Healthcare service quality management: Evidence from Morocco

International Journal of Applied Economics, Finance and Accounting ISSN 2577-767X Vol. 19, No. 1, pp. 196-215 2024 DOI: 10.33094/ijaefa.v19i1.1632 © 2024 by the authors; licensee Online Academic Press, USA Healthcare service quality management: Evidence from Morocco Manal Jeyar1* Abdeslam El Moudden2 Omar Taouab3 Management Business Department, National School of Business and Management, Ibn Tofail University, Kenitra, Morocco. 1,2,3 Email: jeyarmanal1@gmail.com Email: elmoudden.abdesselam@uit.ac.ma 3 Email: taouabomar@yahoo.fr 1 2 Licensed: This work is licensed under a Creative Commons Attribution 4.0 License. Keywords: Information systems Integrated management Performance Quality management Statistical modeling. JEL Classification: I15; I18; H11; C38. Received: 10 January 2024 Revised: 29 March 2024 Accepted: 23 April 2024 Published: 20 June 2024 (* Corresponding Author) Abstract This paper empirically evaluates the influence of implementing quality, safety, environment and information systems security practices on the organizational performance and overall quality of healthcare organizations in the Moroccan context using data from a sample of 50 healthcare entities in the Rabat-Salé-Kénitra region selected from a pool of 76 organizations. This research employs the partial least squares (PLS) method for analysis to test hypotheses regarding the nature of health service quality in Morocco across various forms. The outcomes of this study reveal a significant and positive relationship between organizational performance in Moroccan healthcare facilities and adopting practices emphasizing quality, safety, environment and information security systems. Notably, organizations incorporating these practices generally demonstrate heightened levels of performance. This study posits that the incorporation of an integrated management system can catalyse continuous improvement and enhanced performance within the Moroccan healthcare sector. These results suggest that the implementing integrated management systems could contribute to ongoing improvement and elevate organizational performance standards throughout the broader healthcare sector. However, generalizing these findings to all Moroccan healthcare facilities requires a larger sample spread across all Moroccan regions to enable a comprehensive understanding of the impact of these practices on organizational performance across the entire healthcare landscape of Morocco. Funding: This study received no specific financial support. Institutional Review Board Statement: The Ethical Committee of the Ibn Tofail University, Morocco has granted approval for this study (Ref. No. ETH-2024-001). Transparency: The authors confirm that the manuscript is an honest, accurate, and transparent account of the study; that no vital features of the study have been omitted; and that any discrepancies from the study as planned have been explained. This study followed all ethical practices during writing. Data Availability Statement: The corresponding author may provide study data upon reasonable request. Competing Interests: The authors declare that they have no competing interests. Authors’ Contributions: Both authors contributed equally to the conception and design of the study. Both authors have read and agreed to the published version of the manuscript. 1. Introduction Critical challenges surrounding service and work quality persist presenting variations based on the organization type such as public, semi-public or private in the Moroccan healthcare sector. These challenges carry substantial implications for citizens' health security, a concern further heightened by the ongoing COVID-19 pandemic. The pandemic has accentuated the immediate need for optimized and efficient management of logistical and human resources. The examination of establishing or restoring a specific quality management system for healthcare organizations becomes indispensable with a focus on patients rather than generic consumers given the unique clientele in healthcare. Therefore, tailored scientific research studies for each country are highly desirable. Furthermore, the dual 2RM methodology aims to enhance operational © 2024 by the authors; licensee Online Academic Press, USA 196 International Journal of Applied Economics, Finance and Accounting 2024, Vol. 19, No. 1, pp. 196-215 efficiency in the healthcare sector in Morocco by balancing performance considerations between risk and profitability (Jeyar, El Moudden, & Taouab, 2023). The expansion of the national health insurance (NHI) program and the subsequent increase in social coverage foresee a surge in pressure and demand for both public and private healthcare services in the Moroccan context. This raises a crucial question regarding the ability of these services to cope with the escalating demand for access while upholding an acceptable level of quality and performance. The development of a management system is essential for ensuring the quality of healthcare services and their practical implementation. This system is designed to analyze and trace the origins of anomalies, facilitating quick and comprehensive solutions upstream and downstream. Realizing this goal necessitates a reliable information