Abstract

The performance of private healthcare institutions is vital to national economic growth but is often hindered by poor service quality, inefficiencies, and preventable harm, such as thousands of annual inpatient deaths from medical errors. Although Total Quality Management (TQM) can improve quality and efficiency, its adoption in private hospitals is often ineffective due to traditional leadership styles and cultural barriers at the top. Overcoming these challenges is key to enhancing patient outcomes and ensuring the long-term sustainability of private healthcare. This project pursued the impact of TQM practices on the performance of private hospitals in Kisumu County, Kenya. A descriptive cross-sectional study approach was employed and the study targeted departments within level four and higher private healthcare facilities in Kisumu County. A multi-stage method of portioning samples was applied. Using Yamane’s equation, the study derived a sample size of 107 departments. Data collection involved electronically administered structured questionnaires based on a Likert scale, distributed via Google Forms. Both descriptive and inferential statistics including multiple regression analysis were employed to analyze the quantitative data, while qualitative responses were subjected to content analysis. The study found that customer focus, strong leadership, continuous quality improvement, and employee empowerment significantly enhance the performance of private health facilities in Kisumu County. It recommends strengthening customer feedback systems and urges top management to deepen their commitment through strategic planning and participatory budgeting.

Keywords

Customer Focus, Performance, Leadership, Empowerment, Continuous Improvement

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1. Introduction

Total Quality Management in a business productivity stems from the belief that achieving high performance requires a quality-driven ecosystem. This can solely be possible through all members of the institution collaborating for continued enhancement of processes and sustained long-term impact. Wassan, Memon, Mari and Kalwar (2022) posit that only businesses dedicated to providing quality can prosper in today’s fast-paced, global business ecosystem, where clients are becoming more demanding and worldwide competition is escalating. To thrive, businesses nowadays must maintain extremely high standards of quality in all aspects of their operations.

These claims are supported by Wandie and Muathe (2022) who pointed out that providing excellent services is essential for organizational success and operational excellence in today’s intensely competitive global landscape. Businesses continually pursue high performance by adapting their offerings to meet the evolving needs of their customer base. The demand for the delivery service sector to continue providing timely and high-quality services has increased due to the ever-increasing integration of global markets, including the health business. Wandie and Muathe (2022) note that these difficulties add to the quickly changing dynamics of the market, which cause regular changes in pricing, trends, preferences and resultant performance.

Additionally, Owino and Makokha (2021) demonstrated that TQM is a managerial thinking that is centered on meeting customer demands, strengthening fulfillment of their anticipations and institutional performance, it is crucial for businesses to emphasize Continuous improvement of goods, services, and procedures. TQM therefore can be described as a comprehensive approach to quality improvement, aimed at boosting performance through better products, increased consumer gratification, diminished expenses, boosted finance, advanced outcomes, and improved staff wellness.

Wassan et al. (2022) define institutional achievements as a multifaceted hypothesis that assesses a firm’s standing as opposed to both domestic and exterior yardsticks. The most recognized approach to measuring enterprises is through institutional performance efficiency. The former is typically applied to private establishments, while the latter is used for public. Performance is crucial for effective company management and survival. Researchers have explored various performance dimensions, including quality, finance, innovative, operational, and business performance. Nevertheless, it’s important to explore the link between the various categories of performance and Total Quality Management approaches. An organization’s success is directly reflected in through internal mechanisms to meet the fiscal and strategic objectives (Bhaskar, 2020).

The performance of private health institutions thus carries dual implications: it can either bolster or hinder economic growth on a broader scale. Consequently, it necessitates empirical scrutiny to discern the critical factors influencing the profitability of private hospitals. Such investigations enable relevant stakeholders to prioritize their focus effectively. As a result, the efficient functioning of these institutions assumes paramount importance, prompting researchers to delve into the factors that shape their performance (Pradhan, Waghmare, Alghabshi, Almahdouri, Al Sawafi, Alhadhramy, & AlYaqoubi, 2024). These studies have led to the identification of five practices that are pertinent to this investigation, to successfully implement overall quality management in the private healthcare setting. These practices include the following: client focus, top leadership commitment, Continuous improvement and staff empowerment in creating a culture of accountability, involvement, recognition and capacity development.

1.1. Problem Statement

Kisumu County, located in a high malaria transmission zone and burdened by a persistently high HIV prevalence of 19.0%, continues to face profound public health challenges. Alarmingly, the county reports an infant mortality rate of 95 per 1,000 live births, an under-five mortality rate of 149 per 1,000, and a maternal mortality rate of 590 per 100,000 live births far exceeding national targets (Siso & Sangoro, 2023). These health burdens place immense strain not only on public healthcare systems but also on private hospitals, which must balance quality care delivery with operational efficiency amid growing demand, constrained resources, and rising expectations.

At the same time, global evidence shows that systemic quality gaps persist. Medical errors alone account for an estimated 44,000 - 98,000 inpatient deaths annually in hospitals (Talib et al., 2010). Contrary to public perception, many private healthcare institutions are grappling with internal inefficiencies, struggling to maintain cost-effective operations while ensuring value for money, especially during periods of economic fluctuation.

