An Najah National University Faculty of Graduate Studies Assessment of Perceived Health Care Service Quality at Palestinian Hospitals: A Model for Good Hospital Management Practice (GHMP) By Majd Abd Al-Rhman Fareed Al-Adham Supervised by Dr. Amjed Al- Ghanim Submitted in Partial Fulfillment of the Requirements for the Degree of Master in Public Health, Faculty of Graduate Studies, at An-Najah National University, Nablus. 2004 II Assessment of Perceived Health Care Service Quality at Palestinian Hospitals: A Model for Good Hospital Management Practice (GHMP) By Majd Abd Al-Rhman Fareed Al-Adham This thesis was successfully defended and approved on 9/8/2004 by:- Committee members Signature Dr. ِAmjed Al – Ghanim - Suprvisor Dr. Varsen Aghabekian - External Examiner Dr. Suleiman Al- Khalil - Internal Examiner III إهــداء هللا على نعمة التي ال تحصى وشكر له على ما أنعم به علي من قدرة احمد أعانتني على التفكير وقوة أعانتني على الدراسة والتحصيل، وما أمدني به من تواضعة قد تنفع الدارسين في الوصول إلى نتائج صبر وجهد للوصول إلى نتائج م .أوسع في هذا المجال والى جميع أفـراد ) أمي وأبى(أهدي خالصة جهدي إلى أعز الناس لقلبي أسرتي الذين لم يألوا جهداً ولم يدخروا وسعاً في تهيئة الظـروف المالئمـة لـي .ألتمكن من الدراسة والبحث IV شكر وتقدير فان إلى أساتذتي األفاضل في كلية الصحة العامـة فـي أتقدم بالشكر والعر .جامعة النجاح الوطنية لدعمهم وتشجيعهم لي وأخص الشكر والتقدير الدكتور أمجد الغانم المشرف على هذه الرسالة على .الجهود التي بذلها من أجل إخراج هذه الرسالة إلى النور قاسم المعـاني وأثمـن والشكر والتقدير إلى الدكتور عفيف جودة والدكتور .غالياً تشجيعهما ودعمهما لي، جزاهما اهللا عني خير الجزاء كما أتقدم بالشكر والتقدير إلى كل الدوائر والمؤسسات الرسمية التي فتحت أبوابها أمامي ومكنتني من الوصول إلى ملفاتها بحثـاً عـن الحقـائق واألرقـام، .وأخص الشكرالدكتور كمال الوزني ع البيانـات الذين عملوا وتعاونوا معي في جم شكر جميع الزمالءوأخيراً أ .التي بنيت عليها رسالتي ولكل من كان عوناً وسنداً لي في إنجاز هذه الدراسة V DECLARATION No portion of the work referred in this thesis has been submitted as an application for another degree or qualification of this or any other university or institute of learning. VI List of Contents III اهداء IV شكر وتقدير V Declaration VI List of Contents X List of Tables XII List of Figures XIII List of Graphs XIV List of Abbreviations XV Abstract 1 Chapter One Introduction 2 1.1 General Background 5 Hospital management in Palestine 1.2 5 Health sectors 1.2.1 7 Challenges facing health care in Palestine 1.2.2 7 Factors affecting quality of health care 1.2.2.1 8 Factors contributing to poor efficiency 1.2.2.2 9 Consideration should be given to change 1.2.3 9 Is it management problem? 1.2.4 10 Does total quality management address the basic problem of health care organizations today? 1.2.5 11 Previous work in improving health care in Palestine 1.2.6 13 Statement of the problem 1.3 14 Significance of the study 1.4 15 Purpose of the study 1.5 15 Hypothesis of the study 1.6 17 Limitation of the study 1.7 18 Chapter Tow Literature Review 19 Introduction 2.1 19 A brief history 2.2 20 Modern developments in quality 2.2.1 21 A race without a finish line 2.2.2 22 Meaning of quality 2.3 23 Total quality management "TQM" 2.4 24 Quality management system 2.5 24 Quality improvement vs. quality assurance 2.6 25 Key quality improvement concepts 2.7 25 Processes and systems 2.7.1 26 Customers and suppliers 2.7.2 26 Quality 2.7.3 27 Benchmarking 2.74 27 Teams and team work 2.7.5 27 Quality award models 2.8 VII 28 The four and three Cs of TQM- anew model for TQM 2.81 28 Previous studies 2.9 28 Palestinian studies 2.9.1 31 International studies 2.9.2 32 Regional studies 2.9.3 34 Chapter Three Methodology 35 Study area and sample 3.1 35 Ethical consideration 3.2 36 Framework of study methodology 3.3 37 Model and variables of the study 3.4 41 Survey instrument 3.5 44 Pilot study 3.6 44 Questionnaire reliability 3.7 44 Analysis tools 3.8 44 Used statistical analysis 3.8.1 45 Data collection 3.9 48 Chapter Four Results and Discussion 49 Hypothesis testing 4.1 49 Manager and employee hypotheses testing 4.1.1 59 Patient hypothesis testing 4.1.2 82 Chapter Five Proposed model for hospital quality management system 83 Model principles 5.1 83 Patient focused functions 5.1.1 84 Management of the environment of care “safety protocols and procedures” 5.1.2 84 Management of human resources 5.1.3 84 Management of information 5.1.4 85 Education which is includes patient responsibilities 5.1.5 85 Surveillance, prevention and control of information 5.1.6 85 Improving organizational hospital performance 5.1.7 85 Structures with functions 5.1.8 86 Framework for improving performance 5.2 88 Dimensions of performance 5.2.1 88 Doing the right thing 5.2.1.1 88 Doing the right thing well 5.2.1.2 94 Hospital quality management system requirements 5.3 94 Introduction 5.3.1 94 Scope 5.3.2 95 Application 5.3.3 96 Terms and definitions 5.3.4 96 Quality management system 5.4 96 General requirements 5.4.1 97 Documentation requirement (management of information) 5.4.2 VIII 98 General 5.4.2.1 98 Quality objectives 5.4.2.2 99 Quality manual 5.4.2.3 99 Documentation standards 5.4.2.4 100 Control of documents and records 5.4.2.5 101 Management responsibility 5.5 101 Management commitment 5.5.1 102 Patient focus (patient responsibilities) 5.5.2 102 Patient rights and organizational ethics 5.5.2.1 103 Patient education 5.5.2.2 103 The “continuum of care” 5.5.2.3 104 Pre-entry phase 5.5.2.3.1 104 Entry phase 5.5.2.3.2 104 Within the organization 5.5.2.3.3 105 Exit-phase 5.5.2.3.4 105 Quality policy 4.5.3 105 Quality objectives 5.5.4 106 Responsibility, authority and communication 5.5.5 106 Responsibility and authority 5.5.5.1 106 Management representative 5.5.5.2 106 Internal communication 5.5.5.3 106 Management review 5.5.6 106 General 5.5.6.1 107 Review input 5.5.6.2 107 Review out put 5.5.6.3 107 Resource management 5.6 107 Provision of resources 5.6.1 108 Management of human resources 5.6.2 108 General 5.6.2.1 108 Competence, awareness and training 5.6.2.2 109 Staff right mechanism 5.6.2.3 109 Directing departments 5.6.2.4 110 Infrastructure 5.6.3 110 Leadership 5.6.4 111 Empowerment- encouraging effective employee participation 5.6.4.1 111 Work environment 5.6.5 111 Process management 5.7 111 Planning of process services 5.7.1 112 -Hospital planning standards 5.7.1.1 112 The planning evidence performance 5.7.1.2 113 Design of the process 5.7.1.3 113 Assessment of patient 5.7.2 114 Initial assessment of patient 5.7.2.1 IX 114 Pathology and clinical laboratory services 5.7.2.2 115 Reassessment 5.7.2.3 115 Care decision 5.7.2.4 115 Structures supporting the assessment of patients 5.7.2.5 116 Care of patients 5.7.3 117 Planning and providing care 5.7.3.1 117 Anesthesia care 5.7.3.2 118 Medication use 5.7.3.3 118 Nutrition care 5.7.3.4 119 Operative and invasive procedures 5.7.3.5 119 Rehabilitation care and service 5.7.3.6 120 Nursing 5.7.4 120 Management of the environment of care 5.7.5 121 Social environment 5.7.5.1 122 Surveillance, prevention and control of infection 5.7.6 123 Improving organizational performance 5.8 123 General 5.8.1 124 Monitoring and measurement 5.8.2 124 Patient satisfaction 5.8.2.1 124 Internal audit 5.8.2.2 125 Measurement 5.8.2.3 126 Assessment and analysis of data 5.8.3 127 Improvement 5.8.4 127 Continual Improvement 5.8.4.1 128 Corrective action 5.8.4.2 128 Prevention action 5.8.4.3 129 Chapter Six Conclusion and Recommendations 130 Conclusion 6.1 132 Recommendations 6.2 134 Recommendation for future researches 6.3 135 References 142 Appendices 143 Appendix A 152 Appendix B 154 Appendix C 160 Appendix D b Arabic Abstract X List of Tables Table No. Contents Page No. Table 3.1 Basic characteristics of sample hospitals 35 Table 3.2 Model variables of the study 38 Table 3.3 Explanation of model variables 39 Table 3.4 The four key delivery processes, their related principal performance requirements and key measures. 40 Table 3.5 Questionnaires valid replies percentage 46 Table 3.6 Descriptive statistics of the employee and manager population 46 Table 3.7 Descriptive statistics of the patient population 47 Table 4.1 One-way ANOVA test the study the effect of the variable of service on assessment of level of services offered by hospitals 52 Table 4.2 Means of different categories in tow hospitals according to level of services 52 Table 4.3 One-way ANOVA test the study the effect of academic qualification on assessment of level of services offered by hospitals 54 Table 4.4 Means of academic qualification groups. 54 Table 4.5 One way ANOVA test the study the effect of years of experience on assessment of level of services offered by hospitals 56 Table 4.6 Means of different years of experience 56 Table 4.7 T- test to study the effect of official's gender on the assessment of level of services offered by hospitals 58 Table 4.8 T- test for the assessment of the level of services offered by (Rafidia, Al-Watani). 59 Table 4.9 One-way ANOVA test for effect of the sector of hospitals on the assessment of the level of services 60 Table 4.10 Means of level of services of different sector 62 XI Table No. Contents Page No. Table 4.11 T- test for comparison of services level at Al- Watani and Rafidia hospitals 63 Table 4.12 ANOVA test for effect of individual hospital on the assessment of the level of services 64 Table 4.13 Means of levels of services of hospitals 65 Table 4.14 One-way ANOVA test for effect of academic qualification of patient on assessing of the level of services in hospital. 66 Table 4.15 Mean average of services according to academic qualification of the patient 66 Table 4.16 One-way ANOVA test for effect of sections of hospitals on the assessment of the level of services. 68 Table 4.17 Means of level of services of Hospital departments in all hospitals 70 Table 4.18 Delivery care processes in hospital services 71 Table 4.19 Mean of type hospital cross with delivery care processes. 73 Table 4.20 Patient satisfaction and type of hospital. 74 Table 4.21 Mean average type of delivery care processes cross with mean average of all hospital departments. 77 Table 4.22 Mean average all services in hospital departments cross with hospital type. 78 Table B.1 Descriptive statistics of hospitals in Palestine, 2002 152 Table B.2 Comparison between beds by health providers in 1999 and 2002. 152 Table B.3 MOH- hospital indicators, Palestine in comparison with 1999. 153 XII List of Figures Figure No. Contents Page No. Figure 5.1 Four critical aspects of internal environment of any health care organization and flow chart of the cycle for improving performance. 87 Figure 5.2 The quality cube- a model for assessing the quality of health care 91 Figure 5.3 Matrix the application of the hospital standards to specific individuals and departments 92-93 Figure A.1 Flow chart of patient rights and organizational ethics 143 Figure A.2 Flowchart of education function 144 Figure A.3 Flowchart of continuum of care function 145 Figure A.4 Flowchart of management of human resource 146 Figure A.5 Flowchart of board directors 147 Figure A.6 Flowchart of leadership function 148 Figure A.7 A process 149 Figure A.8 Flowchart assessment of the patient function 150 Figure A.9 Flowchart care of patient function 151 XIII List of Graphs Graph No. Contents Page No. Graph 4.1 Scheffe's means of different categories in public hospitals 53 Graph 4.2 Mean of different categories in public hospitals 53 Graph 4.3 Scheffe's means of academic qualification groups 55 Graph 4.4 Mean of academic qualification among studied groups 55 Graph 4.5 Mean of different categories of years of experience of professionals on assessment level of services offered 57 Graph 4.6 Scheffe's of different categories of years of experience of professionals. 