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The Need for Time Management Training Is Universal: Evidence from Turkey

ADNAN KISA and KORKUT ERSOY

Abstract. In many developing countries, healthcare administrators are currently facing challenges that are representative of those in the United Stares. Most healthcare administrators here are physicians with no formal training in healthcare administration, and this is perhaps most apparent in their difficulties with time management. The authors' purpose in this study was to characterize the time management difficulties of administrators working in primary healthcare facilities of the Ministry of Healthcare. In the study, 67 healthcare administrators each completed a 31-item time management questionnaire. Of the participants, 79.1% reported that they have never attended time management courses or workshops. Although 76.1% said they were free to choose the priority of their daily tasks, only 44.8% felt they knew how much time they should allow for each activity in their daily life. These and other findings in the study suggest that the need for time management education is a well-defined target for intervention, both in university-based programs for future healthcare administrators and in workplace-based programs, such as inservice training for healthcare administrators who ate already working. Key words: time management, Turkish health administrators, Turkish healthcare administrators

n developing countries, healthcare administrators and educators must face the combined challenge of optimizing the current healthcare system while looking for opportunities to change that system fundamentally. One such opportunity for change is the lack of management training among healthcare administrators. The healthcare management situation in many developing countries is beginning to resemble that in the United States, where economic

factors have driven healthcare providers into the large and complex corporate market. Physicians working as hospital administrators have had to become business managers and entrepreneurs, or else be replaced by them (Ashley 1989). One of the clearest contemporary versions of this phenomenon is found in Turkey, where the rapidly Westernizing culture, economy, and educational system have far outpaced the ways in which hospitals and healthcare facilities are managed. Although there is a trend toward local autonomy and Hnancial self-sufficiency in the national healthcare system, most healthcare administrators in Turkey continue to be politically appointed physicians with no formal training in management. Even though the healthcare economy in Turkey is not yet a free market, effective healthcare administration there requires the same creative attention to productivity, efficiency, motivation, and cooperation as required anywhere (Kisa, Kavuncubasi, and Ersoy 2002). An administrator's daily challenge is to treat all these parts as a coherent whole, and this depends crucially on time management. Time management is defined here generally as a healthcare administrator's self-management. The skills that healthcare administrators need for managing themselves are the same skills they need for managing others: {d) the ability to prioritize, {b) plan, (c) delegate, and (d) coordinate (Cohen 1987).

Adnan Kisa is an associate professor of Health Policy and Economics and coordinator of the Graduate Program in Healthcare Administration at Baskent University, Turkey. Korkut Ersoy is a professor and chair of Healthcare Management Program at Baskent University, Turkey.

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For any time management intervention ro work, it must target rhe particular aspects of personal management that need ro be modified. We designed the present study to identify the time management challenges of health administrators who are currently working, and ro suggest some useRil approaches in remedying time management problems.

been working in their current position was 6.24 {SD = 4.58). All participants were physicians (see Table 1).

RESULTS
We arranged the 31 questions in the questionnaire in sections that proceeded from more general to more specific time management issues, starting with priorities and proceeding to workload, delegation, scheduling, and technique. In response to the first secdon, 85.1% of the participants reported that they know their main tasks and responsibilities, and 76.1% said they freely determine which tasks are the most important for their job (see Table 2). However, only 44.8% felt they knew how much time they should allow for each activity in their daily life, and only 53.7% felt that they even had enough time to consider which of their tasks are most important. In response to workload-related questions about time management, 83.6% of the healthcare administrarors felt that they had more tasks than they could do, but 25.4% reported that they could say "yes" to extra tasks even when they were very busy. This pattern is consistent with the participants' responses to questions about task delegation.

