{"paper_id":"4546a7de-10e5-4fdd-85a7-85e3bf3a0bbf","body_text":"Impact of Total Quality Management on Healthcare Service Quality in Yemeni Hospitals: A Cross-Sectional Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Impact of Total Quality Management on Healthcare Service Quality in Yemeni Hospitals: A Cross-Sectional Study Jabran Mohammed Al-Saleet, Munir Musleh Al-Wasabi, Haitham Mohammed Jowah This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7115768/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Healthcare quality is a critical challenge in Yemen's conflict-affected health system. In response, the Ministry of Public Health and Population mandated the implementation of Total Quality Management (TQM) in 2021. This study provides a comprehensive evaluation of the impact of TQM on healthcare service quality, with a focus on frontline nursing and healthcare professionals. Methods: This cross-sectional analytical study included 410 healthcare professionals from four purposively selected hospitals (three public and one private) in Sana'a. Data were collected using a validated questionnaire that measured five TQM dimensions (Leadership Commitment, Human Resources, Policy & Strategy, Partnerships & Resources, Processes) and five dimensions of health service quality. Data were analyzed using descriptive statistics, correlations, and multiple linear regression. Results: The results indicated a high level of TQM implementation (mean = 5.44, 7-point scale). TQM implementation was a strong and significant predictor of health service quality, explaining 64.8% of the variance (R² = 0.648, F(5, 404) = 148.73, p < .001). The \"Processes\" dimension had the largest positive impact (β = 0.468), followed by \"Policy & Strategy\" (β = 0.305). Notably, the \"Human Resources\" dimension was not a significant predictor, and its low descriptive scores suggest it remains a key implementation challenge. Conclusions: TQM implementation significantly enhances healthcare service quality in Yemeni hospitals, demonstrating its effectiveness even in a fragile state. The findings reveal that systematic processes and strategic policies are primary drivers of quality improvement. However, the success of these programs is contingent on addressing the critical human resource challenges related to staff satisfaction and support. Healthcare leaders should prioritize both process optimization and workforce well-being to achieve sustainable quality improvements. Trial Registration: Not applicable. Total Quality Management Healthcare Service Quality Yemen Hospitals Nursing Quality Improvement Figures Figure 1 Figure 2 Figure 3 Background Healthcare quality improvement has emerged as a critical global priority, with Total Quality Management (TQM) representing a comprehensive organizational approach to systematic quality enhancement in medical service delivery systems [ 1 ]. Based on the principles of continuous process optimization, data-driven decision-making, and stakeholder engagement, TQM frameworks have demonstrated significant potential in improving clinical outcomes, patient safety, and operational efficiency across diverse healthcare settings [ 2 , 3 ]. In conflict-affected regions characterized by institutional fragility, healthcare systems face compounded challenges, including infrastructure degradation, critical supply shortages, and professional workforce attrition [ 4 ]. Yemen exemplifies these challenges; recent analyses indicate that over half of the nation's medical facilities have been damaged or destroyed during prolonged conflict, while severe shortages of essential medicines and qualified personnel persist nationwide [ 5 ]. The 2021 mandate by Yemen's Ministry of Public Health and Population for comprehensive TQM implementation represents significant policy intervention within this constrained operational environment. However, while foundational local research by Ali et al. (2022) established a positive correlation between TQM and service improvement in Sana'a, they also highlighted major implementation barriers, underscoring that empirical evidence of TQM's operational effectiveness in this unique context remains limited [ 6 ]. The nursing profession is a particularly critical component of quality improvement initiatives, representing the largest segment of the healthcare workforce and professional cohort, with the most direct and continuous patient contact [ 7 ]. Evidence confirms that nursing engagement significantly influences quality outcomes, with nurse-sensitive indicators serving as reliable predictors of institutional performance [ 8 ]. Within the broader Middle Eastern context, studies have identified distinctive patterns of nursing job satisfaction and engagement that can impact the success of quality initiatives [ 8 ]. Therefore, the intersection of evidence-based nursing practice and TQM implementation in conflict-affected settings represents a significant knowledge gap that requires further investigation. This study addressed three primary research initiatives. To evaluate the implementation status of core TQM dimensions across a sample of public and private Yemeni hospitals. To quantify the predictive relationship between TQM implementation and multiple dimensions of healthcare service quality. To analyze key factors from healthcare professionals' perspective, including the impact of gender and experience, which influence the effectiveness of quality improvement processes. By conducting a systematic analysis of healthcare professionals in Sana'a, this research aims to generate empirical evidence to inform quality improvement strategies in resource-constrained environments while contributing to the broader theoretical understanding of healthcare management in fragile states. Methods Study Design and Conceptual Framework This study employed a quantitative, cross-sectional, descriptive-analytical design to investigate the impact of Total Quality Management (TQM) implementation on health service quality in Yemeni hospitals. The conceptual framework (Fig. 1 ) was adapted from two established models: the TQM dimensions were based on the enablers of the European Foundation for Quality Management (EFQM) model [ 9 ], while the health service quality dimensions were based on the SERVQUAL framework . The independent variable, TQM Implementation, was operationalized through five dimensions: (1) Leadership and Management Commitment, (2) Human Resources, (3) Policy and Strategy, (4) Partnerships and Resources, and (5) processes. The dependent variable Health Service Quality was measured using the following five dimensions: (1) Tangibility, (2) Reliability, (3) Responsiveness, (4) Assurance, and (5) Empathy. Setting and Participants The study was conducted in four major hospitals in Sana'a, Yemen. Hospitals were purposively selected because they were known to have formally adopted TQM programs. The selection included three large public hospitals (22 May Hospital, Al-Thawra Hospital, Al-Manar Hospital) and one large private hospital (The Royal Hospital) to ensure a representative view of both sectors. The target population consisted of all clinical, administrative, and support staff (N = 600) at the four institutions. The required sample size was calculated to be n = 412 using the Krejcie and Morgan (1970) formula [ 10 ], ensuring a 95% confidence level and 5% margin of error. A stratified random sampling technique was used to select participants, with strata based on professional categories (e.g., nurses, physicians, and administrative staff) to ensure proportional representation. The inclusion criteria for participants were as follows: (1) being a full-time employee for at least six months at one of the selected hospitals and (2) providing written informed consent to participate. Data Collection Instrument The primary data collection tool was a self-administered structured questionnaire developed by the researchers based on an extensive literature review and the conceptual framework of the study. The questionnaire was translated from English to Arabic, and then back-translated by an independent bilingual expert to ensure linguistic and conceptual equivalence. This paper is comprised of three sections. Section A : Demographic and professional characteristics of respondents (e.g., gender, qualification, years of experience, and job title). Section B : Items measuring the five dimensions of TQM Implementation. Section C : Items measuring the five dimensions of Health Service Quality. All items in Sections B and C were measured on a 5-point Likert scale, ranging from 1 (Strongly Disagree) to 5 (Strongly Agree). Instrument Validity and Reliability Rigorous procedures were performed to ensure the psychometric properties of the questionnaire. Content Validity : The instrument was reviewed by a panel of seven experts, including three academics in healthcare quality management, two senior hospital administrators, and two senior nursing leaders. They assessed the items for clarity, relevance, and comprehensiveness. The feedback was used to refine the final version of the questionnaire. The Content Validity Index (CVI) for the overall scale was 0.91. Reliability : Internal consistency was assessed using Cronbach's alpha. The overall reliability for the TQM scale was α = 0.92, and for the Health Service Quality scale was α = 0.94. All subscales also demonstrated excellent reliability, with alpha values ranging from 0.85 to 0.95, well above the recommended threshold of 0.70. A pilot study with 30 healthcare professionals was conducted to test for clarity and feasibility before full-scale data collection. Data Analysis Data were coded and analyzed using the Statistical Package for the Social Sciences (SPSS) version 26 and AMOS for structural equation modeling. A p-value of < 0.05 was set as the threshold for statistical significance for all tests. The analysis included: Descriptive Statistics : Frequencies, percentages, means, and standard deviations were used to summarize the demographic data, levels of TQM implementation, and health service quality. Correlation Analysis : Pearson's correlation coefficient was used to examine the bivariate relationships between the TQM dimensions and health service quality dimensions. Inferential Statistics : Multiple linear regression analysis was conducted to determine the predictive power of the TQM dimensions (independent variables) on overall health service quality (dependent variable). The assumptions of the model, including linearity, normality of residuals, and absence of multicollinearity (using the variance inflation factor, VIF), were verified. Ethical Considerations This study was conducted in accordance with the principles of the Declaration of Helsinki. Ethical approval was obtained from the Institutional Review Board (IRB) of the Center of Business Administration, Sana'a University. Formal permission was obtained from the administrative leadership of each participating hospital. Written informed consent was obtained from all participants before they completed the questionnaire. The consent form, provided in Arabic, explained the study's purpose, assured the participants that their involvement was voluntary, and confirmed that they could withdraw at any time without any consequences. To ensure anonymity and confidentiality, no personal identifiers were collected from the questionnaires and all completed forms were stored securely. Results A total of 410 complete and valid questionnaires were included in the final analysis, yielding a high response rate and robust dataset for statistical testing. The results are presented in the following section. Participant Characteristics The demographic profiles of the 410 participating healthcare professionals are summarized in Table 1 . The sample was predominantly female (69.0%). The most frequent academic qualification was a diploma (52.7%), and the workforce was highly experienced, with 37.8% of participants having more than 10 years of service. Nurses and other technical staff comprised the largest professional category (73.9%), ensuring a strong frontline perspective on quality management and service delivery. Table 1 Demographic Characteristics of Study Respondents (n = 410) Characteristic Category Frequency Percentage (%) Gender Male 127 31.0 Female 283 69.0 Highest Qualification Diploma 216 52.7 Bachelor's 148 36.1 High School 24 5.9 Master's 13 3.2 PhD/Board 9 2.2 Years of Experience > 10 years 155 37.8 5 to 10 years 138 33.7 < 5 years 117 28.5 Job Title Technical Staff (Nurse, etc.) 303 73.9 Administrative Staff 59 14.4 Physician / Specialist 48 11.7 Descriptive Statistics and Scale Reliability Descriptive statistics were calculated for all study variables using a 7-point Likert scale. The overall mean score for TQM Implementation was high (M = 5.44, SD = 0.99), as was that for Healthcare Service Quality (M = 5.65, SD = 1.01). Table 2 provides a detailed breakdown of the mean scores for each TQM and service quality dimension. Notably, \"Leadership Commitment\" was the highest-rated TQM dimension, while \"Human Resources\" and \"Partnerships & Resources\" were the lowest-rated TQM dimensions, and \"Assurance\" was the lowest-rated service quality dimension (Fig. 2 ). Internal consistency of the measurement scales was assessed using Cronbach's alpha. All scales demonstrated