57 Graph 4.7 Mean average level of service of Rafidia hospital and Al-Watani hospital 59 Graph 4.8 Mean for average scores of delivery care processes for the different sectors of hospitals 61 Graph 4.9 Mean of patient satisfaction from different sectors 61 Graph 4.10 Compare mean level of services between Rafidia hospital and Al- Watani 63 Graph 4.11 Mean total delivery care processes a according to patient academic qualification 67 Graph 4.12 Mean patient satisfaction according to patient academic qualification. 67 Graph 4.13 Mean delivery care processes in different departments of hospitals 69 Graph 4.14 Mean of patient satisfaction according to level of services of departments in all hospitals. 69 Graph 4.15 Scheffe's for different of delivery care processes in Nablus hospitals. 72 Graph 4.16 Mean of cross with level of delivery care processes 73 Graph 4.17 Mean of patient satisfaction according to the type of hospitals in Nablus. 74 Graph 4.18 Scheffe's for patient satisfaction according to the type of hospitals in Nablus. 75 Graph 4.19 Average of all hospital departments services in Nablus hospitals 79 Graph 4.20 Average of total delivery care processes for governmental hospitals in Nablus. 79 Graph 4.21 Average of total delivery care processes for private hospitals in Nablus. 80 Graph 4.22 Average of total delivery care processes or charity hospitals in Nablus 80 XIV List of Appreciations AIDS Acquired Immunodeficiency Syndrome GDP Gross Domestic Production GNP Gross National Product GP General Practitioner GS Gaza Strips HACCP Hazard Analysis Critical Control Point HMSP Health Management Strengths Project HRD Human Resources Development HRH Human Resource of Health ICU Intensive Care Unit MIS Management Information System MOH Ministry of Health MOPIC Ministry of Planning and International Cooperation NGOs Non Governmental Organizations NHP National Health Plan PHC Primary Health Care PNA Palestinian National Authority Pop. Population QA Quality Assurance QIP Quality Improvement Project QIT Quality Improvement Team SPQUC Strategic Plan for Health Care SPSS Statistical Package for Social Science TQM Total Quality Management UNICEF United Nations International Children’s Emergency UNRWA United Nations for Relief and Work Agency WB West Bank WHO World Health Organization XV Assessment of Perceived Health Care Service Quality at Palestinian Hospitals: A Model for Good Hospital Management Practice (GHMP) By Majd Abd Al-Rhman Fareed Al-Adham Supervisor Dr. Amjad Al-Ghamen Abstract Over the last 20 years, the increasing complexity and technical intensiveness of healthcare in Palestine hospitals have increased the level of uncertainty in the process of care. The variables within the health care environment (demand, cost, system deregulation) are undergoing rapid changes. This study is the first of its kind to investigate beyond quality management approaches, the most important issue in health care management, and the need to implement new organizational model in response to the dynamic changes that are transforming the health care process in Palestine. The study was conducted during January-June 2004 and involved all hospitals working within the City of Nablus. The primary aim of this study was to investigate the possibility of applying quality management approaches into the health care system through the identification of the level of offered services in Nablus hospitals (Public, private and charity) and to search for possible factors affecting level of offered services. The study also aimed at finding out to what extent these hospitals implements the criteria and the standards of quality management system. XVI To achieve our goals, two structured questionnaires especially designed for this purpose were used targeting both staff and patients. Collected data was analyzed using SPSS. Several hypotheses were formulated and tested based upon TQM principles. The results of the current study showed significant differences in the assessment of both staff members and patients and the level of offered services in the various departments within the same hospital and between different hospital sectors. Based upon the criteria level (Likert Scale) set for all hypothesis (3.5 out of 5 points, for good evaluation) most departments showed levels less than 3.5 indicating areas of weakness in most working departments with the exception of working departments in the private sector. A direct relation ship between over all hospital delivery care processes and patient satisfaction, where patient satisfaction is directly related to the attitudes and perception of employee as they, in turn related to the hospital and its management practices was found. The results also showed that total quality management criteria are not considered as hospital priorities. With the exception of Rafidia hospitals none of the operating hospitals is applying any of the TQM principles. Departments applying such principles in Rafidia hospital (only 4) scored higher levels compared to Al-Watani hospital, thus indicating clear advantages in favor of TQM application. Furthermore, correlation analysis confirmed suggestions that further work is required for the establishment of a health care quality management model in hospitals. In conclusion, based upon the findings of the current study a proposed model for the improvement of the existing system was suggested. Chapter One Introduction 2 1.1 General Background Despite much attention and emphasis on primary care as first point of contact for patients, hospitals in most countries remain an important source of critical health care services, providing both basic and advanced care to the population. Hospitals are often the provider of last resort for the critically ill and poor. Yet hospitals also comprise the largest expenditure category of the health system of both industrial and developing countries. As result, although their critical role as an integral part of the health system is well recognized, hospitals are often the target of health sector reforms amid at efficiently, equity, and quality improvement and more systemic reforms in financing and the health care delivery system (Alexander, Preker and Harding, 2003). Over the last 20 years, the increasing complexity and technical intensiveness of health care in Palestine hospitals have increased the level of uncertainty in the process of care. We do not have a clear understanding of transformation that have occurred in the process over the last 20 years, but three general trends can be discerned; First, the process has become more intensive, because the length of stay has been reduced by at least 30% over the last 10 years. Second, the diversity of treatment has increased, due to proliferation of medical specialties, the growing awareness of social perspective of each patient, and the development of new technologies. Third, the combination of a variety of treatment and more intensive care has generated increased uncertainty; i.e. many unpredictable events can occur because the increased needs for coordination between units. Thus, intensity, diversity and uncertainty are three characteristics that define the complexity of the care process. When these characteristics 3 considered together, it is easier to understand the unique qualities of health care and the challenges they present for organization. In Palestine, the design of the organization has been neglected by policy- makers, hospital directors, physicians, and others for over 20 years. This explains why the nature and magnitude of the organizational changes now needed are still being debated. The process of care and its management have traditionally been viewed from the following three perspectives. • Physicians: who directly manage clinical operations, but are rarely involved in the different stages of the care process. They generally focus on one specific stage and rarely meet with members from other care units. Physicians often consider organizational issues as problems for nurses to deal with, and there is a tendency to overlook the real responsibilities of nurses in both clinical land organizational realms. • Nurses: in contrast to physicians, nurses provide care on a continuous basis and must deal with an organization’s problems every day. For these reasons, nurses are interested in implementing organizational changes, even though currently they have no power to do so. • Administrators: the third perspective is that of the hospital director. The term “administrative perspective” highlights the fact that, in Palestine, hospital direction is more about administration than about management. For example, hospital directors often are unable to evaluate and change physician practices or new technologies. This might be due to lack of specially assigned “medical managers” in Palestinian hospitals and most hospital directors are doctors, whom may not have the necessary skills, 4 knowledge and experience to deal with the matters pertaining to complex management situations. These observations might be behind the lack of organizational principles in our health care system. Such poor organization is expected to results in problems that might affect everyone in the health care process (e.g. residents, interns, specialized physicians of all sorts, physiotherapists, psychologists, specialized nurses, patients, patients’ families, and so on). However, figuring out how to develop better coordination is tremendously difficult when one considers the rapid changes occurring in health care and the absence of any established organizational frameworks. Process of care should be designed around the needs of patient. This can be improved only by incorporating process and out come measures into daily work. Such measures make it possible to understand the degree to which performance consist the best practices, and extend to which patient are being helped. Quality of health can be improved if the issue of inefficiency in the delivery of health care needed is tackled. Quality management” offers a solution that stands the highest chances of tackling the problem of inefficiency. Total quality management “TQM” has offered a strategy for improvement, with new tools and methods. TQM is an approach to improve the competitiveness, effectiveness and flexibility of whole organization. It's essentially a way of planning, organization and understanding each activity, and involving each individual at each level. It is away of ensuring customer satisfaction through involvement of all employees in learning how to reliably produce and deliver quality goods and services (Oakland, 2000). The application of TQM to health care setting can cover the whole range of health care delivery spectrum 5 including both health care delivery as well as the administrative superstructure (Massoud, 1993). At hospital field TQM concepts in the standards include the key role that leaders play in enabling the systematic assessment and improvement of performance. As most problems or opportunities for improvement derived from process weaknesses not individual incompetence; the need for careful coordination and collaboration among departments and professional groups is essential (JCAHO, 1994). 1.2 Hospital management in Palestine 1.2.1 Health sectors The Palestinian health care system is a mixture of public, non- governmental, UNRWA, and private (profit and not for profit) service delivery, with a developing governmental health insurance system (Palestine Ministry of Health, 2003). National inputs into health care in Palestine appear to be relatively high. Health outcome indicators for the Palestinian people are comparable to those of other nations with similar economic status. These nations appear to be investing less in health both in terms of per capita expenditures on health and in terms of percent of national product interested in health care delivery. In a study by World Bank (1997) they estimated the per capital health expenditure in West Bank and Gaza skip at 122 US$ in 1996 which means 8.6% of gross domestic product (GDP). For the purpose of comparison, expenditures on health care for neighboring countries (1997) were: Egypt spent 4.8% and Jordan 7.8% and Israel 8.4% (1999) of GDP, with an average annual expenditure of 1384 US$ per person (Palestine Ministry of Health, 2003). 