METHOD
Our purpose in this study was to characterize rhe time management difficulties of administrators working in primary healthcare facilities of the Ministry of Health (MOH) in Turkey. We felt that this group of administrators was the largest population from which a homogenous sample could be drawn and still give broadly applicable results. The rationale for this is that the primary healthcare facilities themselves can be considered as a baseline for healthcare facilities in general in terms of the complexity of the administration required. The primary healthcare facilities are outpatient oriented and provide immunizations and other preventive healthcare services, healthcare education, environmental healthcare services, household visits, school healthcare screenings, prenatal care, and family planning services in addition to a range of outpatient clinical services. The participants in the study were 67 healthcare administrators working at various levels in all the primary healthcare facilities (A'^= 48) in Ankara and its surrounding counties. The participants therefore constituted the population of the study, rather than merely a sample. At an in-service training session organized by the City Healthcare Directorate, one of us administered a 31-item time management questionnaire that the participants completed. This questionnaire was a slightly modified version of the one Erdem (1997) used to examine time management issues among top-level hospital administrators in Ankara. In a small pilot study, five healthcare administrators completed the modified version to evaluate questions for relevancy and clarity.

TABLE 1. Sociodemographic Information about the Participants


Characteristic Gender Female Mate Marital status Married Single Number of children n %

25 42 55 11 25 19 9 1 42 16 14 53 10 3 1

37.3 62.7 83.3 16.7 46.3 35.2 16.7 1.9 72.4 27.6 20.9 79.1 71.4 21.4 7.1

t
2 3 4 Spouse's employment status Spouse is working outside the home Spouse is not working outside the home Experience with courses or workshop in time management Yes No If 'Yes' to the above item, number of courses or workshops attended 1 2 6

DEMOGRAPHIC INFORMATION
Out of the 67 participants, 37.3% {n = 25) were women, 83.3% were married, and their mean number of children was 1.74 {SD = 0.8). Approximately half of the participants (44.6%) had been working as healthcare administrators for fewer than 5 years. The participants had been working for the M O H for a mean of 13.5 years {SD = 6.57), and the mean number of years they had

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TABLE 2. Time Management Skills of Health Administrators Management skill Priorities Do you know your main tasks and responsibilities? Do you know how much time you need to ailow for each activity in your daily life? Do you know what you are going to do next year, in the next 3 and 5 years? Do you freely determine which tasks are the most important in your job? Do you spend more time on routine than unusual tasks? Do you find enough time to consider which tasks are your most important? Workload Do you feel stress or anxiety about performing tasks on time? Do you feel that you have more tasks than you can do? Wtien you are very busy, do you say "yes" to extra tasks? Do you sacrifice your social activities for your job? Delegation Do you perform tasks yourself rather than delegating them to someone? Do you consider task delegation to be an important part of your job? Do you consider task delegation when making plans? Do you feel yourself pressured by deadlines even when you delegate tasks? Scheduling Are you aware of having time to do extra tasks? Do you bring your work home or stay late at the office? Do you feel unable to finish your day's scheduled tasks in one day? Do you arrive late for your appointments? Technique Do you leave your tasks uncompleted? Do you find it difficult to finish work-related conversations? Do you permit your telephone conversations to stop your work? Do you think that meetings are a waste of time? Do you have a lot of documents waiting to be read? Yes % No % Sometimes %

57 30 39 51 21 36 32 56 17 26 16 37 51 57 41 14 11 6 2 16 4 8 26

85.10 44.80 58.20 76.10 31.30 53.70 47.80 83.60 25.40 38.80 23.90 55.20 76.10 85.10 61.20 20.90 16.40 9.00 3.00 23.90 6.00 11.90 38.80

3 9 14 6 25 5 9 6 18 13 19 11 4 3 15 33 21 52 31 14 32 17 24

4.50 13.40 20.90 9.00 37.30 7.50 13.40 9.00 26.90 19.40 28.40 16.40 6.00 4.50 22.40 49.30 31.30 77.60 46.30 20.90 47.80 25.40 35.80