excellent reliability (α > 0.88), confirming that the instrument was a valid and reliable measure of the constructs of this study. Table 2 Descriptive Statistics for Study Dimensions (7-point scale) Construct Dimension Mean Standard Deviation TQM Implementation Leadership Commitment 5.74 1.02 Policy & Strategy 5.59 1.08 Processes 5.52 1.03 Partnerships & Resources 5.20 1.25 Human Resources 5.15 1.25 Overall TQM 5.44 0.99 Health Service Quality Empathy 5.86 1.14 Responsiveness 5.67 1.15 Reliability 5.66 1.09 Tangibility 5.57 1.08 Assurance 5.51 1.12 Overall Service Quality 5.65 1.01 Correlation Analysis Pearson’s correlation analysis was conducted to examine the relationships between the study variables. As shown in Table 3 , all TQM dimensions were strongly and significantly correlated with each other and with the outcome variable. Most importantly, the analysis revealed a strong, positive, and statistically significant relationship between overall TQM and service quality (r = .762, p < .001). Among individual dimensions, processes had the highest correlation with service quality (r = .778, p < .001). Table 3 Pearson Correlation Matrix for TQM Dimensions and Health Service Quality Variable LC HR PS PR P TQM Leadership Commitment (LC) 1 Human Resources (HR) .663** 1 Policy & Strategy (PS) .772** .738** 1 Partnerships & Resources (PR) .605** .704** .715** 1 Processes (P) .735** .680** .818** .730** 1 Overall TQM .849** .871** .915** .864** .895** 1 Overall Service Quality .622** .563** .740** .665** .778** .762 **p < .001 (2-tailed) Hypothesis Testing: The Impact of TQM on Service Quality Multiple linear regression was performed to test the predictive power of TQM dimensions on health service quality. The overall model was statistically significant (F(5, 404) = 148.73, p < .001) and accounted for 64.8% of the variance in service quality (R² = 0.648). Table 4 presents the regression coefficients. The results show that \"Processes\" (β = 0.468, p < .001), \"Policy & Strategy\" (β = 0.305, p = .001), and \"Partnerships & Resources\" (β = 0.179, p < .001) are significant positive predictors of health service quality (Fig. 3 ). In this multivariate model, \"Human Resources\" and \"Leadership Commitment\" were not statistically significant predictors. Table 4 Multiple Regression Model Predicting Health Service Quality Model Predictor Unstandardized Coeff. (B) Std. Error Standardized Coeff. (β) t-value p-value (Constant) 1.274 0.215 5.925 < .001 Processes 0.476 0.055 0.468 8.729 < .001 Policy & Strategy 0.199 0.057 0.305 3.492 .001 Partnerships & Resources 0.164 0.039 0.179 4.248 < .001 Human Resources -0.062 0.039 -0.111 -1.597 .111 Leadership Commitment 0.015 0.045 0.009 0.330 .742 Note: R² = 0.648, Adjusted R² = 0.644, F-statistic = 148.73 Group Differences and Moderation Effects One-way ANOVA was conducted to determine whether perceptions of service quality differed across job titles. The results, shown in Table 5 , indicate no statistically significant differences among the professional groups (F(4, 405) = 0.31, p = 0.871). Table 5 ANOVA for Service Quality Across Job Titles Job Title N Mean Quality Score Std. Deviation Manager / Deputy Manager 4 5.58 0.93 Department Head 68 5.59 1.23 Supervisor 25 5.48 1.22 Specialist Staff 303 5.68 0.95 Administrative Staff 10 5.70 0.69 Total 410 5.65 1.01 Note: F(4, 405) = 0.31, p = 0.871 Additionally, moderation analyses revealed that gender significantly moderated the relationship between all the TQM dimensions and service quality. Experience was also a significant moderator, strengthening the positive effect of the \"Policy & Strategy\" and \"Processes\" dimensions on service quality. Discussion This study provides compelling evidence that Total Quality Management (TQM) implementation significantly enhances healthcare service quality in Yemen's conflict-affected healthcare system, with the overall model explaining 64.8% of the variance in service quality outcomes. The findings revealed both expected and surprising patterns in how different TQM dimensions influence service delivery, offering important insights into improving healthcare quality in fragile and conflict-affected settings. Our findings demonstrate that a focus on these fundamental principles, particularly those related to processes and policy, can be operationalized effectively even in resource-constrained environments. The strong positive relationship between overall TQM implementation and healthcare service quality (R² = 0.648) represents a remarkable achievement in the challenging context of Yemen's healthcare system. This finding aligns closely with the international benchmarks reported in systematic reviews of TQM implementation in healthcare settings, where similar R² values of 0.669 have been documented [ 11 ]. The magnitude of this relationship is particularly significant given that our study was conducted in a context where healthcare infrastructure has been severely compromised, with only 54% of health facilities being fully functional compared to 90% pre-conflict [ 5 ]. The robustness of this relationship suggests that TQM principles retain their effectiveness even under extreme adversity. Alzoubi et al. (2019) identified education and training, continuous quality improvement, patient focus, top management commitment, and teamwork as core predictors of successful TQM implementation in healthcare [ 11 ]. Our findings demonstrate that these fundamental quality management principles can be operationalized effectively, even in resource-constrained environments, providing a foundation for sustainable quality improvement initiatives in similar contexts. The dominance of \"Processes\" (β = 0.468, p < 0.001) and \"Policy & Strategy\" (β = 0.305, p = 0.001) as the most powerful predictors of service quality reflects the critical importance of systematic, evidence-based approaches to care delivery. This finding resonates with the extensive literature on clinical pathways and standardized care protocols, which has been consistently associated with improved patient outcomes and reduced variation in care quality [ 12 ]. The prominence of process-oriented factors in our study aligns with the resilience literature from conflict-affected settings, where standardized protocols and systematic approaches serve as crucial stabilizing forces amid environmental uncertainty [ 13 ]. In Yemen's fragmented healthcare system, where coordination between multiple actors is challenging, well-defined processes provide essential structure and predictability. The electronic Disease Early Warning System (eDEWS) and rapid response teams implemented in Yemen exemplify how process-oriented interventions can maintain service quality even under adverse conditions [ 5 ]. The strong predictive power of \"Policy & Strategy\" underscores the importance of strategic planning and policy coherence in healthcare quality management. This finding is particularly relevant in conflict-affected settings, where policy fragmentation and competing priorities often undermine service delivery [ 14 ]. The implementation of Yemen's Minimum Service Package (MSP) in collaboration with WHO represents a successful example of how strategic policy frameworks can provide direction and coordination for quality improvement efforts across multiple stakeholders [ 5 ]. Perhaps the most intriguing finding of this study is the statistical non-significance of \"Leadership Commitment\" (β = 0.009, p = 0.742) in predicting service quality, even though participants rated this dimension the highest among all TQM components (M = 5.74). This apparent paradox challenges conventional wisdom about leadership's direct impact on quality outcomes and suggests a more nuanced understanding of how leadership influences healthcare quality in conflict settings. The literature on transformational and transactional leadership in healthcare provides insight into this phenomenon. While transformational leadership behaviors correlate with organizational readiness for change (β = 0.39) and improved nurse performance [ 15 ], the impact may be mediated through organizational systems and processes rather than direct effects on service quality. In Yemen's context, where healthcare leaders face unprecedented challenges, including destroyed infrastructure, workforce shortages, and security threats [ 16 ], the relationship between leadership commitment and service quality may be attenuated by systemic constraints beyond leaders' control. Even more concerning is the non-significant relationship between \"Human Resources\" and service quality (β = -0.111, p = 0.111), coupled with this dimension receiving the lowest ratings among all TQM components. This finding reflects the profound human resource crisis facing Yemen's healthcare system, where critical workforce gaps include 47% for physicians, over 80% for nurses and midwives, and 78% for pharmacists [ 5 ]. Literature on healthcare worker burnout in low- and middle-income countries reveals that 28.1% of primary healthcare professionals experience high emotional exhaustion, with 31.9% reporting reduced personal accomplishment [ 17 ]. The human resource challenge is exacerbated by conflict-specific stressors documented in Yemen, including secondary traumatic stress, high rates of PTSD, and professional burnout among healthcare workers [ 16 ]. A recent study of nurses in Yemeni hospitals found that conflict-related stress and excessive workload significantly reduced job satisfaction across all dimensions, contributing to workforce instability and compromised care quality [ 18 ]. Meta-analytic evidence demonstrates that nurse burnout is associated with worsened patient safety outcomes (effect size 2.67, 95% CI: 2.3-3.0) and reduced quality of care [ 19 ]. The implementation of meaningful TQM in Yemen's healthcare system is a remarkable example of resilience in fragile and conflict-affected settings. The literature on health system resilience identifies key characteristics, including the diversity of service providers, integration through coordination platforms, adaptive capacity, and maintenance of essential services during crises [ 13 ]. Yemen's healthcare system has demonstrated several of these resilience characteristics, including the establishment of parallel coordination platforms, deployment of rapid response teams, and implementation of surveillance systems, such as eDEWS [ 5 ]. The moderating effects of gender and experience on TQM-service quality relationships revealed in our study reflect the complex social dynamics operating in conflict-affected healthcare systems. With 69% of our sample being female and 37.8% having more than ten years of experience, these findings highlight the critical role of experienced female healthcare workers in maintaining quality standards. This aligns with research showing that healthcare workers in conflict zones develop adaptive strategies and informal networks that help sustain service delivery [ 13 ]. The non-significant ANOVA results regarding job title differences in quality perceptions suggest that the shared experience of working in a conflict-affected healthcare system may override the traditional hierarchical distinctions. This finding contrasts with studies on stable healthcare systems, where significant differences in quality perceptions often exist between professional groups [ 20 ]. The convergence of quality perceptions across job titles may reflect a collective commitment to maintaining standards, despite extraordinary challenges. These findings have profound implications for nursing practice and leadership in conflict-affected health care settings. The primacy of processes and policies suggests that nurse leaders should prioritize the development and implementation of standardized care protocols, evidence-based practice guidelines, and systematic quality improvement processes. The literature on evidence-based nursing practice demonstrates that structured approaches to care delivery improve patient outcomes and enhance professional satisfaction [ 21 ]. Given the human resource challenges identified in this study, nursing leaders should focus on workforce wellbeing and retention strategies. The high prevalence of burnout among healthcare workers in conflict zones requires targeted interventions, including stress management programs, peer support networks, and mental health services [ 17 ]. The positive moderating effects of experience suggest that mentorship programs that pair experienced nurses with new colleagues can enhance both quality outcomes and workforce stability. The finding that leadership commitment does not directly predict service quality should not be interpreted as diminishing the importance of leadership but rather as highlighting the need for leadership approaches that work through systems and processes. Transformational leadership behaviors that focus on intellectual stimulation, individualized consideration, and inspirational motivation may be more effective in conflict settings than traditional command-and-control approaches [ 15 ]. Policy Recommendations Based on these findings, several policy recommendations have emerged for health care leaders and policymakers in conflict-affected settings. Process-Oriented Quality Improvement : Prioritize the development and implementation of standardized care protocols, clinical