system for the real-time detection and identification of anomalies and their sources. The Moroccan healthcare system exhibits a dynamic interplay between the public and private sectors, offering primary care and hospital services across the nation. The system faces persistent challenges including a shortage of healthcare professionals, access disparities, high fees and regional variations despite notable progress in enhancing accessibility and service quality. Structural components encompass 2,985 primary healthcare centres and 165 hospitals in the public sector, 384 private clinics and 9,603 private practices in the private sector primarily concentrated in urban areas along the northern Atlantic coast. Human resource shortages persist with a physician density of 71 per one hundred thousand inhabitants and a density of 93 nurses and midwives per one hundred thousand inhabitants (World Health Organization, 2021). The ongoing reforms in Morocco's healthcare sector involve the creation of 12 new regions and the introduction of generalized health insurance known as RAMED (Régimed' Assistance Médicale or Medical Assistance Scheme) in 2012. RAMED is a government-sponsored health insurance program aimed at providing access to free healthcare services in the public sector for individuals who are economically disadvantaged to expand access to free public sector healthcare for 8.5 million individuals. Efforts are also underway to extend NHI coverage to self-employed workers constitute a third of the population. However, the expansion of NHI has led to increased healthcare service demands resulting in imbalances in service quality due to resource constraints. This necessitates an in-depth exploration of the existing healthcare model intending to develop a roadmap for achieving high-quality healthcare services. The roadmap seeks to optimize management rationally and efficiently guided by empirical analysis conducted on 50 healthcare organizations within the Rabat-SaléKénitra region. A collaborative strategy is necessary to raise the quality of treatment and strengthen facility management to address obstacles to Morocco's healthcare system improvement (Zakariae & Zouhair, 2023). The implementation of integrated management systems (covering quality, safety, environment and information systems) in the Moroccan healthcare sector should be carefully customized to its specific requirements avoiding mere replication from other organizational experiences. A unified and customized approach is required because of the significant risks involved in providing healthcare services. This work explores the factors contributing to improving quality in the Moroccan healthcare sector, emphasizing their interaction with the specific integrated management system and required information systems. We aim to delve into the nature and implementation mode of specific integrated management systems for healthcare organizations in Morocco informed by the analysis of collected data and derived needs adopting a structural equation modelling approach. The second section presents the literature review to identify the variables of our model. The third section covers the data and methodology employed in the study. Subsequently, we present the analysis of the obtained results and engage in a thorough discussion before arriving at conclusive remarks. This systematic approach ensures a cohesive exploration of the factors influencing quality improvement in the Moroccan healthcare sector. 2. Literature Review Two pivotal constructs are under scrutiny through an examination of factors enhancing the quality of Morocco's health sector. The ensuing challenges serve as a catalyst for comprehensive scientific research endeavours concentrating on analyzing the dynamics and relationships between these constructs. Numerous studies concentrate on the intricate interplay between practices related to quality, safety, environment and information systems security and the criteria governing the performance of health organizations. 2.1. Quality, Safety, Environment and Information System Security Practices The practices related to quality, safety, environment and information system security in the healthcare sector encompass a comprehensive set of measures and protocols designed to ensure high standards in healthcare services. These practices address various aspects including patient care quality, safety protocols, environmental sustainability and the security of information systems within healthcare organizations. Implementation of these practices is crucial to uphold excellence and compliance in the healthcare sector. © 2024 by the authors; licensee Online Academic Press, USA 197 International Journal of Applied Economics, Finance and Accounting 2024, Vol. 19, No. 1, pp. 196-215 These practices have been addressed in numerous studies highlighting the significance and intricacy of their implementation. Quality plays a pivotal role in organizational performance and stakeholder satisfaction (Ramayah, Samat., & May‐Chiun, 2011) and is integral to production and management operations (Asif, Joost de Bruijn, Douglas, & Fisscher, 2009). Beyond producing goods or services in the right quantity and time ensuring they meet required quality standards is crucial for competitiveness and profitability (Azam, Rahman, Talib, & Singh, 2012) (see Table 1). Table 1. Some quality practices as per a literature review. Authors Quality practices or dimensions Thiagaragan, Zairi, and Dale (2001) 1. 