An-Najah National University Faculty of Graduate Studies THE RELATIONSHIP BETWEEN THE ORGANIZATIONAL STRUCTURE AND IMPLEMENTATION OF TOTAL QUALITY MANAGEMENT IN GOVERNMENTAL HOSPITALS IN THE WEST BANK, PALESTINE By Maen Mohammad Salih Alqam Supervisor Dr. Wafaa Minawe This Thesis is Submitted in Partial Fulfillment of the Requirements for the Degree of Master of Public Health Management, Faculty of Graduate Studies, An-Najah National University, Nablus-Palestine. 2023 ii THE RELATIONSHIP BETWEEN THE ORGANIZATIONAL STRUCTURE AND IMPLEMENTATION OF TOTAL QUALITY MANAGEMENT IN GOVERNMENTAL HOSPITALS IN THE WEST BANK, PALESTINE By Maen Mohammad Salih Alqam This Thesis was Defended Successfully on 51/51/2023 and approved by Insert Name Supervisor Signature Insert Name Co-Supervisor Signature Insert Name External Examiner Signature Insert Name Internal Examiner Signature iii Dedication This study is wholeheartedly dedicated to my beloved parents, who have been my source of inspiration and gave me strength when I thought of giving up; they continually provided me with their moral, spiritual, emotional, and financial support and gave the little they had to ensure I would have the opportunity of an education. Their efforts allowed me to unlock the mysteries of our world and beyond to my brothers, sisters, relatives, mentor, friends, and classmates who shared their words of advice and encouragement to finish this study. I also dedicate this work to the soul of my Doctor Wafaa Minawe (may her soul rest in peace) who always guided me to the right path when I was lost during the work of this thesis with her beautiful words and unique advice. iv Acknowledgements First and foremost, I am thankful to Almighty ALLAH for giving me the strength, knowledge, ability and opportunity to undertake this study and complete it satisfactorily. Secondly, I would like to thank my respected teacher and supervisor, Dr. WafaaMinawe (may her soul rest in peace), whose worthy guidance and professional attitude are appreciable in completing this dissertation. I thankfully acknowledge the support and inspiration from my teachers, especially Dr. Abdul-Salam Khayyat and Dr. Mariam Al-Tell. I am thankful to Dr. Marwan Zuhd, for his time completing the statistical analysis. My special thanks to my friends and colleagues for their support. And finally, I am deeply grateful to my parents for their support, appreciation, encouragement, and keen interest in my academic achievements. v Declaration I, the undersigned, declare that I submitted the thesis entitled: THE RELATIONSHIP BETWEEN THE ORGANIZATIONAL STRUCTURE AND IMPLEMENTATION OF TOTAL QUALITY MANAGEMENT IN GOVERNMENTAL HOSPITALS IN THE WEST BANK, PALESTINE I declare that the work provided in this thesis, unless otherwise referenced, is the researcher‘s work and has not been submitted elsewhere for any other degree or qualification. _____________________________________ Student's Name: _____________________________________ Signature: _____________________________________ Date: vi List of Contents Dedication ............................................................................................................. iii Acknowledgements............................................................................................... iv Declaration ............................................................................................................. v List of Contents ..................................................................................................... vi List of Tables ...................................................................................................... viii List of Figures ....................................................................................................... ix List of Appendices ................................................................................................. x Abstract ................................................................................................................. xi Chapter One: Introduction and Theoretical Background...................................... 1 1.1 Introduction ...................................................................................................... 1 1.1.1 Definitions of Terms ..................................................................................... 7 1.1.2 Organizational Structure ............................................................................... 7 1.1.3 Organizational Structure Dimensions .......................................................... 8 1.1.3.1 Formality .................................................................................................... 8 1.1.3.2 Centralization ............................................................................................. 9 1.1.3.3 Professionalism ........................................................................................ 11 1.1.3.4 Structural Complexity ............................................................................. 11 1.1.3.5 Practice Groups........................................................................................ 12 1.1.4 Definition of Quality and Total Quality Management .............................. 12 1.1.4.1 Quality ..................................................................................................... 12 1.1.4.2 Total Quality Management ...................................................................... 13 1.2 Problem of study ............................................................................................ 16 1.3 Aim of the study ............................................................................................ 17 1.4 Objectives of the study .................................................................................. 17 1.5 Hypothesis of the study ................................................................................. 17 1.5.1 Main hypothesis .......................................................................................... 17 1.5.2 Sub-hypotheses ........................................................................................... 17 1.6 Significance of study ..................................................................................... 18 1.7 Literature Review .......................................................................................... 19 1.7.1 Studies Related to Organizational Structure .............................................. 19 1.7.2 Studies Related to Total Quality Management .......................................... 21 vii 1.7.3 Comments on the previous Studies ............................................................ 26 Chapter Two: Methods ........................................................................................ 27 2.1 Introduction .................................................................................................... 27 2.2 Method ........................................................................................................... 27 2.3 Population, Sample and Data collection ....................................................... 28 2.4 Research Instrument applied ......................................................................... 28 2.5 Internal Validity and Reliability .................................................................... 29 2.6 Reliability ....................................................................................................... 30 2.7 Statistical analysis .......................................................................................... 32 2.8 Study procedures ........................................................................................... 32 2.9 Ethical approval ............................................................................................. 33 2.10 Conclusion ................................................................................................... 33 Chapter Three: Results ........................................................................................ 34 3.1 Introduction .................................................................................................... 34 3.2 Demographic analysis ................................................................................... 35 3.3 Descriptive statistics ...................................................................................... 36 3.4 Testing the assumptions ................................................................................ 39 3.5 Correlation Hypothesis .................................................................................. 39 3.6 Regression Analysis ...................................................................................... 45 Chapter Four: Discussions and Conclusions ....................................................... 47 4.1 Discussion ...................................................................................................... 47 4.2 Conclusion ..................................................................................................... 49 4.3 Study limitations ............................................................................................ 49 4.4 Recommendations ......................................................................................... 49 4.5 Future studies ................................................................................................. 50 List of Abbreviations ........................................................................................... 51 References ............................................................................................................ 52 Appendices ........................................................................................................... 61 ..................................................................................................................... الملخص ب viii List of Tables Table 2.1: Cronbach‘s Alpha values for the exploratory sampleamong the employees in governmental hospitals in the northern and middle of the West Bank of Palestine distributed by dimension ....................... 31 Table 3.1: Demographic characteristics of respondents ..................................... 35 Table 3.2: Descriptive statistics of the organizational structure dimensions ..... 37 Table 3.3: Descriptive statistics of the total quality management implementation dimensions level ................................................................................. 38 Table 3.4: Kolmogorov-Smirnov test for normality ........................................... 39 Table 3.5: Pearson correlation between the organizational structure and TQM 39 Table 3.6: Pearson correlation between the organizational structure and teamwork ............................................................................................ 40 Table 3.7: Pearson correlation between the organizational structure and continuous improvement .................................................................... 41 Table 3.8: Pearson correlation between the organizational structure and management commitment .................................................................. 41 Table 3.9: Pearson correlation between the organizational structure and training42 ix List of Figures Figure 1.1: Organizational chart of a hospital ...................................................... 8 Figure 1.2: Definition of TQM ............................................................................ 15 x List of Appendices Appendix A: IRB Approval................................................................................. 61 Appendix B: Facilitation of Researcher‘s mission 1 .......................................... 62 Appendix C: Facilitation of Researcher‘s mission 2 .......................................... 63 Appendix D: Introduction to questionnaire ........................................................ 64 Appendix E: Consent form .................................................................................. 