pathways, and quality improvement processes that can function effectively despite resource and infrastructure limitations. Strategic Policy Framework : Develop coherent policy frameworks that provide a clear direction for quality improvement efforts across multiple stakeholders, similar to Yemen's Minimum Service Package implementation. Human Resources Investment : Comprehensive workforce support programs, including mental health services, stress management interventions, and career development opportunities, address the critical human resource challenges identified in this study. Coordination Mechanisms : Establish robust coordination platforms that bring together diverse healthcare actors to align quality standards and share best practices, recognizing the importance of integration in fragile settings. Experience-based mentorship : Leverages the positive moderating effects of experience by developing formal mentorship programs and knowledge transfer mechanisms that capture and disseminate quality improvement expertise. Gender-Sensitive Policies : Recognize and support the critical role of female healthcare workers in maintaining quality standards, ensuring that policies address their specific needs and challenges. Limitations of the Study Several limitations of this study should be acknowledged when interpreting these findings. The cross-sectional design limits our ability to establish causal relationships between TQM dimensions and service quality outcomes. This study was conducted in specific healthcare facilities in Yemen, which may limit its generalizability to other conflict-affected settings or healthcare systems with different characteristics. The reliance on self-reported measures introduces potential bias, particularly in the context in which healthcare workers may feel pressured to report positive outcomes despite challenging circumstances. The timing of data collection during the ongoing conflict may have influenced participants' responses, potentially affecting the validity of the findings. The study focused on healthcare professionals' perceptions of quality rather than objective clinical outcomes or patient-reported measures. Future research should incorporate multiple perspectives and objective quality indicators to provide a more comprehensive understanding of TQM’s effectiveness in conflict-affected settings. Conclusion This study provides compelling evidence that Total Quality Management principles can be effectively implemented in conflict-affected healthcare settings, with processes and policy strategies serving as primary drivers of service quality improvement. The findings challenge conventional assumptions about leadership's direct impact on quality while highlighting the critical importance of systematic, evidence-based approaches to care delivery. Most importantly, this study reveals the profound human resource challenges facing healthcare systems in conflict zones, where workforce well-being and retention have emerged as fundamental prerequisites for sustainable quality improvement. The results demonstrate that even in the most challenging circumstances, healthcare organizations can achieve meaningful quality improvements through focused attention to process optimization and strategic policy development. However, the success of these efforts ultimately depends on addressing the underlying human resource crisis using comprehensive workforce support strategies. These findings provide a foundation for developing more effective quality improvement interventions in similar contexts, and contribute to the growing body of knowledge on health system resilience in fragile and conflict-affected settings. Abbreviations ANOVA Analysis of Variance CQI Continuous Quality Improvement eDEWS electronic Disease Early Warning System EFQM European Foundation for Quality Management IRB Institutional Review Board JCIA Joint Commission International Accreditation MSP Minimum Service Package PDSA Plan-Do-Study-Act PTSD Post-Traumatic Stress Disorder SERVQUAL Service Quality (A model for measuring service quality) TQM Total Quality Management VIF Variance Inflation Factor WHO World Health Organization Declarations Ethics approval and consent to participate This study was conducted in accordance with the ethical principles of the Declaration of Helsinki. Ethical approval was obtained from the Institutional Review Board (IRB) of the Center of Business Administration, Sana'a University. Formal permission to conduct this study was secured from the administrative leadership of each of the four participating hospitals. All participants were provided with a detailed information sheet that explained the purpose, procedures, and rights of the study. Written informed consent was obtained from all participants prior to their participation in the study. Participation was voluntary and participants were assured that they could withdraw at any time without penalties or professional consequences. Consent for publication Not applicable. Availability of data and materials The datasets generated and/or analyzed during the current study are not publicly available because of the sensitive nature of the research context and to protect the confidentiality and anonymity of the participating healthcare professionals and institutions. The data are available from the corresponding author upon request. Competing interests The authors declare that they have no conflicts of interest. Funding This research received no specific grants from any funding agency in the public, commercial, or not-for-profit sector. Authors' contributions J. M.A. conceived and designed the study, collected and analyzed the data, and was a major contributor to the writing of the manuscript. M.M.A. supervised the project, contributed to the study design and methodology, and critically revised the manuscript. H. M. J. contributed to data interpretation, manuscript drafting, and critical revisions for intellectual content. All authors have read and approved the final manuscript. Acknowledgements The authors would like to express their sincere gratitude to all the healthcare professionals at the participating hospitals in Sana'a who generously gave their time to participate in this study despite their challenging working conditions. We also thank the hospital administrators for granting permission and facilitating the data-collection process. References Mosadeghrad AM. Developing and validating a total quality management model for healthcare organisations. 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Supplementary Files AppendixA.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {\"props\":{\"pageProps\":{\"initialData\":{\"identity\":\"rs-7115768\",\"acceptedTermsAndConditions\":true,\"allowDirectSubmit\":true,\"archivedVersions\":[],\"articleType\":\"Research Article\",\"associatedPublications\":[],\"authors\":[{\"id\":501330811,\"identity\":\"f6afcc30-3591-4658-a4ea-0d381c696ceb\",\"order_by\":0,\"name\":\"Jabran Mohammed Al-Saleet\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Sana'a University\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Jabran\",\"middleName\":\"Mohammed\",\"lastName\":\"Al-Saleet\",\"suffix\":\"\"},{\"id\":501330812,\"identity\":\"e81a9ae8-6ade-4d6b-9fe5-722f1aeae175\",\"order_by\":1,\"name\":\"Munir Musleh Al-Wasabi\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Sana'a University\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Munir\",\"middleName\":\"Musleh\",\"lastName\":\"Al-Wasabi\",\"suffix\":\"\"},{\"id\":501330813,\"identity\":\"537be91f-3760-4184-84c0-22a3b26060f9\",\"order_by\":2,\"name\":\"Haitham Mohammed Jowah\",\"email\":\"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAzUlEQVRIiWNgGAWjYBACAwaGBCB1QA7M4yFFizFJWkDgQGID0VrMGRgePuapuZM+f0YC44O3bQyJ/YS0WDYwJBvzHHuWu+FGArPhXKCWmQ2EHHaAIU06h+1w7gaJBDZpXqCWDQeI0vLvcLr8jAT23yAt+4nSktt2OIHhRgIbM9gWQn4xOAz0y9++w4YbzjxslpxzTsJ4BkFbjvckPpzx7bC8fHvywQ9vymxk+xsIWcPMkwBlMYLUSjgS1MHAwI7qEHvCOkbBKBgFo2CkAQCEAUMIrb03fgAAAABJRU5ErkJggg==\",\"orcid\":\"\",\"institution\":\"Sana'a University\",\"correspondingAuthor\":true,\"prefix\":\"\",\"firstName\":\"Haitham\",\"middleName\":\"Mohammed\",\"lastName\":\"Jowah\",\"suffix\":\"\"}],\"badges\":[],\"createdAt\":\"2025-07-14 00:38:02\",\"currentVersionCode\":1,\"declarations\":\"\",\"doi\":\"10.21203/rs.3.rs-7115768/v1\",\"doiUrl\":\"https://doi.org/10.21203/rs.3.rs-7115768/v1\",\"draftVersion\":[],\"editorialEvents\":[],\"editorialNote\":\"\",\"failedWorkflow\":false,\"files\":[{\"id\":89411518,\"identity\":\"b8daaf69-498d-4a30-b9f3-db495aa0c143\",\"added_by\":\"auto\",\"created_at\":\"2025-08-19 16:21:52\",\"extension\":\"png\",\"order_by\":1,\"title\":\"Figure 1\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":31310,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003e\\u003cstrong\\u003eConceptual Framework of the Study.\\u003c/strong\\u003e The framework illustrates the hypothesized relationship between the independent variable (TQM Implementation) and the dependent variable (Health Service Quality) based on the EFQM and SERVQUAL models.\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"1.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-7115768/v1/054825887f57d2fd13277d48.png\"},{\"id\":89411139,\"identity\":\"0c0957d1-7008-45cd-8cdb-d5dc8952fb26\",\"added_by\":\"auto\",\"created_at\":\"2025-08-19 16:13:53\",\"extension\":\"png\",\"order_by\":2,\"title\":\"Figure 2\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":328263,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003e\\u003cstrong\\u003eMean Perceived Scores for TQM and Service Quality Dimensions.\\u003c/strong\\u003e Bars represent the mean scores on a 7-point Likert scale. Blue bars indicate TQM dimensions; green bars indicate Service Quality dimensions.\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"figure2meanscores.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-7115768/v1/64e9c7b40662862680b4807e.png\"},{\"id\":89411142,\"identity\":\"4b1df25f-3bad-4cb8-913c-4ab5f868f926\",\"added_by\":\"auto\",\"created_at\":\"2025-08-19 16:13:53\",\"extension\":\"png\",\"order_by\":3,\"title\":\"Figure 3\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":85471,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003e\\u003cstrong\\u003eKey Predictors of Health Service Quality.\\u003c/strong\\u003e The chart displays the standardized beta (β) coefficients from the multiple regression analysis. Green bars indicate statistically significant positive predictors (p \\u0026lt; .05); gray bars indicate non-significant predictors.\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"figure3betacoefficients.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-7115768/v1/c3d95dddeb8e53550272637c.png\"},{\"id\":90909835,\"identity\":\"6ba13f66-9f4f-4626-bf37-1b2ef623c430\",\"added_by\":\"auto\",\"created_at\":\"2025-09-09 13:32:17\",\"extension\":\"pdf\",\"order_by\":0,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"manuscript-pdf\",\"size\":1814574,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"manuscript.pdf\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-7115768/v1/07cd33f9-76e9-414d-aa31-9ac442ed6e36.pdf\"},{\"id\":89411135,\"identity\":\"efd8aac1-4750-4ed5-81d3-e3e42eccbc53\",\"added_by\":\"auto\",\"created_at\":\"2025-08-19 16:13:52\",\"extension\":\"docx\",\"order_by\":0,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"supplement\",\"size\":36561,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"AppendixA.docx\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-7115768/v1/4b8dcd5f60d3184ee1fb8d5b.docx\"}],\"financialInterests\":\"No competing interests reported.\",\"formattedTitle\":\"Impact of Total Quality Management on Healthcare Service Quality in Yemeni Hospitals: A Cross-Sectional Study\",\"fulltext\":[{\"header\":\"Background\",\"content\":\"\\u003cp\\u003eHealthcare quality improvement has emerged as a critical global priority, with Total Quality Management (TQM) representing a comprehensive organizational approach to systematic quality enhancement in medical service delivery systems [\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e]. Based on the principles of continuous process optimization, data-driven decision-making, and stakeholder engagement, TQM frameworks have demonstrated significant potential in improving clinical outcomes, patient safety, and operational efficiency across diverse healthcare settings [\\u003cspan citationid=\\\"CR2\\\" class=\\\"CitationRef\\\"\\u003e2\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e].\\u003c/p\\u003e\\u003cp\\u003eIn conflict-affected regions characterized by institutional fragility, healthcare systems face compounded challenges, including infrastructure degradation, critical supply shortages, and professional workforce attrition [\\u003cspan citationid=\\\"CR4\\\" class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e]. Yemen exemplifies these challenges; recent analyses indicate that over half of the nation's medical facilities have been damaged or destroyed during prolonged conflict, while severe shortages of essential medicines and qualified personnel persist nationwide [\\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e]. The 2021 mandate by Yemen's Ministry of Public Health and Population for comprehensive TQM implementation represents significant policy intervention within this constrained operational environment. However, while foundational local research by \\u003cb\\u003eAli et al. (2022)\\u003c/b\\u003e established a positive correlation between TQM and service improvement in Sana'a, they also highlighted major implementation barriers, underscoring that empirical evidence of TQM's operational effectiveness in this unique context remains limited [\\u003cspan citationid=\\\"CR6\\\" class=\\\"CitationRef\\\"\\u003e6\\u003c/span\\u003e].