Quality Management System Implementation Status

and Its Associated Factors Among Clinical Staffs at

Governmental Hospitals in Addis Ababa, Ethiopia
Yeworkwuha Getachew (  hirutgetachew49@gmail.com )
Kotebe Metropolitan University Menelik II Medical and Health Science College
Mulugeta Mekuria
Ambo University college of medicine and health Sciences
Admasu Ketsela
Kotebe Metropolitan University Menelik II Medical and Health Science College
Zewdu Minwuyelet Gebremariam
Kotebe Metropolitan University Menelik II Medical and Health Science College
Mebratu Abraha Kebede
Saint Paul’s Hospital Millennium Medical College

Research Article

Keywords: Clinical staff, Ethiopia, Government hospitals, Quality Management system implementation

Posted Date: August 3rd, 2022

DOI: https://doi.org/10.21203/rs.3.rs-1803009/v1

License:   This work is licensed under a Creative Commons Attribution 4.0 International License.
Read Full License

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Abstract
Introduction: Quality management system is a set of coordinated activities to direct and control an
organization in order to continually improve the effectiveness and efficiency of its performance. So,
information about the status of health sector quality management system implementation is necessary.
However, there is limited information about the quality management system implementation in the study
area as well as at national level.

Objective: the aim of this study is to assess quality management system implementation and its
associated factors at governmental hospitals in Addis Ababa, Ethiopia.

Methods: An institution-based cross-sectional study was conducted among 422 health care providers
working in public hospitals in Addis Ababa. Simple random technique was used to select both the study
settings and study participants. Data were collected by using structured written questionnaire after
obtaining written consent from the respondents. The collected data were entered into Epi-data version 3.1
and analyzed using SPSS Version 25. Bivariate and multivariate analysis was done. Variables which had
p-value <0.05 at 95%CI were considered as statistically significant association with dependent variable in
multivariate analysis. Result was presented in text, table and figures.

Result: A total of 422 study participants were participated in the study with the response rate 100%. The
mean age of the study participants was 31.46 (SD=5.77) years. The majority (44.5%) of the study
participants were below 30 years of age and 55.0% were female by sex. This study revealed that nearly
52% of quality management system were not implemented in the selected health facilities. Being 35
years and above (AOR =1.99) in age, ever heard about QMS (AOR 1.56) by the staff, and those staff
knows the availability of QMS (AOR= 2.31) were among variables that identified as predictors of QMS
implementation in the study area.

Conclusion and recommendation; This study concluded that the level of QMS implementation in the
current study area is suboptimal. Age of the study participants, previous hearing about QMS, and knows
the availability of QMS were among variables that identified as predictors of QMS implementation in the
study area. Therefore, health facilities are recommended to educate their staff about QMS
implementation.

Introduction
Quality management system (QMS) is a set of coordinated activities to direct and control an organization
in order to continually improve the effectiveness and efficiency of its performance (1). Quality
management (QM) is simply the application of a quality management system in managing a process to
achieve maximum customer satisfaction at the lowest overall cost to the organization (2). QM is a
philosophy or discipline for continuous success in an organization. It focuses on customer satisfaction,
and in the processes of continual improvement of services, and products as well as for preventing
problems (3, 4). Implementing QMS enables hospital managers to determine and manage care processes
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to meet patients’ needs and expectations, and to achieve patient and employee satisfaction (5). Further,
QMS improve work quality and safety, service quality, patient/employee satisfaction, organizational
performance, flexibility and competitiveness of the health care facilities (5, 6, 7).

Health sectors should make strategic decision to adopt a quality management system based on the
organization’s strategy, objectives, structure, size, products and services offered (7). With a strong
hospitality management system, hospitals would have the capability to promote a quality service (8). For
this reason, most hospitals focus on quality management system (9). To solve quality related problems,
the government of Ethiopia has considered quality management as a development infrastructure since
1940, and efforts made to disseminate quality service at national level (10).