6 The number of physician in primary and secondary care in the West Bank and Gaza is 2897 physicians (1.1 physicians per 1000 population) in 2002. Number of nursing staff was 2161 in 2002 with a ratio of 7.6 nurses per 10.000 populations, 1.7 nurses per physician and 0.69 nurses working in hospitals per bed. For the purpose of comparison, the physician to 1000 population for neighboring countries 1999 was: Jordan 1.54, Egypt 0.77, Syria 0.85, and Israel 2.9 (Palestine Ministry of Health, 2003). MOH expenditure as % of GDP was 3.2% about one third of all health care expenditure are directed toward ministry of health facilities (including capital expenditures), while private providers, non- government organization, and UNRWA making up the rest. In (2002), about 24.9% of all MOH health care expenditure in Palestine was on drugs, vaccines, and medical disposables, about 57.9% of MOH budget and nearly half of all expenditures in UNRWA and the non- governmental sector consisted of wages and salaries and other forms of employee remuneration. Finally, about 6.4% and 10.8% of total MOH health expenditures were on referral for special treatment and other operating coast respectively (Palestine Ministry of Health, 2003). In Palestine, there are 76 hospitals. The population ratio is 45,585 populations per hospital. The average bed capacity per hospital is 63.03 beds. The total number of beds in Palestine is 4792. In Gaza Strip (GS), there are 24 hospitals making 31.58%. In West Bank (WB) including Jerusalem, there are 52 hospitals making (68.42%). The population/bed ratio is 723 in the whole Palestine including Jerusalem. Hospital bed/ 1000 population is 1.3 in the comparison with the number of beds in Israel is 2.27 per 1000 population (Palestine Ministry of Health, 2003). 7 The occupancy rate 76.8% and the average coast of hospital bed is 56.8 US$, where the average coast of hospital day is 77.7 US$. The average inhabitant coast from hospital coast is 25.7 US$ (Palestine Ministry of Health, 2003). For More details see appendix B. Basic equipment and supplies are generally adequate and available. The deduction is to be made here is certainly not that “no further increase in inputs into health care are required”! Considerable investment will certainly be needed. It is rather that, the mainstay of improvement program should be a plan of action directed at better utilization of existing resources and future investments. This can lead to improvements irrespective of any future investment, or of its size. 1.2.2 Challenges facing health care in Palestine 1.2.2.1 Factors affecting quality of health care Several factors affecting the quality of health care. These can be categorized into three main groups: First, inputs into health care: investment in health care, human resources in the health care sectors, facilities, equipment and supplies. In Palestine, there does not appear to be problem for poor investment of inputs into health care. Quite the contrary, input are relatively high. If anything, national expenditures on health care, are in excess of what would be expected from an economy of such as that of Palestine. Deficiency in inputs cannot be the answer to the poor quality of health care in Palestine. Second, response allocation, improper allocation of health resources: into relatively coast- effective program or the contrary. This is difficult to assess with available data. However, given the relatively large number of community based practices and their staffing (particularly UNRWA and NGO services) together with the high 8 immunization coverage as an example, it dose not appear that the effective primary care measures are neglected. Any assessment of the health services in Palestine leaves no doubt that there is big room for more effective resource allocation. It appears unlikely that infective resource allocation is the major contributor to the poor quality of health care in Palestine. Third, the efficiency of the delivery of health care: the degree to which there exists, or does not exist, duplication of efforts, re-work, unnecessary work and spending, and other different forms of waste in the system. Efficiency is a measure of the inputs invested in a system to the outputs obtained from that system. It is clearly not possible to quantify this on a national scale. However, the issue of efficiency may be approached in a conceptual sense. In the health care sector in Palestine, the investment in inputs is higher than what would be expected for the obtained outcomes. Further more, given the high percentage of GDP spent on health care, increased inputs premises, redistribution of resources, can not possibly be suggested as a solution for improving health care quality. In other words, there appears to be an over-investment leading to outcomes that are normally, achievable with less investment. The real problem seems to be a poor inefficient system of health care delivery. 12.2.2 Factors contributing to poor efficiency Many factors in the health care system contribute to poor quality. At the top of the list among these factors are the mechanisms of financing and the management of the system. 9 Many management factors are affecting the quality of health care in Palestine. At the top of the list of these factors are leadership and organizational culture. 1.2.3 Consideration should be given to change Consideration should be given to change in the external environment that can indirectly influence the implementation of quality improvement such as: Economic; Technological; Socio-cultural; Political- legal; and the international variables. The direct action elements of the external environment: competitors; customers; labor; and financial institution. 1.2.4 Is it management problem? A fragment structure and uneven distribution of services and human resources between the various providers characterizes the Palestine health care system. These characteristics are causing low quality and high coast health care, generating in equities in access to health care, causing conflicts among providers and the patients, occasioning a disparity of care, and promoting moral and ethical dilemmas. There is general discontent among the professional and public in Palestine, regarding the quality of health care. The “quality defect” in the health care system in Palestine seems to revolve around an inefficient system of delivery of health care. This poses two interesting questions; are the limited resources in Palestine are the only cause of poor quality of health care in Palestine? And how much more investment in resources is needed to improve the quality of care? Better quality of health care does not necessarily imply higher health care costs nor does it imply quality irrespective of the cost. The quality of 10 health care in Palestine can be improved with the available resources. There is a need to increase the efficiency of the health care system, and to reduce waste in resources. Cost saving can be obtained from reducing unnecessary care, preventing complications, and eliminating activities that do not add any value to the processes or the outputs of the system. 1.2.5 Does total quality management address the basic problem of health care organizations today? The basic problems in health care organizational today are the great demand for more advanced health care by the patients, the existing inefficiencies in the health care delivery systems, and the escalating costs of the health care services. As a managerial tool, total quality management offers a new approach, with new tools and methods, that could be put into use in order to solve the existing problems. The same, to lesser or greater extent, depending on the problem, issues apply not only in the USA and other industrialized countries, but also to the developing world. There is much discrepancy between the demand for high quality health care services and the actual ability to cover the coast requirements of these services. In health care, quality is measured against the optimal level of medical care given available resources such as medical knowledge and technology. The above definition mentions two important elements: optimal care and available resources. Optimal care simply means that the hospital is doing it's very best to serve their clients up to limit of their physical and non- physical asset. It implies that more quality can be attained by simply using the more quality can be attained by simply using the available resources to it optimum without necessarily increasing its assets. This definition invalidates the simplification that quality is somehow related to level of resources at the hospital’s disposal. That public hospitals, smaller 11 hospitals, and rural hospitals are rendering quality service provided they optimally use whatever resources are available to them. Private hospitals, larger hospitals, and urban hospitals are not necessarily rendering more quality service if they are not using their state of the art facilities to the optimum. TQM” is an approach to improve the competitiveness, effectiveness and flexibility of whole organization; it's essentially a way of planning, organization and understanding each activity, and involving each individual at each level (Juran, and Gryna, 1997). The application of "TQM" to health care setting can cover the whole range of health care delivery spectrum. This can apply to primary, secondary, and tertiary health care delivery institutions. At Hospital fields applying "TQM" completes the transition of hospital standards from those that focus on capability to those that focus on actual performance of clinical and organizational functions and processes that most significantly impact patient care. 1.2.6 Previous work in improving health care in Palestine The first national effort to improve health care quality in Palestine goes back to the central unit for quality of health care at the Palestine council of health care in 1994. At that stage, the primary focus was on understanding the concept of poor quality of care and its impact on the well being of the population. In addition, a great deal of ground work was carried out, primarily by local Palestinian professionals. To sensitize top policy makers and carried out, primarily by local by Palestinian professionals, to sensitize top policy makers and key professionals to the “need and opportunity for health care quality improvement and the 12 development of a national strategy for health care quality improvement (which was outlined in the “strategic plan for quality of health care in Palestine, December 1994 SPQHC”) the SPQHC was enriched and dressed at six national workshops in which over 150 policy makers and key professionals participated, and through reviews conducted by several world authorities on health care quality improvement. On the basis of the SPQHC, the MOH decided in 1996 to launch a three- year institutional capacity building quality improvement project (QIP) in cooperation with the World Bank. Currently, an extension is being considered to achieve the evolving national priorities at the intervention level covering primary, secondary and tertiary health care (Palestine Ministry of Health, 1999). The QIP in the MOH has defined its overall a goal as “Attaining the highest possible level of quality of healthcare in Palestine”. Achieving this goal encompasses two distinct parts: part one is the health system reforms aimed at reforming the Palestinian health system in ways that stimulate and facilitate quality improvement. Part two is the quality of health care program, which relates to the required activities necessary to improve the efficiency of the provider organizations. The initial phase of the QIP concentrated on project setup, training of the MOH/QIP core staff members on the principles and methods of total quality management applied to health care, enhancement of team skills, and development of the mission, vision and understanding of SPQHC. Three development models for the first set of improvement projects were selected at (Shifa and Naser pediatric hospitals in Gaza and Rafidia surgical hospital in the West Bank). Examples included workshops on “sensitization for quality”, with a training curriculum in Arabic, and the formation eight 13 quality improvement project teams. In April 1997, a second cycle of improvement projects was initiated. This witnesses an expansion of activities into 10 sites with 39 improvement projects, involving the training of some 170 professionals over five courses of 6 days each. This large increase in improvement projects necessitated the introduction of a special system in which improvement projects became programmed activities, and a special implementation manual was developed for that purpose. Such approach has been crucial to enable a handful of professionals to meet the challenge of implementing a large number of projects. It also served to create a new generation of quality improvement champions. In January 1998, new aims for improvement were identified at the level of the MOH directorates, including primary and secondary care. Examples include a number of quality improvement activities for new hospitals in Gaza (Nasser in Khan Younis) and new primary and secondary demonstration models (Salfeet, Tulkarm and Ramallah PHC and Hebron Hospital) in the West Bank (Palestine Ministry of Health, 1999). 