To address these challenges, Total Quality Management (TQM) has emerged as a viable framework for improving organizational performance in healthcare. TQM involves four core practices: customer focus, which emphasize understanding and meeting client needs; leadership commitment, which ensures that senior management actively reaches the quality agenda; continuous improvement, which fosters ongoing efforts to refine systems and processes; and employee empowerment, which involves engaging staff at all levels to take ownership of quality outcomes. However, implementing TQM is not without obstacles. Deep-rooted leadership cultures and structural constraints often hinder full adoption, making it a labor-intensive and time-consuming endeavor (Talib et al., 2010).

In 2013, Kenya devolved health service delivery to the county level to promote access, equity, and accountability. While devolution brought promise, it also exposed gaps in leadership capacity, resource mobilization, and sustainability of reforms (Chelagat et al., 2021). Despite the increased investment, Kenya’s healthcare sector nearly doubled in value from Kshs. 51.4 billion in 2005 to Kshs. 91.4 billion in 2020 (Omore & Misuko, 2023) and the system remains under pressure from rapid population growth (2.3% annual rate) and rising demand for affordable, high-quality care (National Centre for Population Growth, 2020; Serafino, 2020).

This study, therefore, investigates the influence of TQM practices; customer focus, leadership commitment, continuous improvement, and employee empowerment on the performance of private healthcare organizations in Kenya, exploring their potential as strategic levers for sustainable growth and improved service delivery in high-burden contexts like Kisumu County.

1.2. Research Objectives

The study specific objectives were:

1) To analyze the effects of customer focus practices on performance of private health organizations in Kisumu County.

2) To assess the effects of top management commitment practices on the performance of private health organizations in Kisumu County.

3) To evaluate the effects of continuous improvement practices on the performance of private health organizations in Kisumu County.

4) To determine whether employee empowerment affects the performance of private health organizations in Kisumu County

2. Review of Literature

2.1. Theoretical Literature Review

This study was anchored on Demming theory, Upper Echelons philosophy and the BSC Model. The Deming Management Theory, originally introduced by Rungtusanatham, Ogden and Wu (2003), presents a holistic Total Quality Management (TQM) approach anchored in fourteen prescriptive principles aimed at improving organizational behavior and performance (Rungtusanatham, Ogden, & Wu, 2003). These principles are designed to address what Deming termed the “seven deadly diseases” and other systemic barriers that hinder quality and productivity. Deming’s PDCA (Plan, Do, Check, Act) cycle remains a cornerstone for applying TQM in modern settings, including private hospitals in Kisumu County. This cycle supports continuous improvement by identifying performance gaps, using patient feedback to set objectives, and implementing strategies such as staff training, integration of Quality Management Systems (QMS), and process enhancement. This method encourages a culture of ongoing evaluation and refinement, boosting service delivery, regulatory compliance, and patient satisfaction. In dynamic healthcare environments, Deming’s systems-oriented and quality-driven approach provides a practical roadmap for achieving sustainable excellence and organizational transformation.

The Upper Echelons Theory (UET), developed by Mason and Hambrick in 1984, emphasizes that an organization’s outcomes are significantly influenced by the backgrounds, values, and personalities of its top executives. When applied to Total Quality Management (TQM), UET provides critical insight into how senior leadership affects the adoption and success of quality initiatives, particularly through management commitment (Abatecola & Cristofaro, 2018). Leaders shape strategic choices and organizational culture, making their attitudes toward quality pivotal in determining performance outcomes. While many studies, including those by Ting, Azizan, and Kweh (2015), have explored the relationship between executive demographics and organizational results, there remains ambiguity around the exact influence of cognitive and psychological traits on economic performance. This study reinforces the idea that executive commitment to quality is central to achieving effective TQM and enhancing overall organizational performance.

The Balanced Scorecard (BSC), developed by Kaplan and Norton in the early 1990s, addresses the limitations of traditional financial metrics by providing a more comprehensive, strategic framework for evaluating organizational performance. In healthcare, its use has grown significantly due to its ability to align operations with customer-oriented strategies and monitor strategic implementation across all levels. Jaber and Nashwan (2022) emphasize its effectiveness in supporting adaptability to regulatory changes and enhancing accountability. A systematic review by Amer et al. (2022) found the BSC positively impacts financial outcomes and patient satisfaction, though effects on employee fulfillment were modest. Sahithi and Chodisetty (2024) further highlight the BSC’s adaptability across sectors, particularly its role in improving employee performance and organizational productivity. In this study, performance indicators such as client retention and patient satisfaction align with the customer perspective of the BSC; revenue growth and cost containment relate to the financial perspective; introduction of new services and innovation reflect the internal business process perspective; while staff training, involvement in quality initiatives, and job satisfaction speak to the learning and growth perspective. This study builds on existing research by exploring how TQM practices influence BSC-measured outcomes in private healthcare settings.