For the successful implementation of QMS, full commitment of top managements and other staff
members is necessary with respect to provision of timely resources and demonstrating his/her
leadership, commitment and customer focused services (11). Hospitals level of analyzing care process
performance (12) and having regular proficiency testing have positive correlation with Quality
management system implementation (13). Further, an organization culture emphasizing standards and
values associated with affiliation, teamwork and innovation, assumption of change and risk taking, play
as the key success factor in QMS implementation (14).

With respect to the implementation of QMS there is limited information both in well-developed as well as
low income counties like Ethiopia. There are only few published literatures that shows about the health
institutions level of QMS implementation. Accordingly, only 4% of hospitals in Netherlands,0% in Hungary
and 3% in Finland were found to be implemented QMS (15). In, Lithuanian of Eastern Europe, quality
management systems have found operating in 39.7% (16). Also, the study from Iran indicated that the
QMS implementation score is 15.3% for public and 20.9% for non-public hospitals (17).

In health care organizations, it is considered as a means to better meet the needs and expectations of
patients (18). However, that there are some challenges encountered during the realization of quality
management system in public organizations due to the bureaucratic culture, organizational features and
ownership affect hospital QMS implementation (19, 20). Additionally, less flexibility in resource allocation
and human resources management of government health institutions could leads to difficulty in proper
implementation of quality management system. This will prevent the institution from providing of quality
healthcare for their clients (7). However, still there is a gap in information that to what extent does health
institution has been implementing the quality management system in the perspective clinical staffs.
Therefore, this study is aimed to assess the implementation status of QMS and factors affecting it
among clinical staffs at government hospitals found in Addis Ababa.

Methods And Materials

Study design, period and area

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Institution based cross sectional study design was conducted among 422 study participants from 1st to
30th of May 2021 at public hospitals in Addis Ababa, Ethiopia. Addis Ababa is capital city of Ethiopia,
with a population of 3.384,569 of people in an area of 540 square Kilometers. The city comprises 11 sub
cities and 116 districts. The city consists of a total of 13 public hospitals, specifically 6 hospitals owned
by Addis Ababa Health Bureau, 5 hospitals owned by Federal Ministry of Health (central), 1 ministry of
defense and 1 police force hospitals which provide different health services. Prior to finalizing of the
research proposal the researcher was collected human resource related information from Addis Ababa
City Administration health bureau. Based on that a total of 4103 clinical staffs are currently working at
the selected six public hospitals found in Addis Ababa.

Source and study populations

All clinical health care providers working at governmental hospitals of Addis Ababa city are source
population and those who were working in the selected hospitals during the data collection period were
the study populations. All clinical health care workers who were working on a fulltime at least for six
months at the institution were included and those who were on annual leave during the data collection
period were excluded

Sample size determination and sampling procedure

The sample size was calculated using the single population proportion formula, taking the assumptions
of 50% of QMS implementation status because there is no previous published data in this area, 95%
confidence level & 5% marginal error. The final sample size became 422 after adding 10 % non-response
rate. Of a total of six public hospitals in the Addis Ababa City Regional Health Bureau, three hospitals
were randomly selected by lotter methods. According to the information obtained from the respective
human resource unit of each health institution, total of 4,103 clinical health care providers were providing
a medical service at the six hospitals and 1, 778 of them were from the selected three hospitals. Then
proportional allocation was used to allocate the numbers of clinical health care providers to be included
from each hospital based on the number. Finally, simple random sampling technique was used to select
the study participants by using the list of the health professional in the selected hospitals.

Data Collection tools and Procedures

Data was collected by using of self-administered semi-structured questionnaire which was developed
after reviewing previous similar studies (18,21). The content of the questionnaire includes socio-
demographic characteristics (age, sex, education, marital status, monthly income), qualification and
experience related factors (professional qualification, work experience, training on QMS, motivation),
institutional related factors (type of the facility, year of establishment, availability of guideline and
protocol) and quality management system implementation related factors which is developed from
previous different research works. The QMS tool has a total of twelve Likert scale based questions with a
value of 1 for strongly disagree, 2 for disagree, 3 for neutral, 4 for agree and 5 for strongly agree Four BSc
nurses for data collection and one BSc public health professionals for supervisions were recruited.
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Data Quality Control Issues, Processing and Analysis