7 28 14 10 21 26 26 5 32 28 32 19 12 7 II 20 35 9 34 37 31 42 17

10.40 41.80 20.90 14.90 31.30 38.80 38.80 7.50 47.80 41.80 47.80 28.40 17.90 10.40 16.40 29.90 52.20 13.40 50.70 55.20 46.30 62.70 25.40

Although 94% said they consider or sometimes consider task delegation when making plans, only 28.4% denied that they perform tasks themselves rather than delegate them. In terms of scheduling, 77.6% were at least sometimes aware of having time to do extra tasks, but 68.6% at least sometimes felt unable to complete their scheduled tasks for each day. The participants' approach to inter-

ruptions during the day might partially explain this apparent paradox; 7 9 . 1 % at least sometimes found it difficult to finish work-related conversations, and 52.3% at least sometimes permitted telephone conversations to halt their work. We also analyzed the questionnaire results by the number of years participants had worked in the M O H system. We divided the results into two

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groups according to whether the participants' number of years working in the system > the mean of 13 years. Just over half of the healthcare administrators (51%) had been working for the MOH for fewer than 13 years. Cross tabulations were made to detect any relationships between response categories and years spent working for the MOH. Participants who had been working in the MOH fewer than 13 years spent more time on routine jJ (4, N = 64) = 4.64, p < 0.10, and were aware of having enough time to do extra tasks y^ (4, A'^ = 64) = 5.18,^ < 0.10, compared with those healthcare administrators who had been working in the

MOH more than 13 years (see Table 3). Moreover, healthcare administrators who worked at the MOH for more than 13 years reported that they had sacrificed their social life because of workload X2(4, 7V=64) = 4.9,/'< 0.10.

DISCUSSION AND SUGGESTIONS


The time-management problems the participants reported in this study are consistent with what one would expect to find among physicians who have become healthcare administrators without training in business or management.

TABLE 3. Time Management Skills of the Health Administrators by Years Worked


Years worked at MOH > 13 years < 13 years n % n % 29 1 3 15 5 13 22 5 6 26 3 4 14 9 10 19 2 12 19 6 8 30 2 1 II 6 16 11 9 13 8 10 15 52.7 33.3 50.0 53.6 55.6 48.1 57.9 41.7 42.9 54.2 50.0 40.0 70.0 37.5 50.0 55.9 40.0 48.0 61.3 75.0 32.0 56.6 33.3 20.0 73.3 35.3 50.0 44.0 81.8 46.4 53.3 55,6 48.4

Management skill Do you know your main tasks and responsibilities? Do you know how much time you need to allow for each activity in your daily life?

Response Yes No Sometimes Yes No Sometimes Yes No Sometimes Yes No Sometimes Yes No Sometimes Yes No Sometimes Yes No Sometimes Yes No Sometimes Yes No Sometimes Yes No Sometimes Yes No Sometimes

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2 3 13 4 14 16 7 8 22 3 6 6 15 10 15 3 13 12 2 17 23 4 4 4 11 16 14 2 15 7 8 16

47.3 66.7 50.0 46.4 44.4 51.9 42.1 58.3 57.1 45.8 50.0 60.0 30.0 62.5 50.0 44.1 60.0 52.0 38.7 25.0 68.0 43.4 66.7 80.0 26.7 64.7 50.0 56.0 18.2 53.6 46.7 44.4 51.6

Do you know what you are going to do next year, in the next 3 and 5 years? Do you freely determine which tasks are the most important in your job? Do you spend more time on routine than unusual tasks? Do you find enough time to consider which tasks are your most important? Do you feel stress or anxiety about performing tasks on time? Do you feel that you have more tasks than you can do? When you are very busy, do you say "yes" to extra tasks? Do you sacrifice your social activities for your job? Do you perform tasks yourself rather than delegating them to someone?