1.3 Statement of the problem Hospitals should view as an entity responsible for overseeing, and integrating its important activities and functions, and not simply as a collection of independent units. There is probably no organization more departmentalized and organized around functional units than a hospital. Hospitals, being recognized for their exceptional clinical performance show great lack of commitment to quality. Hospital services have many faults in the first stages due to process weakness not individual incompetence. The majority of the Palestinian hospitals do not have standardized operational system that defines all types of processes, whether 14 administrative or technical and the staff just relies on their knowledge in the profession. As result, the hospital lacks performance measures and measurement system which badly reflected on the quality service. The most important issue in hospital management is the need to implement new organizational methods in response to dynamic changes that are transforming the care process. Uncertainty, complexity and speed can all be manage by standardizing operating procedures, by using quality management system such as the proposed system presented in this study. 1.4 Significance of the study This study aims at designing a health care services and its related delivery process using quality management improvement model that includes all necessary procedures for an acceptable performance of clinical and organizational functions. The model of hospital quality management system designed to achieve strategic objectives including lowering costs, improving productivity, differentiating services, and innovating organizational processes. The proposed model is expected to improve internal administrative and technical operation by providing a documented system of medical and management procedures with an overall purpose to minimize medical errors. The design emphasizes on prevention of problems, patient satisfaction and continuous improvement in organization’s processes. Hospital management system approach would enable each hospital to position it self in the extent of drastic changes taking place in health care system and turbulent environment, where the prevailing variables (health care demand, spending, and deregulation) are undergoing constant change. 15 1.5 Purpose of the study This study aim to achieve the following purposes: 1. To evaluate differences in provided hospital services in Nablus district. 2. To evaluate commitment to the excellence of patient care. 3. To search for areas of weakness in hospital services which is behind the existing operational problems? 4. To design a key delivery process and their related principal performance requirements and key measures. To prepare an improvement plan that might provide the basis for improving hospital operation and competitiveness based on a planned framework and health care management system 1.6 Hypothesis of the study The study tested the following hypothesis and all hypotheses were tested at (α = 0.05): 1. There is no significant correlation, between TQM and the following variables in the hospitals of Nablus: (customer focus; total involvement to hospital; counter measurement methods; systematic support; continuous improvement, safety measurements). 2. There is no significant correlation, TQM and the following variables in Al-Watani and Rafidia Hospitals: (customer focuses; total involvement to hospital; counter measurement methods; systematic support; continuous improvement, safety measurements). 16 3. There is no significant correlation, management system, and the following variables in the hospitals of Nablus:(training and development; perception for quality; employee satisfaction; leadership; belonging to hospital; safety measurements; equipment maintenance; facilities, equipments and communications). 4. There are no statistically significant differences, in the assessment of the officials, to the services offered by Al- Watani and Rafidia hospitals due to the type's of offered service. 5. There are no statistically significant differences, in the assessment of the officials, to the level of services offered in the hospitals in Nablus, due to educational level. 6. There are no statistically significant differences, in the assessment of the officials, to the level of services offered by hospitals in Nablus, due to experience variable. 7. There are no statistically significant differences, in the assessment of the officials, to the level of services offered by hospitals in Nablus, due to gender. 8. There are no statistically significant differences, in the assessment of the officials, to the level of services offered by Rafidia and Al- Watani hospitals. 9. There are no statistically significant differences, in the assessment of patient, the level of services, offered by hospitals, due to sector variable (governmental, private, or charitable). 10. There are no statistically significant differences, in the assessment of patient, the level of all services, offered by Al-Watani and Rafidia hospitals. 17 11. There are no statistically significant differences, in the assessment of patient, the level of services, offered by hospitals in Nablus. 12. There are no statistically significant differences, in the assessment of patients, the level of offered services, due to sector variable of the academic qualification of the patient. 13. There are no statistically significant differences, in the assessment of patients, the level of delivery care processes, offered by different departments of hospitals in Nablus. 14. There is no significant relationship, between patients overall satisfaction and their assessment of the level of services offered in the hospitals of Nablus. 1.7 Limitation of the study The following were the major limitations of the current study: 1- Lack of resources in the field of Hospital management. 2- Lack of co-operation and concern by some of the administrators. 3- Prevailing political situation in the area which greatly limited movements. Chapter Tow Literature Review 19 2.1 Introduction During the late 1970s and early 1980s the United States received a rude awakening on the importance of quality and this was mainly due to foreign competition, particularly from the Japanese, which resulted in the loss of significant market share for many American companies. For example, in 1980, Detroit's share of the U.S. auto market was 71.3 percent; by 1991 it declined to 62.5 percent. Japan now supplies over one-third of the world's demand. The percentage of U.S. made computers purchased in the United States dropped from 94 percent in 1979 to 66 percent in 1989. Machine tool, electronics, steel, and other industries faced similar fates. In 1987, the Malcolm Baldrige National Quality Award was signed into legislation, spawning a remarkable interest in quality among American business. Perhaps more than any other event, the Baldrige has helped American business take action to accomplish a transformation in management. During the 1990s and far beyond, quality remained the priority for business. The ability to achieve world class status in manufacturing and service depends on a business strategy driven by total quality management (TQM). The followings introduce and address the issue of quality through a brief history, evaluate various definitions and perspectives of the concept in manufacturing and service, and discuss the importance of quality from an economic and competitive view point. 2.2 A brief history Had the Industrial Revolution not occurred, quality would probably be a moot issue. During the middle ages, skilled crafts people served both 20 as manufacturers and inspectors, building quality into their products with considerable pride of workmanship. Craft guilds emerged to ensure that crafts people were adequately trained. The Industrial Revolution led to quality being viewed as an inspection-based activity. Thomas Jefferson brought Honore Le Blanc's concept of interchangeable parts to America. When Eli Whitney was awarded a government contract in 1798 to supply 10,000 muskets in two years, he designed special machine tools and trained unskilled workers to make parts according to a standard design that was measured and compared to a model. Unfortunately, Whitney grossly underestimated the effect of variation in the production process and its impact on quality. It took more than 10 years to complete the project, perhaps the first example of cost-overrun in government contracts. Worker responsibility for quality was influenced greatly by Frederick W. Taylor's concept of "scientific management." By focusing on production efficiency and decomposing jobs into small work tasks, inspection was relegated to an independent "quality control" department in manufacturing organizations. The separation of good from bad product became the chief means of ensuring quality. 2.2.1 Modern developments in quality Modern approaches to quality control had their origins at Western Electric when the inspection department was transferred to Bell Telephone Laboratories in the 1920s. The early pioneers of modern quality assurance like Walter Shewhart, Harold Dodge, George Edwards, and others developed new theories and methods of inspection to improve and maintain quality. Control charts, sampling techniques, and economic analysis tools laid the foundation for modern quality assurance activity and influenced the 21 thinking of two men, W. Edwards Deming and Joseph M. Juran (Evans, 2004). Deming and Juran introduced statistical quality control and various management philosophies to Japanese managers after World War II as part of General MacArthur's rebuilding program. Over the next 20 years, while the Japanese were improving quality at an unprecedented rate, quality levels in the West remained stagnant. By the late 1970s, Japanese companies had gained a significant competitive advantage in world markets, primarily due to higher levels of quality. With a competitive crisis unfolding, coupled with increasing levels of consumer quality awareness, the technological complexity of modern electronics, and a growing recognition of outdated managerial practices, the 1980s became the decade in which America woke up to quality. Most major companies embarked on extensive quality improvement campaigns. In 1984, the U.S. government designated October as National Quality Month. In 1987, the Malcolm Baldrige National Quality Award was established by an act of Congress. (Malcolm Baldrige was a former Secretary of Commerce who died shortly before the legislation was approved. The award was named in his honor). By the end of the decade, Florida Power and Light became the first overseas company to win Japan's coveted Deming Prize for quality. 