2. 3. 4. 5. 6. 1. 2. 3. 4. 5. 1. 2. 3. 4. 5. 6. 7. Thai Hoang, Igel, and Laosirihongthong (2006) Bon and Mustafa (2013) Systematic analysis Training and support Continuous improvement Planning management Staff motivation: Rewards and recognition Customer satisfaction Leadership People management Process and strategy management Innovation climate System analysis Executive leadership Employee involvement Employee empowerment Customer focus Training Information analysis Continuous improvement Number of practices employed 6 5 7 Security is vital to prevent increased anomalies and malfunctions with potentially wide-reaching consequences especially in healthcare (Chiu et al., 2009; Nancy et al., 2006). Integrating security into an organization's risk and quality management is essential (Dimitrov, Panevski, & Nikolov, 2016) (see Table 2). Table 2. Some security practices as per a literature review. Authors Security practices or dimensions Vinodkumar and Bhasi (2011) Fernández-Muñiz, Montes-Peón, and Vázquez-Ordás (2012) Tumbaco, Alcivar, and Merchán (2016) Morgado, Silva, Fonseca (2019) and 1. 2. 3. 4. 5. 1. 2. 3. 4. 5. 6. 1. 2. 3. 4. 5. 6. 1. 2. 3. 4. 5. 6. 7. Executive commitment Security training Employee awareness Security rules and procedures Worker participation in security Hazard and risk identification Evaluation and control measures Risk management Legal requirements Emergency preparedness and response Performance measurement and monitoring Organizational commitment Planning and hazard identification Leadership Planning Support and operations Health and safety policy Reduction of occupational accidents Increase in satisfaction Employee motivation Reduction of accident and occupational illness costs Improvement in product and service quality Decrease in absenteeism Increase in productivity 198 © 2024 by the authors; licensee Online Academic Press, USA Number of practices employed 5 6 6 7 International Journal of Applied Economics, Finance and Accounting 2024, Vol. 19, No. 1, pp. 196-215 Effective internal and external organizational management enhances quality and security benefiting resource allocation particularly in healthcare. An environmental management system is a crucial tool for efficient activity and environmental aspect management (Campos, de Melo Heizen, Verdinelli, & Miguel, 2015) involving a streamlined process approach and stakeholder collaboration within healthcare organizations. Environmental management further improves the organization's image and fosters a competitive mindset (Jacqueson, 2002) (see Table 3). Table 3. Some environmental practices as per a literature review. Authors Environmental practices or dimensions 1. 2. 3. 4. 5. 1. 2. 3. 4. 5. 6. 1. 2. Olivier and JeanMarie (1998) de Vries, Bayramoglu, and Van Der Wiele (2012) Boiral and Henri (2012) 3. 4. 1. 2. 3. 4. 5. Halila and Tell (2013) Commitment and policy Planning Implementation and operation Control and corrective measures System review and «continuous improvement» Strong internal motivation Executive leadership engagement Communication with stakeholder groups Stakeholder involvement Clearly defined environmental management Training and education programs Employee mobilization Employee awareness and participation in the environment Resources Managerial values and support Employee and manager initiatives Communication forum Resources Learning network Mutual engagement and trust Number of practices employed 5 6 4 5 Information system security is paramount for an organization's efficient functioning encompassing human, technical and organizational resources (Abouelmehdi, Beni-Hessane, & Khaloufi, 2018; Monideepa & Steven, 2007; Varun, Myun, & James, 1996). Studies explore the impact of information system competencies on process innovation within a U.S. healthcare firm addressing challenges related to block chain implementation in healthcare systems for security and effectiveness (Swapnil Shrivastava, Srikanth, & Dileep, 2020; Tariq, Qamar, Asim, & Khan, 2020) underscores the critical importance of integrating telemedicine services for healthcare providers in the Indian context (see Table 4). Table 4. Some information system security practices as per a literature review. Authors Dhillon (1997) Barlette (2008) Gikas (2010) Information system's security practices or dimensions 1. 2. 3. 4. 1. 2. 3. 4. 5. 1. 2. 3. 4. 5. 6. 7. 8. Security policy Security evaluation Security design considerations Implementation of information system security Intrinsic motivation Awareness Leadership involvement Employee involvement Device identification System risk identification Security policies Security control identification Network security reference Incident prevention and handling Information system risk management Information security training requirements Risk management © 2024 by the authors; licensee Online Academic Press, USA 199 Number of practices employed 4 5 8 International Journal of Applied Economics, Finance and Accounting 2024, Vol. 19, No. 1, pp. 196-215 Authors Information system's security practices or dimensions Gillies (2011) 1. 