2.2. Empirical Literature Review

2.2.1. Customer Satisfaction and Performance of Private Health Organizations

According to Mehra & Sharma, (2021) in the study exploration of sustainability measures in healthcare, the researchers delved into key indicators relevant to policies, practices, and investigations. The study findings indicated` that investigations, innovation, and local manufacture play pivotal roles in sustainable healthcare. Moreover, intermediary measures such as management of waste, unified facility plan, justifiable purchasing, staff satisfaction, and eco-friendly development could serve as valuable guidelines for healthcare managers and practitioners striving to attain sustainability objectives. In this study, the researchers did not expound on TQM in which customer satisfaction is an element, however, customer satisfaction becomes one of the elements of top management commitment that this study would be interested in.

A Scoping Review by Kamaruddin, Rivai and Zulkifli (2021) on the impact of TQM on client’s level of contentment in health facility conducted by publication mapping in its deductions revealed that the most impactful component of Quality Assurance is Patient Focus. Among 25 journals surveyed, the quality aspect was prominently discussed in over 18 publications. The findings reveal a significant connection between hospital performance and the level of patient satisfaction within healthcare environments. However, the approach in this study differs from that of this study, which aims to gather primary information from participants to examine the relationship between client satisfaction and organizational performance, rather than relying on secondary analysis of published literature.

In Kenya, a descriptive cross-sectional survey conducted by Awuor (2024) to investigate operational efficiency and client satisfaction in the hotel industry in Nairobi County found that businesses can add merit and persuade clients by unceasingly tackling and improving upon client complaints. The study further notes that maintaining client allegiance leads to customers consistently seeking services from the organization. The current study seeks to substantiate these facts in the healthcare industry within Kisumu County.

2.2.2. Top Leadership Commitment and Performance of Private Health Organizations

Based on empirical research on Consequences of TQM approaches on Health facility Services Excellence in United Arab Emirates Hospitals, Aburayya, Alshurideh, Marzouqi, Diabat, Alfarsi, Suson, Bash and Salloum (2020) found strong evidence that factors such as senior leadership Obligation, Collaboration and Participation, Procedure Organization, Continuous Improvement, Institutional Ethos, and Client Focus all exert a strong positive impact on the quality of hospital service delivery. In contrast, the previous study focused on hospitals in the United Arab Emirates, whereas the present study will be conducted in Kenya, introducing a difference in context.

Alshourah (2021) in a study in hospitals in Jordan opined that top management demonstrates support for TQM through a commitment to integrating its practices across various organizational activities. The study further indicates that the absence of robust Top management commitment can impede TQM implementation resulting in poor organizational performance. Typically, top management’s commitment influences employees’ attitudes toward TQM adoption. In the healthcare sector, maintaining leadership engagement and facilitating employee training are deemed essential for organizational success. Top management serves as the primary catalyst for TQM implementation, aiming to enhance service quality and customer satisfaction in whichever institution. It is therefore the obligation of top leaders to devise effective training plans and educational initiatives to foster a culture of continuous learning among employees as a catalyst to performance.

These results are consistent with the conclusions of another descriptive research conducted by Njuguna and Muathe (2020) to evaluate the influence of Strategic Preference on outcomes of Faith based health facilities in the County Kiambu, Kenya, the study concluded that the hospitals had adopted various leadership development strategies which significantly improved service delivery. The commitment of the hospital’s leadership to service excellence was evident, with a clear emphasis placed on prioritizing leadership development initiatives. Recognizing the pivotal role of leadership in strategy execution, the hospital accorded top priority to fostering effective leadership practices. Effective leadership is crucial for successful strategy implementation, and any shortcomings in leadership can present formidable challenges. Unfortunately, the absence of commitment to leadership, particularly strategic leadership, among the top management of mission hospitals in Kiambu County has emerged as a significant barrier to their successes.

2.2.3. Continuous Improvement and Performance of Private Health Organizations

Van Kleeff, Van Harten Knies and Boselie (2023) studied the relationship between health facilities’ staff observations of Lean and its influence on their views of achievement and well-being, considering the role of autonomy. The results revealed that the impact of involvement in Continual Enhancement and Lean practices on employees’ well-being and performance perceptions is multifaceted and nuanced. Rather than a straightforward relationship, Lean practices exhibit varied associations with wellbeing and performance, depending on the specific Lean dimension. While consistent improvements portray a critical function in enhancing both interests of employees as well as their output, LT primarily influences specified aspects of output, like productivity, without significantly affecting employee wellbeing. Furthermore, the findings emphasize the importance of integrating different facets of autonomy into Lean practices.

A study carried out by Atalıç and Çiçek (2021) in Türkiye explored the attitudes of healthcare providers toward applying TQM practices as a strategy for Continuous improvement in a public hospital, providing empirical evidence supporting the credibility of healthcare quality standards as a potential solution for improving healthcare services and performance in developing countries. This study confirmed a dependable approach for assessing healthcare sector performance from the viewpoint of healthcare providers, who are key implementers of strategic initiatives, and it encourages further exploration into the effectiveness of TQM practices within the health sector.