2.2.2 A race without a finish line Despite all the publicity, a recent study by the American Quality Foundation and Ernst & Young (1991) showed some sobering results. Among the findings was that while 55 percent of U.S. firms use quality information to evaluate business performance monthly or more frequently, 70 percent of Japanese firms do. Eighteen percent of U.S. businesses look 22 at the business consequences of quality performance less than once each year; the comparable figure in Japan is 2 percent, and in Germany, 9 percent. Even though considerable attention is paid to quality in the United States, we may not be closing the gap with foreign competitors. Business schools are only just beginning to incorporate quality principles into their curriculum; in Japan, elementary schools teach statistical process control. While the next generation of managers may be adequately trained in quality principles, we cannot afford to wait. As one Xerox executive noted, quality is a race without a finish line. 2.3 Meaning of quality Quality has been an elusive concept in business. Many people think of quality as some level of superiority or innate excellence; others view it as a lack of manufacturing defects. The official definition of quality, standardized by the American National Standards Institute (ANSI) and the American Society for Quality Control (ASQC) in 1978, is "the totality of features and characteristics of a product or service that bears on its ability to satisfy given needs." This definition implies that we must be able to identify the features and characteristics of products and services that determine customer satisfaction and form the basis for measurement and control. The "ability to satisfy given needs" reflects the value of the product or service to the customer, including the economic value, safety, reliability, and maintainability. Well known definitions include: "conformance to requirements" (Crosby); "the efficient production of the quality that the market expects" (Deming); "fitness for use, product performance and freedom from deficiencies" (Juran); "the total composite product and service characteristics of marketing, engineering, 23 manufacturing, and maintenance through which the product and service in use will meet the expectations of the customer " (Felgenbaum); "anything that can be improved" (Imal); "meeting or exceeding customer expectations at a cost that represents value to them" (Harrington); "does not impart loss to society" (Taguchi); and "degree of excellence" (Webster's Third New International Dictionary) (Schlenker, 1988). 2.4 Total quality management "TQM" Our standing for “total quality management” developed the 1980s, a broad perspective was given, and linking the TQM approaches to the direction, policies and strategies of the business or organization. The TQM philosophy of management is customer-oriented. All members of a total quality management (control) organization strive to systematically manage the improvement of the organization through the ongoing participation of all employees in problem solving efforts across functional and hierarchical boundaries. TQM is a technique which will also improve the competitiveness, effectiveness and flexibility of an organization. A fundamental requirement is sound quality policy, supported by effective quality plans and resources for implementation (Schlenker, 1988). TQM incorporates the concepts of product quality, process control, quality assurance, and quality improvement. Consequently, it is the control of all transformation processes of an organization to better satisfy customer needs in the most economical way. Total quality management is based on internal or self- control, which is embedded in each unit of the work system (technology and people). Pushing problem solving and decision-making down in the organization allows people who do the work to both measure and take 24 corrective action in order to deliver a product or service that meets the needs of their customer (Schlenker, 1988). 2.5 Quality management system An appropriate quality management system will enable the objectives set out in the quality policy to be accomplished. British Standards (BS 5750) were also introduced, developing into the international standard, ISO 9000. The international organization for standardization (ISO) 9000:2000 series set out methods by which a system can be implemented to ensure that the specified customer requirements are met (ISO 9000:2000). A quality system may be defined as an assembly of components such as the management responsibilities, process, and resources. A documented Quality Management System, such as ISO 9001, is a real support for TQM as it helps to clearly document an organization's quality objectives, processes and procedures and allows any quality improvements to be enshrined into new clearly defined practices. Having set an organization's strategic quality direction, performance measures are required to monitor and control progress towards the various quality goals. In recent years, TQM has developed into more advanced techniques, aimed at helping organizations achieve overall business excellence. Six Sigma and Business Process Re-engineering (BPR) are examples of these programmers. 2.6 Quality improvement vs. quality assurance It is important to avoid equating quality improvement with quality assurance. Quality assurance is a system of activities designed to ensure production that meets pre-established requirements. It gives the customer a 25 guarantee of quality by measuring product conformance with process and performance specifications. Quality improvement refers to all efforts directed to increase effectiveness and efficiency in meeting accepted customer expectations. It is a continuous process to achieve a better understanding of the market; to innovate products and processes; to manage and distribute material and products; and to provide service to customers. The success of quality improvement is based on the understanding of every member of the organization concerning the needs of their customers. Maintenance of that understanding requires continuing dialogue and negotiation with the customer and measurement of one's products and services against the customer expectations (Schlenker, 1988). 2.7 Key quality improvement concepts 2.7.1 Processes and Systems In 1986, Deming (Deaming, 1986) describes organizations as composites of systems designed to meet customer needs. Common systems in organizations are human resources processes such as compensation or financial ones like accounting. In such systems, processes and tasks are linked together and affect one another. For example, status changes for employees will require interdependent tasks on the part of employees in payroll, compensation, benefits, training and the relevant supervisor. The basic assumptions of the Total Quality Control approach include: the practice of defining the steps and outcomes (Products and Services) in their processes and systems by employee's results in a common language, and understanding of what their jobs should be and how they fit into a larger picture. With the application of the scientific approach using flow charts, work-flow diagrams, deployment charts, brainstorming, pareto charts, process mapping and cause and effect diagrams people can see their 26 interdependence and that the quality of what comes out is in measure determined by the quality that goes into a process. 2.7.2 Customers and suppliers Customers and suppliers are both inside (internal) and outside (external) the organization. People in and out side organizations that provide input to the steps in a process are "suppliers" and those who use products or service are "customers". Thus, employees in one phase of a work process are customers of the employees who produced the goods or services used by them in their work processes. Sales employees are customers of the marketing research employees. The marketing research employees are customers of statisticians and computer information systems employees who are assisting them and maintaining computing capacity for use in analyzing data. Employees within the organization receive work passed through the system, the "internal" suppliers. 2.7.3 Quality The quality that comes out of a process is affected by the quality of what goes in and what happens at every step along the way. It follows that we must build quality into every step, process, and system to produce quality in the outcome. To do this, we must collaborate with internal and external suppliers and communicate with internal and external customers to determine their needs. Attainment of quality in products and services at competitive prices requires an emphasis on doing the right things (products and services that reflect target features based on the needs of intended customers) and doing the right things right (using efficient processes). 27 2.7.4 Benchmarking Benchmarking is the comparison of the processes and systems of a given business function across companies. It can be applied to any area of an organization. It is a way for managers and employees to compare their functional performance to that of others, particularly those excellent and identifying why they may differ. Benchmarking can be defined as: analyzing how to best achieve the performance, and using information as the basis for evaluation of targets, strategies, and applications. 2.7.5 Teams and teamwork When TQM is successful employees at every level participate in decisions affecting their work. The most common vehicle for employee participation is a team. Teams range in scope and responsibility from problem-solving groups to self-managed work teams that schedule work, assign jobs, hire members, and set the standards and volume of output. A participative work culture is encouraged when quality becomes everybody's responsibility. 2.8 Quality award models Regardless of variation in quality definitions and implications, international efforts were made to establish common models for quality management that would assure minimum performance requirements by organizations to give customers sufficient confidence that a product or service is actually complying with requirements mandated by competition and market dynamic (Oakland, 2000; Al-Ghanim, 2003). International quality model ISO 9000 series, established by the international organization for standardization has gained a wide spaced reputation for 28 improving quality levels and business performance. Besides, national quality models have been established in the form of quality prizes such as the Baklom Baldrige national quality award in the USA, the Deming prize in Japan, the European quality award in the European Union, King Abdullah if quality award in Jordan, and others (Al- Ghanim, 2003). 2.8.1 The four and three Cs of TQM- a new model for TQM This new TQM model, based on all the excellent work done during the last century, provides a simple framework for excellent performance, covering all angles and aspects of an organization and its operation. Performance is achieved, using a business excellence approach, and by planning the involvement of people in the improvement of processes, which include (Oakland, 2000): - Planning – the development and deployment of policies and strategies; setting up appropriate partnerships and resources; and designing in quality. - Performance - establishing a performance measure framework- a ‘balanced scorecard’ for the organization; carrying out self- assessment, audits, reviews and benchmarking. - Processes – understanding, management, design and redesign; quality management systems; continuous improvement. - People- meaning the human resources; culture change; teamwork; communications; innovation and learning. 