Data quality control issue was insured by conducting pre-test among five percent total samples obtained
from health care workers working at Yekatit 12 Hospital to assess the appropriateness of wording, clarity
of the questions and respondent reaction to the questions and interviewer. Training was given to the data
collectors and supervisors on the data collection tool, sampling techniques and ethical consideration by
the researcher prior to the data collection. Supervision was held regularly during data collection period
both by the researcher and supervisor. The collected data were checked on daily basis for completeness
and consistence by the supervisor and researcher. After cleaning data was entered in to EPI info version
3.1 then it was exported to SPSS versions 25 for analysis. Descriptive statistics (frequencies and
percentages) was used to explain the study participant response in relation to study variables. Then it
was presented in text, table and graphs. After the dependent variable has been classified in two value
based categorical variable based on the overall mean, the bivariate and multivariate analysis was used to
determine the presences of statistically significant associations between the independent variables and
QMS implementation. Variables which had p-value <0.05 during bivariate analysis were considered for
further multivariate analysis to control confounding. The strength of the association was presented by
odds ratio (OR), Adjusted Odds Ratio (AOR) and 95% confidence interval. A p value of < 0.05 on
multivariate analyses was considered as statistically significant.

Result
Socio-demographic characteristics of the respondents
A total of 422 study participants were included in the study which makes the response rate 100%. The
mean age of the respondents was 31.46 (SD = 5.77) years. Among the respondents, the majority (44.5%)
were in age of below 30 years, (55.0%) were female and (49.3%) were unmarried. Also, the vast of the
study participants which accounts (75.8%) of had a degree level of educational, background. Regarding
monthly income of the study participants, around half of them (45%) had a monthly income in the range
of 5000 to 7500 Ethiopian birr (Table 1).

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 Table 1
-Descriptions of Socio demographic factors of the health care providers at
governmental hospitals in Addis Ababa, Ethiopia, 2021
Variable Categories Frequency Percent (%)

Age below 30 years 188 44.5

30–34 years 139 32.9

35 years and above 95 22.5

Sex Male 190 45.0

Female 232 55.0

Marital status Married 180 42.7

Single 208 49.3

Divorced and widowed 34 8.1

Educational background Diploma 51 12.1

Degree 320 75.8

Masters/specialist 51 12.1

Monthly income 5000 and below 49 11.6

5001–7500 birr 190 45.0

above 7500 birr 183 43.4

Profession experience and institutional profile related characteristics of the respondent.

Data were collected regarding to professional experience and institutional profile of the study
participants. The result of the study showed that, 48.8% of the study participants were BSc nurse in
profession, and more than three-fourth (79.4%) of them were a clinical staff during the data collection
period. Also the majority that 45.3% of them had more than five years of overall working experience and
(73.9%) of them were ever heard about quality management system. Also, 67.3% of them were not ever
taken quality management system related trainings (Table 2).

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 Table 2
; Profession experience and institutional profile related description of the health care providers at
governmental hospitals in Addis Ababa, Ethiopia, 2021.
Variables Categories Frequency Percent
(%)

Profession clinical nurse 55 13.0

BSC nurse 206 48.8

HO 22 5.2

Midwifery 26 6.2

Pharmacist 22 5.2

medical doctor 46 10.9

laboratory technician 40 9.5

other specify* 5 1.2

Current position clinical staff 335 79.4

unit/department head 67 15.9

Head and vice head of 6 1.4

institution

other specify** 14 3.3

Work experience 2 years and below 83 19.7

> 2 years to 5 years 148 35.1

more than 5 years 191 45.3

Ever heard about quality management system Yes 312 73.9

No 110 26.1

Ever taken quality management system Yes 138 32.7

related trainings

No 284 67.3

other specify*(environmental health, Radiography technologists occupational health);

other specify** (Infection preventions)

Institutional strategy related factors

Concerning institutional profile related response of the study participants, 65.6% and 58.3% of them were
from medical institutions and referral hospitals respectively with respect to the type and hierarchy of the
institution. Also, 3.1% of the respondents mentioned that there is QMS guideline/protocol at the
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institutions. Almost, half of them ()44.8% did not whether there is or not availability of Mission regarding
quality care delivery. Further, many of them that (43.1%) and 46.4% of the participants mentioned didn’t
know for the question regarding availability of quality plan of the hospital and availability of
departmental quality plan respectively. In addition, the majority of the current study participants were
didn’t know whether there is or not allocated of availability of budget for quality improvement of the
institution which is responded by 55.9% of them (Table 3).