In Kenya, Ntwiga, Muchara and Kiriri (2019) studied the impact of constant quality enhancement on clients’ fulfilment within health facilities in Nairobi, a Positivism research philosophy that deduced that continuous quality improvement has a strong and positive correlation with patients’ satisfaction in Nairobi hospitals and achieving successful continuous quality improvement entails recognizing risks to healthcare quality and implementing solutions to address them. It is, however, not clear from the study methodology and implementation whether emphasis on top management involvement as key drivers of CQI as a strategy was established. This study, therefore, seeks to determine effects of CQI as driven by the top management as strategy towards the overall quality and hospital performance.

2.2.4. Employee Empowerment and Performance of Private Health Organizations

Staff members of any organization serve as product ambassadors and crucial touchpoints for any establishment’s clients, representing key partners who can significantly influence the satisfaction level of customers. Employee engagement is vital in every industry. In a critical analysis of literature by Sugandha (2022) the repercussions and indicators of employee engagement, found that understanding the determinants of involvement helps managers and their staff create a healthy work environment suitable in fostering association among colleagues thus enhancing work performance and benefiting the entire organization. This study notes that this review considered studies that were done in India while the current study sought to substantiate these facts in healthcare context in Kisumu County, Kenya.

In another study by Wandie and Muathe (2022) investigating what improves service delivery in governmental hospitals in Kenya concluded that healthcare administrators should focus on strengthening staff empowerment, implementing and updating technological changes, ensuring consistent improvement, and offering client-centered services. The study further recommends that organizations identify and prioritize the greatest critical TQM approaches that align with their enterprise goals, strategic direction, expected outcomes, and existing conditions. For instance, leadership can boost employee involvement by establishing a structure that promotes active participation in TQM initiatives within their institutions. Although the study emphasizes the value of employee engagement, it was conducted in government hospitals in Nairobi County. In contrast, the present study focused on evaluating the influence of employee engagement within private healthcare facilities in Kisumu County.

A descriptive survey conducted by Mwikali and Bett (2019) found compelling evidence that TQM as a practice exert a substantially positive influence on services offered within Nairobi Hospital, in Kenya. The research indicated a strong embrace of employee engagement as a TQM practice, manifested through active staff involvement in decision-making processes and system enhancements. The study also highlighted the hospital’s noteworthy customer focus, with a significant emphasis placed on understanding and addressing customer needs, expectations, values, and engagement as a catalyst to effective communication which emerged as another pivotal TQM practice embraced by the highly performing Hospital. Furthermore, the research underscored the considerable commitment of the hospital’s top management to quality service delivery. This commitment was evident in the establishment of vibrant vision and mission statements, defined aims and morals, robust structures and guidelines, effective channels to communicate, incentivization structures, and resource allocation mechanisms geared towards promoting service excellence within the facility.

3. Research Methodology

3.1. Research Design

This study adopted cross-sectional survey design. According to Wang and Cheng (2020), a cross-sectional design is an observational study design where data is gathered from a populace at a distinct point in time. In this type of study, researchers assess both the outcomes and exposures of the subjects simultaneously. It’s often likened to taking a “snapshot” of a group of individuals to understand their characteristics and relationships at a particular moment. This design is suitable for the study as data was collected from participants at one moment making the study implementation relatively quick and inexpensive to conduct considering the available resources.

3.2. Target Population, sampling and Sample Size

The target population comprised departments within the hospitals’ management structures. The unit of analysis included level four and above private hospitals in Kisumu County according to KMPDC (2024). Of the possible 13 hospitals, the researcher proposes a purposive sampling of 6 hospitals as unit of analysis. According to census report for hospitals by Ministry of Health (2023), government, private-owned, and church-based hospitals constituted 47%, 46%, and 8% of the hospitals in Kenya, respectively. Level six hospitals were exclusively owned by the government, 49% of Level four and 44% of Level five of hospitals belonged to the private sector. Nation Newspaper (2020) in explaining the requirements for level four hospitals notes that this level of facility has more advanced services and specialty workforce than level three, a consideration that guided the purposive sampling of the hospitals. The unit of observation incorporated includes departments in which a representative was interviewed. The unit of observation chosen is directly involved in the process of TQM implementation, monitoring, and reporting.

This research utilized multistage sampling techniques. The initial stage of sampling used a purposive sampling method to select private health organizations of level four and above. This technique was used since it permits exclusive focus on the population of specific interest in this case level four and above private health organizations that are represented in the County Government of Kisumu Private Hospitals Caucus of Human Resource Managers.

In the second stage, departments within these organizations were randomly selected, and their representatives were recruited as study participants. This approach was used in the second stage because it is effective when the study aims to produce results that can be generalized to the entire population. In data collection execution, the Hospital Management or Ethics Committee was engaged and requested to approve data collection from the facility. The organizational structure served as the entry point for identifying unit managers, senior supervisors, and senior leadership teams. Using the hospital leadership positions listed in an Excel sheet, random sampling was conducted in SPSS to select participants. The researcher then visited each selected office holder for consent and data collection.

