The Republic of South Africa (RSA) is shifting towards universal health coverage and a unified health system. This milestone can be achieved through the implementation of National Health Insurance (NHI). To employ NHI, health establishments in the country are compelled to comply with quality standards. The non-compliance with quality standards at primary health care (PHC) clinics within a district in Gauteng, which was verified by quality standards’ audit reports, prompted an intervention. No prior research aimed at facilitating managers’ compliance with quality standards has been conducted within the context under study. This research gap necessitated an exploration on how managers’ compliance to quality standards at PHC clinics within a district in Gauteng could best be facilitated.
To describe recommendations to facilitate managers’ compliance with quality standards at PHC clinics within a district in Gauteng.
A qualitative, exploratory, descriptive and contextual research design was used in this study. Semi-structured, individual interviews were conducted.
The recommendations to facilitate managers’ compliance with quality standards at PHC clinics within a district in Gauteng were described. However, for the purpose of this article, only the recommendations seeking to address challenges with management practices as a reason for non-compliance with quality standards at PHC clinics will be discussed. These recommendations include involvement of PHC clinic managers in decision-making, adequate support from senior management and improvement of internal communication practices.
The researcher concludes that the senior management team in the district under study should strive to embrace the described recommendations as a strategy to facilitate managers’ compliance to quality standards at PHC clinics.
The National Department of Health (NDOH) of the Republic of South Africa (RSA) (
The pattern of non-compliance with quality standards at PHC clinics within a district in Gauteng had been evident in the data gathered from audits, such as monthly supervisory visits, quarterly programme in-depth reviews, clinical programme support and the outcomes of national core standards (NCS) audits. In response to this non-compliance, reference materials including policies, strategies and guidelines on clinical programmes were distributed. Together with these, reference materials, management development training, quality improvement workshops, meetings, continuous guidance, support and mentoring through regular support visits were conducted to facilitate managers’ compliance with quality standards. The reports from these support visits indicated that remediation measures, to facilitate managers’ compliance quality standards, were discussed.
Despite the aforementioned implemented interventions, managers’ non-compliance to quality standards at PHC clinics within a district in Gauteng continued to be a reality. Persistence of non-compliance to quality standards is significantly detrimental to the RSA in realising quality health care for all through the implementation of the National Health Insurance (NHI). This predicament necessitated an exploration and description of the reasons for managers’ non-compliance with quality standards at PHC clinics within a district in Gauteng so that recommendations could be described in order. This article focusses only on one part of a larger study, that is, recommendations to facilitate compliance with these quality standards.
‘Compliance’ is the practice of obeying rules or requests made by people in authority (Oxford Advanced Learner’s Dictionary
Compliance with quality standards, particularly the NCS, has been identified in the South African NDOH’s Policy Paper on NHI (
As a crucial step towards a strengthened, effective health system that aims to improve health outcomes and ensure a better life for all South Africans (NDOH
The South African NDOH (
This study utilised a qualitative, exploratory, descriptive and contextual research design. Twelve in-depth, semi-structured interviews with managers of PHC clinics were conducted within a district in Gauteng.
The population of the study comprised managers of the 82 PHC clinics within a district in Gauteng. A purposive sampling method was used in this study. Those who had 5 or more years of experience in managing a PHC clinic, who had undergone a quality standards audit and who were willing to participate in the study were included in this study. The sample size of 12 managers who participated was determined by data saturation.
An experienced interviewer well-versed with qualitative research conducted the in-depth, semi-structured individual interviews. As a quality standards compliance officer in the district under study, the researcher did not participate in the data collection as this might result in bias and the Hawthorne effect. The date and time were fixed (allowing 30–45 min per individual interview). However, the interviewer had to be flexible to ensure that participants were given sufficient time to share their perspectives on how best their compliance to quality standards could be facilitated. The venue for the interview was prepared and communicated to the participants in advance and was agreed upon by all parties. The interviewer held a briefing session with the participants before the actual interviews to facilitate rapport.
The question posed to the managers in an attempt to address non-compliance to quality standards at PHC clinics within a district in Gauteng was:
What can be done to facilitate managers’ compliance with quality standards in this clinic?
After obtaining permission from the participants, the interviews were recorded using an audio tape recorder, and the information was transcribed verbatim.
