Drivers of Healthcare Quality in a Conflict-Affected Setting: A Cross-Sectional Study on Total Quality Management Implementation in Yemen

Abstract Background Healthcare quality in Yemen's conflict-affected health system is a critical challenge. In 2021, the Ministry of Public Health mandated the implementation of Total Quality Management (TQM). This study provides a comprehensive evaluation of TQM's impact on service quality with a focus on fragile frontline healthcare professionals. Methods This cross-sectional analytical study included 410 healthcare professionals from four purposively selected hospitals in Sana'a. Data were collected using a validated questionnaire that measured five TQM dimensions (based on the EFQM model) and five health service quality dimensions (based on the SERVQUAL model). The relationships were analyzed using multiple linear regression. Results Despite the challenging context, TQM was implemented to a high degree (mean = 5.44 on a 7-point scale). TQM implementation was a powerful predictor of health service quality, explaining 64.8% of the variance (R² = 0.648, F(5, 404) = 148.73, p < .001). "Systematic Processes" (β = 0.468) and "Policy & Strategy" (β = 0.305) were the strongest drivers of quality. Paradoxically, "Leadership Commitment" was the highest-rated dimension by staff but had no significant predictive power (β = 0.009, p = 0.742). Furthermore, "Human Resources" was a non-significant predictor and the lowest-rated TQM dimension, highlighting a critical implementation gap. Conclusions TQM can be effectively implemented to improve healthcare quality, even in conflict zones. However, success is driven primarily by robust systems and policies rather than perceived leadership commitment. Addressing profound human resource challenges related to workforce well-being is fundamental to the sustainability of quality improvements in such settings. Trial Registration Not applicable.