The Relationship Between Hospital Management Practices and Quality of Care: A Global Systematic Review
Ensuring high quality of care is paramount for countries aiming to achieve universal health coverage, particularly as poor quality of care is estimated to contribute to millions of deaths annually in low- and middle-income countries (LMICs). While much research has focused on health technologies, medical training, and clinical audits, less attention has been paid to broader organization-level factors, such as hospital management, that shape quality of care. Despite a widely held view that effective management improves organizational performance, the relationship between management practices and health service delivery in the complex environment of hospitals is not always straightforward. High-profile inquiries have even highlighted instances where incompetent hospital management led to catastrophic failures in patient care. However, hospitals differ from other organizations, with potential factors such as intertwined managerial and clinical roles, competing demands for quality and financial sustainability, and specific incentives in public/not-for-profit settings possibly weakening the link between management practices and performance.
To address this gap, a comprehensive global systematic literature review was conducted to synthesize quantitative evidence on the link between the adoption of management practices and quality of care in hospitals. The review aimed to summarize this evidence across all income settings and describe the range of tools used to measure management practices. It included empirical studies from January 1, 2000, onwards, examining the quantitative association between hospital management practices and various dimensions of quality of care, including structural quality (resource availability), clinical quality (adherence to guidelines), health outcomes, and patient satisfaction or experience with care. The search spanned five major databases and utilized active learning software to enhance efficiency in screening a large volume of records.
Key Findings: The review analyzed 25 studies, comprising a total of 111 associations, revealing mixed global evidence on the relationship between management practices and quality of care.
- Overall Association: Out of 111 associations tested, 55 (49.5%) were significantly positive, 1 (1%) was significantly negative, and 55 (49.5%) were null. This indicates a similar proportion of positive and null associations across studies.
- Quality of Care Dimensions:
- Structural Quality: The majority of associations (79%) between management practices and structural quality (e.g., availability of drugs, equipment, staff, guidelines) were significantly positive.
- Clinical Quality: A substantial proportion of associations (60%) were significantly positive for clinical quality (e.g., provider compliance with care guidelines).
- Health Outcomes: Over half of the associations (57%) with health outcomes (e.g., mortality indicators) were significantly positive.
- Patient Satisfaction: In stark contrast, most associations (80%) between hospital management practices and patient satisfaction or experience with care were found to be null. This limited association may be due to management processes primarily focusing on improving clinical care rather than patient experience, and the inherent difficulties in reliably measuring self-reported patient satisfaction.
- Geographic and Sectoral Distribution: The findings showed little difference in the proportion of significant positive and null associations between studies conducted in high-income countries versus LMICs. When examining sector-specific associations, studies conducted in the public sector only showed a higher proportion of significantly positive associations (79%) compared to those in the private sector only (43%).
- Methodological Limitations: A crucial limitation identified was the risk of bias introduced by nonrandomized study designs. All included studies had at least a moderate risk of bias, and those with a serious risk of bias actually reported a higher proportion of significantly positive associations compared to those with moderate risk of bias.
Implications for Future Research: The mixed findings, especially the evidence of positive associations in certain settings, underscore the need for further investigation through intervention studies or natural experiments, ideally utilizing randomized designs. Such future research should leverage methodological developments in quantitatively measuring management practices and aim to develop interventions that enhance hospital management to positively impact quality of care and health outcomes. This would also benefit from a more in-depth understanding of the causal pathways between management and health outcomes, possibly through defining intermediary outcomes and incorporating qualitative health systems research.
Reference Ward, C., Phiri, E. R. M., Goodman, C., Nyondo-Mipando, A. L., Malata, M., Manda, W. C., Mwapasa, V., & Powell-Jackson, T. (2025). What is the relationship between hospital management practices and quality of care? A systematic review of the global evidence. Health Policy and Planning, 40(3), 409–421. https://doi.org/10.1093/heapol/czae112