(table continues)

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TABLE 3.Continued
Years worked at MOH > 13 years n % n %

< 13 years

Management skill Do you consider task delegation to be an important part of your job? Do you consider task delegation when making plans? Do you feel yourself pressured by deadlines even when you delegate tasks? Are you aware of having time to do extra tasks? Do you bring your work home or stay late at the office? Do you feel unable to finish your day's scheduled tasks in one day? Do you arrive late for your appointments? Do you leave your tasks uncompleted? Do you find it difficult to finish work-related conversations? Do you permit your telephone conversations to stop your work? Do you think that meetings are a waste of time? Do you have a lot of documents waiting to be read?

Response

Yes No Sometimes Yes No Sometimes Yes No Sometimes Yes No Sometimes Yes No Sometimes Yes No Sometimes Yes No Sometimes Yes No Sometimes Yes No Sometimes Yes No Sometimes Yes No Sometimes Yes No Sometimes

19 7 7 25 3 5 29 4 25 4 4 11 16 6 6 11 16 4 28 1 2 14 17 10 4 19

54.3 70.0 36.8 52.1 75.0 41.7 53.7 57.1 62.5 30.8 36.4 78.6 53.3 30.0 60.0 55.0 47.1 66.7 57.1 11.1 100.0 50.0 50.0 66.7 28.6 54.3 100.0 63.3 33.3 71.4 68.8 41.5 62.5 50.0 37.5

16 3 12 23 1 7 25 3 3 15 9 7 3 14 14 4 9 18 2 21 8 14 17 5 10 16 11 20 2 5 24 9 12 10

45.7 30.0 63.2 47.9 25.0 58.3 46.3 100.0 42.9 37.5 69.2 63.6 21.4 46.7 70.0 40.0 45.0 52.9 33.3 42.9 88.9 50.0 50.0 33.3 71.4 45.7 36.7 66.7 28.6 31,2 58.5 37.5 50.0

4
19 10 5 11 17 15 12 6

62.5

Note. MOH = Ministry of Health.

These problems are also consistenr with rhose reporred in orher studies (Erdem 1997; Sreinerr, Nasmith, and Daigle 2003). In Turkey and in many middle-income countries, this situation is driven more by cultural and political traditions of physicians running hospitals rather than by economic changes that have required hospitals to run as competitive businesses. Therefore, at least until market behaviors become part of the healthcare sector in these countries, the incentives working to change the traditions involve

the possibility of more efficient healthcare services and better use of resources, rather than the possibility of higher profits for healthcare organizations. In Turkey, a major short-term incentive for better healthcare administration is Turkey's candidacy for membership in the European Union (Kisa, Kavuncubasi, and Ersoy 2002). Like most of the recently admitted EU members, Turkey's progress toward full membership will require active reform in almost every sector. Healthcare issues remain a

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major hurdle for Turkey; besides falling short of European standards in the current health status of its population, Turkey also makes much less efficient use of its healthcare facilities when compared with European countries. Eor example, the overall capacity rate used in public hospitals in Turkey is 55%-60%, compared with the 80%-85% typically found in Europe (Turkish Ministry of Healthcare 2001). The research literature shows that if time management behaviors are not developed among healthcare administrators, this can contribute to workplace stressors, including role conflict, role overload, workfamily, and familywork conflicts (Jex and Elacqua 1999). Role conflict occnts when one aspect of an administrator's role begins to interfere with one or more other aspects of that role. Role overload is characterized by an inability to judge which tasks demand the most attention, resulting in a neglect of one or more of them. Work-family conflict occurs when the demands of work interfere with family responsibilities, whereas family-work conflict emerges when family demands interfere with those of work. These workplace stressors can be viewed in terms of time-management concepts, such as delegating, investing time in people, using electronic tools effectively (such as e-mail and palm pilots), and giving clearer instructions to subordinates (Adkins 1989). In healthcare, success means delivering the highest quality of care by getting organized, meeting deadlines, creating efficient schedules, and appropriately budgeting resources (Collins and Collins 2004). In the healthcare sector in Turkey, especially in public facilities, delegation has been particularly difficult because of high turnover, which in turn is because of the frequent changes of government in recent years (Tengilimoglu, Kisa, and Dziegielewski 1999). Administrators of government facilities, such as hospitals and primary healthcare facilities, are typically political appointees, and there are no jobrelated criteria regarding management training. The role of healthcare facilities is changing worldwide, from that of simply providing patient care to integrating services with the surrounding society. This increases the responsibilities of healthcare administrators in terms ofthe variety of tasks they must perform (Steinert, Nasmith, and Daigle 2003). It is therefore not surprising that even among healthcare administrators who have been working for several years in their position, there is a need for specific time-management train-