65 Appendix F: Demographic Background ............................................................. 66 Appendix G: Questionnaire ................................................................................. 67 Appendix H: Tables of Study .............................................................................. 73 Table H.1: Descriptive statistics shows the level of organizational structure statements distributed by dimension .................................................. 73 Table H.2: Descriptive statistics shows the level of the total quality management implementation statements distributed by dimension ....................... 76 Table H.3: Pearson correlation between the organizational structure and customer focus .................................................................................... 79 Table H.4: Pearson correlation between the organizational structure and employee involvement ....................................................................... 79 Table H.5: Pearson correlation between the organizational structure and organizational culture ......................................................................... 79 Table H.6: Pearson correlation between the organizational structure and operations ........................................................................................... 79 Table H.7: Pearson correlation between the organizational structure and strategic planning ............................................................................... 79 Table H.8: Pearson correlation between the organizational structure and leadership ............................................................................................ 80 Table H.9: Pearson correlation between the organizational structure and leadership ............................................................................................ 80 Table H.10: Pearson correlation between the organizational structure and performance results ............................................................................ 80 Table H.11: Multiple regression – R and R square (model summary) .............. 80 Table H.12: Multiple regression .......................................................................... 80 Table H.13: Multiple regression – coefficients................................................... 81 xi THE RELATIONSHIP BETWEEN THE ORGANIZATIONAL STRUCTURE AND IMPLEMENTATION OF TOTAL QUALITY MANAGEMENT IN GOVERNMENTAL HOSPITALS IN THE WEST BANK, PALESTINE By Maen Mohammad Salih Alqam Supervisor Dr. Wafaa Minawe Abstract Introduction: The purpose of this study is to consider the relationship between the organizational structure and the implementation of total quality management in government hospitals in the West Bank, Palestine. To identify the degree of the application of total quality management in government hospitals in the West Bank, Palestine. Methodology: To identify the most influential organizational structural areas in the components of total quality management. A well-structured questionnaire was used as a data collection tool consisting of questions related to the structure of the organization and about the components of TQM, which was distributed to each employee with an administrative title from various job categories. Results: After the collection of information, using SPSS25, the researcher presented an analysis to address the issues and confirm or deny the hypothesis. The results show that it is evident that organizational structure has an impact on and a significant relationship with TQM implementation in Palestinian government hospitals. Conclusion: It came to light that OS has an impact on how TQM and its elements are implemented. According to regression analysis, workgroups have an adverse impact on the implementation of TQM, whereas formality makes the greatest contribution. Keywords: Total quality management; organizational structure; hospitals; relationship; implementation. 1 Chapter One Introduction and Theoretical Background This chapter describes and gives an overview of the problem under investigation. It starts with the study's introduction, then the problem statement, the importance of the study, the aim, the objectives, the questions and the hypothesis of the study. Next, it is followed by the conceptual operational terms of the study, previous studies and the theoretical background. 1.1 Introduction Services are the most important capital of organizations, particularly; health organizations such as hospitals. To construct the structure of organizations nowadays, a strong emphasis is placed on the quality of services provided by medical professionals at hospitals who devote more than one-third of their lives to the organization. So, an organizational structure is the further most vital factor in getting service quality in this sector (Mosadeghrad, 2014).Organizational structure describes formal relationships and defines how power is delegated, responsibility and required resources are allocated, how jobs and tasks are departmentalized and coordinated as well as procedures within an organization which is vital for the decision-making process through authority centralism, hierarchy levels and horizontal integration(Hao et al., 2012). Organizations vary significantly in structure, affecting organizational and individual outcomes (Tolbert & Hall, 2009). In the realm of healthcare operations modern hospitals often embrace structures to navigate the intricate landscape of delivering healthcare services. According to a study conducted by Walker and colleagues in 2020 there is a shift, towards utilizing matrix structures that combine elements of divisional structures to promote collaboration across different functions and improve communication. It has always been difficult to achieve adequate standards of quality in the health industry. Significant losses in terms of time, money, and resources—both human and material—occur every year as a result of inadequate or nonexistent quality management techniques, particularly in the health sector. However it's important to understand that dealing with quality problems in health management is a difficult task. The intricate 2 nature of the industry's operations, which include both major and minor activities, is the source of this complexity. The difficulties are further compounded by the fact that this service sector encompasses a wide range of professions, organizations, and vocations (Jraisat et al., 2016). Several authors have linked organizational structures that deviate from Total Quality Management (TQM) principles to the failures of TQM initiatives (Jabnoun, 2005). Within the healthcare sector the principles of Total Quality Management (TQM) play a role in driving improvement prioritizing patient satisfaction and making decisions based on evidence. Gijo and Antony (2014) underscore that TQM principles serve as the cornerstone for elevating the quality of healthcare services. In today‘s dynamic healthcare environment TQM is increasingly acknowledged as a framework for enhancing excellence, in care. Abu Daqar (2020) argues that the healthcare sector is perceiving many consecutive variables globally. The desired development in healthcare requires continuous improvement and development of the quality management system (QMS) to speed up the pace of product innovation and to best manage resources so that service quality and care can be improved to satisfy customers and promptly address their expectations and aspirations appropriately. Building on Abu Daqar's (2020) insights, several scholars have underscored the ever-evolving nature of the healthcare sector and the imperative for continuous improvements in quality management systems (QMS). Smith et al. (2018) explore the impact of technology on healthcare transformation, proposing the integration of cutting-edge technologies into QMS for optimized resource utilization and improved overall service quality. Furthermore, Johnson and Patel (2019) stress the importance of patient-centered approaches in healthcare management, advocating for the alignment of QMS with patient expectations and preferences to ensure utmost satisfaction. In a broader global context, Garcia and Nguyen (2021) delve into the significance of international collaboration and standardization in QMS, aiming to guarantee a uniform and elevated standard of healthcare quality across borders. Collectively, these complementary studies contribute to the recognition that a resilient and adaptive QMS is crucial for driving continuous enhancements in the healthcare sector on a global scale. 3 Quality is distinguished differently by several people and several sectors. Yet, everyone understands what "quality" means by the way he is interested. In the manufacturing sector, the client as an end user can tell how well something fits, is finished, looks, works, and performs. (Juran & De Feo, 2010). The degree of customer satisfaction may be used to rate the quality of service and factors like the length of time it takes to complete the task at hand or the level of customer care provided. For example, a service that one client may find lacking may be scored well by another. The definition of quality that applies to this situation is "the degree of excellence." (Rashed , 2014) The modern focus on patient-centered care demands that organizational structures be reevaluated. Hospitals must adopt more horizontal organizational structures in order to improve interdisciplinary collaboration because a patient-centric approach necessitates responsiveness and flexibility (Labonte et al., 2016). Hospitals of today are restructuring their buildings to put the needs and preferences of their patients first. Singh et al. (2018) found that Total Quality Management (TQM) practices significantly improve organization performance, financial performance and customer gratification. Shafiq et al. (2019) declared that many businesses use TQM to enhance the quality of their services and products, lower flaws rates, and increase customer gratification. Aligning the structure, with Total Quality Management (TQM), in hospitals poses certain difficulties. The conventional hierarchical setups commonly seen in healthcare establishments could hinder the flexibility needed for TQM integration (Chahal, 2018). To address these obstacles, an cooperative strategy is essential to connect the structure with the principles. According to Abdullah (2018), the healthcare sector is considered the fundamental pillar of the country; due to the intense rivalry in Palestine's healthcare industry, improving the quality of the services offered to patients is the top priority for decision-makers and top management. The study's importance stems from the current skills gap in the Palestinian healthcare system, which is caused by a lack of qualified personnel who can effectively manage these organizations to raise the standard of care. The administrative and medical staff were covered by this gap. In order to investigate the connection between organizational 4 structure and the implementation of total quality management in Palestinian hospitals in the West Bank, the researcher in this study concentrated on managerial staff in this industry. The hierarchical framework in many organizations, including the healthcare organization, has been shaped by traditional organizational structures. Organizations with traditional structures are usually set up in a top-down fashion, with higher management at the top and lower levels having the final say over decisions. This model frequently has distinct reporting relationships, specialized roles, and clear lines of authority. Robbins and Coulter (2017) assert that traditional organizational structures offer a well-defined structure for overseeing sizable and intricate entities, as they are distinguished by stability and a codified chain of command. In healthcare settings, where a distinct organizational hierarchy is considered essential for efficient