\\u003c/p\\u003e\\u003cp\\u003eThe nursing profession is a particularly critical component of quality improvement initiatives, representing the largest segment of the healthcare workforce and professional cohort, with the most direct and continuous patient contact [\\u003cspan citationid=\\\"CR7\\\" class=\\\"CitationRef\\\"\\u003e7\\u003c/span\\u003e]. Evidence confirms that nursing engagement significantly influences quality outcomes, with nurse-sensitive indicators serving as reliable predictors of institutional performance [\\u003cspan citationid=\\\"CR8\\\" class=\\\"CitationRef\\\"\\u003e8\\u003c/span\\u003e]. Within the broader Middle Eastern context, studies have identified distinctive patterns of nursing job satisfaction and engagement that can impact the success of quality initiatives [\\u003cspan citationid=\\\"CR8\\\" class=\\\"CitationRef\\\"\\u003e8\\u003c/span\\u003e]. Therefore, the intersection of evidence-based nursing practice and TQM implementation in conflict-affected settings represents a significant knowledge gap that requires further investigation.\\u003c/p\\u003e\\u003cp\\u003eThis study addressed three primary research initiatives.\\u003c/p\\u003e\\u003cp\\u003e\\u003c/p\\u003e\\u003col\\u003e\\u003cspan\\u003e\\u003cli\\u003e\\u003cp\\u003eTo evaluate the implementation status of core TQM dimensions across a sample of public and private Yemeni hospitals.\\u003c/p\\u003e\\u003c/li\\u003e\\u003c/span\\u003e\\u003cspan\\u003e\\u003cli\\u003e\\u003cp\\u003eTo quantify the predictive relationship between TQM implementation and multiple dimensions of healthcare service quality.\\u003c/p\\u003e\\u003c/li\\u003e\\u003c/span\\u003e\\u003cspan\\u003e\\u003cli\\u003e\\u003cp\\u003eTo analyze key factors from healthcare professionals' perspective, including the impact of gender and experience, which influence the effectiveness of quality improvement processes.\\u003c/p\\u003e\\u003c/li\\u003e\\u003c/span\\u003e\\u003c/ol\\u003e\\u003cp\\u003e\\u003c/p\\u003e\\u003cp\\u003eBy conducting a systematic analysis of healthcare professionals in Sana'a, this research aims to generate empirical evidence to inform quality improvement strategies in resource-constrained environments while contributing to the broader theoretical understanding of healthcare management in fragile states.\\u003c/p\\u003e\\u003c/div\\u003e\"},{\"header\":\"Methods\",\"content\":\"\\u003cp\\u003e\\u003cb\\u003eStudy Design and Conceptual Framework\\u003c/b\\u003e\\u003c/p\\u003e\\u003cp\\u003eThis study employed a quantitative, cross-sectional, descriptive-analytical design to investigate the impact of Total Quality Management (TQM) implementation on health service quality in Yemeni hospitals. The conceptual framework (Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e) was adapted from two established models: the TQM dimensions were based on the enablers of the \\u003cb\\u003eEuropean Foundation for Quality Management (EFQM) model\\u003c/b\\u003e [\\u003cspan citationid=\\\"CR9\\\" class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e], while the health service quality dimensions were based on the \\u003cb\\u003eSERVQUAL framework\\u003c/b\\u003e. The independent variable, TQM Implementation, was operationalized through five dimensions: (1) Leadership and Management Commitment, (2) Human Resources, (3) Policy and Strategy, (4) Partnerships and Resources, and (5) processes. The dependent variable Health Service Quality was measured using the following five dimensions: (1) Tangibility, (2) Reliability, (3) Responsiveness, (4) Assurance, and (5) Empathy.\\u003c/p\\u003e\\u003cp\\u003e\\u003cb\\u003eSetting and Participants\\u003c/b\\u003e\\u003c/p\\u003e\\u003cp\\u003eThe study was conducted in four major hospitals in Sana'a, Yemen. Hospitals were purposively selected because they were known to have formally adopted TQM programs. The selection included three large public hospitals (22 May Hospital, Al-Thawra Hospital, Al-Manar Hospital) and one large private hospital (The Royal Hospital) to ensure a representative view of both sectors.\\u003c/p\\u003e\\u003cp\\u003eThe target population consisted of all clinical, administrative, and support staff (N = 600) at the four institutions. The required sample size was calculated to be \\u003cb\\u003en = 412\\u003c/b\\u003e using the Krejcie and Morgan (1970) formula [\\u003cspan citationid=\\\"CR10\\\" class=\\\"CitationRef\\\"\\u003e10\\u003c/span\\u003e], ensuring a 95% confidence level and 5% margin of error. A stratified random sampling technique was used to select participants, with strata based on professional categories (e.g., nurses, physicians, and administrative staff) to ensure proportional representation. The inclusion criteria for participants were as follows: (1) being a full-time employee for at least six months at one of the selected hospitals and (2) providing written informed consent to participate.\\u003c/p\\u003e\\u003cp\\u003e\\u003cb\\u003eData Collection Instrument\\u003c/b\\u003e\\u003c/p\\u003e\\u003cp\\u003eThe primary data collection tool was a self-administered structured questionnaire developed by the researchers based on an extensive literature review and the conceptual framework of the study. The questionnaire was translated from English to Arabic, and then back-translated by an independent bilingual expert to ensure linguistic and conceptual equivalence. This paper is comprised of three sections.\\u003c/p\\u003e\\u003cul\\u003e\\u003cli\\u003e\\u003cp\\u003e\\u003cb\\u003eSection A\\u003c/b\\u003e: Demographic and professional characteristics of respondents (e.g., gender, qualification, years of experience, and job title).\\u003c/p\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cp\\u003e\\u003cb\\u003eSection B\\u003c/b\\u003e: Items measuring the five dimensions of TQM Implementation.\\u003c/p\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cp\\u003e\\u003cb\\u003eSection C\\u003c/b\\u003e: Items measuring the five dimensions of Health Service Quality.\\u003c/p\\u003e\\u003c/li\\u003e\\u003c/ul\\u003e\\u003cp\\u003eAll items in Sections B and C were measured on a 5-point Likert scale, ranging from 1 (Strongly Disagree) to 5 (Strongly Agree).\\u003c/p\\u003e\\u003cp\\u003e\\u003cb\\u003eInstrument Validity and Reliability\\u003c/b\\u003e\\u003c/p\\u003e\\u003cp\\u003eRigorous procedures were performed to ensure the psychometric properties of the questionnaire.\\u003c/p\\u003e\\u003cul\\u003e\\u003cli\\u003e\\u003cp\\u003e\\u003cb\\u003eContent Validity\\u003c/b\\u003e: The instrument was reviewed by a panel of seven experts, including three academics in healthcare quality management, two senior hospital administrators, and two senior nursing leaders. They assessed the items for clarity, relevance, and comprehensiveness. The feedback was used to refine the final version of the questionnaire. The Content Validity Index (CVI) for the overall scale was 0.91.\\u003c/p\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cp\\u003e\\u003cb\\u003eReliability\\u003c/b\\u003e: Internal consistency was assessed using Cronbach's alpha. The overall reliability for the TQM scale was α = 0.92, and for the Health Service Quality scale was α = 0.94. All subscales also demonstrated excellent reliability, with alpha values ranging from 0.85 to 0.95, well above the recommended threshold of 0.70. A pilot study with 30 healthcare professionals was conducted to test for clarity and feasibility before full-scale data collection.\\u003c/p\\u003e\\u003c/li\\u003e\\u003c/ul\\u003e\\u003ch2\\u003eData Analysis\\u003c/h2\\u003e\\u003cp\\u003eData were coded and analyzed using the Statistical Package for the Social Sciences (SPSS) version 26 and AMOS for structural equation modeling. A p-value of \\u0026lt; 0.05 was set as the threshold for statistical significance for all tests. The analysis included:\\u003c/p\\u003e\\u003col\\u003e\\u003cspan\\u003e\\u003cli\\u003e\\u003cp\\u003e\\u003cb\\u003eDescriptive Statistics\\u003c/b\\u003e: Frequencies, percentages, means, and standard deviations were used to summarize the demographic data, levels of TQM implementation, and health service quality.\\u003c/p\\u003e\\u003c/li\\u003e\\u003c/span\\u003e\\u003cspan\\u003e\\u003cli\\u003e\\u003cp\\u003e\\u003cb\\u003eCorrelation Analysis\\u003c/b\\u003e: Pearson's correlation coefficient was used to examine the bivariate relationships between the TQM dimensions and health service quality dimensions.\\u003c/p\\u003e\\u003c/li\\u003e\\u003c/span\\u003e\\u003cspan\\u003e\\u003cli\\u003e\\u003cp\\u003e\\u003cb\\u003eInferential Statistics\\u003c/b\\u003e: Multiple linear regression analysis was conducted to determine the predictive power of the TQM dimensions (independent variables) on overall health service quality (dependent variable). The assumptions of the model, including linearity, normality of residuals, and absence of multicollinearity (using the variance inflation factor, VIF), were verified.\\u003c/p\\u003e\\u003c/li\\u003e\\u003c/span\\u003e\\u003c/ol\\u003e\\u003cp\\u003e\\u003cb\\u003eEthical Considerations\\u003c/b\\u003e\\u003c/p\\u003e\\u003cp\\u003e This study was conducted in accordance with the principles of the Declaration of Helsinki. Ethical approval was obtained from the Institutional Review Board (IRB) of the Center of Business Administration, Sana'a University. Formal permission was obtained from the administrative leadership of each participating hospital. Written informed consent was obtained from all participants before they completed the questionnaire. The consent form, provided in Arabic, explained the study's purpose, assured the participants that their involvement was voluntary, and confirmed that they could withdraw at any time without any consequences. To ensure anonymity and confidentiality, no personal identifiers were collected from the questionnaires and all completed forms were stored securely.\\u003c/p\\u003e\"},{\"header\":\"Results\",\"content\":\"\\u003cp\\u003eA total of 410 complete and valid questionnaires were included in the final analysis, yielding a high response rate and robust dataset for statistical testing. The results are presented in the following section.\\u003c/p\\u003e\\u003cp\\u003e\\u003cb\\u003eParticipant Characteristics\\u003c/b\\u003e\\u003c/p\\u003e\\u003cp\\u003eThe demographic profiles of the 410 participating healthcare professionals are summarized in Table\\u0026nbsp;\\u003cspan refid=\\\"Tab1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e. The sample was predominantly female (69.0%). The most frequent academic qualification was a diploma (52.7%), and the workforce was highly experienced, with 37.8% of participants having more than 10 years of service. Nurses and other technical staff comprised the largest professional category (73.9%), ensuring a strong frontline perspective on quality management and service delivery.\\u003c/p\\u003e\\u003cp\\u003e\\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab1\\\" border=\\\"1\\\"\\u003e\\u003ccaption language=\\\"En\\\"\\u003e\\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 1\\u003c/div\\u003e\\u003cdiv class=\\\"CaptionContent\\\"\\u003e\\u003cp\\u003eDemographic Characteristics of Study Respondents (n\\u0026thinsp;=\\u0026thinsp;410)\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/caption\\u003e\\u003ccolgroup cols=\\\"4\\\"\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c3\\\" colnum=\\\"3\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c4\\\" colnum=\\\"4\\\"\\u003e\\u003c/div\\u003e\\u003cthead\\u003e\\u003ctr\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eCharacteristic\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003eCategory\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003eFrequency\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003ePercentage (%)\\u003c/p\\u003e\\u003c/th\\u003e\\u003c/tr\\u003e\\u003c/thead\\u003e\\u003ctbody\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003e\\u003cb\\u003eGender\\u003c/b\\u003e\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003eMale\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e127\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e31.0\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003eFemale\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e283\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e69.0\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003e\\u003cb\\u003eHighest Qualification\\u003c/b\\u003e\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003eDiploma\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e216\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e52.7\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003eBachelor's\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e148\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e36.1\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003eHigh School\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e24\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e5.9\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003eMaster's\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e13\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e3.2\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003ePhD/Board\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e9\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e2.2\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003e\\u003cb\\u003eYears of Experience\\u003c/b\\u003e\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e\\u0026gt;\\u0026thinsp;10 years\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e155\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e37.8\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e5 to 10 years\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e138\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e33.7\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e\\u0026lt;\\u0026thinsp;5 years\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e117\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e28.5\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003e\\u003cb\\u003eJob Title\\u003c/b\\u003e\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003eTechnical Staff (Nurse, etc.)