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 Table 3
; Institutional strategy related response of the study participants at governmental hospitals in Addis
Ababa, Ethiopia, 2021
Variables Categories Frequency Percent
(%)

Type of institution academic institution 145 34.4

medical institution 277 65.6

Hierarchy of the institution Primary hospital 37 8.8

General hospital 139 32.9

Referral hospital 246 58.3

Availability of QMS guideline/protocol Yes 224 53.1

No 52 12.3

I don't know 146 34.6

Availability of Mission regarding quality care don't know 189 44.8

delivery

not available 89 21.1

available but not 89 21.1

communicated

available and 55 13.0

communicated

Availability of Quality plan of the hospital don't know 182 43.1

not available 73 17.3

available but not 94 22.3

communicated t

Available and 73 17.3

communicated

Availability of Departmental quality plan don't know 196 46.4

not available 75 17.8

available but not 91 21.6

communicated t

Available and 60 14.2

communicated

Availability of Budget for quality don't know 236 55.9

improvement

not available 59 14.0

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 Variables Categories Frequency Percent
(%)

available but separated for 73 17.3

quality

there is a specific budget for 54 12.8

q

Employee Empowerment And Participation Related

Response
Employee’s empowerment and participation in quality management system related information has been
collected for the current study. Based on the response of the current participants 35.8% of them explained
that the system is significant but it can’t be practically implemented in hospitals. The majority of them
(47.4%) said that quality management system committee is established at the institution but not fully
functional and 36.0% of them said that it is leaded by Professionals. Of those, 27.3% of then considered
that more than 50% staffs have general information about QMS, whereas 30.6% which accounts 129 of
them mentioned that less than 50% of the professional staff are being participated on quality
management system activities. For information about training of employees on QMS, the current study
finding showed that 33.9% of the study participants thought that training is provided only for case team
leaders and 26.3% stated that less than 50% of the staffs with the position of manager received tarring
on QMS. The researcher was also further included information how the study participants saw the
system of monitoring employee quality improvement by department heads/case team leaders, as per the
finding the majority that 32.0% of them describe even if there is a regular monitoring system but not on
standard indicators (Table 4).

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 Table 4
; Employee level of empowerment and participation in QMS related response of the health care providers
at government hospitals, Addis Ababa, Ethiopia, 2021
Variables Frequency Percent
(%)

QMS in hospital The system had no 39 9.2

significance at all

Its negative effect is more 60 14.2

visible than the positive effect

The system is significant but it 151 35.8

can’t be practically
implemented in hospitals

The system creates improved 122 28.9

environment in different
aspects of the service

The system is a necessity 50 11.8

question for the wellbeing of
the hospital

QMS committee status of the hospital not established 28 6.6

Established but there is no 49 11.6

move

established but not fully 200 47.4

functional

established and fully 73 17.3

functioned

don't know 67 15.9

other specify 5 1.2

Main player in the QMS no one 39 9.2

quality committee 113 26.8

Professionals 152 36.0

staffs in managerial position 76 18.0

other specify 42 10.0

Staff awareness about QMS not aware at all 59 14.0

only < 50% of the staff has 97 23.0

information general

>=50% staffs has general 115 27.3

information

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Variables Frequency Percent
(%)