patient care and administrative operations, this hierarchical approach has historically been common (Robbins et al., 2017). Modern viewpoints on organizational structures, however, highlight the shortcomings of the conventional paradigm, especially in dynamic and quickly changing contexts like the healthcare industry. According to Mintzberg (2017), organizational agility and responsiveness may be hampered by traditional structures' inability to adjust to changes in the external environment. The healthcare industry is moving toward more flexible and decentralized structures as a result of its growing emphasis on patient-centered care and interdisciplinary collaboration. According to researchers like Scott, Mannion, Davies, and Marshall (2003), the conventional bureaucratic model may stifle creativity and make it more difficult for healthcare organizations to respond quickly and effectively to new challenges. Despite the fact that traditional organizational structures have been vital in establishing stability and order, recent criticisms indicate that these models might not be well suited to the dynamic nature of the healthcare sector. In order to promote flexibility and responsiveness to the changing needs of patients and the larger healthcare environment, organizational structures need to be reevaluated in light of the changing landscape of healthcare services (Scott et al., 2003), (Mintzberg, 2017 ). A growing number of healthcare institutions are realizing that different organizational structures might be 5 more suited to meet the changing needs of the industry as they work to improve patient outcomes and care quality. In the healthcare sector, total quality management, or TQM, has experienced a substantial evolution that is indicative of a growing focus on patient-centric care, efficiency, and continuous improvement. Initially, TQM was mainly implemented by healthcare organizations based on manufacturing industry principles, with the goal of lowering errors and improving overall quality. Nonetheless, in order to better reflect the intricate and ever-changing nature of healthcare, the landscape has changed to include a more holistic approach. Clinical results, patient experience in general, and patient safety initiatives all benefit from the integration of TQM, according to recent studies (Kaplan et al., 2021). In order to meet patients' varied needs and improve healthcare quality, it is imperative that we make the transition to patient-centered TQM. Technology has also been a major factor in the advancement of TQM in the healthcare industry. Data analytics tools and electronic health records are now essential for tracking and enhancing the quality of healthcare. Healthcare providers can quickly identify areas for improvement and apply evidence-based practices thanks to real-time data. Furthermore, patient feedback obtained via digital platforms offers insightful information that supports ongoing efforts to improve quality (Shah et al., 2021). The integration of technology, patient engagement, and evidence-based practices will be essential in achieving long-term improvements in healthcare quality as Total Quality Management (TQM) in the healthcare industry continues to develop. Theories of organizational structure, including scientific and bureaucratic management, have had a big impact on how modern organizations are built and run. Max Weber's bureaucratic theory places a strong emphasis on a hierarchical organization with well defined roles, regulations, and processes. This theory still holds true today, especially in large organizations where formalization and efficiency are essential. Meyer (2020) has observed that bureaucratic structures have a lasting effect on the stability and effectiveness of organizations. Frederick Taylor popularized scientific management, which aims to maximize productivity via methodical process standardization and analysis. Taylor's ideas have changed over time and still have an impact on modern management techniques, 6 especially in the manufacturing and service sectors. Studies looking at scientific management's application in contemporary settings show how relevant it is and how it continues to have an impact on worker productivity and operational efficiency (Taylor,2004; Kanawattanachai & Yoo, 2007). Although organizational structure has its roots in these theories, it's important to remember that modern organizations frequently combine aspects of different theories in order to adapt to the ever-changing business environment. Organizations can maintain efficiency and foster flexibility and innovation by implementing hybrid structures that integrate both scientific and bureaucratic management principles (Lawrence & Lorsch, 1967). In response to the demands of the contemporary business environment, organizational structure theories are continuously evolving, as evidenced by this synthesis of traditional theories with new perspectives. Hospital organizational structure conceptualization requires a sophisticated grasp of the intricate healthcare system. The significance of customizing organizational structures to promote innovation, increase efficiency, and improve patient care is highlighted by recent research. Tolf‘s study from 2015 highlights the necessity of adaptability in hospital organizational structures because healthcare delivery is a dynamic process. In order to optimize resource allocation and adjust to changing healthcare demands, hospitals frequently combine components of various structures, such as functional, divisional, and matrix structures (Tolf et al., 2015). With this strategy, hospitals are able to strike a balance between the need for coordinated, patient-centered care and the need for specialization in a variety of medical fields. Apart from the structural adaptability, the focus on patient-centered care has led to a change in hospital structures towards ones that are more team-oriented and flatter. The idea of patient-centered care is ingrained in systems that value healthcare professionals' interdisciplinary cooperation. According to a study by Shortell et al. (2020), team-based structures have a positive effect on both patient outcomes and the general performance of the organization. Putting in place team-based structures encourages efficient communication, group decision-making, and a patient-centered approach that is in line with the changing demands of the healthcare industry. 7 1.1.1 Definitions of Terms The researcher defined the main terms mentioned in the current study in this subsection. 1.1.2 Organizational Structure According to Shoghi and Nazari (2012), Organizational structure is ―the basis for the interaction of various occupations, operational systems and processes, as well as people and groups that pursue the achievement of goals. Organizational structure represents the level of formal hierarchy and defines the areas of control of managers and leaders (it is important to note that a proper structure is an important capital of an organization). The results of the creation and design of an organizational structure include the formal relationships between individuals, the location of jobs and positions within the organization, the degree of access to information, the formulation and interpretation of tasks and tasks, the allocation of resources, rules and regulations. And mechanisms. Implementing and enforcing regulations and encouraging inter-service collaboration. An essential managerial lever for open innovation is organizational structure. Since the proper administration of acquired external knowledge requires the development of internal networks, successful innovation can be substantially influenced by effective decision-making and organizational processes. When control is bolstered by higher centralization of authority, organizational effectiveness declines. Under a centralized decision-making framework, subordinate initiative and creative ideas may be discouraged as organizations struggle structurally to produce innovation (Lee et al., 2016). According to Ahmadi et al. (2013), different organizational structures are used depending on the circumstances of each organization. According to Burns and Stalker, the best kind of construction is one that adapts to its surroundings. As organizational structures become more complex due to the evolution of business strategies, centralization and inculcation become more comprehensive in procedures and controls (Martinez‐Le َ n & Martnez‐Garca). Three essential elements make up the definition of an organizational structure according to (Daft, 2015) 8 1. The organizational structure identifies formal reporting links, indicating the hierarchy and authority levels of managers and supervisors. 2. The division of people into departments and the entire organization is known as the organization structure. 3. The design of systems to guarantee efficient communication, collaboration, and integration of efforts across departments is a component of organizational structure. Figure 1.1 Organizational chart of a hospital 1.1.3 Organizational Structure Dimensions Organizational structure has the following dimensions according to the literature review: 1.1.3.1 Formality According to Rezaeyan (2008), formality refers to the standard level of management functions. In formal organizations with organizational charts, organizational relationships are intentionally and carefully explained to employees. And if necessary, the leader will indicate additional changes. However, in informal organizations, organizational relationships are explained verbally to employees and are naturally modified as needed. When the formality of a task is high, performers have the least freedom to perform related activities and the least amount of time and method to complete them. 9 In such a condition, to achieve some preset goals, the personnel are anticipated to hire the same structures in a particular way. Therefore, with high formality, we see descriptions of specific tasks, a large number of rules and regulations, and a clear indication of the work processes of the organization. Staff behavior may be less planned when there is less formality, which gives people greater leeway to apply their ideas to their tasks.(Robbins & Decenzo, 2008). From a negative standpoint, formality is frequently connected to actions that no longer accomplish their intended goals. As a result, formality may occasionally be used to characterize a course of activity whose true aim is unknown (Brooks, 2016). 1.1.3.2 Centralization Development of appropriate frameworks that provide institutional support and system stability for other internal organizational features, like routines and values, is regarded as one of the primary duties of managers. The extent to which decision-making is centrally or decentralized is a key indicator of how an organization allocates resources, establishes goals, and formulates policies. According to organizational theorists, the "hierarchy of authority" and the "degree of participation in decision-making" inside an organization serve as indicators of the relative degree of centralization since they show how power is distributed throughout the entire organization (Andrews et al., 2009). The delegation of authority is vital to the centralization and decentralization debates. When only a little amount of authority is distributed, an organization is often characterized as centralized, and when a significant amount of authority is devolved to lower levels, an organization is said to be decentralized. There are different levels of centralization and decentralization, which are opposites. Subordinates have partial decision-making authority in highly centralized organizations. On the other hand, subordinates in a decentralized organization have a wide range of decision-making authority. The effects of decision-making decentralization differ between inbound and outbound open innovation (Montana & Charnov, 1993). The term "centralization" describes a few tiers of the option hierarchy, which may also comprise a few choices. According to the hierarchy, high-level management should directly and vertically delegate authority to low-level management. Option hierarchy establishes the managers' area of control (monitoring) and indicates to whom each 10 person should report. A formal organizational mechanism for establishing alternatives, responsibilities, and relationships is hierarchy.