The data obtained during the in-depth, semi-structured individual interviews from the PHC clinic managers were analysed using Tesch’s method of analysis for qualitative data (Tesch
The Faculty of Health Sciences Academic Ethics Committee (REC-01-151-2015) at the University of Johannesburg and Research Ethics Committee (15/05/2015-3) of the district under study granted ethical approval for the study. The following ethical principles were adhered to throughout the study: respect for persons; the principle of justice; and the principle of beneficence (Dhai & McQuoid-Mason
One central theme with two main themes emerged from the data analysis. However, for the purpose of this article, only recommendations pertaining to sub-themes of Theme 1 (challenges with management practices) will be described. These include:
Involvement of PHC clinic managers in decision-making by senior management
Implementation of effective and functional support systems to facilitate compliance with quality standards
Improvement of internal communication practices to facilitate compliance with quality standards.
Based on the challenges with management practices described above, the following recommendations were described. These recommendations, aimed at the local area managers, sub-district and district managers within a district in Gauteng were informed by the participants’ propositions and were integrated into relevant and international literature to add credibility and meaning.
Participants indicated that they should be involved and consulted whenever important decisions pertaining to their clinics are made. This is evident in the following statements:
‘We should be involved in decision-making and not only be invited to meetings which are about what the principals want and what they have decided already.’ (P9, P10)
‘I am not saying management should always accept what we have to say, but we must be involved in decision-making.’ (P10)
‘As a clinic manager, I need to be involved when decisions are being taken, for example, when interviews are being conducted for lower categories, I must be invited.’ (P4)
Quagraine (
Nooritajer and Mahfozpour (
The researcher believes that senior management within the district under study can facilitate managers’ compliance with quality standards by engaging PHC clinic managers in decisions taken, particularly those decisions regarding issues that affect the clinics’ day-to-day operations. Bhuiyan (
Having articulated a lack of support from the senior management within the district under study as a reason for non-compliance with quality standards, PHC clinic managers announced a need for further support from senior management, including guidance and assistance to comply with quality standards.
This is evident in the following statements:
‘If one could receive support from the principals (top management), that would make a lot of difference.’ (P3)
‘I do not have a diploma or a degree in management, but I am a clinic manager and I need to be supported.’ (P11)
The Canadian Nurses Association (CNA) (
The senior managers in healthcare institutions have to provide support to employees with the purpose of enabling them to achieve set objectives, such as compliance with quality standards (Brown et al.
For the PHC clinic managers to comply with quality standards, they require functional support systems that enable people management and work environments, as this is fundamental for high quality care and good health outcomes (Dixon-Woods et al.
The implementation of policies and legislations, such as the NHI, requires all health establishments to comply with quality standards, including the NCS. Helfrich et al. (
While participants cited the need for general support from senior management to assist participants to comply with quality standards, some participants were specific about the type of support they required, namely, (1) support with standard operating procedures and quality improvement plans and (2) support at clinic visits.
This is evident in the following statements:
‘I should be assisted and supported by management on how to draft and compile some documents such as standard operating procedures (SOPs) at an operational level.’ (P11)
‘Management should come to the clinic to assist and support us comply with the quality standards, and ensure that things like quality improvement (QI) plans are compiled.’ (P7)
‘If I inform my manager that [a] hand-washing campaign or patient satisfaction survey is to be held on such and such a day, the manager should come to support and ensure that we doing it the correct way.’ (P7)
McInnes et al. (
Tucker and Singer (
It is evident that participants require management support when compiling the required QI documentation and supporting QI initiatives. In addition, senior managers’ attendance and support during hand-washing audits were suggestions made to facilitate managers’ compliance with quality standards at PHC clinics within a district in Gauteng.
Participants stated that senior management needed to show their support by being present at PHC clinics for supervisory visits at least weekly, and by being actively involved in their staff’s needs.
This is confirmed in the following statements:
‘Management must support my clinic, not just by talking, but by doing as well. They need to conduct regular support visits to the facility, ensure that they come down and ensure that we have all what we need.’ (P7)
‘It’s not like we expect management to hold our hands every step of the way, but they should come to the facility for support at least once a week.’ (P4, P7, P9)
‘With constant supervision and support, whereby our managers come to the clinics on a regular basis, we can move towards compliance with quality standards.’ (P5, P7, P9)
Sullivan and Wyatt (
Mann (
West et al. (
Birken, Daniel Lee and Weiner (
The Policy on Quality in Health Care for the South African NDOH (
Other participants stated that in order for them to comply with quality standards, management should conduct support visits at PHC clinics to show their appreciation for the good work being done, rather than only visiting clinics when mistakes were made.
This is evident in the following statements:
‘It would be nice to have my manager coming to me just to say, ‘Thank you, you are doing very well’. Manager[
‘I want my manager to be there for me, she must come and support and not only come when I have [
Participants at the Celebrating Innovative Health Management Conference of 2011 (Daire & Gilson 2011:76) articulated that healthcare facility managers are willing to address the challenges in the health system. However, support from the senior management team is paramount at all times, and not only when there is a crisis, such as non-compliance with quality standards wherein fingers are pointed, as in the context of this study (Daire & Gilson 2011:76).