>=50% staffs has detail 69 16.4

information

Other specify 82 19.4

Participation of professionals in QMS not participated at all 70 16.6

< 50% of the staff participated 129 30.6

50 and more staff participated 107 25.4

don't know 88 20.9

other specify 28 6.6

Training for employees on QMS not provided 57 13.5

only for case team leaders 143 33.9

< 50% of the staff provided 92 21.8

>=50% of the staff provided 46 10.9

don't know 80 19.0

other specify 4 .9

Training of managers on QMS not provided 54 12.8

< 50% of the staff provided 111 26.3

>=50% of the staff provided 99 23.5

don't know 50 11.8

other specify 108 25.6

Monitoring system on employee quality not available at all 35 8.3

improvement activities by department
heads/case team leaders the system is available but not 81 19.2
regular and standard based

regular but not on standard 135 32.0

indicators

regular and standard based 64 15.2

monitoring system

don't know 107 25.4

Quality Management System Implementation Status Of The

Study Participants
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Quality management system implementation status was measured as it is described at section four
operational definition part by using a Likert scale based twelve questions. The finding showed that an
overall quality management implementation status was 47.2% (Fig. 1).

Factors associated with level of quality management system implementation among health care
providers of governmental hospitals

For each explanatory variable, bivariate analysis was done and socio-demographic factors such as age
of 30–34 years as well as above 35 years and monthly income of having above 7500 Ethiopian birr;
professional and experience related factors such as being nursing profession and ever heard about
quality management system; further institutional related factors such as working at general and referral
hospitals and availability of MQS guideline/protocol were variables fulfilled the minimum requirement of
p-value < 0.05 significance level for implementation of quality management system for further
multivariate logistic analysis. For those variables which have p-value of less than 0.05 were entered to
multivariate analysis to check the true association. On the multivariate analysis; Health care providers of
age 35 years and above (AOR 1.99, 95%CI (1.18, 3.39)), those who were ever heard about QMS (AOR 1.56,
95%CI (1.01, 2.51)), and staffs who knows the availability of QMS (AOR 2.31, 95%CI (1.20, 4.43)) were
among the variables that had showed significant association with implementation of quality
management system (Table 5).

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 Table 5
; Factors associated with level of quality management system implementation at governmental hospitals
in Addis Ababa, Ethiopia,2021
Explanatory QMS implementation status COR,95%(CI) AOR,95%(CI) P-
Variables value
Not Implemented
Implemented

Age

below 30 years 117 71 1 1

30–34 years 65 74 1.88 (1.20, 1.57 (0.98, 0.062

2.93)* 2.52)

35 years and 41 54 2.17 (1.31, 1.99 (1.18, 0.010

above 3.59)* 3.39)**

Monthly Income

5000 and below 31 18 1 1

5001–7500 birr 111 79 1.23 (0.64, 1.35 (0.69, 0.381

2.34) 2.67)

above 7500 birr 81 102 2.17 (1.13, 1.79 (0.90, 0.096

4.15)* 3.56)

Profession

Nurses 148 113 1 1

Other professions 75 86 1.50 (1.01, 1.35 (0.88, 0.165

2.23)* 2.06)

Ever hear about QMS

Yes 153 159 1.82 (1.16, 1.56 (1.01, 0.045

2.85)* 2.51)**

No 70 40 1 1

Hierarchy of the institution

Primary hospital 26 11 1 1

General hospital 68 71 2.47 (1.13, 1.95 (0.86, 0.108

5.38)* 4.42)

Referral hospital 129 117 2.14 (1.02, 1.89 (0.87, 0.110

4.53)* 4.11)

Availability QMS guideline/protocol

* Significant association (p-value < 0.05 in bivariate)

**-significant association (p-value < 0.05in multivariate analysis)

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 Explanatory QMS implementation status COR,95%(CI) AOR,95%(CI) P-
Variables value
Not Implemented
Implemented

Yes 101 123 2.30 (1.23, 2.31 (1.20, 0.012

4.32)* 4.43)**

I don't know 88 58 1.25 (0.64, 1.35 (0.68, 0.394

2.41) 2.70)

No 34 18 1 1

* Significant association (p-value < 0.05 in bivariate)

**-significant association (p-value < 0.05in multivariate analysis)

Other professions = Medical doctors, health officers, pharmacy professionals, laboratory professionals,
midwiferies