2. 3. 4. 5. 6. 7. 8. 9. Number of practices employed Security policy Information security organization Asset management Human resource security Physical and environmental security Communication and operations management Information system acquisition, development, and maintenance Information security incident management Business continuity management 9 For instance, Hohan, Olaru, and Keppler (2015) advocate an approach that integrates information security management into an integrated management system enhancing efficiency in Romanian public administration entities while adhering to management standards. This underscores the importance of integrating risk management and continuous improvement processes for effective implementation as organizations contend with diverse requirements. Subsequently, Moumen and El Aoufir (2017) explore empirical studies on the adoption of quality, safety, and environmental management systems in various countries including Spain, Italy, China, India and Australia. It assesses the performance of Moroccan companies across sectors identifies improvement priorities and evaluates strengths and weaknesses shedding light on firms' perceptions of the benefits and challenges of integrating these management systems. Similarly, Kizilelma, Tutuncu, and Aydin (2023) investigate the interconnections among information security, patient safety climate and quality management in a healthcare system revealing a strong and positive relationship between quality and information security management and safety climate suggesting potential improvements in patient safety through enhancements in quality and information security measures. Thus, Benyettou and Megnounif (2022) introduce a theoretical model for an Integrated Management System (IMS), merging quality, safety, health, environment and food safety systems into a unified framework fostering implementation across various sectors particularly in the food industry. Purwanto (2020) investigates the impact of an IMS on the business performance of Indonesian packaging industries highlighting the significant positive influence of a Food Safety Management System (FSMS). Quality Management Systems (QMS), Safety Management Systems (SMS) and Environment Management Systems (EMS) show positive effects but they are not statistically significant in this context. 2.2. Healthcare Organizational Performance Criteria Healthcare organizational performance criteria encompass standards for evaluating effectiveness, efficiency and quality in healthcare institutions. According to the study conducted by Bremer et al. (2021) hospitals implementing the Malcolm Baldrige Health Care Criteria for Performance Excellence (HCPE) exhibited superior performance on patient experience measures when compared to non-HCPE hospitals. This suggests that HCPE serves as an effective model for aligning organizational design, strategy, systems and human capital to foster long-term effectiveness within a high-performance culture. Additionally, monitoring, planning, organizing, leadership, resource management, communication and patient orientation are the seven main themes that Abbas et al. (2019) highlighted while exploring the responsibilities of hospital managers in their qualitative phenomenological study. This study underscores the importance of evaluating and addressing managers' performance as a critical factor in improving overall hospital function and achieving optimal efficiency in healthcare delivery. Otay, Sezi, and Cengiz (2017) present the criteria used for assessing healthcare performance (see Table 5). These criteria serve as the foundational elements for evaluating various aspects of healthcare delivery which are identified as follows: Table 5. Healthcare organizational performance criteria. Inputs Patient care and other expenditures Number of beds Number of physicians Number of nurses Number of other staff range of services Technology level Service combination Outputs Annual revenues Number of outpatient visits Overall patient satisfaction Number of admissions to inpatient service Organizational agility and responsiveness Conformance to quality procedures Bed usage rate Source: Otay et al. (2017). 200 © 2024 by the authors; licensee Online Academic Press, USA International Journal of Applied Economics, Finance and Accounting 2024, Vol. 19, No. 1, pp. 196-215 We organised a focus group with experts based on this study to classify these criteria. The resulting list is as follows: • Optimization of human and material resources (OHMR). • Quality of services provided and patient satisfaction (SPPS). • Organizational agility and responsiveness (OAR). We consolidate all the elements from the selected constructs identified in the literature review in the following Table 6. Table 6. List of elements in the constructs of the proposed conceptual model. Elements in the constructs Construct 1: Quality, safety, environment and information system security practices Construct 2: Healthcare organizational performance criteria Code (LDE) (PPM) (TC) (DMIS) (RM) (CI) (OHMR) (SPPS) (OAR) Titled Leadership’s engagement Process planning and management Training and communication Development and maintenance of information systems Risk management Continuous improvement Optimization of human and material