The following statements indicate a need for management support and how this assistance will influence health workers other than the PHC clinic managers to comply with quality standards.
Participants said:
‘Management needs to be more supportive by ensuring that compliance with the quality standards becomes a shared responsibility and not my responsibility alone.’ (P11)
‘Presence of managers at the clinic will show staff that compliance with the quality standards is a requirement and not the clinic manager’s agenda.’ (P11)
In support of the participants’ statements, McFadden, Henagan and Gowen (
Mosadeghrad (
Other participants articulated the need for support from senior management to comply with the NCS:
‘Getting enough support from our supervisors would assist, by helping and being with us in this boat of National Core Standards, especially with the things that I struggle with as a clinic manager.’ (P12)
‘We should hold working meetings and go through all the domains in the National Core Standards with our supervisor, and then readily get clarity on things that we do not understand.’ (P12)
Parand et al. (
The Policy on Quality in Health Care for the South African NDOH (
Participants stated that senior management within the district under study should ensure that adequate support is given to PHC clinic managers by being visible at the clinics and helping them to comply with quality standards. Therefore, it is concluded that the senior management is duty bound to support the PHC clinic managers to enable them to comply with quality standards.
Internal communication is a subset of effective organisational communication, which is built upon this simple foundation: communication is a dialogue, not a monologue – it is therefore the dialogic process or conversation between employees and employer and employees and employees (Hopkins
The managers recommended that poor internal communication practices such as lack of time, or having limited time, to conduct feedback sessions and staff meetings at PHC clinics within a district in Gauteng need to be improved in order to comply with quality standards. They stated that the time to hold feedback sessions and meetings with staff to share new information and discuss staff issues should be allocated.
This is confirmed in the following statements:
‘We must be allocated time for meetings to give feedback to our staff.’ (P11)
‘We can give feedback to our staff if we [are] allowed to meet on a monthly basis.’ (P4)
In support of what the participants said, Booyens (
Other participants said:
‘There should be time when I can say just for an hour on a Thursday’ [
‘It is very essential that I hold meetings with my staff and highlight issues and deal with issues from the staff as well, because if I don’t hold meetings then it’s a problem.’ (P12)
‘I should be allowed to have meetings with staff, otherwise the staff dissatisfactions and problems may go unnoticed by me as a clinic manager.’ (P12)
Brown et al. (
The importance of regular team meetings and enhanced communication is highlighted by Xyrichis and Lowton (
Regular scheduled meetings for all employees to contribute to practice discussions allow teams to determine positive changes in a practice and to sustain those changes over time. These are described as ‘safe places where employees can raise the issues and receive respectful, collaborative, problem-solving responses’ (Roth & Markova
The participants in this study articulated that they lacked time to communicate both necessary and relevant information through feedback sessions. Therefore, the researcher can infer that because of these poor internal communication practices, interaction among health workers at PHC clinics within a district in Gauteng is poor; and as such, non-compliance with quality standards, that is, patient safety and poor health outcomes, is likely to result. Adequate time for staff meetings and feedback sessions must be granted to enable health workers to collaboratively identify and address work problems together.
Although this study provided significant findings, the study used a qualitative research approach using only managers and no other healthcare workers in a PHC clinic. Therefore, only qualitative data that are not multifaceted and that represent only the managers’ views regarding non-compliance with quality standards could be obtained from the participants. The results of this study are not transferable as the study was contextual in nature. The district under study has 82 PHC clinics, and the GDOH manages only two of them, while the local government authority oversees the rest. The managers of the GDOH clinics could not avail themselves for data collection, and these clinics are subjected to different management dynamics; therefore, the findings of this study cannot be generalised to the entire district.
The following recommendations are based on the findings of the study. These can be applied in areas of nursing practice, nursing education and future research.
The proposed recommendations to facilitate compliance with quality standards at PHC clinics within a district in Gauteng were presented as the findings in this study. These results have specific practical implications for the senior management team within the district under study, whereby this team is challenged to implement effective management practices informed by the proposed recommendations as a strategy to facilitate compliance with quality standards.
The authors would like to thank the management of the district under study for granting permission to conduct this study. They are deeply indebted to the PHC clinic managers for their time and valuable contributions to the study.
The authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article.
L.J.M. was the Master’s degree student and primary researcher, and was involved in drafting the article. H.A. was the supervisor and N.B.D.M. was the co-supervisor and they both were involved in the final editing and reviewing of the manuscript.
No funding was received for this project.