2.9 Previous studies 2.9.1 Palestinian studies In 1997, Barghouthi and Lennock published a report entitled “ Health in Palestine: potential and challenges”, were they examine the health 29 situation in the West Bank and Gaza strip in the light of recent developments that have taken place following the Oslo agreement [9]. Another publication “Palestinian health: Towards a healthy development strategy in West Bank and Gaza strip” (Barhouthi, 1992) discusses priorities for future development and planning of the Palestinian health care system [10]. Furthermore, a study describing plans for health research, finance, legislation, insurance and other institutional aspects as well the current status of primary health care in Palestine and out-line plans for the various sectors was published by the PMH entitled “National Strategic Health Plan” (Palestinian Ministry of Health, 1999). Another report was published by the World Bank entitled “West Bank and Gaza medium term development strategy and public financing priorities for health sector”, recommends short and long strategies. The report recommended short and long strategies “to insure the financial sustainability of health sector while improving access to health care its efficiency and quality” (World Bank, 1997). In a further study “Palestinian health strategy: challenges ahead”, Abdeen approached a long- term national health policy (Abdeen, 1997). WHO collaborating center in health manpower development in the West Bank” conducted a study that discussed staffing of the government health sector and proposed a strategy for its development (The World Bank, 1993). A review of health standards and services in the West Bank and Gaza Strip was carried out by Berizeit University Community Health Unit. The review tackled information concerning health status indicators and selected determinants of health (Birzeit University Community Health Unit, 1987). In Gaza Strip “Health Management Information System (HMIS): strategic plan”, presented potential challenges facing HMIS during implementation stages (Palestinian Ministry of Health, 1995). 30 Palestine Council of Health and Quality of Health Care Unit compared the situation in the area with that of similar economic status “The strategic plan for quality health care in Palestine". The report showed that Palestine invests more resources on health. The report summarized the accomplished so far on the national program in quality of health care (NPQHC) (Palestine Council of Health, 1994). An assessment named “Health Management Training Needs” was conducted by Health Services Management Unit at Birzeit University, handled the needs for training on health management in hospitals (Palestinian Ministry of Health, 1996). Massoud, analyzed health outcome indicators in Palestine compared to other nations with similar economic status. The study proposes a solution in two pronged approach to improving quality (Massoud, 1995). Another study conducted by Massoud, reviewed TQM principles, methods of TQM and its possible application in health care system in Palestine (Massoud, 1993). In Palestine, only two studies were conducted addressing ISO 9000 and TQM implementations (Hraish, 2000; Abdellatif, 2002). Harish study was a descriptive survey of organizations that implemented the ISO 9000 system. The survey provided a demographic description of companies and summarizing manager’s opinions on problems facing the implementation and achieved benefits. On the other hand, Abdellatif study was the first analytical study that assessed the extent of implementing TQM principles and tools in nongovernmental organizations in West Bank including banks, hospitals, insurance companies, and telecommunications. The study showed that gaps present to a substantial extent in the implementation of TQM principles. To overcome implementation difficulties, the study 31 presented a management model for implementing TQM principles and tools that would lead to the establishment of a new work culture where human resources should be the focus for development. 2.9.2 International studies Several studies attempted to discover the possible links between strategic behavior and performance in hospital management. In 1992 the American Hospital Association (AHA) showed that 44% of surveyed hospitals used TQM to improve quality and cut costs (Burda, 1991). The quality measure will be a composite of service, length of stay (LOS), and efficiency (Cleverley and Harvey, 1992b). They also tried to differentiate between successful and unsuccessful strategies, according to profitability indicator (Cleverley and Harvey, 1992a). In a similar way using different strategic typology, Eastaugh (1992) claims that a hospital applying a defensive strategy- based on productivity improvement and specializing in a limited number of products-, have seen profits fall in recent years. Ginn et al., (1995) used a somewhat similar line of reasoning when testing various hypotheses to explore the link between the business strategies and financial structure in hospitals. Meanwhile, using the industrial economic structure, behavior performance paradigm, Gilliard (1999) analyzed strategic groups; he explored links between conditions in the sector, strategies adopted by hospitals and the results obtained. Within this framework, Lament and Marlin (1993) investigate the relationship between porter’s generic strategies (taking the lead in costs or differentiation), environmental conditions and results. Likewise, Cody et al., (1995) assessed the impact of different functional business strategies on results, which they measure 32 using the ‘economic margin’ variable. Their conclusions point to the importance of environmental change, occupancy management, length of stay analysis and minimizing the need for hospital admissions. Finally, studies by Lang land –Organ et al. (1996) and Gapenski et al., (1993) analyzed the determinants of hospital profitability; showing that it is more closely related to the strategies, practices and policies of hospital administrators than to market factors. In studies of strategic management in hospitals, it is difficult to use financial indicators to measure performance, especially when hospitals in the public sector are under consideration. It is therefore worth exerting effort to use operational performance indicators (Venkatraman and Ramanujan, 1986; Kaplan and Norton, 1992). The output measures normally used to measure clinical activity in the health services are those that focus on intermediate processes. Such measures can be the length of stay, clinical procedures, number of visits, diagnostic checks, rehabilitation physiotherapy sessions, etc., which are easier to define. 2.9.3 Regional Studies Several studies were conducted in various Arab countries that dealt with the impact of ISO 9000 and TQM implementation at various manufacturing and service sectors. Some of these studies addressed ISO 9000 implementation aspects at specific large firms, while others dealt with sectoral impact of ISO 9000 quality initiatives. For example, Ajluni (1999) conducted a study to determine behavior of financial performance in Jordanian public shareholding companies that were implementing ISO 9000 initiatives. He found a positive relationship between these two 33 dimensions. Tarawneh (2000) implemented a study for assessing the advantages of ISO 9000 at manufacturing firms in Jordan. He found a positive strong relationship between organizational aspects and the various clauses of the standards. Obaidat and Kurdi (1998) showed that quality levels at printing industrial firms in Jordan were still moderate, thus warranting the immediate attention to quality matters as a major business dimension. Hajj (1997) and Shajrawi (1996) conducted research studies at various Jordanian companies that implemented a form of ISO 9000. The research revealed that implementation of the quality system actually improved, with varying degrees, the performance of organizations in terms of lower production costs; higher employee morale; customer loyalty; revenues; and other related benefits. In the United Arab Emirates (UAE), Badri investigated the effect of quality management on firm performance using path analysis technique. He concluded that top management support is a primary force behind creating a supporting environment for successful implementation of quality practices (Ajluni, 1999). In Egypt, Farid examined the potential and impact of applying TQM principles to Egyptian garment and textile industries (Hajj Ali, 1998). In Saudi Arabia, Khalaf illustrated the effect of quality as a component of the excellence triode represented by quality, productivity and cost (Shajrawi, 1997). It is worth noting that none of the research conducted in the field of TQM and ISO 9000 in neighboring countries tried to like these to health care sectors. Chapter Three Methodology 35 3.1 Study area and sample The study was conducted during the period January- May, 2004. It was implemented in all working hospitals in the city of Nablus (two public, two private for profit and two charitable). This study is an investigation to basic and principle section opinions, portrays patients currently utilizing services, the employees and chief executive officer of hospital facilities or, when that was not possible, the clinical director or chief of administration. The patient questionnaire was conducted by face to face interviews. Therefore, questions needed to be exceptionally clear and easy to respond for this type of questionnaire to be successful. The researcher himself conducted the interview. For purpose of simplicity alphabetical numbers were used. Table 3.1 summarizes the basic characteristics of each hospital obtained from data that were collected. Table 3.1 Basic characteristics of sample hospitals. Hospital alphabetic al number Ownership Number of Employee Number of beds Average of LOS Occupan cy rate A Private 85 70 3 45 B Private 47 25 2 32.7 C Charity 142 61 2.5 47 D Charity 95 48 1.1 18.2 E Public 225 94 2.2 63.2 F Public 325 156 2.6 71.26 * A: Nablus specialty hospital; B: Al-Arabi specialty hospital; C: Al-Etihad hospital; D: St. Johns Hospital; E: Al-Watani hospital; F: Rafedia hospital 3.2 Ethical consideration A formal letter: from the dean of graduate studies at An-Najah University was sent to each center requesting the director, or chief 36 executive manager of the hospital as applicable, to allow the researcher to conduct the study. Explanatory form: every eligible manager of the hospitals was given a full explanation about research, including the purpose, nature of the study, importance of participation in addition to assurance of confidentiality of information and voluntary participation and was given total freedom to accept or reject participation in the research. 3.3 Framework of study methodology This study was based on a quantitative statistical assessment of the impact of implementing quality management model principles on organizational effectiveness. It should be noticed here the influence the quality management system was investigated with respect to its underlying quality principles whose impact on performance measures were assessed. Based on this approach, the following methodology was implemented: 1- Determine a set of quality principles that reflect the face contents and interpretations of the quality management system clauses (i.e., causes). 