In pursuit of improved management, a number of Turkish public hospitals have secured ISO 9001 certification. This study attempts to answer four main research questions: (1) to what extend have ISO certified government hospitals actually implemented new management measures? (2) Do the quality and performance improvement initiatives in Turkish government hospitals via ISO 9001 certification lead to improved performance? (3) What are the impacts of national and organizational culture on Turkish results-based improvement initiatives? (4) How have political forces -- both external and internal-- affected the implementation and success of the management reforms? The qualitative analysis of 46 semistructured interviews indicates that customer feedback, employee participation in decision-making, and employee training were used more widely at certified hospitals than at non-certified hospitals. However, certified hospitals were not more likely to implement performance measurement or reward and recognition systems. The implemented management reforms did not lead to major improvements in measured performance. Increasing bed occupancy rate was the only performance category in which certified hospitals outperformed those non-certified hospitals, while there was no significant difference between performances of both groups in following categories: the bed occupancy rate, the number of outpatients per physician, the number of surgical operations per specialist, and crude death rate. The inconsistent record of improvement may be explained in part by obstacles of organizational culture. Further qualitative analyses indicate that Turkish national and organizational cultures have had positive impacts on employee participation in decision-making, but also lead to negative impacts, such as low power sharing practices among hospital employees, weak performance measurement practices and reward mechanisms, and the lack of long term strategic plans at Turkish hospitals. The study indicates that the reforms produced important shifts in the internal political alignments including decreasing doctors' power within the Turkish hospitals. Also, one aspect of external political battle, unique to Turkey, is that the bureaucratic elites have used charges of Islamic religious domination to fight the government's decentralization reforms.