resources Quality of services provided and patient satisfaction Organizational agility and responsiveness Restoring effective service quality management in the Moroccan healthcare sector requires strong performance and mastery of implemented interfaces and dashboards. The study aims to validate theoretically constructed hypotheses operationally relying on survey results from healthcare organizations in the central region of Rabat-Salé-Kénitra, Morocco. Key hypotheses are presented in Table 7. Table 7. Derived hypotheses. Hypothesis no H1 H2 H3 H4 H5 H6 H7 H8 H9 H10 H11 H12 H13 H14 H15 Causal links LDE ------------>PPM LDE ------------>TC LDE ------------> DMIS PPM ------------> RM PPM ------------>CI TC --------------> RM TC --------------> CI DMIS ----------> RM DMIS-----------> CI RM -------------> OHMR RM -------------> SPPS RM -------------> OAR CI ---------------> OHMR CI ---------------> SPPS CI ---------------> OAR Formulated derived hypotheses LDE has a positive impact on PPM. LDE has a positive impact on the TC. LDE has a positive impact on DMIS. PPM has a positive impact on RM. PPM has a positive impact on CI. TC has a positive impact on RM. TC has a positive impact on CI. DMIS has a positive impact on RM. DMIS has a positive impact on CI. RM has a positive impact on OHMR. RM has a positive impact on SPPS. RM has a positive impact on OAR. CI has a positive impact on OHMR. CI has a positive impact on SPPS. CI has a positive impact on OAR. The exploration also aims to verify if quality, safety, environment and information security system practices positively impact the organizational performance of healthcare institutions. The overarching hypothesis is deconstructed into several sub-hypotheses identifying 15 derived sub-hypotheses (see Table 7). Finally, the research explores the impact of the leadership's level of commitment on process approach planning, training and communication systems as well as the development and maintenance of the information system in Moroccan healthcare services. These practices, in turn, positively impact effective risk management and the implementation of the continuous improvement approach contributing to the total quality of service in Moroccan healthcare service organizations. This study aims to explore the real-existing nature of the relationship between the implementation of quality practices and the performance of health services in Morocco using a database of 50 health organizations chosen from the central region of Morocco: Rabat-Salé-Kenitra. 3. Research Methodology This study examines complex structural equation models with multiple interdependent variables focusing on regression, principal component analysis (PCA) and PLS regression to estimate relationships among latent variables using the partial least squares structural equation modeling (PLS-SEM) method (Hair, Ringle, & Sarstedt, 2011). PLS-SEM proves advantageous for handling small sample sizes coping with violations of the © 2024 by the authors; licensee Online Academic Press, USA 201 International Journal of Applied Economics, Finance and Accounting 2024, Vol. 19, No. 1, pp. 196-215 normality assumption and accommodating non-linear models. The method's iterative nature and the use of the bootstrap technique for result reliability assessment are highlighted by Henseler, Christian, and Rudolf (2009). PLS-SEM flexibility allows for analyzing intricate models involving latent and observed variables without requiring a normal distribution. The book "Handbook of Partial Least Squares”, concepts, methods, and applications edited by Chin, Esposito Vinzi, Henseler, and Wang (2010) offers comprehensive coverage, including the maximization of explained variance in PLS-SEM. This study collected data using questionnaires and employed regression estimation. According to Tahir, Kristian Hovde, and Lars Snipen (2012) PLSR regression (PLSR) is a statistical method where various variable selection methods for PLSR are presented and classified into three categories: filter methods, wrapper methods and embedded methods. PLSR is used for regression modelling especially when dealing with datasets containing a large number of variables. It aims to identify and select relevant variables while addressing the risk of overfitting and the conclusion emphasizes the importance of proper validation in the variable selection process. PLSR integrates variable selection into the modelling process offering a structural approach to enhance interpretability and model performance. José, Jorge, and Jacinto (2014) conducted a study exploring the relationships between Principal Component Analysis (PCA) and PLSR. The PLSR is a numerical technique for constructing linear models that capture the primary relationships among process variables. PLSR reduces challenges associated with illconditioned datasets particularly beneficial for managing high-dimensional multivariate systems with collinear variables. It can be considered a specific case within broader regression approaches, including ordinary least squares and principal component regression. We thoroughly explored various regional healthcare organizations to empirically verify our study's hypotheses. This process enabled us to select a representative sample. We followed up with in-person meetings