008) asserted that, some of these factors are more difficult to study such that their existence underscore the complexity of the problem. Mills (2014) conducted a study on healthcare systems in low-income and middle-income countries and identified service delivery issues such as, shortage and poor distribution of qualified staff; low pay and poor motivation; weak technical guidance; poor program management, and supervision; inadequate drugs and medical supplies; and lack of equipment and infrastructure, as some of the problems facing healthcare delivery (p. 554). Carney, M.
(2011) conducted a study at an acute healthcare facility and identifies some culture related dimensions as pertinent in the provision of quality care. These include, ethical values, involvement, professionalism, value-for-money, cost of care, commitment to quality and strategic thinking.
To help solve some of the problems associated with healthcare delivery, some researchers and practitioners have suggested ways such as, the use of disruptive innovation, thus, a product which is not as potent as the one already in use but, presents a more convenient and affordable access by those who otherwise may not have access to healthcare (e.g. Christensen, Grossman, & Hwang, 2009;Hwang & Christensen, 2008). To reiterate the need for disruptive innovation in healthcare delivery, Christensen et al (2009) Koning, et al., 2006). We propose, that in addition to the Six Sigma idea, a wellplanned cultural change and restructuring of the healthcare delivery systems will help achieve excellence in healthcare delivery. This cultural change and system restructuring should be tailored to serve specific needs within specific situations (Osafo & Yawson, 2017). At the later part of this paper, we present a model of Total Quality Care in healthcare delivery by altering the existing healthcare delivery culture in the countries of interest.

Purpose and Theoretical Framework of Study
The purpose of this paper is to identify problems in healthcare delivery and to suggest ways to improve and sustain quality healthcare delivery in Ghana. Cultural change themes underlie this research. Specifically, the Total Quality Care (TQC) Model will be presented in the later part of this paper as an ideal model to help reduce some of the institutional problems that threaten healthcare delivery in Ghana. The TQC model was developed based on data collected from FOCOS Orthopaedic Hospital. We will proceed with a brief overview of the theories of performance, because, improved performance is the basis of this study. Furthermore, we will review relevant literature on healthcare delivery and the problems encountered in the Ghana healthcare sector. Next, theories of performance which is the theoretical framework for the study will be discussed. Assumptions formulated from the literature review will be outlined, and a report of a case study conducted at the FOCOS Orthopaedic Hospital in Pantang, near Accra, Ghana discussed. The literature review will cover a broad range of materials including, journal articles, books, and other relevant material on healthcare delivery in Ghana. Literature will be accessed mainly from the electronic library of a large size research university in Midwestern United States. Keywords such as healthcare delivery, problems in health care provision, human resource issues in healthcare, and the quality of healthcare delivery in Ghana will be identified.

Theories of Performance
One important theory that cannot be overlooked when discussing issues of work performance is Herzberg-Two Factor Theory (Herzberg, Mausner, & Snyderman, 1959;Herzberg, 1966). Herzberg discussed motivation to perform under two main factors; motivation factors and hygiene factors. According to Herzberg et al. (1959), motivation factors (recognition, sense of achievement, growth and promotional opportunities, responsibility, and meaningfulness of work) are intrinsic factors that when present motivate employees to expend more effort on achieving work goals. Hygiene factors (pay, company policies and administration, fringe benefits, physical working conditions, status, interpersonal relations, supervisory practices, and job security, among other things) on the other hand are extrinsic factors that may not directly inspire employees to expend more effort on their jobs but, their absence can lead to dissatisfaction (Herzberg et al., 1959). Even though this theory seems outdated and has been criticized for many reasons, including its lack of attention to individual differences in their response to situational factors, it provided the impetus for research into work design and how it affects employees performance. It is recommended that the tenets of the Two-Factor Theory are critically considered in designing work (Hackman & Oldham, 1976) to enhance performance. Motowidlo and Van Scotter (1994) defined performance in the dimensions of task and contextual performance. Task performance refers to those behaviors that directly impact the organization's technical core, either by implementing the organization's technical processes or by maintaining and servicing its technical requirements (Motowidlo & Van Scotter, 1994).
Contextual performance behaviors aid the technical core by shaping "the organizational, social, and psychological context that serves as the catalyst for task activities and processes...…….the social and psychological environment in which the technical core must function" (Motowidlo & Van Scotter, 1994, p. 476).
Contextual performance comprise of two classes of behaviors, thus, organizational citizenship behavior (OCB) and counterproductive workplace behavior (CWB). "OCB is defined as extra-role discretionary behavior intended to help others in the organization or to demonstrate conscientiousness in support of the organization" (Boman & Motowidlo, 1997, p. 100).
Examples of OCBs are altruism and compliance. CWB on the other hand refer to behaviors intended to contradict the organization's legitimate interest (Sackett, 2002). change the status quo, "a mode of communicative behavior and a type of communication event" (Bell, 2008. P. 16).
Other scholars have defined performance. For example Daft (2012) defined organizational performance in the domain of effectiveness; "the degree to which organization achieves its goals", and efficiency; "the amount of resources used to achieve organizational goals" (p. 23). Thus, effectiveness refers to goal clarity, focus, and the strategies used to accomplish such goals. Efficiency relates more to the volume of raw materials, money, and man hours needed to accomplish a particular organizational goal (Daft, 2012). There is agreement in the performance literature regarding the potency of effectiveness and efficiency in defining organizational performance, other researchers have suggested that, beyond effectiveness and efficiency, providing comparative net value to customers is imperative in ensuring survival in a competitive market (Fugate, Mentzer, & Stank, 2010).
Problems associated with key performance indicators such as supervisory practices, employee motivation, and other task and behavioral concerns continuously threaten quality healthcare delivery worldwide. In a triangulation manner, strategies designed to enhance effective healthcare delivery should explore various models and contextualize ideas from these models to solve specific situational problems. To afford distinctive net value to patients without compromising quality, performance in healthcare delivery should be assessed by using a multilevel approach that provides solutions based on well-defined endemic units.