2- Determine asset of business performance indicators that are directly linked to the selected quality principles (e.g., effects). 3- Formulate statistical hypotheses that will respond to the questions raised in this study. 4- Collect data and validate field data and normalization. 5- Use statistical tools to analyze data and test hypothesis. 6- According to results of analysis, key delivery processes, their related principle performance requirements and key measures. 37 7- Formulate and generalize results and accordingly develop recommendations for improved implementation of total quality management standard. 8- Development of a modified management model to Palestinian hospitals to better implementation of total quality management standard. 3.4 Model and variables of the study According to the general framework, two sets of variables were defined of this purpose; independent or control variables, and dependent or response variables. The independent variables represented strategies, plans and actions taken by management that translated the implementation of basic quality principles and requirements of quality management system. Dependent variables were those reflecting the outcomes of implementing of quality principles and requirements the two sets are defined and explained in tables 3.2 and 3.3. It should be noted that, on the hand, the selection of independent variables was guided the archived literature (Alexander, Preker, Aprin and Harding, 2003; Cartin, 1993; Perigord, 1990; Kannan, Tan and Ghosh, 1999). The clauses of the system, for example, include management commitment to clear quality strategy, leadership and employee involvement, patient's satisfaction, and measurement and analysis. The characteristics of dependent variables, namely, quality, employee satisfaction, delivery processes and productivity represented key performance indicator to measure hospital goals and hoped outcomes of model of the hospital management implementation. 38 Table 3.2 Model variables. Independent variables: Quality management system Dependent variables: Hospital performance indicator I. Adopted strategy 1. Mission and quality objectives 2. Annual hospital planning I. Employee satisfaction 1. Job suitability 2. Fellow workers and superiors 3. Pay and promotion 4. Satisfaction with hospital growth. II. Patient satisfaction efforts 3. Patient focus and feed back 4. Responsiveness 5. Dependability(sustaining quality level II. Delivery processes and level of performance (productivity level). 5. Time utilization 6. Appropriate service utilization 7. Accuracy III. Continuous improvement 6. Planning for quality 7. Use of quality management tools. 8. Measurement and analysis 9. Reporting, communications and feed back. III. Quality level 8. Number of patients’ complaints. 9. Unplanned readmits and returns to emergency room or operation or any service (process non-conformities) 10. Volume of service rework. IV. Leadership development 10. Unified goals 11. Extensive education/ training at all levels. 12. Reward and recognition tied to performance. 13. Employee participation in problem solving. 39 Table 3.3 Explanation of model variables. Variable Explanations Quality management principles Such principles emphasize management of the entire hospital in such a way that it excels in all dimensions of its operations. It implies commitment to quality as a strategic dimension, patient focus and related efforts, leadership development and continuous improvement efforts (Alexander, Preker, Aprin and Harding, 2003). Quality starts at top management levels as a strategic dimension that is continuously reflected in a solid understanding of quality requirements and annual business plans. These quality principles call for the entire hospital to work in unity for the purpose of patient satisfaction in a dependable, responsive and sustainable manner. Continuous improvement mandates quality planning, use of measurements and analysis techniques. And established of proper reporting and communications tools (Cartin, 1993). Leadership development is critical to the evolution of a quality culture in the organization. This requires unified goals, employee training and participation, and reward and recognition (Alexander, Preker, Aprin and Harding, 2003). Employee satisfaction Defined as employees’ and managers’ satisfaction with fellow workers, jobs, superiors, their hospital compared with others, pay, progress in the hospital, and opportunities for advancement in the future (Alexander, Preker, Aprin and Harding, 2003). Productivity level Defined as assessment by employees and mangers of the efficiency of work done in the divisions or departments as well as the quality with which the work is done. Productivity is measured in terms of output production volume per unit time. Another indication for productivity used here is percent of time utilized of production resources including employee and equipment time (Perigord, 1990). Quality level Defined as assessment of the quality of work done in their hospitals according to the requirements set to meet patient needs and satisfaction; quality as conformance to specifications. Quality is measured in terms of volumes of service rework, scrap, process non- conformities, and number of patient complaints (Perigord, 1990). 40 Table 3.4 The four key delivery processes, their related principal performance requirements and key measures. Process of Admit Key requirements Key measures Admitting and registration Timeliness *Time to admit patients to the setting of care * Timeliness in admitting and registration rate on patient satisfaction survey questions Assess Patient assessment Timeliness * Percentage of histories and physicals charted within 24 h. prior to surgery *Pain assessed at appropriate intervals, per hospital policy Clinical laboratory and radiology services Accuracy and timeliness *Quality control results/repeat rates *Turnaround time *Response rate on medical staff satisfaction survey Care delivery/treatment Provision of clinical care Nurse responsiveness Pain management Successful clinical outcomes Pain management Successful clinical outcomes *Response rate on patient satisfaction and medical staff survey questions *wait time for pain medications *Percentage congestive heart failure patients received medication instructions and weighing *Percentage ischemic heart patients discharged on proven therapies *Unplanned readmits and returns to emergency room or operating room *Mortality Pharmacy/ medication use Accuracy *use of dangerous abbreviations in medication orders *Medication error rate or adverse drug events resulting from medication Surgical services/anesth esia Professional-skill, competence and communication *Clear documentation of informed surgical and anesthesia consent * Preoperative mortality *Surgical site infection rates Discharge Case management Appropriate utilization *Average length of stay *Payment denials *Unplanned readmits Discharge from setting of care Assistance , And clear directions *Discharge instructions documented and provided to patient *Response rate on patient satisfaction survey 41 3.5 Survey instrument The survey instrument adopted was tow questionnaires one for the patients whom utilizing the services and another for the employees and managers whom working at hospitals (see appendix D). The Patient's questionnaire has been developed by International Info-medics Corporation in cooperation with Consult Group Ltd. and Mohawk collage 1997. While, the employees and managers questionnaire was developed by researcher with respect to quality principles in literature. The questionnaires were written in Arabic language to be easily understood by providers. The two questionnaires designed on the basis of [Likert scale] which consisted a 5- point scale respondent were asked to rate their agreement to each statement on a scale of (1-5). In employee a manager questionnaire, the 5-point scale system respondent responses ranging from “strongly agree” (5), “agree” (4), “neither agree nor disagree” (3), “disagree” (2) and “strongly disagree” (1). The employee and managers questionnaire is divided into two main sections, where the first part provided a general demographic hospital description such as hospital category, number of hospital beds, number of employees, and other aspects. The second part was dedicated to capturing hospital ‘responses to the dependent and independent variables stated above through a form containing 48 related questions representing categories of variables: 1- Customer focus, illustrated in items [11, 37, 38, 39, 40, 41, 42] 2-Total involvement illustrated in items [9, 15, 16, 17, 19, 20, 22, 25, 26, 27, 30]. 42 3- Measurements techniques illustrated in items [1, 3, 5, 6, 7, 10, 23, 24, 25, 29, 32, 33, 34, 36, 41, 42, 43, 45, 48]. 4-Systematic supports illustrated in items [2, 3, 4, 5, 6, 7, 8, 9, 10, 16, 18, 21, 22, 25, 28, 33, 34, 35, 36, 44, 46, 47, 48]. 5- Continuous improvement illustrated in items [14, 13, 15, 31, 32, 33, 34, 38, 43, 44, 45]. 6- Management system illustrated in items [1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 18, 30, 29]. 7- Leadership illustrated in items [16, 17, 22, 23, 24, 28, 30]. 8- Perception for quality illustrated in items [10, 11, 13, 21, 25, 35, 36, 37, 38, 39, 40, 41, 42, 45]. 9- Training and developments illustrated in items [14, 15, 16, 31, 32, 33, 34, 43, 44, 45]. 10- Employee satisfaction illustrated in items [17, 18, 19, 20, 22, 26, 30]. 11- Incentives and empowerment illustrated in items [27, 28, 29]. 12- Facilities equipment and communication illustrated in items [21, 38, 43, 44, 45]. 13- Safety measurements illustrated in items [48]. In patient questionnaire, the 5-point scale system represented responses ranging from “very high” (5), “through high” (4), ‘moderate’ (3), ‘low’ (3), and finally ‘very low’ (1). 43 The patient questionnaire is divided into three main sections, where the first part provided a general demographic firm description. The second and the third parts were dedicated capturing hospitals’ responses to four key delivery processes area Table (3.4), through a form containing 38 related questions representing categories of variables:- 1- Patient satisfaction illustrated in items [32, 34, 35, 36, 36, 37, 38]. 2- Delivery processes were categorized into:- a- Admission and registration process illustrated in items [5, 6, 7]. b- Information and willingness of nurses to answers questions illustrated in items [13, 14]. c- Medical treatment from (nursing) illustrated in items [10, 11, 12, 15, 19]. d- Coordination and cooperation from medical staff illustrated in items [7, 21, 22]. e- Medication availability and accuracy using medication which are illustrated in items [16, 17, 18]. f- Services provide (cleaning and food) illustrated in items [25, 27]. j- Laboratory and radiology services illustrated in items [8]. h- Appearance and behavioral skills from all staff illustrated in items [8, 9, 19, 20, 30]. i- Facilities and equipments illustrated in items [28, 29]. g- Contact physician illustrated in items [23, 24]. 44 3.6 Pilot study Pilot testing was conducted before used for actual data collection, the two questionnaires was tested and validated to assure understanding and meanings of presented concepts, clarity of statements, and adequacy of the representation of the basic variable categories. Specifically, readability and comprehension were key concerns given that many often questionnaire respondents (patients) would have low levels of education. Such verification process was made through the advisor who had research background, three chief executive managers of hospitals include in this study and quality management expert from ministry of health. 3.7 Questionnaire reliability The reliability of the scale in this study was estimated using conbach’s alpha formula to determine mean interim correlation where a value of 0.7 or more represents a good criterion for scale reliability (Motwani, Kumar and Cheng, 1996). The questionnaires reliability was at α = 0.89. 