to administer the final questionnaire. This approach facilitated discussions on quality management themes within Moroccan healthcare institutions. We meticulously selected a sample of 50 healthcare organizations to ensure a meaningful representation and enhance the efficacy and accuracy of our tests from an initial pool of 57 clinics and 19 public hospitals. We used SPSS (Statistical Package for the Social Sciences) version 26 to carry out principal component and factor analyses. In this case, SPSS was used specifically for these purposes. These statistical techniques were instrumental in condensing questionnaire data and evaluating the research model and sub-hypotheses as shown in Figure 1. Figure 1. Interactional diagram of practices and criteria in the service quality management model of an organization. 202 © 2024 by the authors; licensee Online Academic Press, USA International Journal of Applied Economics, Finance and Accounting 2024, Vol. 19, No. 1, pp. 196-215 Figure 2. Path diagram using XL. Table 8 illustrates the dimension reduction process allowing to proceed with the evaluation of measurement reliability and the unidimensionality of the blocks after item reduction. The results confirm the suitability of our variable measurement model supported by a Kaiser-Meyer-Olkin adequacy index exceeding 0.7 and a significant Bartlett's sphericity test (p < 0.001). Table 8. KMO index and Bartlett's test. Measurement of Kaiser-Meyer-Olkin sampling adequacy 0.868 Approximate chi-square 240.603 Test of sphericity: Bartlett's test Degrees of freedom 28 The significance of Bartlett 0.000 We verified this dimension reduction condition to evaluate measurement reliability and construct onedimensionality following item reduction. We initially conducted a descriptive analysis of the sample's characteristics before assessing measurement, reliability and model validity using the PLS approach to structural equations. This involved examining the location of healthcare organizations, respondents' job positions, the type of organization certification, the implementation of quality safety and environmental approaches and the reasons for pursuing certification. This analysis aims to ensure the consistency and reliability of the description of quality practices within Moroccan healthcare organizations. According to the approach of Douglas and Judge Jr (2001) the geographical distribution of these organizations and the hierarchical distribution of practitioners involved in these practices. Our study's sample comprises 74% of healthcare establishments and structures located in Rabat followed by 24% in the city of Kenitra and 2% in the city of Salé. This distribution aligns perfectly with the organizations' geographical distribution in proportion to each city's population size. The data from this sample will be reliable for a comprehensive vision that can be generalized. The sample encompasses responses from 54% of interviewed physicians, 24% of administrative staff, 12% of nurses and 10% of managers. This distribution adequately reflects the degree of involvement of healthcare practitioners in the quality management process. Most organizations select the certification of their quality practices, notably ISO certifications. In our survey, we sought to explore the behavior of healthcare organizations in Morocco represented in our sample regarding their access to ISO certification. 4. Results We can affirm the suitability of our variable measurement model as indicated by the Kaiser-Meyer-Olkin adequacy index which stands at 0.868 surpassing the threshold of 0.7 based on the information provided in Table 8 and employing the principal component analysis method. Subsequently, we conducted partial statistical tests to assess various components of the model focusing on the reliability and one-dimensionality of test of the constructs. It is essential to establish the reliability of measurements signifying the precision of the conducted measurements to ensure the robustness of our empirical study. In our study, we ascertain the reliability of latent variable measurements by calculating each variable's Cronbach's alpha and Dillon Goldstein's Rho indices. Additionally, only 22% of the surveyed healthcare structures hold ISO 9001 certification with the majority yet to attain this certification within our sample. This reveals a relatively low rate of ISO certification among © 2024 by the authors; licensee Online Academic Press, USA 203 International Journal of Applied Economics, Finance and Accounting 2024, Vol. 19, No. 1, pp. 196-215 the surveyed healthcare organizations suggesting a need for increased motivation and immersion in the quality measurement of services and their environment (see Tables 9, 10 and 11). Table 9. ISO 9001 certification. Valid Yes No Total Counts Percentage 11 22 % 39 78 % 50 100 % Table 10. ISO 45001 certification. Valid No Counts 50 Percentage 100 % Table 11. ISO 14001 certification. Valid No Counts 50 Percentage 100 % Furthermore, the motivations driving organizations to pursue quality practice certification become apparent through the data. Among the surveyed establishments, 82% aspire to achieve quality, safety or environmental certifications. Within this group, the intention to obtain ISO certification is justified