This study employed Yamane’s (1967) formula in computation of the number of participants as given below.

$n=\frac{N}{1+N\left(e^2\right)}$

Where by: n = no. of samples; N = total population; and e = error margin/margin of error (0.05)

$n=\frac{146}{1+146\left({0.05}^2\right)}=107$

3.3. Data Collection and Analysis

This research utilized electronic structured surveys based on Likert scale administered digitally through Microsoft/Google forms as data collection instruments. Google Forms, like Microsoft Forms, are versatile and user-friendly tools for online surveys and data collection, developed by Google and Microsoft. These platforms feature intuitive interfaces and seamlessly integrate with Excel, allowing users to easily create customized surveys and questionnaires. They offer a range of question types, such as multiple-choice, open-ended, and scale questions (Jaiswal, 2024). According to Jebb, Ng and Tay (2021), utilization of the Likert scale is based on its benefits, some of which are: the ability to efficiently collect data from numerous respondents in a short span of time, their capacity to generate highly reliable estimates of individual abilities, and the potential to validate interpretations derived from the collected data.

Statistical inferences and descriptions utilized in analysis of quantifiable information while content was analyzed to examine the narratives and the presentation of observations is proposed to be done in tables, graphical as well as in prose. Multiple regression model was employed to analyze data in accordance with the following equation.

$Y={\beta }_0+{\beta }_1{X}_1++{\beta }_2{X}_2+{\beta }_3{X}_3+{\beta }_4{X}_4+\epsilon$

Where by, Y = Hospital Performance; X₁ = Customer Satisfaction index; X₂ = Top management Commitment; X₃ = Continuous Improvement; X₄ = Employee Engagement; β₀ = Constant Term; β₁, β₂, β₃, β₄ = Beta Coefficients; ε = Error Term.

4. Research Findings and Discussion

A total of 107 digital questionnaires were sent via email and WhatsApp to the selected departmental representatives across various hospitals. Out of these, 75 responses were received, resulting in an approximate response rate of 70%. According to Jaiswal (2024) a meta-analysis on Response rates of online surveys found that the average response rate for education-related research is 44.1%, highlighting that response rates can vary due to multiple factors. Consequently, a 70% response rate indicates a satisfactory level of participant engagement, enabling meaningful data analysis.

4.1. Descriptive Statistics

The study analyzed the core variables using descriptive statistics, including mean and standard deviation. These statistical measures provided a foundation for understanding the fundamental characteristics of the sample, ensuring a structured approach to quantitative data analysis.

4.1.1. Customer Focus and Performance of Private Hospitals

Table 1 presents participants’ perceptions of the hospital’s customer feedback mechanisms. It includes responses from 75 participants, evaluating various aspects of feedback management using a five-point Likert scale (1 = Strongly Disagree, 5 = Strongly Agree).

Table 1. Descriptive statistics on customer focus.

Table 1 highlights the presence of strong mechanisms for managing customer feedback within the private hospitals in Kisumu County, with all aspects averaging a score of 4.2, corresponding to “agree” on the scale. The highest mean score (4.36) indicates a well-established customer feedback mechanism, followed by mechanisms to investigate and act on feedback (mean = 4.17), categorize feedback into positives and negatives (mean = 4.13), monitor and trend feedback (mean = 4.09), and the effectiveness of the customer support unit (mean = 4.03). The standard deviations, ranging from 1.022 to 1.190, indicate some variability in responses. Overall, these findings suggest a structured and systematic approach to customer feedback management, reinforcing the principles of TQM.

The findings concur with the study by Ferreira et al. (2023) emphasizes the importance of patient satisfaction surveys as tools for quality improvement in hospitals. The study suggests that effectively analyzing and acting upon patient feedback can lead to enhanced service delivery and patient outcomes. In another study, Leivang and Sharma (2023) also highlight that higher service quality positively influences patient satisfaction, which in turn can lead to improved hospital performance. Additionally, Félicité et al., 2023) in their study examined the impact of customer care practices on patient satisfaction and loyalty and realized that effective customer care practices, including robust feedback mechanisms, significantly contribute to patient satisfaction and can lead to increased patient loyalty.

4.1.2. Top Leadership and Performance of Private Hospitals

Table 2 evaluates top management’s commitment, strategic planning, resource allocation, and interdepartmental collaboration within private hospitals in Kisumu County.

Table 2. Descriptive statistics on top leadership.

The highest mean score (4.36) indicates that top management’s commitment significantly influences hospital performance. Budget approval mechanisms (mean = 4.16), strategic plan development (mean = 4.04), and leadership in championing strategic plan implementation (mean = 4.01). Interdepartmental collaboration programs scored lower (mean = 3.77), suggesting potential areas for improvement. The standard deviations, ranging from 0.864 to 1.247, indicate some variability in responses. Overall, the findings underscore the vital role of leadership in shaping hospital performance.