3.8 Analysis tools Once questionnaires were completed, data were entered onto the SPSS advanced statistics package was utilized for descriptive and multivariate analysis. 3.8.1 Used statistical analysis The various statistical analysis tools used in this research were as follows: 1- Cronbach alpha test to examine the reliability of the data. 45 2- The t-test to examine the validity of the formulated hypothesis. 3- One way ANOVA to examine the validity of the formulated hypothesis. 4- Correlation coefficient procedure to determine the strength of the relationship among variables, in the hypothesis. 5- Multiple linear regressions to examine the significance of the correlation coefficients between quality principles and health care organizational effectiveness. 3.9 Data collection From the 500 employees and manager questionnaires that were distributed, 351 valid replies were returned, that is a reply rate of 70%, which is acceptable with this method of data collection. Of the 351 valid replies, 48.7% were from public hospitals, 22.8% from private hospitals, and 28.5% were from charity hospitals. In terms of size, 20% came form small, 20 to 50 bed facilities, 52.8% from intermediate size, 50-100 bed hospitals, and 27.4% came from large hospitals with over 100 beds. From 351 employee and manager questionnaires, 125 valid replies came from manager of response rate 35.6% and 226 valid replies from general employees of response rate 64.4%. From 150 patient’s questionnaires that were distributed, 108 valid replies were returned, that is a reply rate 72%. Of the 108 valid replies, 54.6% from public hospitals, 22.2 from private for profit hospitals and 23.1% from charity hospitals. 46 Table 3.5 Questionnaires valid replies percentage. Questionnaire groups Public hospitals Private non profit Private for profit Managers and employees N0. (%) N0. (%) N0. (%) 171(48.7) 100 (28.5) 28.5 22.8 Patients N0. (%) N0. (%) N0. (%) 59 (54.6) 24 (23.1) 25 (22.2) From descriptive statistics of employees and manager questionnaire presented in table 6, approximately 52.1% of the people were males. The majority of worker at hospitals had advanced degree such as diploma 43.9% and bachelor 40.5%. On average (estimated) questionnaire respondent was more than 10 years experience, which reflects the high percentage of experience workers at hospitals. Table 3.6 Descriptive statistics of the employee and manger population N= 351. Study variables Percentage Gender Male 52.1 Female 47.39 Education High school 4.3 Diploma 43.9 Bachelor (B.A) 40.5 Master 11.4 Years of experience 1-4 years 24.8 5-9 years 29.1 More than 10 years 46.2 From descriptive statistics of patient population, approximately 56.5% of people questionnaire were females. The majority of questionnaire respondents did not completed a high school 66.7%. Approximately 48.1% 47 of respondents reported their health status when they admitted to hospital to be poor, and on average (estimated) length of stay at hospital was 2 days in percentage 56.5%. Approximately 50.9% had been referred by a consultant. Table 3.7 Descriptive statistics of the patient's population. Study variables Percentage Gender Male 435 Female 56.5 Education High school or less 66.7 Diploma 12 Bachelor degree 20.4 Master degree 0.9 Years of experience 1-4 years 24.8 5-9 years 29.1 More than 10 years 46.2 Length of stay (LOS) 1-3 days 56.5 3-5 days 18.5 5-7 days 12 More than week 13 Place of living City 52.8 Village 32.4 Camp 14.8 Self perceived health on admission Poor 48.1 Fair 17.6 Good 25 Very good 9 Way admitted to hospital - Patient registration 3.7 - Emergency room 38.9 - Transferred from another facility 3.7 - Refers by a consultant 50.9 - Other 2.8 48 Chapter Four Results and Discussion 49 4.1 Hypothesis testing 4.1.1 Manager and employee hypotheses testing The study tested the following hypothesis and all hypotheses were tested at (α = 0.05): Hypothesis 1 There is no significant correlation at α = 0.05, between TQM and the following variables in the hospitals of Nablus: [(x1) customer focus; (x2) total involvement to hospital; (x3) counter measurement methods; (x4) systematic support; (x5) continuous improvement, (x6) safety measurements. To support the hypothesis, we applied the linear multiple regression model, with TQM, measured as average of total scores in the questionnaire of officials, as depended variable, and the six variables x1,..x6, given above as independent variables. The resulting equation was: TQM = 0.09954 + 0.124 × 1 + 0.187 x 2 + 0.207 x 3 + 0.353 x 4 + 0.103 x 5 + 0.001876 x 6 With the exception of the safety measurement variable (x6), all the other variables were with statistically significant values (P = 0.000), which is less than 0.05; hence the hypothesis is rejected. A possible explanation for the lack of significance regarding safety measure could be the use limited number of questions in the study concerning this sector. Applying step-wise multiple regression analysis on the above tested variables, the following equation was obtained: TQM =0.098 + 0.125 × 1 + 0.189 × 2 + 0.207 × 3 + 0.355 × 4 +0.103 ×5. 50 One–way ANOVA test also supported the findings on significant levels (P = 0.000) with an R square value of 0.99. Such findings explain almost completely the variance of the TQM values, and the fact that the correlation is very high. Hypothesis 2 There is no significant correlation at α = 0.05 between TQM and the following variables in Al-Watani and Rafidia Hospitals: (x1, customer focuses; x2, total involvement to hospital; x3, counter measurement methods; x4, systematic support; x5, continuous improvement, x6, safety measurements). To support the hypothesis, we applied the linear multiple regression model, with TQM measured by using the average of total scores in the questionnaire in both hospitals. The resulting equation was: TQM = 0.0832 + 0.125 1× + 0.189 x 2 + 0.215 x 3 + 0.370 x 4 + 0.08437 x 5 - 0.00323 x 6 With the exception of the safety measurement (x6), all the other variables showed significantly different values (P = 0.000), which is less than 0.05; hence the above hypothesis was rejected. Applying step-wise multiple regression analysis to the significant independent variables, the following equation was obtained: TQM = 0.08624 + 0.124 × 1 + 0.189 × 2 + 0.366 × 4 + 0.08398 × 5 One–way ANOVA supports the above conclusion with significance level of (P = 0.000) and an R square = 0.99 which explains almost completely the variance of the TQM values, and the fact that the correlation was very high. 51 Hypotheses 3 There is no significant correlation between management system at α = 0.05 and the following variables in the hospitals of Nablus: x1, training and development; x2, perception for quality; x3,employee satisfaction; x4, leadership; x5, belonging to hospital; x6, safety measurements; x7, equipment maintenance and x8, facilities, equipments and communications. To support the hypothesis, we applied the linear multiple regression model, with management system (MS) as a dependent variable and the other 8 variables x1,..x8 as independent variables. The resulting equation was: MS = 0.245 + 0.243 x 1 + 0.403 x 2 + 0.229 x 3 + 0.119 x 4 + 0.0984 x 5 + 0.0378 x 6 + 0.0132 x 7 – 0.213 x 8 Variables x1, x2, x3, x5 and x8 were with significant levels (0.000, 0.000, 0.000, 0.035, and 0.001, respectively), which means that they have significant correlation with MS. (we reject the hypothesis, and conclude that, there is significant correlation, in the significant level 0.05, between management system in the hospitals of Nablus and variables: training and development, perception for quality, employee satisfaction, belonging to hospital and facilities. One-way ANOVA test supports the conclusion with significance level 0.000; and also R square = 0.445, which measures the explanation of the variables to variance in Management System. Hypotheses 4 There are no statistically significant differences at α = 0.05 between assessment of the officials and the services offered by Al-Watani and Rafidia hospitals due to types of offered service. 52 H0: M1 = M2 = M3 = M4 = M5= M6 / H1: H0 is not true. In order to support the hypothesis, we applied One- way ANOVA test to the average scores of the items of the questionnaire of the officials, distributed among the different categories of services, in the two hospitals; the results were presented in table 4.1. Table 4.1 One-way ANOVA test the study the effect of the variable of service on assessment of level of services offered by hospitals. Sum of squares Df Mean square F P Between groups 9.031 5 1.806 5.148 0.000 Within groups 57.894 165 0.351 Total 66.926 170 From the table 8, the observed P value of 0.000 is a significant value for the differences; hence, the hypothesis was rejected. Since the hypothesis was rejected, Scheffe’s test was used to determine which differences between means contributed to rejection of the hypothesis. The means of different categories are given in table 4.2. Table 4.2 Means of different categories in tow hospitals according to level of services. Services N Mean Doctors 33 2.7424 Nurses 87 2.5398 Pharmacists 13 3.0016 Radiologist, and liberationists 19 2.8388 Engineers & cooks 2 3.3125 H. R. D. secretaries and accountants 18 3.1968 Total 172 2.7243 The results of Scheffe’ test showed that the means differences were significant at the 0.05 level for both doctors and nurses. 53 Graph 4.1 Scheffe's mean of different categories in public Hospitals. H. R. D. secretaries Engineers & cooks Radiologist, and lab Pharmacists Nurses Doctors M ea n 3.4 3.2 3.0 2.8 2.6 2.4 Graph 4.2 Mean of different categories in public hospitals. H. R. D. secretaries Engineers & cooks Radiologist, and lab Pharmacists Nurses Doctors M ea n 3.4 3.2 3.0 2.8 2.6 2.4 54 Hypotheses 5 There are no statistically significant differences at α = 0.05, assessment of the officials, between services offered by Al- Watani and Rafidia hospitals due to the type of offered service. H0: M1 = M2 =M3 = M4 / `H1: No is not true. In order to support of the hypotheses, One- way ANOVA test was used based on the average scores of the items of the questionnaire of the officials, the results are shown in table 4.3. Table 4.3 ANOVA test the study the effect of academic qualification on assessment of level of services offered by hospitals. Sum of squares Df Mean square F P Between Groups 7.173 3 2.391 6.481 0.000 Within Groups 128.007 347 0.369 Total 135.180 350 Observed P value of 0.000 is an evident of significant differences, thus, the hypothesis was rejected. Scheffe’s test was used to determine which differences between means contributed to rejection of the hypothesis. The means of different categories are given in table 4.4. Table 4.4 Means of academic qualification groups. Group N Mean High school 15 3.5083 Diploma 154 2.8773 B. A. 142 2.9770 Master 40 3.1646 Total 351 2.9773 55 The results of Scheffe’s test showed that the means differences were significant at the 0.05 level for: High school and diploma groups, and high school and B. A. groups. From the table of the means, it is clear that the highest mean was that of the high school group and the lower mean was that of the diploma group. MasterB. A.DiplomaHigh school M ea n 3.6 3.5 3.4 3.3 3.2 3.1 3.0 2.9 2.8 Graph 4.3 Scheffe's means of academic qualification groups. MasterB. A.DiplomaHigh school M ea n 3.6 3.4 3.2 3.0 2.8 Graph 4.4 Means of academic qualification among studied groups. 56 Hypothesis 6 There are no statistically significant differences, in the assessment of the officials, at α = 0.05 between level of services offered by hospitals in Nablus and years of experience. H0: M1 = M2 = M3 / H1: No is not true. In order support the hypothesis, One- way ANOVA test was conducted using the average scores of the items of the que