Research Question
The main research question in this study is: How can a change in healthcare delivery culture improve performance and drive quality healthcare delivery in Ghana?

Literature Review
Ghana is a sub-Saharan African country with a population of approximately 25 million.
Compared to other sub-Saharan African Countries, Ghana enjoys relatively stable economy, but ironically, about 79% of the population lived on $2 or less per day between 1999 and 2005 (Asante & Zwi, 2009). Thus, economic problems, present a challenge to healthcare accessibility in Ghana, with the northern part of the country experiencing the poorest healthcare delivery status (Asante & Zwi, 2009). The literature review will focus on healthcare delivery in Ghana.

Healthcare Delivery in Ghana
Healthcare delivery problems in Ghana seem to be unrelenting with issues ranging from resource allocation to behavior of healthcare workers continually threatening the healthcare system with strikes and other agitations. Problems with healthcare delivery in Ghana have been widely described to include lack of infrastructure; insufficient resources, both human and material; lack of essential equipment, and attitudinal problems of healthcare workers among other things. Agyepong, Anafi, Asiamah, Ansah, Ashon, and Narh-Dometey (2004) conducted a study of healthcare delivery in the public healthcare sector of Ghana and posited that, one of the main causes of poor quality healthcare delivery in the Ghana public health sector is a frustrated and dispirited labor force who encounter daily obstacles such as lack of equipment and essential tools. Agyepong et al. (2004) categorized healthcare delivery problems in Ghana into two: Unresolved work situation obstacles, and service quality problems. According to Agyepong et al. (2004), unresolved work situation obstacles comprise of poor or absent supervisory and support mechanisms; delayed promotion; lack of essential equipment, tools, and supplies; inadequate basic and in-service training; effect of job placement on social factors such as children's education, and marital situation; inadequate/inappropriate incentives and reward systems; low salaries; staff shortage; and exodus to look for better jobs. Service quality problems on the other hand comprise of, easily angered and impatient providers; inconvenient hours of operation/non availability of providers; long waiting times and delayed service; failure to provide required technical level of care to achieve prompt recovery without complications for clients; excessive formal and informal out of pocket service charge; and strikes by service providers (Agyepong et al., 2004). According to Agyepong et al. (2004), these workplace obstacles repress staffs' performance and consequently lead to poor quality healthcare delivery.
Turkson (2009), conducted research in a rural district of Ghana and identified issues similar to those outlined by Agyepong et al. (2004) as some of the factors that influence the quality of healthcare delivery in Ghana. These include, limitation of medication to painkillers, vitamins, and antimalarial as prescribed drugs for most ailments; inadequate staffing; rude and unfriendly staff; lack of ambulances; poor supervision of healthcare workers; long wait times; and lack of avenues to seek information and launch complaints (Turkson, 2009). Other notable problems that affect the quality of healthcare delivery in the public health sector of Ghana are the dwindling financial inflow and technical inefficiencies (Akazili, Adjuik, Jehu-Appiah, & Zere, 2008). Incessant financial problems and inefficient use of resources put pressure on core healthcare components such as infrastructure and human resources. Human resource has been described as "the crucial core of a health system" (Hongoro, & McPake, 2004, p. 1451 and $30 per person per year on healthcare (Kirigia, Preker, Carrin, Mwikisa, & Diarra-Nama, 2007).
In Ghana, as in much of sub-Saharan Africa, there are problems with the functioning of basic healthcare systems. These problems encompass issues such as the quality of the services available, geographical and financial access to services, and efficiency of service delivery and availability of adequate resources to finance and sustain health systems. These and other problems such as migration of health professionals (Martineau, Decker, & Bundred, 2002) continue to threaten healthcare delivery in Ghana on daily basis. Problems such as poor quality service, negative attitude of healthcare workers, and inadequate financing reemerges with the healthcare delivery at all levels (Witter, Arhinful, Kusi, & Zakariah-Akoto, 2007). Another area of prodigious concern in the healthcare sector of Ghana is infant mortality. Problems similar to those already mentioned earlier have been identified as threats to maternal delivery in Ghana.
One nerve-wracking issue that has exacerbated the already gargantuan problems faced by  Agyepong, 1999) because, the urban dwellers had more access to money than the rural folks who relied mainly on subsistence farming for their livelihood.