(NiazAzari, 2006). Today, the level of centralization or decentralization which executives choose to implement their own decisions and accomplish organizational objectives. What works well in one organization might not necessarily work well in another. Therefore, managers should assess the level of decentralization within each organization's parts.(Robbins & Decenzo, 2008). Edward O. Onono, in his study of 2018, states that centralization and decentralization are essential in maintaining the authority and direction of the organization. Decentralization help exercises authority by various employees by allowing many individuals within the organization to have decision-making responsibilities. Marume and Jubenkanda (2016) advise that decentralization should be used to avoid further complexities in large organizations, in contrast to small businesses where top management controls the decision over the organization. Divisions, departments, and functional units make up the organizational structure at the functional management level. The department, which can operate independently or in conjunction with divisions, is the basic organizational unit. Departments and divisions within autonomous organizations (AO) can fall under one of the following categories: clinical departments and divisions, which are frequently linked to medical specializations; scientific support departments; or administrative support divisions and departments. Nursing Services are organized under various hospital settings to assist Clinical Departments/Divisions, providing flexibility and eradicating the "silo" effect that some traditionally structured organization encounter. Organizational structures should differ depending on the hospital size: smaller hospitals often have much simpler organizational structures than larger ones (Lourenco, 2015). Hospitals and healthcare organizations are frequently referred to as exceptional or at the very least distinct from other forms of organizations, particularly industrial ones. These distinctions are also thought to be necessary for hospital management. Several of the most common distinctions listed were:  It might be challenging to define and gauge output. 11  The task is perceived as more complex and highly varied than in other organizations.  A more significant portion of the task is urgent and non-deferable.  There is little room for error or ambiguity in work.  Because the work activities are interrelated, there must be close coordination between various professional groups.  The work requires a tremendous amount of specialization.  Organizational members are highly professionalized, and they have solid professional loyalty. 1.1.3.3 Professionalism Professionalism describes carrying out a task in the most exacting and meticulous way possible with the fewest errors. In addition, it has been said that striving for progress, demonstrating originality via constant improvement, understanding even the tiniest nuances of the job, and going above and beyond by identifying the crucial components are all signs of professionalism (Yorulmaz et al., 2015). Government administration and public services would decline in quality due to a lack of professionalism in executing their tasks and functions (Insani, 2020). 1.1.3.4 Structural Complexity One of the critical aspects of organizational design, structural complexity (also known as specialization or differentiation), describes the level of differentiation present within an organization. Because they become specialized in those activities, Complexity is likely to enhance employees' abilities and skills in routine tasks (Ali et al., 2018). San Cristóbal (2022) findings indicate that by changing the company's current organizational structure, the company would lessen complexity and increase structural agility and performance. 12 1.1.3.5 Practice Groups Groups of people known as practice groups regularly communicate to learn from and with one another about issues that are of genuine interest to them in the real world (Wenger et al., 2002). Communities of practice (practice groups) don't have to be formal; they are inherently self-reliant and driven by people's common collective thoughts. Therefore, both those who regularly engage in collective thought and those who have meaningful access to it fall under the purview of communities of practice. People in communities of practice share their knowledge‘s in creative ways that foster new approaches (Pyrko et al., 2017). The term organizational structure used in the current study was defined through a questionnaire that dealt with (5) organizational structural domains (formality, professionalism, centralization, complexity, and group of practices). These domains included 26 statements/questions, which relied on the five-point Likert scale; each question has five possible answers (Strongly disagree, Disagree, Neutral, Agree, Strongly Agree) and is scaled from 1 - 5. 1.1.4 Definition of Quality and Total Quality Management 1.1.4.1 Quality There are various ways to define quality; we might apply a different meaning for this idea depending on the industry. In other words, there are numerous ways to define quality. There have been attempts to define the meaning of this concept of "quality" for a long time, frequently in general terms. We attribute this to the variety of explanations that have been made, the ability of each side to express its viewpoint, and the fact that some definitions are based on reliable documentation while others are the expression of personal experiences, opinions, and conjecture. In Rashed (2014), the British Standard Institution defines quality as ―the entirety of features and characteristics of a product or service that tolerate on its capability to satisfy definite and applied needs‖. Another definition is ―fitness for purpose/use‖. Customer satisfaction drives this concept, which has become the primary definition of quality in the commercial and service industries. The definition of quality is placing the product features and process 13 parameters within the design requirements or tolerance limits. which is ―standardization of the product characteristics or delivery of a service around a nominal or goal value‖(Rashed , 2014). Quality expert Crosby (2001) states that quality means conformity. The previous definition is based on the assumption that the specifications and requirements have already been established. The next thing to note is the observance of these characteristics. According to Juran, another commonly used meaning is utility. This definition shows the value of customers using your product (Hoyer et al., 2001). Tirupathi (2009) asserts that a facility's aesthetic appeal serves as a gauge of its quality. By applying this criteria, a high-quality project can be identified by attributes like energy efficiency, simplicity of operation, minimal maintenance requirements, degree of conflict in drawings and specifications, and the economics of construction. In Tirupathi (2009), according to Edward Deming, is "a predictable degree of uniformity and dependability with a quality standard suited to the customer." The fundamental viewpoint of all definitions is the same: steadiness of conformance to specifications and performance and keeping the customer in concentration. Another widely accepted definition by Ennew, C. T., Reed, G. V., &Binks, M. R. (1993) is; the degree to which performance lives up to expectations defines that quality. This definition offers a way to evaluate quality using a comparative standard. Quality is defined by the American Society for Quality (ASQ) as excellence in goods and services, especially in terms of how well they satisfy customers and meet requirements. It is vital to note that quality is defined as being proportional to variability, meaning that as quality rises, variability will also decrease.(Montgomery et al., 2011). 1.1.4.2 Total Quality Management Total Quality Management (TQM) is a system that holds managers and clinicians accountable for the caliber of their healthcare organization, say Talib, Rahman, and Azam (2010).To prevent the majority of connected administrative and clinical issues, boost patient happiness, continually enhance organizational procedures, and deliver good or better healthcare services, systems in total quality management have been http://www.cambridge.org/us/academic/subjects/engineering/engineering-mathematics-and-programming/quality-and-reliability-engineering#bookPeople 14 designed. As a universal management concept, TQM includes the following concepts: employee contribution, error anticipation, customer focus, teamwork, management systemization, and continuous quality improvement. TQM is a management philosophy that interacts with people and work processes with the aim of increasing client satisfaction and efficiency within an organization, according to Davies' 2003 study. Davies (2003) discusses improving the organization's financial performance in addition to achieving the maximum degree of patient satisfaction with the services provided. Another definition based on US theories emphasizes the effectiveness of TQM as a management strategy (Dagger et al., 2007). TQM is a continuous quality improvement that unites two concepts: management method and philosophy, as demonstrated by Al-Shdaifat (2015). In order to shape the interaction between TQM and organizational structure, leadership plays a crucial role. To encourage a TQM mindset among employees, modern hospital managers must promote a culture of innovation, transparency, and continuous improvement (Mahadevan, 2022). In order to successfully integrate TQM and overcome resistance, leadership commitment is essential. Without also addressing the cultural and political aspects, total quality management technology transformation would fail. An organisation's culture and working methods significantly change due to TQM. With the help of the TQM management system, a complete service may increase customer satisfaction, ongoing improvement, and staff engagement. This has led to the definition of several quality management concepts that alter employee attitudes and organizational culture. 90% of total quality management is a mindset, particularly the willingness to listen to customers (Awu, 2022). According to TQM, the notion of customer-provided quality should be at the heart of an organization's management process, a business theory, method, or practice. The TQM's ideal is continuous service and product quality improvement (Awu, 2022). The following elements that affect TQM adoption were ranked according to: (Alawag et al., 2022). 1. A. Leadership. 2. Customer satisfaction. 15 3. Continuous Improvement. 4. Process Management. 5. Teamwork 6. Top Management Commitment. Figure 1.2 Definition of TQM According to Munhurrunet al. (2011), factors that should be adopted in organizations to achieve business excellence are: Factor 1: Top management commitment: Management sets the tone for TQM implementation by establishing the standards, objectives, and plans necessary to meet customer demands and improve an organization's performance. Factor 2: Employee Involvement: An essential part of Total Quality Management is employee participation. TQM necessitates complete management commitment in order to guarantee that workers foster a quality work environment and that the company presents a positive image to it)s clients by providing high-quality services. An environment of open feedback and communication is necessary for TQM implementation. This entails pushing employees to share their concerns, recommendations, and comments about policies and procedures. It is important for 16 leaders to actively listen to their input and use it to keep improving the TQM methodology.