These findings align with the study by Giese et al. (2024) that found better patient experience is associated with a higher proportion of elective patients, greater revenue, and lower costs in hospitals. This suggests that effective leadership in implementing patient-centered strategies can lead to improved financial performance. In Vietnam, Nguyen et al. (2021) identified four dimensions of service quality emotion, function, social influence, and trust that significantly impact patient satisfaction and perceived value. The study emphasizes the need for hospital leaders to invest in social branding and e-services to enhance customer relationships and loyalty. Additionally, research by Félicité et al. (2023) in Burundian private hospitals underscores the importance of leadership in fostering a culture that prioritizes patient needs and feedback.

4.1.3. Continual Improvement and Performance of Private Hospitals

Table 3 evaluates the role of continuous improvement practices in enhancing overall hospital performance outcomes.

Table 3. Descriptive statistics on continual improvement.

The high mean score (4.36), equivalent to “agree” on the Likert scale, for the facility’s expenditure monitoring mechanism reflects strong financial oversight. However, the neutral response on reported expenditure reduction (mean = 3.40) suggests that while controls exist, achieving actual cost reductions remains challenging. This aligns with findings by Chepkirui (2021) which indicated that effective internal controls enhance financial performance in Kenyan hospitals by improving accountability and efficiency. However, these controls as continual improvement practices do not directly lower expenditure due to external economic factors such as inflation, fluctuating operational costs, and regulatory requirements, limiting cost-cutting efforts despite robust monitoring systems.

Additionally, Jumapili and Muathe (2025) further assert the role of quality management in healthcare success. However, feedback mechanisms for staff and their impact on retention scored a mean close to “neutral” on the Likert scale, indicating mixed perceptions and inconsistencies in implementation. Research by Njuguna et al. (2021) suggests that while structured feedback enhances performance, factors such as workload and career growth play a significant role in staff retention. Similarly, Kerich et al. (2024) highlights the importance of actionable employee engagement strategies, which align with the Ministry of Health (2021) report, underscoring the significance of data-driven continuous improvement in enhancing healthcare service delivery.

4.1.4. Employee Empowerment and Performance of Private Hospitals

Table 4 below presents descriptive statistics on employee empowerment within private hospitals.

Table 4. Descriptive statistics of employee empowerment.

The findings suggest that while policies on capacity development (Mean = 3.72) and delegation of duties (Mean = 4.01) are in place, the actual execution of these policies, such as implementing capacity development initiatives appears to lag with a near “neutral” (Mean = 3.40), indicating potential gaps between policy formulation and practice. Other practices such as employee engagement in hospitals activities (Mean = 3.69), encouragement for participation scoring higher (Mean = 3.97), feedback mechanisms (Mean = 3.68) and formalized delegation processes (Mean = 3.84) all scored weak “agree”. Overall, employee empowerment is perceived to positively influence hospital performance (Mean = 3.95), underscoring the importance of effectively implementing structured policies and engagement programs.

A study conducted by Ntwiga et al. (2021) in Nairobi, Kenya, examined the impact of employee empowerment on competitive advantage within hospitals with the findings indicating that employee empowerment significantly predicted competitive advantage, with high responsiveness, good attitude, reliability, empathy, and assurance to patients enhancing both patient and employee satisfaction. The study emphasized the importance of realigning staff inputs towards improving patient experiences and considering individual employee performance alongside team dynamics. A critical literature review by Afram et al. (2022) highlights that organizations implementing empowerment strategies often experience enhanced effectiveness, increased employee engagement, and improved motivation, leading to the successful achievement of business objectives. Similarly, a study by Kyei-Frimpong et al. (2024) in Ghana’s hospitality sector a service industry like private hospitals found a strong correlation between employee empowerment and organizational commitment, particularly with the perceived supervisory support.

4.1.5. Performance of Private Hospitals

Table 5 presents descriptive statistics on key hospital performance indicators, with grading categorized as follows: 1 = 1% - 5%, 2 = 5% - 10%, 3 = 10% - 15%, 4 = 15% - 20%, and 5 = over 20% growth.

Table 5. Descriptive statistics on performance of private hospitals.

The data from 75 respondents indicate notable successes and areas requiring improvement. Client retention (mean = 3.80) and service quality improvement (mean = 3.84) suggest growth nearing 20%, reflecting positive customer experiences. New product and service development (means of 3.64 and 3.69, respectively) show innovative efforts translating into an estimated 15% - 20% growth. However, employee satisfaction (mean = 3.01) and staff development opportunities (mean = 2.91) indicate growth of less than 15%, highlighting areas needing attention and so is cost reduction efforts (mean = 3.00), suggesting no significant decline in operational expenses despite monitoring efforts. Financially, the hospital has recorded growth in annual gross revenue (mean = 3.65) to close to an average of 18%, supporting a positive trajectory in service expansion and customer retention.