Discussion
The finding of this study revealed that an overall 47.2% of quality management system at the selected
hospitals. This result is in line with the previous study finding where it was reported in Lithuanian support
treatment and nursing hospitals that the currently implementation of QMS is 46.6% (19). However, the
current study finding is higher than the previous study findings which were done different part of Europe
that a mean of 22 QM-activities per hospital was found in the Netherlands and Finland versus 20 QM
activities in Hungarian hospitals. Further, only 4% of hospitals in Netherlands, 0% in Hungary and 3% in
Finland have already implemented a QMS (15). Also, it was higher than the finding from Isfahan
University Hospitals (IUHs) of Iran, that implementation status was very low, low, medium and highly
successful respectively in 16.7, 58.3 and 8.3 percent of the hospitals (22). The difference might be due to
the variation in sample size and study population that was included a total of 276 hospitals as a study
setting and directors of the hospitals or the quality coordinators as study populations (15), and total of
667 employees and 12 hospital managers were included at IUHs study (22).

With respect to associated factors, the current study found that those who were in the age categories of
35 years and above were 1.99 times more likely to considered quality management system has been
implemented as compared to those below the age of 30 years. This could be because of exposing to
different management related activities and updating themselves through education through time. An
organization which creates an opportunity like teamwork, innovation, assumption of change and risk
taking, play as the key success factor in QMS implementation of employees’ (14). Also, education and
training, responsibility and teamwork and ongoing improvement problem prevention have a positive
implementation of QMS (15).

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Further, those who ever heard about QMS were 1.56 times more likely to perceived that QMS was
implemented in relation to those not ever heard about it. This is supported by different studies that
knowledge of the staff and training (17, 23, 24, 25, 26) had a significant association with QMS
implementation.

In addition, the current study found that those who mentioned there is available quality management
system guideline or protocol were 2.31 times more likely considered that QMS has implemented at the
institution. This might be due the available protocol helps the staffs to judge about the current status of
QMS at the institution. The most critical issues related to the QMS implementation include procedure
development, information, and development of work guidelines (19). Organizational culture like having
developed QMS guideline has a significant effect on QM practice (24). The other systematic review study
has also mentioned that an organization culture emphasizing on standards and values associated with
key success of QMS implementation (14). Further, the level of compliance in guideline has an effect on
quality management system implementation (27).

Limitation Of The Study

Since, there was a limited published data regarding the current research topic it was difficult to make a
comprehensive and detail comparison with other previous study findings. Also, it is quantitative data
based only. Unable to get a validated tool of the dependent variable in Ethiopia context.

Conclusion And Recommendation

In the current study areas, the level of quality management system implementation is not satisfactory.
Many number of the study participants’ didn.t know about their hospitals strategies with respect to
settled mission, quality plan and allocated budgets for quality management system. Only few study
participants know that QMS necessities for the institution. Based on the majority of the study
participants’ response more than 50% of the professionals have not currently being participated on QMS
related activities. Also, only, around ten percent of the employees’ received training on QMS and one-
fourth of study participants didn’t know whether there is or not a system of monitoring employee quality
improvement by department heads/case team leaders. Therefore, Addis Ababa health bureau should
develop a mechanism which help to enhance level of QMS at hospital levels. The health
institutions/hospitals should desensitize to all staff members about the available QMS guidelines or
protocols if there is but if there is no protocol the institutions should develop a protocol/guideline.
Training on QMS should be given for staffs. The QMS committee should be multidisciplinary and should
announce to all staffs while it has established. Generally creating a suitable environment that helps
staffs to know about QMS of the institution including its mission, plan and budget is a mandatory.

Declarations
Ethics approval and consent to participate

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Ethical clearance was obtained from Kotebe Metropolitan University Menelik Health Science College IRB,
Ethiopian FMoH IRB and Addis Ababa regional health bureau Ethical Review Committee. In addition,
permission letter was obtained from the study site. Prior to data collection, written consent was obtained
from all study participants and were informed that participation was voluntary and they can withdraw
themselves from the study at any time. Data were kept confidential and anonymous and it was used only
for the research purpose. The study participants were informed that there is no harm due to participating
in the study. The confidentiality of the study participants’ related data were maintained by avoiding
possible identifiers such as name of the participants. Only identification number was used as a reference.