To help clean the perceived mess created by the Hospital Fee Legislation and the Cash and Carry systems, a policy of delivery fee exemption was introduced in 2004 with funds from the Highly Indebted Poor Countries (HIPC) initiative to help assuage the suffering of the Ghanaian regarding healthcare delivery, and to make healthcare accessible to both the "rich" and the "poor". The Free Medical Care for Pregnant Women was also introduced with funding from a bilateral UK grant of £42.5 million (Witter et al., 2009) To help improve the quality of healthcare delivery in Ghana, some researchers have suggested ways to reduce the recurrence of some persistent problems. However, problems with healthcare delivery in Ghana appear unending as many of the initiatives proposed for improvement in the past have been ineffective. For example, in the 1980s, policy makers suggested the recruitment and training of Community Health Nurses to provide more efficient and professional care than the volunteers who were used to augment the existing workforce, due to the shortage of registered nurses (Nyonator et al., 2007). However, questions regarding the efficiency of these nurses and continuous financing of the project have been raised (Nyonator et al., 2007). In spite of the many attempts made in the 1980s to make healthcare accessible to all Ghanaians, about 70% of Ghanaians had to travel eight kilometers or further to access healthcare  Jones, & Miller, 2005). The CHPS initiative promotes the utilization of cultural institutions and volunteers to improve healthcare delivery and accessibility to local communities (Nyonator et al., 2005).
In-service training has been suggested as another strategy to close competency gaps of healthcare staff but, this strategy is embedded with some problems because, the program is "centralized, short-term, predominantly classroom training offered from the regional or national level" (Agyepong, 1999. p. 64). Beside the problems with funding, the program is sponsored under specific programs that may not serve the needs of all. For instance, selection of who to train is mainly based on availability of funding, leaving many healthcare staff who need training out (Agyepong, 1999). Also, funds released for malaria control for instance can only be used for malaria control training, irrespective of whether other areas of healthcare need more training than malaria control (Agyepong, 1999). Above all, training may require the introduction of new resources which in many cases are not provided (Agyepong, 1999). These and other problems continue to impede progress in solving some pertinent healthcare problems in Ghana.
Auspiciously, global efforts to reduce financial barriers to healthcare is ongoing, with emphasis on venerable groups (Witter, Adjei, Armar-Klemesu, & Graham, 2009 Phillips, & Jones, 2007). As part of the strategies to ensure success with this effort, measures have been put in place to increase accessibility to healthcare, to eliminate obstacles to healthcare delivery, and to enhance the technical competence of service providers, and respect for human dignity and rights (Nyonator et al., 2007). One major scheme to achieve this goal is to establish small-scale healthcare projects within communities to cater for the healthcare needs of community members who otherwise would have difficulty accessing healthcare (Nyonator, 2002).

Research Methodology and Methods
The qualitative methodology, specifically a case study method was utilized in this study.
The study is situated in interpretivist epistemology and constructivist ontology. Data collection was based on in-depth interviews, direct observations, and analysis of relevant documents.
Face-to-face interviews were conducted at the FOCOS Orthopaedic Hospital facility near Accra, Ghana. A total of 25 managers and supervisors of FOCOS participated in the study. The interviews were organized in an interactive manner. Open ended questions based on some indicators of task and contextual performance were asked. Questions to assess performance centered on the dimensions outlined by Poister (2008) and Lambert (2007). Other measures used to assess contextual performance were, employee satisfaction and commitment to the organization, trust in leadership, and altruism.
Data were coded and analyzed using the qualitative data analysis procedures presented by Bernard and Ryan (2010). The methods used include transcribing and summarizing the voice recorded responses of each individual interviewee. Individual interview data were coded, and common themes identified of the overall data set. Document reviews were conducted of the policies and protocols used by the organization in its operations. Information gathered from direct observation were also recorded. Data from all three sources; direct interviews, document analyses, and direct observations were compared for validity checks. The proceeding findings from the study are purely based on the data analyses.

Performance of FOCOS Orthopaedic Hospital
For the purpose of this study, performance at FOCOS was assessed by the scope used by Boman and Motowidlo (1997) in their definition, thus, task performance and contextual performance. Furthermore, various other dimensions outlined by Poister (2008) and Lambert (2007) were used to assess task performance and contextual performance.