A study by Jumapili and Muathe (2025) highlighted that strengthening customer focus and continuous improvement significantly enhances the performance of public healthcare institutions in Kenya. This aligns with the county healthcare efficiency study by Moses et al. (2021), which found that delays in fund allocation and inefficiencies in budget absorption negatively impact performance. This study additionally observed that Mandera County had the highest technical efficiency growth (18.34% per year), while other counties declined in efficiency due to operational bottlenecks. This suggests that healthcare institutions adopting structured quality improvement frameworks may be more likely to experience sustained financial growth and service expansion. Health workforce study by Okoroafor et al. (2022) indicated that Kenya’s healthcare workforce density was only 68% of the required SDG threshold, signaling a need for better resource allocation. TQM principles emphasize staff empowerment, continuous capacity development and engagement to improve performance and service delivery aligning with this study finding that employee satisfaction and development opportunities scored the lowest, reinforcing the need for enhanced workforce management strategies under TQM frameworks.

4.2. Inferential Statistics

Multivariate regression analysis was conducted to examine the impact of customer focus, top leadership, continual improvement, and employee empowerment on organizational performance of private health organizations in Kisumu County, Kenya. The R-squared values are presented in Table 6.

Table 6. Model summary for TQM practices and Organizational performance

a. Predictors: (Constant), Employee Empowerment, Customer Focus, Continual Improvement, Leadership

The model summary indicates that the regression model, which includes customer focus, continual improvement, top leadership and employee empowerment as predictors, has an R-squared value of 0.659. This suggests that approximately 65.9% of the variance in the dependent variable (organizational performance) can be explained by these predictors collectively.

An analysis of variance (ANOVA) is used to assess whether the model is a good fit for data. The F-statistics and its corresponding p-value in the ANOVA table help determine the statistical significance of the overall regression model. The results are presented in Table 7.

Table 7. ANOVA for TQM practices and organizational Performance.

a. Dependent Variable: Organization Performance; b. Predictors: (Constant), Employee Empowerment, Customer Focus, Continual Improvement, Leadership

As shown in Table 7, the F-calculated (106.033) was greater than F-critical from the F-value (2.74) in the distribution table. In addition, the p-value (0.000) was less than the significance level of 0.05. Therefore, there is a significant relationship between the predictors (customer focus, continual improvement, top leadership and employee empowerment) and the dependent variable (organizational performance).

Table 8. Coefficients for TQM practices and Organizational Performance.

a. Dependent Variable: Organization Performance.

Regression equation for the unstandardized coefficients was.

Y = 0.744 + 0.194X₁ + 0.186X₂ + 0.212X₃ + 0.394X₄

As shown on Table 8 above, the results show that customer focus practices have a positive and significant effect on the organizational performance of private health organizations in Kisumu County, Kenya (β₁ = 0.194, p = 0.010). With a p-value less than 0.05, customer focus has a statistically significant effect on organizational performance. This implies that a one-unit increase in customer focus is associated with a 0.194-unit increase in organizational performance, suggesting that prioritizing client needs, expectations, and satisfaction is crucial in enhancing institutional outcomes. The findings are in agreement with Chidozie and Anayochukwu (2019) observation that customer focus has a positive effect on organizational performance. In addition, the findings align with Mehra and Sharma (2021), who assert that customer-centric approaches enhance organizational effectiveness by fostering stronger client relationships, improving service delivery, and promoting continuous feedback mechanisms that lead to service innovation. Furthermore, the results are supported by Kamaruddin et al. (2021), who demonstrate that customer-oriented strategies positively affect institutional performance. From a theoretical standpoint, this relationship is consistent with Total Quality Management (TQM) principles, particularly the emphasis on customer focus as a driver of performance and competitive advantage.

The findings demonstrate that top leadership practices have a positive and statistically significant effect on the organizational performance of private health organizations in Kisumu County, Kenya (β₂ = 0.186, p = 0.011). Since the p-value is less than 0.05, top leadership has a statistically significant impact on the organizational performance of private health organizations. This indicates that a one-unit increase in the quality or effectiveness of top leadership results in a 0.186-unit improvement in organizational performance. These results underscore the critical role of strategic leadership in setting organizational vision, shaping culture, and aligning operational goals with broader performance objectives. The outcome supports Alshourah’s (2021) study conducted in Jordanian hospitals, which found that transformational leadership styles significantly enhance institutional performance by motivating staff, fostering accountability, and promoting innovation in service delivery. These consistent findings across different contexts suggest a universal applicability of effective leadership principles. The results can also be theoretically anchored in the Upper Echelons Theory, which posits that the experiences, values, and personalities of top leaders significantly shape organizational outcomes. Therefore, for private health organizations in Kenya, investing in the development and empowerment of top leadership is not only a strategic necessity but also a key performance determinant.