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e303\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e73.9\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003eAdministrative Staff\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e59\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e14.4\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003ePhysician / Specialist\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e48\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e11.7\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003c/tbody\\u003e\\u003c/colgroup\\u003e\\u003c/table\\u003e\\u003c/div\\u003e\\u003c/p\\u003e\\u003cp\\u003e\\u003cb\\u003eDescriptive Statistics and Scale Reliability\\u003c/b\\u003e\\u003c/p\\u003e\\u003cp\\u003eDescriptive statistics were calculated for all study variables using a 7-point Likert scale. The overall mean score for TQM Implementation was high (M\\u0026thinsp;=\\u0026thinsp;5.44, SD\\u0026thinsp;=\\u0026thinsp;0.99), as was that for Healthcare Service Quality (M\\u0026thinsp;=\\u0026thinsp;5.65, SD\\u0026thinsp;=\\u0026thinsp;1.01). Table\\u0026nbsp;\\u003cspan refid=\\\"Tab2\\\" class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e provides a detailed breakdown of the mean scores for each TQM and service quality dimension. Notably, \\\"Leadership Commitment\\\" was the highest-rated TQM dimension, while \\\"Human Resources\\\" and \\\"Partnerships \\u0026amp; Resources\\\" were the lowest-rated TQM dimensions, and \\\"Assurance\\\" was the lowest-rated service quality dimension (Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig2\\\" class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e). Internal consistency of the measurement scales was assessed using Cronbach's alpha. All scales demonstrated excellent reliability (α\\u0026thinsp;\\u0026gt;\\u0026thinsp;0.88), confirming that the instrument was a valid and reliable measure of the constructs of this study.\\u003c/p\\u003e\\u003cp\\u003e\\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab2\\\" border=\\\"1\\\"\\u003e\\u003ccaption language=\\\"En\\\"\\u003e\\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 2\\u003c/div\\u003e\\u003cdiv class=\\\"CaptionContent\\\"\\u003e\\u003cp\\u003eDescriptive Statistics for Study Dimensions (7-point scale)\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/caption\\u003e\\u003ccolgroup cols=\\\"4\\\"\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c3\\\" colnum=\\\"3\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c4\\\" colnum=\\\"4\\\"\\u003e\\u003c/div\\u003e\\u003cthead\\u003e\\u003ctr\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eConstruct\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003eDimension\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003eMean\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003eStandard Deviation\\u003c/p\\u003e\\u003c/th\\u003e\\u003c/tr\\u003e\\u003c/thead\\u003e\\u003ctbody\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003e\\u003cb\\u003eTQM Implementation\\u003c/b\\u003e\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003eLeadership Commitment\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e5.74\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e1.02\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003ePolicy \\u0026amp; Strategy\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e5.59\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e1.08\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003eProcesses\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e5.52\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e1.03\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003ePartnerships \\u0026amp; Resources\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e5.20\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e1.25\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003eHuman Resources\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e5.15\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e1.25\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e\\u003cb\\u003eOverall TQM\\u003c/b\\u003e\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e\\u003cb\\u003e5.44\\u003c/b\\u003e\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e\\u003cb\\u003e0.99\\u003c/b\\u003e\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003e\\u003cb\\u003eHealth Service Quality\\u003c/b\\u003e\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003eEmpathy\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e5.86\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e1.14\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003eResponsiveness\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e5.67\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e1.15\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003eReliability\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e5.66\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e1.09\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003eTangibility\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e5.57\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e1.08\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003eAssurance\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e5.51\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e1.12\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e\\u003cb\\u003eOverall Service Quality\\u003c/b\\u003e\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e\\u003cb\\u003e5.65\\u003c/b\\u003e\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e\\u003cb\\u003e1.01\\u003c/b\\u003e\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003c/tbody\\u003e\\u003c/colgroup\\u003e\\u003c/table\\u003e\\u003c/div\\u003e\\u003c/p\\u003e\\u003cp\\u003e\\u003c/p\\u003e\\u003cp\\u003e\\u003cb\\u003eCorrelation Analysis\\u003c/b\\u003e\\u003c/p\\u003e\\u003cp\\u003ePearson\\u0026rsquo;s correlation analysis was conducted to examine the relationships between the study variables. As shown in Table\\u0026nbsp;\\u003cspan refid=\\\"Tab3\\\" class=\\\"InternalRef\\\"\\u003e3\\u003c/span\\u003e, all TQM dimensions were strongly and significantly correlated with each other and with the outcome variable. Most importantly, the analysis revealed a strong, positive, and statistically significant relationship between overall TQM and service quality (r\\u0026thinsp;=\\u0026thinsp;.762, p\\u0026thinsp;\\u0026lt;\\u0026thinsp;.001). Among individual dimensions, processes had the highest correlation with service quality (r\\u0026thinsp;=\\u0026thinsp;.778, p\\u0026thinsp;\\u0026lt;\\u0026thinsp;.001).\\u003c/p\\u003e\\u003cp\\u003e\\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab3\\\" border=\\\"1\\\"\\u003e\\u003ccaption language=\\\"En\\\"\\u003e\\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 3\\u003c/div\\u003e\\u003cdiv class=\\\"CaptionContent\\\"\\u003e\\u003cp\\u003ePearson Correlation Matrix for TQM Dimensions and Health Service Quality\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/caption\\u003e\\u003ccolgroup cols=\\\"7\\\"\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c3\\\" colnum=\\\"3\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c4\\\" colnum=\\\"4\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c5\\\" colnum=\\\"5\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c6\\\" colnum=\\\"6\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c7\\\" colnum=\\\"7\\\"\\u003e\\u003c/div\\u003e\\u003cthead\\u003e\\u003ctr\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eVariable\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003eLC\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003eHR\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003ePS\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u003cp\\u003ePR\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u003cp\\u003eP\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c7\\\"\\u003e\\u003cp\\u003eTQM\\u003c/p\\u003e\\u003c/th\\u003e\\u003c/tr\\u003e\\u003c/thead\\u003e\\u003ctbody\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eLeadership Commitment (LC)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e1\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eHuman Resources (HR)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e\\u003cb\\u003e.663**\\u003c/b\\u003e\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e1\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003ePolicy \\u0026amp; Strategy (PS)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e\\u003cb\\u003e.772**\\u003c/b\\u003e\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e\\u003cb\\u003e.738**\\u003c/b\\u003e\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e1\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003ePartnerships \\u0026amp; Resources (PR)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e\\u003cb\\u003e.605**\\u003c/b\\u003e\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e\\u003cb\\u003e.704**\\u003c/b\\u003e\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e\\u003cb\\u003e.715**\\u003c/b\\u003e\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u003cp\\u003e1\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eProcesses (P)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e\\u003cb\\u003e.735**\\u003c/b\\u003e\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e\\u003cb\\u003e.680**\\u003c/b\\u003e\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e\\u003cb\\u003e.818**\\u003c/b\\u003e\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u003cp\\u003e\\u003cb\\u003e.730**\\u003c/b\\u003e\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u003cp\\u003e1\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eOverall TQM\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e\\u003cb\\u003e.849**\\u003c/b\\u003e\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e\\u003cb\\u003e.871**\\u003c/b\\u003e\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e\\u003cb\\u003e.915**\\u003c/b\\u003e\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u003cp\\u003e\\u003cb\\u003e.864**\\u003c/b\\u003e\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u003cp\\u003e\\u003cb\\u003e.895**\\u003c/b\\u003e\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e\\u003cp\\u003e1\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eOverall Service Quality\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e\\u003cb\\u003e.622**\\u003c/b\\u003e\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e\\u003cb\\u003e.563**\\u003c/b\\u003e\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e\\u003cb\\u003e.740**\\u003c/b\\u003e\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u003cp\\u003e\\u003cb\\u003e.665**\\u003c/b\\u003e\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u003cp\\u003e\\u003cb\\u003e.778**\\u003c/b\\u003e\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e\\u003cp\\u003e.762\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colspan=\\\"7\\\" nameend=\\\"c7\\\" namest=\\\"c1\\\"\\u003e\\u003cp\\u003e**p\\u0026thinsp;\\u0026lt;\\u0026thinsp;.001 (2-tailed)\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003c/tbody\\u003e\\u003c/colgroup\\u003e\\u003c/table\\u003e\\u003c/div\\u003e\\u003c/p\\u003e\\u003cp\\u003e\\u003cb\\u003eHypothesis Testing: The Impact of TQM on Service Quality\\u003c/b\\u003e\\u003c/p\\u003e\\u003cp\\u003eMultiple linear regression was performed to test the predictive power of TQM dimensions on health service quality. The overall model was statistically significant (F(5, 404)\\u0026thinsp;=\\u0026thinsp;148.73, p\\u0026thinsp;\\u0026lt;\\u0026thinsp;.001) and accounted for 64.8% of the variance in service quality (R\\u0026sup2; = 0.648).