(Toke & Kalpande, 2020) Factor 3: Customer satisfaction: TQM emphasizes making customer satisfaction the primary organizational goal by guaranteeing that every transaction meets or exceeds the expectations of the external customer. Factor 4: Teamwork: Teamwork is a key component of TQM since it is necessary for effective process management and improvement, particularly in the field of medicine. Factor 5: Processes: TQM is centered on process management that works and ongoing client satisfaction. Factor 6: Continuous improvement: The idea of continuous improvement is a potent one since it refers to pursuing constant progress in satisfying both internal and external client needs. 1.2 Problem of study Hospitals should be treated as a single organization that oversees and integrates all of its essential operations and functions rather than as a group of separate units. A hospital is perhaps the most departmentalized and structured into functional units of any Health care organization. The need to incorporate new operational approaches in response to dynamic changes that are changing the care process is the most pressing problem in hospital management. Uncertainty, difficulty, and pace can all be handled using a quality control framework to standardize operating procedures. (Van der Aalst et al., 2005) In recent decades, nationwide healthcare systems have faced growing demand for high- quality, patient-centered services, but inadequate structures frequently threaten their stability. Because of the rise in chronic illnesses, aging population, advancements in technology, scarcity of financial resources, and growing awareness of patients' rights to care and cures, new markets and needs are emerging, and many pandemics like the COVID era. To improve patient- care, hospitals' organizational structures must be innovative and approaches toward total quality management must take a step forward. (Harper, 2014). 17 Most Palestinian hospitals do not have a standardized operational system that defines all types of processes. Hospitals lack performance metrics and measuring systems as a result, which negatively affects the level of service. Hence, no studies have been conducted on the relationship between the organizational structure and implementation of total quality management in Palestinian Hospitals. (Al-Adham, 2004). 1.3 Aim of the study This study aims to examine the relationship between the organizational structure of government hospitals and the implementation of total quality management. 1.4 Objectives of the study 1. To determine which organizational-structural dimensions are applied in governmental hospitals in the West Bank, Palestine. 2. To identify the extent of the implementation of total quality management within government hospitals in the West Bank, Palestine. 3. To determine which organizational structural domains are more influential towards which TQM components. 1.5 Hypothesis of the study 1.5.1 Main hypothesis There is no significant relationship at the level of α ≤ 0.05 between organizational structure and components of TQM. 1.5.2 Sub-hypotheses 1. There is no significant relationship between organizational structure and teamwork at a level of α ≤ 0.05. 2. There is no significant relationship between organizational structure and continuous improvement at the level of α ≤ 0.05. 3. There is no significant relationship between organisational structure and management commitment at the level of α ≤ 0.05. 18 4. There is no significant relationship between organisational structure and training at a level of α ≤ 0.05. 5. There is no significant relationship between organizational structure and customer focus at the level of α ≤ 0.05. 6. There is no significant relationship between organisational structure and employee involvement at the level of α ≤ 0.05. 7. There is no significant relationship between organizational structure and organizational culture at the level of α ≤ 0.05. 8. There is no significant relationship between organisational structure and processes at a level of α ≤ 0.05. 9. There is no significant relationship between organisational structure and strategic planning at a level of α ≤ 0.05. 10. There is no significant relationship between organisational structure and leadership at a level of α ≤ 0.05. 11. There is no significant relationship between organisational structure and performance results at a level of α ≤ 0.05. 1.6 Significance of study In recent years, there has been a notable increase in the focus on the role that organizations play in providing care. Finding methods to enhance care by enhancing the organizations that deliver its problem that faces academics, medical professionals, and legislators. Health care delivery systems are arranged hierarchically, with each level influencing the levels below it. All tiers of the current healthcare system must be redesigned in order to improve the quality of care. (Chassin & Galvin, 1998). The purpose of this research is to examine how the organizational design and the application of total quality management relate to government hospitals located in the central West Bank of Palestine. 19 Valmohammadiand Roshanzamir (2015) added that the shared values of an organization's members include its methods of operation, traditions, beliefs, and acceptable means of achieving objectives. The findings demonstrate the beneficial direct effects of culture and TQM on organizational performance and the beneficial indirect impacts of culture via the enhancement of TQM. According to Mary Walton, The Deming Management Method states that "good employees are not an asset to the organization without acquiring new knowledge, execute the tools adopted, and apply new skills acquired by employees that deal with novel resources and new methods of production." For long-term planning that results in development, it is necessary to invest in people through education and retraining (Maheswari & Padmaja, 2018). According to Kulenovic (2021), the implementation of Total Quality Management (TQM) is contingent upon six critical success factors, namely: commitment and leadership from top management, customer focus, employee training, procurement management (suppliers), data and analysis, and procedure management. In the current study, the term Total quality management used was defined through a questionnaire that dealt with (11) factors that affect the adoption of TQM (Teamwork, continuous improvement, organizational commitment, training, customer focus, employee participation, organizational culture, process, strategic plan, leadership and performance). These factors included 37 statements/questions, which relied on the five- point Likert scale; each question has five possible answers (Strongly disagree, Disagree, Neutral, Agree, Strongly Agree) and is scaled from 1 - 5. 1.7 Literature Review 1.7.1 Studies Related to Organizational Structure In order to examine the connection between organizational structure and women employees' quality of work life in Islamic Azad university branches, Salimbahrami et al. (2015) conducted a study. Using Krejci and Morgan's table, a correlation-based descriptive survey has been implemented. The eleven91 individuals were chosen at random. Surveys on "organizational structure" and "work-life quality" were employed to collect the information. The results showed that the components of organizational 20 structure and quality of work life were strongly positively correlated. Furthermore, some significant predictors of the quality of work life were the components of organizational structure, namely centralization, option hierarchy, and formality. In 2013, Shoeb Ahmad conducted research on the connection between life quality and organizational structures. He came to the conclusion that the fundamental elements of each organization's quality of work life are human interactions, work-life balance, job security, job satisfaction, stress, and workplace health and security. Staff participation, teamwork, awards, the schedule of work hours, and organizational culture are further ways for enhancing the quality of life at work in businesses with centralized organizational structures. The effectiveness of the organizational structure and quality of work life (a healthy atmosphere, job security and law on the job, and the development of human skills) have a substantial positive link, according to Bagherpour's (2012) study. A favorable correlation was observed between several indicators of job status, variability, and matching job and one's skill and competence with life quality by Javaheriet et al. (2010) in their study "Analyzing the Effects of Women's Employment on Their Life Quality". In actuality, people who have more appropriate work statuses lead more acceptable lives. Wagner (2014) results show that a less developed quality management system is linked to an OS with fewer protocols, whereas a more advanced quality management system is linked to an OS that encourages innovation in care. Wagner et al. (2014), a study of organizational culture and structure on quality implementation, discovered that organization structure is related to quality control, with organizations getting a lower Quality Management System Index (QMSI) score if they have fewer practices supervised by protocols. As a result, it seems that if hospitals were to enhance their success in implementing quality control programs, they should focus more on designing structured procedures, guidelines, and legislation, even with incentives attached. Results suggest that quality-improvement decision-making should be decentralized to the local level, but this should not be entirely lenient. Furthermore, hospitals may need structured guidelines to help arrange the list of options available in order to facilitate local decisions. It seems that organization structure affects quality management strategy 21 implementation, but that particular organizational culture styles were not linked to the implementation of quality management strategy. In European hospitals, no single dominant organizational culture class is more positively correlated with quality control than others. 