Task Performance
Three of Poister (2008)  depends on financial stability. It was discovered during the interviews that FOCOS' annual budget is approximately six million dollars ($6 million), out of which the organization generates about four million dollars from its operations. An executive member whom we interviewed informed us that, it behooves management to raise the difference of two million ($2 million) from other sources. The organization organizes fundraising, galas, and other activities to raise money to keep the facility running. The executive officer stated that, it is a huge responsibility but with the help of some philanthropists and by the grace of God we are surviving……I can confidently say we are financially stable……at least for now. FOCOS invests any excess money back into the organization.
Long versus short-term impact. In the interim, FOCOS concentrates on orthopedic care but, there are plans in place to expand their services to include other specialized areas of healthcare delivery. As part of the agenda to sustain their labor needs, FOCOS has instituted a training program for young medical doctors to embrace orthopedic care as their specialty. The ultimate goal of FOCOS is to reach the status of a teaching hospital where orthopedic professionals will be trained. The projected medical school will not only produce professionals with the right skills but, the right attitudes as well. This is because, FOCOS views the provision of quality care not only from the lens of successful surgery or exhibition of excellent skills, but also, having the right attitude to create harmony and inspire others to put up their best. As one participant put it, training people to acquire the right skills is good but, training people to adopt good working habits is paramount…… our long-term goal is to make FOCOS a brand, and of course, the best specialized hospital in West Africa and beyond. To achieve the goal of the best orthopedic care facility in West Africa, FOCOS aims at maintaining excellence and delivering optimum satisfaction to their patients.

Contextual Performance
Contextual performance was assessed by using one of Poister's dimensions, thus, client satisfaction, and two of Lambert's dimensions, community support and publicity. Other areas of interest were assessed through direct observation and interaction with patients and staffs. Areas assessed include, employee satisfaction and commitment to the organization, trust in leadership, and altruism. Each of the dimensions will be examined in details next.

Client satisfaction.
Based on the information obtained from participants of the study, patient satisfaction is central to FOCOS' mission. Patient satisfaction is so pertinent to FOCOS such that, healthcare professionals respond to patients' calls even beyond their work schedule. are encouraged to ask for help when needed, and to offer assistance whenever possible.

Discussion and Research Implications
The findings from this research present a challenge to policy makers and officials of the total quality care delivery whilst efficiency relates more to equitable distribution of available resources to achieve total quality care goals. Other contextual factors such as adherence to workplace ethics are critical to total quality care goal achievement.
Value-based leadership helps to establish an ethically charged work environment where trust, respect, and fairness are key drivers of total quality care delivery. Healthcare delivery should be viewed as a relationship rather than a system of rules that need to be followed. Caring for others should be more of a moral response than a job demand. Skillful and committed employee that experience ccontinuous training and development to sharpen their skills and discover their potential are more likely to be motivated by who lack the necessary skills to perform their duties. Skillful and talented employees are more likely to be efficient and contribute significantly to team performance and overall total quality care delivery goals achievement than semi-skilled employees. Collaboration and recognition of employees' good work coupled with a culture that espouses patient-centered thinking are also important to the total quality care delivery agenda. Working as team rather than a decentered experts will more likely lead to better results and heighten the need to consider patients interest as paramount.
Answering the research question, "how can a change in healthcare delivery culture inspire quality healthcare delivery in Ghana", requires a clear definition of each of the dimensions in the TQC model to include the criteria for measuring each of them and continuous monitoring of how the dimensions interact to enhance organizational effectiveness. Also, examining the information gathered to identify systemic strengths and weaknesses, adopting strategies to improve upon weak ends whilst striving to maintain strengths, and developing new strategies to control contradictory occurrences in both the internal and external environments as a result of interactions between the components of the TQC model are important. Careful adherence to these steps will help ensure total quality healthcare delivery for Ghanaians.

Conclusion
Quality health care delivery is important to every nation, however, healthcare delivery in many developing countries including Ghana is embedded with unfathomable problems. Attempts to solve some these problems are met with challenges including insufficient funding and poor work attitudes. Also, most interventions target specific problems with no plan to solve other extraneous problems that impede successful implementation of these interventions. The Total Quality Care Model is presented as an alternative model that espouses the need for a holistic approach to solving healthcare problems and achieving the goal of total quality care delivery for all. Careful adherence to the ideas presented in the TQC will enhance policy decision making regarding quality healthcare delivery.

Limitations
The study was conducted at a nonprofit healthcare facility therefore, the results may not be generalized to all healthcare systems, thus, public and for-profit private facilities. It is recommended that future research include nonprofit, for-profit and, the public healthcare systems to make well informed decision about quality healthcare delivery in Ghana.