\\u003c/p\\u003e\\u003cp\\u003eTable\\u0026nbsp;\\u003cspan refid=\\\"Tab4\\\" class=\\\"InternalRef\\\"\\u003e4\\u003c/span\\u003e presents the regression coefficients. The results show that \\u003cb\\u003e\\\"Processes\\\"\\u003c/b\\u003e (β\\u0026thinsp;=\\u0026thinsp;0.468, p\\u0026thinsp;\\u0026lt;\\u0026thinsp;.001), \\u003cb\\u003e\\\"Policy \\u0026amp; Strategy\\\"\\u003c/b\\u003e (β\\u0026thinsp;=\\u0026thinsp;0.305, p\\u0026thinsp;=\\u0026thinsp;.001), and \\u003cb\\u003e\\\"Partnerships \\u0026amp; Resources\\\"\\u003c/b\\u003e (β\\u0026thinsp;=\\u0026thinsp;0.179, p\\u0026thinsp;\\u0026lt;\\u0026thinsp;.001) are significant positive predictors of health service quality (Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig3\\\" class=\\\"InternalRef\\\"\\u003e3\\u003c/span\\u003e). In this multivariate model, \\\"Human Resources\\\" and \\\"Leadership Commitment\\\" were not statistically significant predictors.\\u003c/p\\u003e\\u003cp\\u003e\\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab4\\\" border=\\\"1\\\"\\u003e\\u003ccaption language=\\\"En\\\"\\u003e\\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 4\\u003c/div\\u003e\\u003cdiv class=\\\"CaptionContent\\\"\\u003e\\u003cp\\u003eMultiple Regression Model Predicting Health Service Quality\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/caption\\u003e\\u003ccolgroup cols=\\\"6\\\"\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c3\\\" colnum=\\\"3\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c4\\\" colnum=\\\"4\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c5\\\" colnum=\\\"5\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c6\\\" colnum=\\\"6\\\"\\u003e\\u003c/div\\u003e\\u003cthead\\u003e\\u003ctr\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eModel Predictor\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003eUnstandardized Coeff. (B)\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003eStd. Error\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003eStandardized Coeff. (β)\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u003cp\\u003et-value\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u003cp\\u003ep-value\\u003c/p\\u003e\\u003c/th\\u003e\\u003c/tr\\u003e\\u003c/thead\\u003e\\u003ctbody\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003e(Constant)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e1.274\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e0.215\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u003cp\\u003e5.925\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u003cp\\u003e\\u0026lt;\\u0026thinsp;.001\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003e\\u003cb\\u003eProcesses\\u003c/b\\u003e\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e\\u003cb\\u003e0.476\\u003c/b\\u003e\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e\\u003cb\\u003e0.055\\u003c/b\\u003e\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e\\u003cb\\u003e0.468\\u003c/b\\u003e\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u003cp\\u003e\\u003cb\\u003e8.729\\u003c/b\\u003e\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u003cp\\u003e\\u003cb\\u003e\\u0026lt;\\u0026thinsp;.001\\u003c/b\\u003e\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003e\\u003cb\\u003ePolicy \\u0026amp; Strategy\\u003c/b\\u003e\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e\\u003cb\\u003e0.199\\u003c/b\\u003e\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e\\u003cb\\u003e0.057\\u003c/b\\u003e\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e\\u003cb\\u003e0.305\\u003c/b\\u003e\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u003cp\\u003e\\u003cb\\u003e3.492\\u003c/b\\u003e\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u003cp\\u003e\\u003cb\\u003e.001\\u003c/b\\u003e\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003e\\u003cb\\u003ePartnerships \\u0026amp; Resources\\u003c/b\\u003e\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e\\u003cb\\u003e0.164\\u003c/b\\u003e\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e\\u003cb\\u003e0.039\\u003c/b\\u003e\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e\\u003cb\\u003e0.179\\u003c/b\\u003e\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u003cp\\u003e\\u003cb\\u003e4.248\\u003c/b\\u003e\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u003cp\\u003e\\u003cb\\u003e\\u0026lt;\\u0026thinsp;.001\\u003c/b\\u003e\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eHuman Resources\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e-0.062\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e0.039\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e-0.111\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u003cp\\u003e-1.597\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u003cp\\u003e.111\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eLeadership Commitment\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e0.015\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e0.045\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e0.009\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u003cp\\u003e0.330\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u003cp\\u003e.742\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colspan=\\\"6\\\" nameend=\\\"c6\\\" namest=\\\"c1\\\"\\u003e\\u003cp\\u003eNote: R\\u0026sup2; = 0.648, Adjusted R\\u0026sup2; = 0.644, F-statistic\\u0026thinsp;=\\u0026thinsp;148.73\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003c/tbody\\u003e\\u003c/colgroup\\u003e\\u003c/table\\u003e\\u003c/div\\u003e\\u003c/p\\u003e\\u003cp\\u003e\\u003c/p\\u003e\\u003cp\\u003e\\u003cb\\u003eGroup Differences and Moderation Effects\\u003c/b\\u003e\\u003c/p\\u003e\\u003cp\\u003eOne-way ANOVA was conducted to determine whether perceptions of service quality differed across job titles. The results, shown in Table\\u0026nbsp;\\u003cspan refid=\\\"Tab5\\\" class=\\\"InternalRef\\\"\\u003e5\\u003c/span\\u003e, indicate no statistically significant differences among the professional groups (F(4, 405)\\u0026thinsp;=\\u0026thinsp;0.31, p\\u0026thinsp;=\\u0026thinsp;0.871).\\u003c/p\\u003e\\u003cp\\u003e\\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab5\\\" border=\\\"1\\\"\\u003e\\u003ccaption language=\\\"En\\\"\\u003e\\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 5\\u003c/div\\u003e\\u003cdiv class=\\\"CaptionContent\\\"\\u003e\\u003cp\\u003eANOVA for Service Quality Across Job Titles\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/caption\\u003e\\u003ccolgroup cols=\\\"4\\\"\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c3\\\" colnum=\\\"3\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c4\\\" colnum=\\\"4\\\"\\u003e\\u003c/div\\u003e\\u003cthead\\u003e\\u003ctr\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eJob Title\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003eN\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003eMean Quality Score\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003eStd. Deviation\\u003c/p\\u003e\\u003c/th\\u003e\\u003c/tr\\u003e\\u003c/thead\\u003e\\u003ctbody\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eManager / Deputy Manager\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e4\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e5.58\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e0.93\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eDepartment Head\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e68\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e5.59\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e1.23\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eSupervisor\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e25\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e5.48\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e1.22\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eSpecialist Staff\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e303\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e5.68\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e0.95\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eAdministrative Staff\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e10\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e5.70\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e0.69\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003e\\u003cb\\u003eTotal\\u003c/b\\u003e\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e\\u003cb\\u003e410\\u003c/b\\u003e\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e\\u003cb\\u003e5.65\\u003c/b\\u003e\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e\\u003cb\\u003e1.01\\u003c/b\\u003e\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colspan=\\\"4\\\" nameend=\\\"c4\\\" namest=\\\"c1\\\"\\u003e\\u003cp\\u003eNote: F(4, 405)\\u0026thinsp;=\\u0026thinsp;0.31, p\\u0026thinsp;=\\u0026thinsp;0.871\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003c/tbody\\u003e\\u003c/colgroup\\u003e\\u003c/table\\u003e\\u003c/div\\u003e\\u003c/p\\u003e\\u003cp\\u003eAdditionally, moderation analyses revealed that \\u003cb\\u003egender\\u003c/b\\u003e significantly moderated the relationship between all the TQM dimensions and service quality. \\u003cb\\u003eExperience\\u003c/b\\u003e was also a significant moderator, strengthening the positive effect of the \\\"Policy \\u0026amp; Strategy\\\" and \\\"Processes\\\" dimensions on service quality.\\u003c/p\\u003e\"},{\"header\":\"Discussion\",\"content\":\"\\u003cp\\u003eThis study provides compelling evidence that Total Quality Management (TQM) implementation significantly enhances healthcare service quality in Yemen's conflict-affected healthcare system, with the overall model explaining 64.8% of the variance in service quality outcomes. The findings revealed both expected and surprising patterns in how different TQM dimensions influence service delivery, offering important insights into improving healthcare quality in fragile and conflict-affected settings. Our findings demonstrate that a focus on these fundamental principles, particularly those related to processes and policy, can be operationalized effectively even in resource-constrained environments.\\u003c/p\\u003e\\u003cp\\u003eThe strong positive relationship between overall TQM implementation and healthcare service quality (R\\u0026sup2; = 0.648) represents a remarkable achievement in the challenging context of Yemen's healthcare system. This finding aligns closely with the international benchmarks reported in systematic reviews of TQM implementation in healthcare settings, where similar R\\u0026sup2; values of 0.669 have been documented [\\u003cspan citationid=\\\"CR11\\\" class=\\\"CitationRef\\\"\\u003e11\\u003c/span\\u003e]. The magnitude of this relationship is particularly significant given that our study was conducted in a context where healthcare infrastructure has been severely compromised, with only 54% of health facilities being fully functional compared to 90% pre-conflict [\\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e].\\u003c/p\\u003e\\u003cp\\u003eThe robustness of this relationship suggests that TQM principles retain their effectiveness even under extreme adversity. Alzoubi et al. (2019) identified education and training, continuous quality improvement, patient focus, top management commitment, and teamwork as core predictors of successful TQM implementation in healthcare [\\u003cspan citationid=\\\"CR11\\\" class=\\\"CitationRef\\\"\\u003e11\\u003c/span\\u003e]. Our findings demonstrate that these fundamental quality management principles can be operationalized effectively, even in resource-constrained environments, providing a foundation for sustainable quality improvement initiatives in similar contexts.\\u003c/p\\u003e\\u003cp\\u003eThe dominance of \\\"Processes\\\" (β\\u0026thinsp;=\\u0026thinsp;0.468, p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001) and \\\"Policy \\u0026amp; Strategy\\\" (β\\u0026thinsp;=\\u0026thinsp;0.305, p\\u0026thinsp;=\\u0026thinsp;0.001) as the most powerful predictors of service quality reflects the critical importance of systematic, evidence-based approaches to care delivery. This finding resonates with the extensive literature on clinical pathways and standardized care protocols, which has been consistently associated with improved patient outcomes and reduced variation in care quality [\\u003cspan citationid=\\\"CR12\\\" class=\\\"CitationRef\\\"\\u003e12\\u003c/span\\u003e].\\u003c/p\\u003e\\u003cp\\u003eThe prominence of process-oriented factors in our study aligns with the resilience literature from conflict-affected settings, where standardized protocols and systematic approaches serve as crucial stabilizing forces amid environmental uncertainty [\\u003cspan citationid=\\\"CR13\\\" class=\\\"CitationRef\\\"\\u003e13\\u003c/span\\u003e]. In Yemen's fragmented healthcare system, where coordination between multiple actors is challenging, well-defined processes provide essential structure and predictability. The electronic Disease Early Warning System (eDEWS) and rapid response teams implemented in Yemen exemplify how process-oriented interventions can maintain service quality even under adverse conditions [\\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e].