1.7.2 Studies Related to Total Quality Management Abu Daqar (2020) conducted a study about the role of total quality management in enhancing the quality of private healthcare services. The study looks through how total quality management, or TQM, could raise the standard of care that private healthcare providers in the Northern Areas of the West Bank offer. The study involves choosing North West Bank private hospitals and healthcare facilities for a survey using questionnaires. Two hundred administrative employees were selected via a stratified sampling method. The results from structural equation modeling (SEM) demonstrate that all TQM parameters in the private healthcare sector were directly and positively related to one another. Processes have a direct and negative relationship with service quality, whereas four TQM factors—continuous improvement, employee involvement, customer satisfaction, and top management commitment—have a positive and direct relationship with service quality.95% of the variation in healthcare service quality was explained by TQM factors (customer satisfaction, employee involvement, continuous improvements, processes, and top management commitment) (R2 = 0.950, P < 0.05). Continuous improvement, which has a strong connection to private healthcare procedures, is the cornerstone of Total Quality Management (TQM) application in the healthcare sector. (R² = 0.907, P < 0.01), While the most important factor in raising the level of service quality is top management commitment. The key components of a successful TQM implementation were full comprehension and commitment from managers at all levels and the activation of effective communication between employees at all levels in the organization.; it aidsstrengthen teamwork efficiency. Top management mustevade monotonic managerial practices, especially in the organizational processes, as it negatively impacts private healthcare service quality. Abdullah‘s (2018) one of the most recent studies conducted in Palestine looked into the lack of skills in the healthcare industry. The study's noteworthy findings categorize the lack of skills among managerial and administrative employees. Using new devices, dealing with patients, leadership, work loyalty, teamwork, communication, efficiency of 22 training, and handling responsibilities are the core causes of the skills gap and deficiency for mid-level positions, whereas for managerial positions, they were top management skills, financial skills, leadership, communication, treating patients with respect, and time commitment. Nasser, Khraim, and Mousa (2016) conducted a study in the West Bank, Palestine, to evaluate the adoption of TQM in public hospitals. To evaluate the hospitals' commitment to putting the TQM factors into practice, they used the following TQM model: top management commitment, customer focus, employee involvement, training, continual improvements, and leadership. The respondents had lower levels of knowledge about three different factors, including employee involvement (42,9%), patent focus (33,9%), and ongoing improvements (42,9%), according to the authors. Nasrallah (2009), in his study, examined the extent to which TQM success factors were implemented in the Palestinian healthcare system, including both public and private hospitals.TQM was determined by the author using a variety of factors, including process management, staff and patient attention, top management commitment and leadership, and ongoing improvements. The results indicated that these hospitals had a high level of implementation of these TQM dimensions, which contributes to upholding the ISO standards for the healthcare industry, particularly for hospitals.The study found that the TQM components that the healthcare industry should concentrate on to increase TQM adoption and boost customer satisfaction. Top management and leadership, an emphasis on the needs of the employees, hospital information systems, governance, and social responsibility are a few of these. Mosadeghrad (2014) An effective TQM implementation requires adequate education and training, encouraging leadership, consistent top-level support, a customer-focused approach, employee involvement, process management, and ongoing process improvement. Effective Total Quality Management (TQM) implementation in hospitals requires a number of factors, including top-level management commitment, employee involvement, education and training, rewards and recognition, process management, information analysis, strategic planning, organizational culture, continuous improvement, and customer focus (Aburayya et al., 2020). Notably, this study found 23 that the two critical success factors (CSFs) that had the biggest effects on the implementation of TQM were top management commitment and customer focus. Furthermore, Aburayya highlighted that organizational culture had the biggest influence on hospital service quality out of the eight TQM implementation factors that were examined. The study conducted by Baidoun in 2018 revealed that Palestinian hospitals in the Gaza Strip perform at a generally satisfactory level. When Total Quality Management (TQM) is implemented to a greater extent, non-governmental hospitals outperformed governmental hospitals (Baidoun et al., 2018). Applying Total Quality Management's guiding ideologies, including customer focus, teamwork, top management commitment, and continuous improvement, can reduce variation in implementation by 70% (Al-Shdaifat, 2013). According to the study's findings, continuous improvement emerged as the most critical factor in explaining the variation in how TQM principles were applied. El-Tohamy and AlRaoush's (2015) study showed that all Total Quality Management (TQM) principles have a significant impact on hospitals' overall effectiveness. Furthermore, Zaid et al. (2020) found a positive relationship between patient satisfaction and TQM and perceived service quality in Palestinian healthcare organizations. Organizational TQM has a major impact on the quality of health services in addition to increasing the organization's value and competitiveness. A study discovered that inside hotel organizations, there is a lack of coordination and collaboration across several departments. The hotel subsidiary's several departments' lack of cooperation and coordination was one of the main problems, and a lack of understanding of the necessity of overall quality management, regulatory processes, and competitive restrictions. TQM adoption's effectiveness depended on communication between the institution's senior management and executive management (AL-Hazmi & Alkhateeb, 2020). Healthcare organizations face a number of challenges when integrating Total Quality Management (TQM) with organizational structure. These challenges must be carefully considered in order to optimize both organizational efficiency and patient outcomes. 24 First of all, it can be difficult to reconcile the hierarchical structure of conventional organizational structures with TQM principles. According to a study by Shortell et al. (2019), cultivating a culture of cooperation and communication within hierarchical structures is crucial for guaranteeing that TQM principles are successfully applied at all organizational levels in the healthcare system. This entails dismantling organizational silos and promoting interdisciplinary collaboration to support ongoing enhancement and patient-focused treatment. Second, a typical obstacle faced by healthcare organizations trying to incorporate TQM into their current organizational structures is resistance to change. The literature addresses this issue by highlighting the significance of engagement and commitment on the part of the leader. Strong leadership support and a common vision for quality improvement are crucial for overcoming resistance and promoting a culture of ongoing learning and adaptation, according to research by Hidayah (2022). Leaders must support TQM programs by giving employees the tools and rewards they need to participate in quality-improvement initiatives. The efficient use of technology and data within the combined framework of TQM and organizational structure presents another major challenge. Electronic Health Records (EHRs) and performance analytics are two examples of the technology solutions that healthcare organizations are depending more and more on for data-driven decision- making. However, careful planning and financial commitment are needed to guarantee the smooth integration of these technologies with TQM procedures. According to Jamal et al. (2020), information systems must be in line with TQM principles in order to drive continuous improvement. This will prevent data from adding to complexity and instead be used to drive it. Moreover, striking a balance between flexibility and standardization presents a special difficulty in the healthcare industry. While TQM promotes standardizing procedures to improve quality and efficiency, healthcare is a dynamic field that necessitates flexibility in response to shifting patient requirements and developing best practices. Research such as that conducted by Kaplan and Norton (2001) emphasize the significance of a balanced strategy in which flexible structures that can adapt to changes in patient conditions and preferences coexist with standardized protocols. This method makes sure 25 that TQM principles aren't unduly strict, enabling healthcare organizations to adapt to the changing and varied healthcare environment. In summary, the amalgamation of organizational structure and Total Quality Management within the healthcare industry is a complex undertaking necessitating a methodical and all-encompassing approach. Overcoming these obstacles requires a commitment from the leadership, a collaborative culture, data-driven decision-making, and a measured approach to standardization. The solutions put forth in the literature offer insightful guidance to healthcare organizations looking to adopt TQM principles and optimize their organizational structures for ongoing patient care and effectiveness improvements. Modern healthcare practices are always changing to meet the intricate problems of the contemporary world. The growing use of data analytics and technology in healthcare systems is one notable trend (Wang et al., 2019).For example, telemedicine has become increasingly popular as it enables patients to receive medical consultations from a distance, improving healthcare accessibility and lowering geographic barriers (Bashshur et al., 2016). Furthermore, massive datasets are being analyzed using artificial intelligence (AI) and machine learning applications, which help with early disease detection, customized treatment plans, and predictive analytics for public health management (Topol, 2019). In addition, patient-centered care is now a key component of modern healthcare strategies. According to Epstein and Street (2011), this paradigm shift places an emphasis on a more collaborative and holistic approach that involves patients in their care decisions and takes into account their unique needs, preferences, and values. In order to improve treatment adherence and patient satisfaction, shared decision-making between patients and healthcare providers is being encouraged (Barry and Edgman- Levitan, 2012). In an effort to deliver more individualized and culturally competent care, this approach acknowledges the significance of taking social determinants of health and cultural factors into account. Organizational structures are becoming more and more focused on value-based care models. According to Conrad and Perry (2009), healthcare systems are shifting from conventional fee-for-service models to payment schemes that incentivize effective 26 resource use and favorable patient outcomes. This change in emphasis pushes healthcare professionals to concentrate on patient involvement, care coordination, and preventive measures with the ultimate goal of raising overall healthcare quality while lowering costs. These modern methods capture a changing environment as healthcare systems work to adjust to patients' and the public's changing needs. 1.7.3 Comments on the previous Studies This study delves into the connection between organizational structure and the implementation of Total Quality Management (TQM) in governmental hospitals in the West Bank, Palestine. In line with similar research endeavors exploring aspects like quality of life, this study shares common ground with previous investigations on organizational structure, such as those conducted by Salimbahrami et al. (2015), Shoeb Ahmad (2013), and Bagherpour (2012), which explored the relationship between organizational structure and various variables. Furthermore, this study aligns with prior research on Total Quality Management, mirroring the objectives of studies like Abu Daqar (2020), Abdullah (2018), Nasser, Khraim, and Mousa (2016), and Narallah (2009), all of which examined the implementation of TQM in Palestinian hospitals. The recent study examined organizational structure and implementation of Total Quality Management (TQM) at Palestinian hospitals in 2022. 27 Chapter Two Methods 2.1 Introduction This chapter introduces the research strategies and methods used, the data collection process, the data sources, the tools used, the sample and sampling methods observed, the data collection methods applied, and the statistical tools applied to the data treated by research tools. In this study, the researcher utilized the quantitative approach by using the questionnaire to solve the research problem and answer the research question. An essential element in a research study was determining an appropriate research methodology. All techniques employed by a researcher during a research study were referred to as research methods, which included theoretical procedures, experimental studies, numerical structures, and statistical approaches. It helps the researcher‘s collect data and find the research results.In this chapter, the methods used in the study include the study design, study population, study sample, Instruments of study and validation indicators, analysis plan, study procedures, and ethical approval. 