So, in general we carried out the current research by fulfilling all the requirements of the
institutional Kotebe Metropolitan University Menelik Health Science College IRB, Ethiopian FMoH IRB
and Addis Ababa regional health bureau Ethical Review Committee guidelines and regulations and also it
fulfilled the Declaration of Helsinki.

Consent for publication

Not applicable

Availability of data and materials

Raw data were generated at public hospitals in Addis Ababa city, Ethiopia. Derived data supporting the
findings of this study are available from the corresponding author YG and co-author MM, AK, and MAK.
This is also to confirm you that there is hardcopy of ethical approval letter that we have got it from
Kotebe Metropolitan University Menelik Health Science College IRB, Ethiopian FMoH IRB and Addis Ababa
regional health bureau Ethical Review Committee after the research proposal had been reviewed and
approved. The collected hardcopy questionnaires are available with the principal investigator YG,
whereas the softcopy of SPSS data is currently available among some of the co-investigators such as
MAK by keeping it in confidential.

Acknowledgements

The authors acknowledge Kotebe Metropolitan University Menelik Health Science College Department of
Health Service Management for the chance give us to conduct this research proposal. Also, the authors
appreciate the respective study institution and the study participants for their cooperation in providing the
necessary information.

Authors’ contributions

YG was conceived the study and involved in developing the proposal, the study design, reviewed the
article, analysis, report writing and drafted and write up the manuscript; MM and AK were involved in
reviewing the proposal, result and manuscript as well as providing constructive comments after reviewing
of the proposal and final paper; ZMG and MAK were involved in reviewing of the final thesis paper as well
as developing the manuscript.
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Funding

There is no source of funding for the current manuscript

Competing interest

All authors read and approved the final manuscript.The authors declare that they have no competing
interests.

Authors' information

Mrs. Yeworkwuha Getachew is a staff of Kotebe Metropolitan University Menelik II Medical and Health
Science Collegeand currently she is working at Health Service Management department as a lecturer. She
is the principal and corresponding author of the current study which submitted to your journal.

References
1. Oakland, J. S, Oakland on Quality Management, GB: Butterworth Heinemann, 2004, Vol (3)
2. Padmasiri.K. Successful total quality management implementation in shirilahnka public hospitals.
Annals of business administrative science. 2009; (8) : 55–74.
3. Al-Asiri, M. M, Factors affecting the practices of ISO 9001:2000 quality management system in Saudi
business organizations Dissertation/Thesis. ProQuest Dissertations Publishing, 2004
4. Low, S. P., &Ong, J. (2014). Project Quality Management: Critical Success Factors for Buildings, DE:
Springer Verlag, 2014, Vol. 1
5. Buciuniene, I., Malciankina, S., Lydeka, Z. and Kazlauskaite, R. (2006), “Managerial attitude to the
implementation of quality management systems in Lithuanian support treatment and nursing
hospitals”, BMC Health Services Research, Vol. 6 No. 12, available at: https://doi.org/10.1186/1472-
6963-6-120
6. Garza-Reyes, J.A., Rocha-Lona, L. and Kumar, V. (2015), “A conceptual framework for the
implementation of quality management systems”, Total Quality Management and Business
Excellence, Vol. 26 Nos 11–12, pp. 1298–1310, available at:
https://doi.org/10.1080/14783363.2014. 929254
7. Dr. Emmanuel OtienoAwuor, Total Quality Management Practices in Selected Private Hospitals in
Nairobi, Kenya, European Journal of Business and Management www.iiste.org ISSN 2222 – 1905
(Paper) ISSN 2222–2839 (Online) Vol.5, No.13, 2013
8. Han, H, The Healthcare Hotel: Distinctive Attributes for International Medical Travellers. Tourism
Management, 2013, 36, 257–268
9. Voon, B.H., Abdullah, F., Lee, N. &Kueh, K, Developing a HospiSE Scale for Hospital Service
Excellence, International Journal of Quality & Reliability Management,2014, 31(3), 261–280