\\u003c/p\\u003e\\u003cp\\u003eThe strong predictive power of \\\"Policy \\u0026amp; Strategy\\\" underscores the importance of strategic planning and policy coherence in healthcare quality management. This finding is particularly relevant in conflict-affected settings, where policy fragmentation and competing priorities often undermine service delivery [\\u003cspan citationid=\\\"CR14\\\" class=\\\"CitationRef\\\"\\u003e14\\u003c/span\\u003e]. The implementation of Yemen's Minimum Service Package (MSP) in collaboration with WHO represents a successful example of how strategic policy frameworks can provide direction and coordination for quality improvement efforts across multiple stakeholders [\\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e].\\u003c/p\\u003e\\u003cp\\u003e Perhaps the most intriguing finding of this study is the statistical non-significance of \\\"Leadership Commitment\\\" (β\\u0026thinsp;=\\u0026thinsp;0.009, p\\u0026thinsp;=\\u0026thinsp;0.742) in predicting service quality, even though participants rated this dimension the highest among all TQM components (M\\u0026thinsp;=\\u0026thinsp;5.74). This apparent paradox challenges conventional wisdom about leadership's direct impact on quality outcomes and suggests a more nuanced understanding of how leadership influences healthcare quality in conflict settings.\\u003c/p\\u003e\\u003cp\\u003eThe literature on transformational and transactional leadership in healthcare provides insight into this phenomenon. While transformational leadership behaviors correlate with organizational readiness for change (β\\u0026thinsp;=\\u0026thinsp;0.39) and improved nurse performance [\\u003cspan citationid=\\\"CR15\\\" class=\\\"CitationRef\\\"\\u003e15\\u003c/span\\u003e], the impact may be mediated through organizational systems and processes rather than direct effects on service quality. In Yemen's context, where healthcare leaders face unprecedented challenges, including destroyed infrastructure, workforce shortages, and security threats [\\u003cspan citationid=\\\"CR16\\\" class=\\\"CitationRef\\\"\\u003e16\\u003c/span\\u003e], the relationship between leadership commitment and service quality may be attenuated by systemic constraints beyond leaders' control.\\u003c/p\\u003e\\u003cp\\u003eEven more concerning is the non-significant relationship between \\\"Human Resources\\\" and service quality (β = -0.111, p\\u0026thinsp;=\\u0026thinsp;0.111), coupled with this dimension receiving the lowest ratings among all TQM components. This finding reflects the profound human resource crisis facing Yemen's healthcare system, where critical workforce gaps include 47% for physicians, over 80% for nurses and midwives, and 78% for pharmacists [\\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e]. Literature on healthcare worker burnout in low- and middle-income countries reveals that 28.1% of primary healthcare professionals experience high emotional exhaustion, with 31.9% reporting reduced personal accomplishment [\\u003cspan citationid=\\\"CR17\\\" class=\\\"CitationRef\\\"\\u003e17\\u003c/span\\u003e].\\u003c/p\\u003e\\u003cp\\u003eThe human resource challenge is exacerbated by conflict-specific stressors documented in Yemen, including secondary traumatic stress, high rates of PTSD, and professional burnout among healthcare workers [\\u003cspan citationid=\\\"CR16\\\" class=\\\"CitationRef\\\"\\u003e16\\u003c/span\\u003e]. A recent study of nurses in Yemeni hospitals found that conflict-related stress and excessive workload significantly reduced job satisfaction across all dimensions, contributing to workforce instability and compromised care quality [\\u003cspan citationid=\\\"CR18\\\" class=\\\"CitationRef\\\"\\u003e18\\u003c/span\\u003e]. Meta-analytic evidence demonstrates that nurse burnout is associated with worsened patient safety outcomes (effect size 2.67, 95% CI: 2.3-3.0) and reduced quality of care [\\u003cspan citationid=\\\"CR19\\\" class=\\\"CitationRef\\\"\\u003e19\\u003c/span\\u003e].\\u003c/p\\u003e\\u003cp\\u003eThe implementation of meaningful TQM in Yemen's healthcare system is a remarkable example of resilience in fragile and conflict-affected settings. The literature on health system resilience identifies key characteristics, including the diversity of service providers, integration through coordination platforms, adaptive capacity, and maintenance of essential services during crises [\\u003cspan citationid=\\\"CR13\\\" class=\\\"CitationRef\\\"\\u003e13\\u003c/span\\u003e]. Yemen's healthcare system has demonstrated several of these resilience characteristics, including the establishment of parallel coordination platforms, deployment of rapid response teams, and implementation of surveillance systems, such as eDEWS [\\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e].\\u003c/p\\u003e\\u003cp\\u003eThe moderating effects of gender and experience on TQM-service quality relationships revealed in our study reflect the complex social dynamics operating in conflict-affected healthcare systems. With 69% of our sample being female and 37.8% having more than ten years of experience, these findings highlight the critical role of experienced female healthcare workers in maintaining quality standards. This aligns with research showing that healthcare workers in conflict zones develop adaptive strategies and informal networks that help sustain service delivery [\\u003cspan citationid=\\\"CR13\\\" class=\\\"CitationRef\\\"\\u003e13\\u003c/span\\u003e].\\u003c/p\\u003e\\u003cp\\u003eThe non-significant ANOVA results regarding job title differences in quality perceptions suggest that the shared experience of working in a conflict-affected healthcare system may override the traditional hierarchical distinctions. This finding contrasts with studies on stable healthcare systems, where significant differences in quality perceptions often exist between professional groups [\\u003cspan citationid=\\\"CR20\\\" class=\\\"CitationRef\\\"\\u003e20\\u003c/span\\u003e]. The convergence of quality perceptions across job titles may reflect a collective commitment to maintaining standards, despite extraordinary challenges.\\u003c/p\\u003e\\u003cp\\u003eThese findings have profound implications for nursing practice and leadership in conflict-affected health care settings. The primacy of processes and policies suggests that nurse leaders should prioritize the development and implementation of standardized care protocols, evidence-based practice guidelines, and systematic quality improvement processes. The literature on evidence-based nursing practice demonstrates that structured approaches to care delivery improve patient outcomes and enhance professional satisfaction [\\u003cspan citationid=\\\"CR21\\\" class=\\\"CitationRef\\\"\\u003e21\\u003c/span\\u003e].\\u003c/p\\u003e\\u003cp\\u003eGiven the human resource challenges identified in this study, nursing leaders should focus on workforce wellbeing and retention strategies. The high prevalence of burnout among healthcare workers in conflict zones requires targeted interventions, including stress management programs, peer support networks, and mental health services [\\u003cspan citationid=\\\"CR17\\\" class=\\\"CitationRef\\\"\\u003e17\\u003c/span\\u003e]. The positive moderating effects of experience suggest that mentorship programs that pair experienced nurses with new colleagues can enhance both quality outcomes and workforce stability.\\u003c/p\\u003e\\u003cp\\u003eThe finding that leadership commitment does not directly predict service quality should not be interpreted as diminishing the importance of leadership but rather as highlighting the need for leadership approaches that work through systems and processes. Transformational leadership behaviors that focus on intellectual stimulation, individualized consideration, and inspirational motivation may be more effective in conflict settings than traditional command-and-control approaches [\\u003cspan citationid=\\\"CR15\\\" class=\\\"CitationRef\\\"\\u003e15\\u003c/span\\u003e].\\u003c/p\\u003e\\u003cp\\u003e\\u003cb\\u003ePolicy Recommendations\\u003c/b\\u003e\\u003c/p\\u003e\\u003cp\\u003eBased on these findings, several policy recommendations have emerged for health care leaders and policymakers in conflict-affected settings.\\u003c/p\\u003e\\u003cp\\u003e\\u003col\\u003e\\u003cspan\\u003e\\u003cli\\u003e\\u003cp\\u003e\\u003cb\\u003eProcess-Oriented Quality Improvement\\u003c/b\\u003e: Prioritize the development and implementation of standardized care protocols, clinical pathways, and quality improvement processes that can function effectively despite resource and infrastructure limitations.\\u003c/p\\u003e\\u003c/li\\u003e\\u003c/span\\u003e\\u003cspan\\u003e\\u003cli\\u003e\\u003cp\\u003e\\u003cb\\u003eStrategic Policy Framework\\u003c/b\\u003e: Develop coherent policy frameworks that provide a clear direction for quality improvement efforts across multiple stakeholders, similar to Yemen's Minimum Service Package implementation.\\u003c/p\\u003e\\u003c/li\\u003e\\u003c/span\\u003e\\u003cspan\\u003e\\u003cli\\u003e\\u003cp\\u003e\\u003cb\\u003eHuman Resources Investment\\u003c/b\\u003e: Comprehensive workforce support programs, including mental health services, stress management interventions, and career development opportunities, address the critical human resource challenges identified in this study.\\u003c/p\\u003e\\u003c/li\\u003e\\u003c/span\\u003e\\u003cspan\\u003e\\u003cli\\u003e\\u003cp\\u003e\\u003cb\\u003eCoordination Mechanisms\\u003c/b\\u003e: Establish robust coordination platforms that bring together diverse healthcare actors to align quality standards and share best practices, recognizing the importance of integration in fragile settings.\\u003c/p\\u003e\\u003c/li\\u003e\\u003c/span\\u003e\\u003cspan\\u003e\\u003cli\\u003e\\u003cp\\u003e\\u003cb\\u003eExperience-based mentorship\\u003c/b\\u003e: Leverages the positive moderating effects of experience by developing formal mentorship programs and knowledge transfer mechanisms that capture and disseminate quality improvement expertise.\\u003c/p\\u003e\\u003c/li\\u003e\\u003c/span\\u003e\\u003cspan\\u003e\\u003cli\\u003e\\u003cp\\u003e\\u003cb\\u003eGender-Sensitive Policies\\u003c/b\\u003e: Recognize and support the critical role of female healthcare workers in maintaining quality standards, ensuring that policies address their specific needs and challenges.\\u003c/p\\u003e\\u003c/li\\u003e\\u003c/span\\u003e\\u003c/ol\\u003e\\u003c/p\\u003e\\u003cp\\u003e\\u003cb\\u003eLimitations of the Study\\u003c/b\\u003e\\u003c/p\\u003e\\u003cp\\u003eSeveral limitations of this study should be acknowledged when interpreting these findings. The cross-sectional design limits our ability to establish causal relationships between TQM dimensions and service quality outcomes. This study was conducted in specific healthcare facilities in Yemen, which may limit its generalizability to other conflict-affected settings or healthcare systems with different characteristics.\\u003c/p\\u003e\\u003cp\\u003eThe reliance on self-reported measures introduces potential bias, particularly in the context in which healthcare workers may feel pressured to report positive outcomes despite challenging circumstances. The timing of data collection during the ongoing conflict may have influenced participants' responses, potentially affecting the validity of the findings.\\u003c/p\\u003e\\u003cp\\u003eThe study focused on healthcare professionals' perceptions of quality rather than objective clinical outcomes or patient-reported measures. Future research should incorporate multiple perspectives and objective quality indicators to provide a more comprehensive understanding of TQM\\u0026rsquo;s effectiveness in conflict-affected settings.\\u003c/p\\u003e\"},{\"header\":\"Conclusion\",\"content\":\"\\u003cp\\u003eThis study provides compelling evidence that Total Quality Management principles can be effectively implemented in conflict-affected healthcare settings, with processes and policy strategies serving as primary drivers of service quality improvement. The findings challenge conventional assumptions about leadership's direct impact on quality while highlighting the critical importance of systematic, evidence-based approaches to care delivery. Most importantly, this study reveals the profound human resource challenges facing healthcare systems in conflict zones, where workforce well-being and retention have emerged as fundamental prerequisites for sustainable quality improvement.\\u003c/p\\u003e\\u003cp\\u003eThe results demonstrate that even in the most challenging circumstances, healthcare organizations can achieve meaningful quality improvements through focused attention to process optimization and strategic policy development. However, the success of these efforts ultimately depends on addressing the underlying human resource crisis using comprehensive workforce support strategies. These findings provide a foundation for developing more effective quality improvement interventions in similar contexts, and contribute to the growing body of knowledge on health system resilience in fragile and conflict-affected settings.