2.2 Method The design of this study was descriptive;a cross-sectional design has been used to achieve the aim and objectives of the study, that is, to examine the relationship between the organizational structure and implementation of total quality management in governmental hospitals (Rafidia, Ramallah, Jericho, Tulkarem, Qalqelya, Jenin and Salfit) in the northern and middle of West Bank of Palestine. These hospitals had the same instructions about the organizational structure fromthe Ministry of Health. Thus, the study focused on hospitals in the northern and middle of the West Bank (Rafidia, Ramallah, Jericho, Tulkarem, Qalqelya, Jenin and Salfit). The cross-sectional design takes into account the facts that were true at the time the data was collected. Compared to other longitudinal studies, it is less expensive and takes less time. Participants were interviewed to collect data to fill out the questionnaire. 28 2.3 Population, Sample and Data collection The research population consisted of the administrative employees in the governmental hospitals (Rafidia, Ramallah, Jericho, Tulkarem, Qalqelya, Jenin and Salfit) in the northern and middle of West Bank of Palestine, totalling (384). The sampling method was purposive and cross-sectional, representing the study populations. The total number of (192) questionnaires (with a confidence interval of 95% and a margin of error of 5%) were distributed in governmental hospitals (Rafidia, Ramallah, Jericho, Tulkarem, Qalqelya, Jenin and Salfit) in the northern and middle of West Bank of Palestine. (191) questionnaires were retrieved.The data collection tool used was paper and electronic questionnaires to collect the data. The sample size was calculated using Robert Masoon equation. (2.1) draw by random sample approach. N: Population size. S: 1.96 /standard error=0.05 P: Percentage of picking a choice expressed as decimal=0.5 2.4 Research Instrument applied A well-structured questionnaire was used as a data collection tool (APPENDIX F). The first part discussed demographic information about participants like age, sex, marital status, education, health status, job title, experience, supervisory position title and income. The second consisted of questions related to the organization‘s structure, and the third was about total quality management components. The tool of this study has been adapted and prepared using different literature reviews about both organizational structure and TQM. The part about organizational structure and its dimensions was adapted from Radwan's (2015) study on the ministry of social affairs, and the second part was adapted from Munhurrun's (2010) study about components of TQM and 29 Baidounet al. (2018) study. The questionnaire was created with accuracy in mind so that it can measure both the dependent and independent variables in this study. According to Malhotraand Birks (2007) said that the ―Likert scale allowed the respondent to choose the degree of agreeing or disagree with each item in the questionnaire‖ when it comes to the inducementresolution, the different factors were measured on 5- point Likert scale to check the applicant‘s degree of convenient with the statement or not, as below: 1. Strongly disagree (SD) 2. Disagree (D) 3. Neutral (Ne) 4. Agree (A) 5. Strongly Agree (SA) In order to assess the degree of organizational structure and total quality management implementation in governmental hospitals in the West Bank of Palestine, we employed the same scale that was initially employed by Radwan & Munhurrun, the original authors of the questionnaires. This scale is dependent on interval length, which is equal to range/number of intervals and interval length, which is equal to (5-1)/3=1.33. The following scale represents the result: 1. less than 2.33 is low; 2. 2.33- less than 3.66 is medium, and 3. 3.66-5 is high. 2.5 Internal Validity and Reliability Oluwa tayo(2012) define validity as ―the accuracy of an assessment‖ in other words, did the instruments used determine what they were supposed to determine?To have confidence about the validity of the questionnaire before distributing it to the last respondent, it has been sent to be evaluated by several external evaluators, their replies were given orally. The evaluator reviewed the questionnaire for readability, clarity, and 30 comprehensiveness and provided a consensus on which items should be included in the final questionnaire. While reliability means the consistency of assessment and free of error (Fraenkel & Wallen, 2003),which means that all items in the instrument determined the same construct, and to determine the reliability or consistency of the instrument, a statistical tool was used called Cronbach Alpha, this tool developed by Lee Cronbach in 1951 to achieve the purpose mentioned before. It is expressed with a numerical value located between 0 and 1. If the alpha score is more than 0.7, the questionnaire is reliable and vice versa. If the result is less than 0.7, the questionnaire is unreliable and needs to be modified. Exploratory data analysis is a collection of procedures used by quantitative researchers to investigate a novel domain of social or psychological life. They accomplish this by gathering open-ended questions that help them develop new theories and hypotheses about the domain. The most effective exploratory data analysis gives these researchers the most freedom to come up with fresh ideas and generalizations. To assess construct validity, the instrument was utilized on an exploratory sample of (51) employees in a governmental hospital in the Northern and Middle of the West Bank of Palestine. Participants from the study population who were not in the sample were given it. The exploratory sample's goals are to increase the questionnaire's degree of accuracy, determine how well respondents comprehend its questions, and identify any issues that may arise while the study is being conducted, additionally, a Pearson correlation coefficient between the items and the related dimension's overall score was calculated through the exploratory sample to examine the possibility of its application to determine the tool's validity. This value was then compared to the accepted threshold for accepting an item, according to Garcia and Gonzalez (2006), which stated that if the correlation coefficient was greater than (.40), the item was statistically acceptable. 2.6 Reliability The reliability coefficient (Cronbach alpha), which determines how homogeneous the instrument's level is, is calculated to determine the tool's level of dependability. An accepted level would be more than (70%). Table (2.3) summarizes the Cronbach‘s alpha values of the exploratory sample. 31 Table 2.1 Cronbach’s Alpha values for the exploratory sampleamong the employees in governmental hospitals in the northern and middle of the West Bank of Palestine distributed by dimension Dimension Cronbach's Alpha Significance Organizational Structure Formality 0.85 0.00 Specialization 0.71 0.00 Centralization 0.80 0.00 Complexity 0.84 0.00 Practice groups 0.70 0.00 Organizational Structure (total degree) 0.90 0.00 TQM (Total Quality Management) Teamwork 0.97 0.00 Continuous improvement 0.11 0.00 Management Commitment 0.79 0.00 Training 0.97 0.00 Customer focus 0.17 0.00 Employee Involvement 0.11 0.00 Organizational culture 0.71 0.00 Operations 0.97 0.00 Strategic planning 0.97 0.00 Leadership 0.79 0.00 Performance results 0.95 0.00 Total Quality Management (Total degree) 0.71 0.00 We found from table (2.3) that Cronbach‘s Alpha for all dimensions of Organizational structure is located between (0.70-0.90), TQM between (0.71-0.93), and all dimensions were more than 0.70. The reliability for the total score for organizational structure equals (0.90), and TQM (0.98), And the reliability for the whole instrument equals (0.97) Variables. 32 2.7 Statistical analysis The Statistical Package for Social Science (SPSS 25.0) was used to analyze the collected data:  Frequencies, percentages, means and standard variations were calculated for the collected data.  Statistical tests (multiple regression analysis).  Pearson correlation and multiple regression was used to conduct the results. P ≤ 0.05 would be accepted as statistically significant. 2.8 Study procedures The following steps were followed:  Initially, a research proposal for the current study was prepared and the study tool (questionnaire) was presented to the experts and a group of arbitrators, then submitted on 16 June 2021.  Official approvals were obtained from the Faculty of Graduate Studies and IRB at A- Najah National University and official authorities to facilitate carrying out the field study by distributing questionnaires to collect data between 20 June 2021 and 18 August 2021; see appendices (D, E and F).  A review of previous studies and theoretical frameworks in the field of research to build the theoretical framework for the current study has been issued.  A pilot study was conducted on 17 September 2021 to ensure the validity and reliability of the study tool.  The study tool was applied to the study sample, and the data were collected, analyzed, and converted into information through special tables between 3 November 2021 and 17 January 2022.  Finally, Interpreting and discussing results and formulating recommendations, proposals, and conclusions. 33 2.9 Ethical approval After getting ethical approval from the master of the public health management program and IRB committee at An-Najah National University (APPENDIX A), an approval letter has been requested from MOH for hospitals to get their permission to conduct this study in their centers (APPENDIX B & C).  The participants have been handed the consent form and the questionnaire.  The researcher personally distributed and collected the documents at the selected hospitals.  Completed questionnaires were collected in the same day.  The data were checked, coded and entered into SPSS for statistical analysis. 2.10 Conclusion This chapter has identified the methodological approach selected for this thesis study. In this part, the researcher identified in detail the research instrument that was applied to test the hypothesis to reach the final results, which illustrate the relationship between the organizational structure and the implementation of total quality management in governmental hospitals in the West Bank of Palestine, also in this chapter the researcher identifies the internal validity and reliability of the questionnaire used. Apearson correlation testing was done, and the results were used to make the necessary modifications to the instrument. Moreover,the researcher identified the population and the targeted research sample in this chapter. Finally, the researcher explained the procedures used to collect and analyze data. 34 Chapter Three Results 3.1 Introduction In this chapter, the researcher presents an analysis using SPSS25 to answer the questions and reject or fail to reject the hypothesis. This chapter is separated into four parts, the first one: is demographic analysis, the second part is descriptive analysis, and then the third part is hypothesis testing to find significant mean differences according to demographic variables. The correlation analysis was done in the final part to check the relationship between the organizational structure and the implementation of total quality management in governmental hospitals in the West Bank of Palestine. 