ing. This training could be offered in the form of in-service instruction provided in partnership with management programs at local universities or through Internet-based distance learning programs for administrators in remote regions. The lack of time management skills among healthcare administrators also points to a need for time management courses in undergraduate programs in healthcare administration. Practical examples and real-life case studies should be included in both inservice training and university courses. The graduates of the university programs will increasingly assume leadership roles in healthcare facilities as the healthcare sector evolves along with the wider economy, and, therefore, they need more than theoretical concepts. Any attempt to improve healthcare administration through time-management education must measure the objective differences, if any, that such education would make in the field. Effects of time management education can be measured in terms of increased effectiveness and efficiency in work life and social life. Over the long run, insufficient personal time affects managers' overall mood and individual effectiveness. As part of effective time management, physician-managers are well advised to prioritize decisions on the basis of saving the organization money or developing important strategic goals. The possibility of finding common themes for healthcare administration education that reach across diverse market structures is an appealing one, not only in terms of the practical benefits of better services but also in terms of the less tangible but no less real benefits of diverse cultures sharing educational ideals. Multinational corporations are often seen as driving globalization, but educational globalization via the Internet is a daily fact of life. As educators who routinely communicate internationally via e-mail, they have both a responsibility and a very exciting opportunity to find ways to "think globally and act locally." Time management is a simple concept that healthcare administrators can apply in ways independent of the local healthcare economy; after all, every administrative task involves an element of optimal timing (Lyons 2002; Lando 1999). In countries where healthcare administrators are untrained in management, those administrators are a valuable potential resource that could be developed with targeted educational programs (Waterworth 2003; Humphrey 2003). Their lack of training also

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emphasizes the need for healthcare administration curricula that prepare university students for the hectic, complex flow of events that make up an administrator's daily work life. The basic problem that physicians encounter when they make the transition from clinician to administrator is that their old and new workdays are built from fundamentally different units. A clinician's basic duty is to organize a constellation of physical procedures to achieve concrete physiologic goals in individual people, namely patients. In contrast, an administrator's basic duty is to organize a constellation of people to achieve what are known, somewhat vaguely, as organizational goals. Time management for a clinician involves juggling patients and procedures, and the problem is to determine which patients need which procedures. Patients wait and procedures are scheduled, so the problem boils down to a matter of logistics. Time management for an administrator is altogether different and involves juggling abstractions like motivation, efficiency, and productivity. These seem arbitrary and ephemeral compared with things like liver enzymes and chest X-rays, but it is obvious that no one can work toward goals until they are chosen. Administrative time management, therefore, involves intuitively analyzing the workday into units of human action. Eor clinicians who find themselves working as administrators, the first step toward good time management is to design their own system of such units and proceed with enthusiasm. Two practical approaches that all physician administrators can use are to delegate routine tasks and to work with experts whenever possible. A good example of a routine task that can be delegated is that of scheduling meetings and contacting those who will attend. An example of working with an expert is to recruit an experienced office manager to main-

tain the ongoing structure of daily business, especially official correspondence. CONCLUSION In conclusion, this study shows that time management problems among physician administrators are not limited to healthcare institutions in market economies, but are universal.
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