as it is demanded by 48% of patients and 20% of suppliers. Additionally, 58% of these establishments view certification as essential for enhancing performance with 20% considering it a fundamental commitment (see Tables 12, 13, 14 and 15). These findings underscore the growing trend among healthcare organizations in Morocco to adopt quality service measurement tools and frameworks driven by heightened competition in the privatized healthcare sector and evolving patient-client expectations. Table 12. Certification required by patients. Valid Yes No Total Effective 24 26 50 Percentage 48 % 52 % 100 % Table 13. Certification required by suppliers. Valid Yes No Total Counts 10 40 50 Percentage 20 % 80 % 100 % Table 14. Certification required for performance improvement. Valid Yes No Total Effective 29 21 50 Percentage 58 % 42 % 100 % Table 15. Certification required by the will of the establishment. Valid Yes No Total Counts 10 40 50 Percentage 20 % 80 % 100 % Two equations are tested using the PLS approach through the XL-STAT software yielding structural equations for the conceptual model as follows: Figures 3, 4, 5 and 6 show hypothesis testing. 204 © 2024 by the authors; licensee Online Academic Press, USA International Journal of Applied Economics, Finance and Accounting 2024, Vol. 19, No. 1, pp. 196-215 Figure 3. Impact and contribution of the LDE variable for PPM. Figure 4. Impact and contribution of the LDE variable for TC. Figure 5. Impact and contribution of the LDE variable for DMIS. © 2024 by the authors; licensee Online Academic Press, USA 205 International Journal of Applied Economics, Finance and Accounting 2024, Vol. 19, No. 1, pp. 196-215 Figure 6. Impact and contribution of TC, PPM and DMIS variables for RM. Figure 3 shows the impact of leadership engagement (LDE) on process planning and management (PPM) given the equation PPM=0,6173×LDE. For training and communication (TC), Figure 4 presents the equation TC=0,7314×LDE. The equation DMIS=0,4733×LDE refers to the leadership's engagement (LDE) in the development and maintenance of IS (DMIS) as shown in Figure 5. Figure 6 shows how the variables PPM, TC and DMIS contribute to the dependent variable risk management (RM) resulting in the following equation: RM is equal to 0,2476×PPM+0,2830×TC+0,2909×DMIS. Finally, for the dependent variable continuous improvement (CI), the effect size index (f²) is examined to validate the structural coefficients. This index quantifies the level of explained variance when the explanatory latent variable is included in the model compared to when it is excluded. It is calculated as follows: R2 incl − R2 excl f² = 1 − R2 incl We systematically evaluate and confirm the proposed hypotheses, contributing to a comprehensive understanding of the complex relationships in the model by applying this approach. According to Cohen (1988) the interpretations of effect sizes are linked to the following reference values: Effect Size: 0.02: small, 0.15: medium and 0.35: large. The causal relationships between the different latent variables forming the model are measured using the correlation coefficient (R), the path coefficient (β) and Cohen's f² coefficient. The results from Table 25 reveal the outcomes of 15 derived hypotheses within our proposed model. It is evident that the exogenous variable leadership and management engagement significantly and positively impacts PPM, TC and DMIS for the relationships in the quality safety environment and information systems security practices. Moreover, RM is positively influenced by TC and DMIS although with weaker effects from PMM. Training and communication exhibit a strong influence on continuous improvement while continuous improvement is statistically significantly impacted with a large positive effect by the variables training and communication and a medium effect by the variables PMM and DMIS. In the relationships between quality, safety, environment, information systems security practices and healthcare organizational performance criteria, risk management demonstrates a positive effect on organizational agility and responsiveness but a weak effect on services rendered, patient satisfaction and optimization of human and material resources. Additionally, continuous improvement has a substantial positive influence on optimization of human and material resources and weak effects on services rendered, patient satisfaction and organizational agility and responsiveness. Four hypotheses were found to be invalid. Therefore, the PLS evaluation of our conceptual model is presented in Figure 7. 206 © 2024 by the authors; licensee Online Academic Press, USA International Journal of Applied Economics, Finance and Accounting 2024, Vol. 19, No. 1, pp. 196-215 Figure 7. Evaluation of the conceptual model using the PLS approach for structural equations. 