Administrative Control and Sustained Quality Improvement in Hospitals: Evidence from a Conflict-Affected Health System

Abstract Background Hospitals increasingly rely on performance measurement, accreditation, and corrective-action systems to improve quality; however, less is known about whether managerial control helps quality gains endure, particularly under persistent resource disruption. Purpose This study examined the relationship between administrative control effectiveness (ACE) and sustained quality improvement (SQI) in private hospitals and tested whether conflict-related resource constraints (CRRC) weaken this relationship. Methodology/Approach: A multicenter, time-lagged survey was conducted among 287 managers and healthcare professionals from four category-A private hospitals in Sanaa, Yemen. The ACE was modeled as a higher-order construct comprising performance standard setting, performance measurement and monitoring, variance identification and diagnosis, corrective action, managerial follow-up, and accountability. The CRRC captures workforce, financial, supply, infrastructure, and operational constraints. Partial least squares structural equation modeling was used to assess measurement quality, structural relationships, moderation, predictive performance, and robustness. Results ACE was positively associated with the SQI (β = .548, 95% CI [.451, .640], p < .001; f² = .326). CRRC was negatively associated with the SQI (β = −.217, p < .001) and significantly weakened the ACE–SQI relationship (β = −.184, 95% CI [− .267, − .099], p < .001). The model explained 52.1% of the variance in the SQI and demonstrated satisfactory measurement quality and predictive performance. Conclusion Administrative control appears most useful for sustaining quality when monitoring is connected to diagnosis, corrective action, follow-up, and accountability. Its effectiveness, however, is constrained when hospitals lack the resources required to act on performance information. Practice Implications: Hospital executives should evaluate control systems on the basis of their ability to close the performance‒feedback loop rather than on the basis of the volume of indicators or reports produced. Under severe resource constraints, corrective-action systems should explicitly connect identified deviations with resource prioritization, escalation, and contingency planning.