Further, the results show that continual improvement practices have a positive and significant effect on organizational performance (β₃ = 0.212, p = 0.003). Since the p-value is less than 0.05, continual improvement shows a statistically significant effect on the performance of private health organizations. This implies that for every unit improvement in continual improvement practices, such as reduction in OPEX, improved SQ and employee satisfaction index, organizational performance improves by 0.212 units. The results support Weiner et al. (2006), who argued that continual improvement mechanisms, particularly in healthcare, lead to better patient outcomes, streamlined operations, and increased employee accountability. Likewise, Van Kleeff et al. (2023) confirmed that the application of continuous improvement cycles such as Plan-Do-Check-Act (PDCA) in health institutions improves decision-making and responsiveness to dynamic healthcare needs. In the Kenyan context, Ntwiga et al. (2019) found that continuous quality improvement practices have a significant impact on patient satisfaction, especially when supported by data-driven performance monitoring. These findings collectively point to the strategic role of continual improvement in creating a culture of excellence, innovation, and adaptability factors that are particularly critical in complex and rapidly evolving health service environments.

Also, the results show that employee empowerment has a positive and significant effect on organizational performance (β₄ = 0.394, p = 0.000). Because the p-value is much less than 0.05, employee empowerment exhibits a highly significant effect on the performance of private health organizations. This indicates that for every unit an increase in employee empowerment, through capacity development opportunities, activities participation rate and recognition, organizational performance improves by 0.394 units. This notable effect size reinforces the idea that empowering employees is a critical driver of institutional efficiency, service quality, and responsiveness. These findings are consistent with Sugandha (2022), who asserted that empowered employees demonstrate higher levels of innovation, job satisfaction, and commitment to organizational goals. Similarly, Wandie and Muathe (2022) found that empowering healthcare workers in public hospitals enhanced service delivery and patient care outcomes. Mwikali and Bett (2019) also supported this view, noting that employee empowerment, as a core element of Total Quality Management (TQM), significantly improved healthcare service quality at Nairobi Hospital. Framing these findings within Philip Crosby’s quality management theory, which emphasizes “doing it right the first time” and the concept that quality is conformance to requirements, employee empowerment becomes a foundational mechanism for achieving zero-defect performance.

5. Conclusion

The study concludes that customer focus practices have a positive and significant effect on organizational performance. These practices help private health organizations better understand patient needs, resulting in improved service delivery and overall performance in Kisumu County, Kenya. In addition, the study concludes that top leadership practices, including strategic planning, budget approval, and collaboration, have a positive and significant effect on the performance of private health organizations. Further, the study concludes that continuous improvement practices have a positive and significant effect on organizational performance. Moreover, the study concludes that employee empowerment practices have a positive and significant effect on the performance of private health organizations. Initiatives like capacity development, staff involvement in activities, and recognition of contributions promote staff motivation and engagement.

5.1. Policy Recommendation

Considering the study findings, it is recommended that health policy frameworks for private healthcare organizations in Kisumu County prioritize the institutionalization of robust customer focus policies. These should mandate the development of structured feedback systems that categorize input into positive and negative responses, alongside the implementation of tools for monitoring satisfaction trends. Policies should also require the proper resourcing and empowerment of customer support units to ensure a timely and effective response to patient concerns. Additionally, policy should promote strategic leadership practices by mandating comprehensive strategic planning, participatory budgeting processes, and performance monitoring systems to support informed decision-making and interdepartmental coordination.

Moreover, policies should encourage continuous improvement by requiring healthcare organizations to adopt standard procedures for tracking operational expenditures, enhancing service quality, and aligning staff retention with patient feedback systems. Regulatory guidelines should also support the integration of periodic performance evaluations to ensure sustained improvements in healthcare delivery. Lastly, policy should promote employee empowerment through the establishment of capacity development programs, structured delegation practices, and frameworks for staff engagement in institutional processes. Formal recognition systems and ongoing training should be embedded in policy to foster a motivated and productive workforce, ultimately improving organizational outcomes and service quality in the healthcare sector.

5.2. Limitations and Future Research Direction

The purpose of this research was to examine how customer focus practices, top leadership commitment, continuous improvement practices, and employee empowerment affect the performance of private health organizations in Kisumu County, Kenya. The study focused solely on private health organizations in Kisumu County, which may differ from those in other regions. Therefore, the study recommends that additional research be conducted in other counties or regions to gain a broader understanding of the factors influencing the performance of private health organizations across Kenya. Furthermore, while the study found that the four variables accounted for 65.9% of the performance variance, there is still an unexplained variance of 34.1%. As a result, the study calls for further exploration into other organizational practices (34.1% of the total) and external factors that may also impact the performance of private health organizations, to fully understand the comprehensive drivers of success.

Acknowledgements

We gratefully acknowledge Professor Muathe for his invaluable leadership and guidance throughout this research process. We also extend our sincere appreciation to the management of Aga Khan Hospital Kisumu, Avenue Hospital Kisumu, Kisumu Specialists Hospital, Synergy Clinics Hospital, and Nightingale Hospital for granting permission to collect data within their facilities. Their support was instrumental to the successful completion of this study. Lastly, we thank all participants and contributors whose input enriched the research outcomes.

Conflicts of Interest

The authors declare no conflicts of interest regarding the publication of this paper.

References