\\u003c/p\\u003e\"},{\"header\":\"Abbreviations\",\"content\":\"\\u003cdiv class=\\\"DefinitionList\\\"\\u003e\\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e\\u003cdiv class=\\\"Term\\\"\\u003e\\u003cb\\u003eANOVA\\u003c/b\\u003e\\u003c/div\\u003e\\u003cdiv class=\\\"Description\\\"\\u003e\\u003cp\\u003eAnalysis of Variance\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/div\\u003e\\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e\\u003cdiv class=\\\"Term\\\"\\u003e\\u003cb\\u003eCQI\\u003c/b\\u003e\\u003c/div\\u003e\\u003cdiv class=\\\"Description\\\"\\u003e\\u003cp\\u003eContinuous Quality Improvement\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/div\\u003e\\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e\\u003cdiv class=\\\"Term\\\"\\u003e\\u003cb\\u003eeDEWS\\u003c/b\\u003e\\u003c/div\\u003e\\u003cdiv class=\\\"Description\\\"\\u003e\\u003cp\\u003eelectronic Disease Early Warning System\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/div\\u003e\\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e\\u003cdiv class=\\\"Term\\\"\\u003e\\u003cb\\u003eEFQM\\u003c/b\\u003e\\u003c/div\\u003e\\u003cdiv class=\\\"Description\\\"\\u003e\\u003cp\\u003eEuropean Foundation for Quality Management\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/div\\u003e\\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e\\u003cdiv class=\\\"Term\\\"\\u003e\\u003cb\\u003eIRB\\u003c/b\\u003e\\u003c/div\\u003e\\u003cdiv class=\\\"Description\\\"\\u003e\\u003cp\\u003eInstitutional Review Board\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/div\\u003e\\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e\\u003cdiv class=\\\"Term\\\"\\u003e\\u003cb\\u003eJCIA\\u003c/b\\u003e\\u003c/div\\u003e\\u003cdiv class=\\\"Description\\\"\\u003e\\u003cp\\u003eJoint Commission International Accreditation\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/div\\u003e\\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e\\u003cdiv class=\\\"Term\\\"\\u003e\\u003cb\\u003eMSP\\u003c/b\\u003e\\u003c/div\\u003e\\u003cdiv class=\\\"Description\\\"\\u003e\\u003cp\\u003eMinimum Service Package\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/div\\u003e\\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e\\u003cdiv class=\\\"Term\\\"\\u003e\\u003cb\\u003ePDSA\\u003c/b\\u003e\\u003c/div\\u003e\\u003cdiv class=\\\"Description\\\"\\u003e\\u003cp\\u003ePlan-Do-Study-Act\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/div\\u003e\\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e\\u003cdiv class=\\\"Term\\\"\\u003e\\u003cb\\u003ePTSD\\u003c/b\\u003e\\u003c/div\\u003e\\u003cdiv class=\\\"Description\\\"\\u003e\\u003cp\\u003ePost-Traumatic Stress Disorder\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/div\\u003e\\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e\\u003cdiv class=\\\"Term\\\"\\u003e\\u003cb\\u003eSERVQUAL\\u003c/b\\u003e\\u003c/div\\u003e\\u003cdiv class=\\\"Description\\\"\\u003e\\u003cp\\u003eService Quality (A model for measuring service quality)\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/div\\u003e\\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e\\u003cdiv class=\\\"Term\\\"\\u003e\\u003cb\\u003eTQM\\u003c/b\\u003e\\u003c/div\\u003e\\u003cdiv class=\\\"Description\\\"\\u003e\\u003cp\\u003eTotal Quality Management\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/div\\u003e\\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e\\u003cdiv class=\\\"Term\\\"\\u003e\\u003cb\\u003eVIF\\u003c/b\\u003e\\u003c/div\\u003e\\u003cdiv class=\\\"Description\\\"\\u003e\\u003cp\\u003eVariance Inflation Factor\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/div\\u003e\\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e\\u003cdiv class=\\\"Term\\\"\\u003e\\u003cb\\u003eWHO\\u003c/b\\u003e\\u003c/div\\u003e\\u003cdiv class=\\\"Description\\\"\\u003e\\u003cp\\u003eWorld Health Organization\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/div\\u003e\\u003c/div\\u003e\"},{\"header\":\"Declarations\",\"content\":\"\\u003ch2\\u003eEthics approval and consent to participate\\u003c/h2\\u003e\\n\\u003cp\\u003eThis study was conducted in accordance with the ethical principles of the Declaration of Helsinki. Ethical approval was obtained from the Institutional Review Board (IRB) of the Center of Business Administration, Sana\\u0026apos;a University. Formal permission to conduct this study was secured from the administrative leadership of each of the four participating hospitals. All participants were provided with a detailed information sheet that explained the purpose, procedures, and rights of the study. Written informed consent was obtained from all participants prior to their participation in the study. Participation was voluntary and participants were assured that they could withdraw at any time without penalties or professional consequences.\\u003c/p\\u003e\\n\\u003ch2\\u003eConsent for publication\\u003c/h2\\u003e\\n\\u003cp\\u003eNot applicable.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003ch2\\u003eAvailability of data and materials\\u003c/h2\\u003e\\n\\u003cp\\u003eThe datasets generated and/or analyzed during the current study are not publicly available because of the sensitive nature of the research context and to protect the confidentiality and anonymity of the participating healthcare professionals and institutions. The data are available from the corresponding author upon request.\\u003c/p\\u003e\\n\\u003ch2\\u003eCompeting interests\\u003c/h2\\u003e\\n\\u003cp\\u003eThe authors declare that they have no conflicts of interest.\\u003c/p\\u003e\\n\\u003ch2\\u003eFunding\\u003c/h2\\u003e\\n\\u003cp\\u003eThis research received no specific grants from any funding agency in the public, commercial, or not-for-profit sector.\\u003c/p\\u003e\\n\\u003ch2\\u003eAuthors\\u0026apos; contributions\\u003c/h2\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eJ. M.A.\\u0026nbsp;\\u003c/strong\\u003e\\u0026nbsp; conceived and designed the study, collected and analyzed the data, and was a major contributor to the writing of the manuscript. \\u003cstrong\\u003eM.M.A.\\u0026nbsp;\\u003c/strong\\u003e\\u0026nbsp; supervised the project, contributed to the study design and methodology, and critically revised the manuscript. \\u003cstrong\\u003eH. M. J.\\u0026nbsp;\\u003c/strong\\u003e\\u0026nbsp; contributed to data interpretation, manuscript drafting, and critical revisions for intellectual content. All authors have read and approved the final manuscript.\\u003c/p\\u003e\\n\\u003ch2\\u003eAcknowledgements\\u003c/h2\\u003e\\n\\u003cp\\u003eThe authors would like to express their sincere gratitude to all the healthcare professionals at the participating hospitals in Sana\\u0026apos;a who generously gave their time to participate in this study despite their challenging working conditions. We also thank the hospital administrators for granting permission and facilitating the data-collection process.\\u003c/p\\u003e\"},{\"header\":\"References\",\"content\":\"\\u003col\\u003e\\u003cli\\u003e\\u003cspan\\u003eMosadeghrad AM. Developing and validating a total quality management model for healthcare organisations. 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Lancet. 2014;383:1824\\u0026ndash;30. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://doi.org/10.1016/S0140-6736(13)62631-8\\u003c/span\\u003e\\u003cspan address=\\\"10.1016/S0140-6736(13)62631-8\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eMelnyk BM, Gallagher-Ford L, Long LE, Fineout‐Overholt E. The Establishment of Evidence‐Based Practice Competencies for Practicing Registered Nurses and Advanced Practice Nurses in Real‐World Clinical Settings: Proficiencies to Improve Healthcare Quality, Reliability, Patient Outcomes, and Costs. Worldviews Evid Based Nurs. 2014;11:5\\u0026ndash;15. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://doi.org/10.1111/wvn.12021\\u003c/span\\u003e\\u003cspan address=\\\"10.1111/wvn.12021\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e.\\u003c/span\\u003e\\u003c/li\\u003e\\u003c/ol\\u003e\"}],\"fulltextSource\":\"\",\"fullText\":\"\",\"funders\":[],\"hasAdminPriorityOnWorkflow\":false,\"hasManuscriptDocX\":true,\"hasOptedInToPreprint\":true,\"hasPassedJournalQc\":\"\",\"hasAnyPriority\":false,\"hideJournal\":true,\"highlight\":\"\",\"institution\":\"\",\"isAcceptedByJournal\":false,\"isAuthorSuppliedPdf\":false,\"isDeskRejected\":\"\",\"isHiddenFromSearch\":false,\"isInQc\":false,\"isInWorkflow\":false,\"isPdf\":false,\"isPdfUpToDate\":true,\"isWithdrawnOrRetracted\":false,\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"researchsquare\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":true,\"externalIdentity\":\"\",\"sideBox\":\"\",\"snPcode\":\"\",\"submissionUrl\":\"/submission\",\"title\":\"Research Square\",\"twitterHandle\":\"researchsquare\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"\",\"reportingPortfolio\":\"\",\"inReviewEnabled\":false,\"inReviewRevisionsEnabled\":true},\"keywords\":\"Total Quality Management, Healthcare Service Quality, Yemen, Hospitals, Nursing, Quality Improvement\",\"lastPublishedDoi\":\"10.21203/rs.3.rs-7115768/v1\",\"lastPublishedDoiUrl\":\"https://doi.org/10.21203/rs.3.rs-7115768/v1\",\"license\":{\"name\":\"CC BY 4.0\",\"url\":\"https://creativecommons.org/licenses/by/4.0/\"},\"manuscriptAbstract\":\"\\u003cp\\u003e\\u003cstrong\\u003eBackground:\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eHealthcare quality is a critical challenge in Yemen's conflict-affected health system. In response, the Ministry of Public Health and Population mandated the implementation of Total Quality Management (TQM) in 2021. This study provides a comprehensive evaluation of the impact of TQM on healthcare service quality, with a focus on frontline nursing and healthcare professionals.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eMethods:\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThis cross-sectional analytical study included 410 healthcare professionals from four purposively selected hospitals (three public and one private) in Sana'a. Data were collected using a validated questionnaire that measured five TQM dimensions (Leadership Commitment, Human Resources, Policy \\u0026amp; Strategy, Partnerships \\u0026amp; Resources, Processes) and five dimensions of health service quality. Data were analyzed using descriptive statistics, correlations, and multiple linear regression.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eResults:\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe results indicated a high level of TQM implementation (mean = 5.44, 7-point scale). TQM implementation was a strong and significant predictor of health service quality, explaining 64.8% of the variance (R² = 0.648, F(5, 404) = 148.73, p \\u0026lt; .001). The \\\"Processes\\\" dimension had the largest positive impact (β = 0.468), followed by \\\"Policy \\u0026amp; Strategy\\\" (β = 0.305). Notably, the \\\"Human Resources\\\" dimension was not a significant predictor, and its low descriptive scores suggest it remains a key implementation challenge.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eConclusions:\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eTQM implementation significantly enhances healthcare service quality in Yemeni hospitals, demonstrating its effectiveness even in a fragile state. The findings reveal that systematic processes and strategic policies are primary drivers of quality improvement. However, the success of these programs is contingent on addressing the critical human resource challenges related to staff satisfaction and support. Healthcare leaders should prioritize both process optimization and workforce well-being to achieve sustainable quality improvements.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eTrial Registration: \\u003c/strong\\u003eNot applicable.\\u003c/p\\u003e\",\"manuscriptTitle\":\"Impact of Total Quality Management on Healthcare Service Quality in Yemeni Hospitals: A Cross-Sectional Study\",\"msid\":\"\",\"msnumber\":\"\",\"nonDraftVersions\":[{\"code\":1,\"date\":\"2025-08-19 16:13:48\",\"doi\":\"10.21203/rs.3.rs-7115768/v1\",\"editorialEvents\":[{\"type\":\"communityComments\",\"content\":0}],\"status\":\"published\",\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"researchsquare\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":true,\"externalIdentity\":\"\",\"sideBox\":\"\",\"snPcode\":\"\",\"submissionUrl\":\"/submission\",\"title\":\"Research Square\",\"twitterHandle\":\"researchsquare\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"\",\"reportingPortfolio\":\"\",\"inReviewEnabled\":false,\"inReviewRevisionsEnabled\":true}}],\"origin\":\"\",\"ownerIdentity\":\"05b1dc45-21cd-4e82-9c5d-7a0ba1efc3b1\",\"owner\":[],\"postedDate\":\"August 19th, 2025\",\"published\":true,\"recentEditorialEvents\":[],\"rejectedJournal\":[],\"revision\":\"\",\"amendment\":\"\",\"status\":\"posted\",\"subjectAreas\":[],\"tags\":[],\"updatedAt\":\"2025-09-09T13:24:05+00:00\",\"versionOfRecord\":[],\"versionCreatedAt\":\"2025-08-19 16:13:48\",\"video\":\"\",\"vorDoi\":\"\",\"vorDoiUrl\":\"\",\"workflowStages\":[]},\"version\":\"v1\",\"identity\":\"rs-7115768\",\"journalConfig\":\"researchsquare\"},\"__N_SSP\":true},\"page\":\"/article/[identity]/[[...version]]\",\"query\":{\"redirect\":\"/article/rs-7115768\",\"identity\":\"rs-7115768\",\"version\":[\"v1\"]},\"buildId\":\"8U1c8b4HqxoKbykW_rLl7\",\"isFallback\":false,\"isExperimentalCompile\":false,\"dynamicIds\":[84888],\"gssp\":true,\"scriptLoader\":[]}","source_license":"CC-BY-4.0","license_restricted":false}