35 3.2 Demographic analysis Using a printed and electronic questionnaire and the results of the sample were detailed as follows: Table 3.1 Demographic characteristics of respondents Source: SPSS outcome. variables Answers Frequency Percent (%) Gender Male 71 1519 Female 79 7119 Total 191 100 Age Between 22-30 years 50 26.2 Between 31-40 years 85 44.5 Between 41-50 years 49 25.7 Between 51-60 years 7 3.7 Total 191 100 Job title Doctor 95 5719 Allied medical professions and clinical support (pharmacist assistant, radiology, laboratory, occupational therapy,psychology) 17 9119 Pharmacist 57 117 Nursing and midwifery 71 9517 Total 191 100 Supervisory title Department manager 15 7.9 Head of the department 76 39.8 Section director 31 16.2 Administrative employee 69 36.1 Total 191 100 Educational qualifications Diploma or less 22 11.5 B.A 120 62.8 Master's 28 14.7 PhD or more 21 11 Total 191 100 Experience years Less than (5) years 34 17.8 (5-10) years 65 34 (11-15) years 51 26.7 More than 15 years 41 21.5 Total 191 100 Income level (NIS) Between 1500-2000 5 2.6 Between 2001-3000 4 2.1 Between 3001-4000 16 8.4 More than 4000 166 86.9 Total 191 100 36 In the surveyed population of employees in governmental hospitals across various regions in the northern and middle parts of the West Bank in Palestine, several key demographic patterns emerged. Firstly, the age distribution showed that the majority of respondents fell within the 31-40 years age group, constituting 44.5% of the sample, while the 51-60 age group was the smallest, accounting for only 3.7%. Secondly, in terms of gender, administrative male employees predominated, making up 51.3% of the total sample. Concerning job titles, the participants were divided into categories such as nursing and midwifery (31.4%), allied medical professions and clinical support (28.3%), doctors (16.2%), and pharmacists (8.4%). Regarding supervisory roles, heads of departments were the most common, comprising 39.8% of the sample, while department managers constituted 7.9%. In educational qualifications, the majority held a B.A. degree (62.8%), with only 11% having attained a Ph.D. or higher. Experience- wise, 48.2% of respondents had over 11 years of experience, while 17.8% had less than 5 years. Lastly, income levels revealed that a significant portion (86.9%) earned more than 4000 NIS, with only 2.1% falling within the 2001-3000 NIS bracket. 3.3 Descriptive statistics The descriptive analysis part describes the gathered numerical data to make it easier to explain; also, descriptive analysis results show the mean and standard deviation for each statement to determine the items with the highest and lowest mean in each factor. The purpose of this analysis is to identify the central tendency of the responses through mean results and the spread of a set of observations through the standard deviation results,which means that when the standard deviation is low, it expresses that most of the respondents had the same opinion (concentrated) toward the same statement. In contrast, when the standard deviation score is high, the respondents had a different opinion toward the same statement (Cicenaite et al., 2012). The 5-point Likert scale was used, where five means strongly agree, and one means strongly disagree. The first main Question is: What is the level of the organizational structure in governmental hospitals in the northern and middle of the West Bank of Palestine among the administrative employees? 37 To answer this question, the means and standard deviations were calculated to know the level of the organizational structure dimensions in the governmental hospitals in the northern and middle of West Bank of Palestine among the administrative employees. Table 3.2 Descriptive statistics of the organizational structure dimensions Source: SPSS outcome. We notice that the level of the organizational structurein the governmental hospitals in the northern and middle of West Bank of Palestine among the administrative employees is medium, the mean score equals (3.38), the highest mean score of the dimensions equals (3.70) related to "work groups" with a high level. The lowest mean score related to the ―centralization‖ dimension with a mean score equal to (3.10) and a medium-level. Table (3.2) represents the descriptive statistics of the organizational structure statements among the administrative employees. The statement describes ‗the hospital has a large number of specialized units and organizational departments which appear clearly in the organizational structure‘ with the highest mean score (3.72) and a high level. It shows that most of the respondents agree with this statement, while the lowest mean score (2.58) related to ‗the employee is involved in reviewing the organizational structure and the associated processes such as preparing the hospital's strategic and operational plans‘, with a medium level which explain that respondents were not sure that the statement did. Q2- What is the total quality management implementation level in the governmental hospitals in the northern and middle West Bank of Palestine among the administrative employees? Dimensions Mean Standard Deviation Level Formality 3.39 0.77 Medium Specialization 3.27 0.72 Medium Centralization 3.10 0.84 Medium Complexity 3.53 0.70 Medium Workgroups 3.70 0.82 High Average 3.3 0.54 Medium 38 To answer this question, the means and standard deviations were calculated to know the total quality management implementation level in the governmental hospitals in the northern and middle of the West Bank of Palestine among the administrative employees. Table 3.3 Descriptive statistics of the total quality management implementation dimensions level Source: SPSS outcome. We notice that the level of the total quality management implementation in the governmental hospitals in the northern and middle of West Bank of Palestine among the administrative employees is medium, the mean score equals (3.25), the highest mean score of the dimensions equals (3.45) related to "organizational culture" with a medium level. The lowest mean score is related to the ―operations‖ dimension, with a mean score equal (2.89) and a medium-level score. Table (3.3) represents the descriptive statistics of the total quality management implementation statements distributed by dimension among the administrative employees. The level of all statements of the total quality management implementation was medium. The statement represents ‗The hospital has an effective system for evaluating its operational performance‘ has the highest mean score (3.60) with a medium level, while the lowest mean score (2.84) related to ‗The hospital has a program to determine the lost time and costs in all internal operations‘, with a medium level, explain that respondents not sure that the statement actually done. Dimension Mean Standard Deviation Level Teamwork 3.40 0.86 Medium Continuous improvement 3.20 0.82 Medium Management Commitment 3.21 0.83 Medium Training 3.17 0.88 Medium Customer focus 3.24 0.68 Medium Employee Involvement 3.39 0.76 Medium Organizational culture 3.45 0.73 Medium Operations 2.89 0.95 Medium Strategic planning 3.21 0.86 Medium Leadership 2.97 0.98 Medium Performance results 3.40 0.79 Medium Total Quality Management 3.25 0.63 Medium 39 3.4 Testing the assumptions The researcher tested the assumption through (Normality) to determine which testing hypothesis was needed (parametric or nonparametric). To check the normality test Kolmogorov-Smirnov test is used. The following table shows the result: Table 3.4 Kolmogorov-Smirnov test for normality We assumethat the data is distributed normally, referring to the significance=0.11> 0.05. We accept the assumption, meaning we would use the parametric tests. Testing hypothesis: 3.5 Correlation Hypothesis (H0), Main null hypothesis: There is no significant relationship at the level of )α ≤ 0.05( between organizational structure and TQM in the governmental hospitals in the northern and middle of West Bank of Palestine. The researcher was curious to see if there was a significant correlation between the organizational structure and TQM;a Pearson correlation was found to know the result. Table (3.7) shows the answer: Table 3.5 Pearson correlation between the organizational structure and TQM Dimension TQM Organizational Structure Pearson Correlation 0.717** Sig. (2-tailed) 0.00 N 575 Source: SPSS outcome, ** sig (α≤0.01) Test Test value Significance Result Kolmogorov-Smirnov 1.979 0.11 Accept 40 From Table (317), the researcher rejects the null hypothesis. The significance level is less than 0.01, which means the organizational structure ispositively correlated with TQM, the correlation between the organizational structure and TQM equals (0.684) and issignificant. Now the researcher tests the sub-hypothesis between organizational structure and components of TQM: (H0.1), There is no significant relationship at the level of )α≤0.05( between organizational structure and teamwork in the governmental hospitals in the northern and middle of West Bank of Palestine. The researcher was curious to see if there was a significant correlation between the organizational structure and teamwork; Pearson correlation was found to know the result. Table (3.8) shows the answer: Table 3.6 Pearson correlation between the organizational structure and teamwork Dimension Teamwork Organizational Structure Pearson Correlation 0.795** Sig. (2-tailed) 0.00 N 575 Source: SPSS outcome, ** sig (α≤0.01) From table (3.7), the researcher rejects the null hypothesis; the significance level is less than 0.01, which means the organizational structurepositively correlated with teamwork, the correlation between the organizational structureand teamwork equals (0.795) and significant. (H0.2), There is no significant relationship at the level of )α≤0.05( between organizational structure and continuous improvement in the governmental hospitals in the northern and middle of the West Bank of Palestine. The researcher was curious to see if there was a significant correlation between the organizational structure and continuous improvement;the Pearson correlation was found in order to know the result. Table (3.8) shows the answer: 41 Table 3.7 Pearson correlation between the organizational structure and continuous improvement Dimension Continuous Improvement Organizational Structure Pearson Correlation 0.466** Sig. (2-tailed) 0.00 N 575 Source: SPSS outcome, ** sig (α≤0.01) From table (3.9), the researcher rejects the null hypothesis; the significance level is less than 0.01, which means the organizational structurepositively correlated with continuous improvement, and the correlation between the organizational structureand continuous improvement equals (0.466) and significant. (H0.3), There is no significant relationship at the level of )α≤0.05( between organizational structure and management commitment in the governmental hospitals in the northern and middle of the West Bank of Palestine. The researcher was curious to see if there was a significant correlation between organizational structure and management commitment;a Pearson correlation was found in order to know the result. Table (3.9) shows the answer: Table 3.8 Pearson correlation between the organizational structure and management commitment Dimension Management Commitment Organizational Structure Pearson Correlation 0.576** Sig. (2-tailed) 0.00 N 575 Source: SPSS outcome, ** sig (α≤0.01) From table (3.10), the researcher rejects the null hypothesis; the significance level is less than 0.01, which means the organizational structurepositively correlated with management commitment, and the correlation between the organizational structureand management commitment equals (0.576) and significant. 42 (H0.4), There is no significant relationship at the level of )α≤0.05( between organizational structure and training in the governmental hospitals in the northern and middle of the West Bank of Palestine. The researcher was curious to see if there was a significant correlation between the organizational structure and training;a Pearson correlation was found in order to k