Page 18/20
10. The Federal Democratic Republic of Ethiopia Ministry of Health, Health Sector Transformation Plan
HSTP 2015/16–2019/20 (2008–2012 EFY) October 2015
11. WHO, WHO GUIDELINE ON THE IMPLEMENTATION OF QUALITY MANAGEMENT SYSTEMS FOR
NATIONAL REGULATORY AUTHORITIES, January 2019, DRAFT FOR COMMENTS- prepared by
EMP/RSS
12. EhsanZarei, SoghraKarimi, SoadMahfoozpour, SimaMarzban, Assessing hospital quality
management systems: evidence from Iran, International Journal of Health Care Quality Assurance
Vol. 32 No. 1, 2019 pp. 87–96, Emerald Publishing Limited 0952–6862 DOI 10.1108/IJHCQA-11-
2017-0208
13. AbaySisay, AshebirGurmessa, WondimenehLiknew, Factors Affecting Implementation of Laboratory
Quality Management System in Addis Ababa Public Health Laboratories, Addis Ababa, Ethiopia. J
Trop Dis, 2020, 8:343. doi: 10.35248/2329-891X.20.8.343
14. VieraWardhani, AdiUtarini, Jitse Pieter van Dijkc, Doeke Post, Johan Willem Groothoff, Determinants
of quality management systems implementation in hospitals, Health Policy 89 (2009) 239–251
15. C Wagner, L Gulácsi, E Takacs and M Outinen, the implementation of quality management systems
in hospitals: a comparison between three countries, BMC Health Services Research 2006, 6:50
doi:10.1186/1472-6963-6-50
16. Buciuniene.I ,Malcia. S ,Lydeka. Z ,Kalzalusk. R. Managerial attitude to the implementation of quality
management system in luhthahnia support and nursing hospital. BMC health service research. 2016
; 6:120
17. EhsanZarei and SoghraKarimi, ssessing hospital quality management systems: evidence from Iran,
International Journal of Health Care Quality Assurance, Vol. 32 No. 1, 2019 pp. 87–96
18. Yang, C-C, “The establishment of a TQM system for the health care industry”, The TQM Magazine,
2003, Vol. 15(2), p. 93–98
19. Walsh, A., Hughes, H., & Maddox, D.P., (2002), “Total quality management continuous improvement:
is the philosophy a reality?”, Journal of European Industrial Training, Vol. 26(6), p. 299–307
20. Herrera, C.A., Rada, G., Kuhn-Barrientos, L. and Barrios, “Does ownership matter? An overview of
systematic reviews of the performance of private for-profit, private not-for-profit and public
healthcare providers”, PLoS One, 2014, Vol. 9 No. 12, e93456
21. Silva.F.quality management and employee’s attitude: An example from certified enterprise. Working
paper series.2016;(13)
22. Mohammad. A, Rad. M, The impact of organizational culture on successful implementation of total
quality management, emeraldmgmt first journal. 2006; 18 (6)
23. Ismail. S, Fathi S, Mohammed. S, The impact of creativity and innovation on level of knowledge and
understanding of total quality management benefit among health care managers. European
scientific journal. 2015; 11
24. Awour.E. Total quality management practice in selected private hospitals in Nairobi. European
journal of business and management, 2013; 15(13)
Page 19/20
25. Dr. N. Nithya, An Empirical Study through Principal Component Analysis, International Journal of
Applied Engineering Research ISSN 0973–4562 Volume 13, Number 17 (2018) pp. 13085–13092
26. Rad, A.M.M., “A survey of total quality management in Iran Barriers to successful implementation in
health care organizations”, Leadership in Health Services, 2005, Vol. 18(3), p. 12–34
27. Francois. P, Claude. J, Touboul. M, Evaluating implementation of quality management system in a
teaching hospital clinical departments. Int’l journal for quality in health care, 2003; 15 (1): 47–55

Figures

Figure 1

Quality management system implementation status at governmental hospitals in Addis Ababa, Ethiopia,
2021

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