5. Discussion Many studies have examined the impact of quality management practices on healthcare organizational performance criteria in the area of healthcare quality. According to Zakariae and Zouhair (2023) hospital accreditation is a significant initiative aimed at ensuring the excellence of care and efficiency in the management of health establishments. Similarly, Chahouati (2020) affirms that quality management represents revolutionary platform for hospital management, remedying the shortcomings of traditional models guaranteeing effective management and sustainable improvement in the services of public hospitals. However, Oumlil (2022) highlights persistent shortcomings in the health sector in Morocco despite government initiatives aimed at improving management and quality of care. This observation is particularly relevant in the context of information technology integration in a provincial hospital as highlighted by the study. The structure of the practices of quality, security, environment and information system security consists of 6 latent variables of which one is exogenous and five are endogenous. The values of Cronbach's alpha and Dillon Goldstein's Rho for the variables of this construct are summarized in Tables 16 and 17 which presents Cronbach's alpha values and Dillon Goldstein's Rho values for the dimensions within the healthcare organizational performance criteria. All variables within the overall performance of the territorial community exhibit excellent reliability with α > 0.7 and Dillon-Goldstein's Rho > 0.8 demonstrating strong reliability as per the criteria set by Nunnally and Berstein (1994) and Kate and Christopher (2004). Table 16. Reliability analysis of quality, safety, environment and information system security practices. Latent variables LDE PPM TC DMIS RM CI Number of items Before After purification purification 5 5 8 7 7 6 5 3 6 6 4 4 Cronbach's alpha Before After purification purification 0.841 0.841 0.910 0.919 0.809 0.882 0.917 0.873 0.910 0.910 0.890 0.890 Rhô de D. G Before After purification purification 0.888 0.888 0.926 0.935 0.835 0.910 0.968 0.922 0.930 0.930 0.924 0.924 Table 17. Reliability analysis of healthcare organizational performance criteria. Latent variables OHMR SPPS OAR Number of items Before After purification purification 7 6 8 7 5 5 © 2024 by the authors; licensee Online Academic Press, USA Cronbach's alpha Before After purification purification 0.819 0.821 0.881 0.892 0.889 0.889 207 Rhô de D. G Before After purification purification 0.868 0.871 0.904 0.916 0.918 0.918 International Journal of Applied Economics, Finance and Accounting 2024, Vol. 19, No. 1, pp. 196-215 The next step involves testing the one-dimensionality of the blocks surrounding their latent variables. The reliability of the variables in our model has been confirmed (Fornell & Larcker, 1981). These latent variables are expressed through variables that manifest themselves in the form of blocks. We compared the largest eigenvalue of each block of latent variables to the other eigenvalues within the same block to ensure the one-dimensionality of these blocks. Our criterion requires this primary eigenvalue to account for at least 50% of the sum of all eigenvalues within its block. This assessment ensures that the manifest variables effectively reflect their corresponding latent variables. Table 18 confirms block one-dimensionality allowing us to ensure our causal model's internal and external validity. After validating measurement reliability, we used the PLS approach for structural equation modelling with XLSTAT (2017) (see Figure 2). In our study, we employed the reflective scheme to link manifest variables to latent variables assessing how latent variables influence manifest variables while acknowledging the inherent subjectivity involved. We tested convergent and discriminant validity to evaluate our model's external validity. Convergent validity assessed through factor loadings and average variance extracted (AVE) indicates that items within the same latent variable share more variance with that latent variable than with specific measurement errors demonstrating strong convergent validity (see Table 19). AVE values exceeding 0.7 reinforce good convergent validity (see Table 20) consistent with Fornell and Larcker (1981) and Nunnally & Berstein (1994). Divergent validity is established when items measuring the same phenomenon exhibit low correlations with items measuring other concepts meaning that items of a single concept contribute less strongly to other concepts. This verification is performed according to the guidelines of Chin et al. (2010). We compare the square root of the Average Variance Extracted (AVE) of each dimension (latent variable) with the correlations between different dimensions (pairwise). Divergent validity is confirmed when the square root of the AVE exceeds the correlations between the different dimensions in the model. Table 18. Eigen values of the latent variables in our model. Latent variables Dimensions Own values LDE PPM TC DMIS RM CI OHMR SPPS OAR 5 3.069 0.823 0.527 0.304 0.276 - 8 4.727 0.703 0.538 0.373 0.249 0.230 0.177 6 3.778 0.748 0.493 0.403 0.321 0.253 - 3 2.396 0.422 0.180 - 6 4.156 0.845 0.385 0.332 0.147 0.130 - 4 3.013 0.485 0.275 0.225 - 6 3.205 0.949 0.721 0.551 0.430 0.141 - 7 4.290 0.829 0.787 0.430 0.328 0.194 0.139 5 3.471 0.509 0.421 0.324 0.273 - Table 19. Factorial contributions. Latent variables LDE1 LDE2 LDE3 LDE4 LDE5 PPM1 PPM2 PPM3 PPM5 PPM6 PPM7 PPM8 TC1 TC3 TC4 TC5 TC6 TC7 DMIS2 DMIS3 DMIS4 RM1 RM2 LDE 0.729 0.688 0.791 0.883 0.784 0.476 0.487 0.528 0.512 0.427 0.538 0.560 0.596 0.598 0.558 0.520 0.633 0.566 0.332 0.447 0.480 0.414 0.519 PPM 0.294 0.176 0.630 0.681 0.381 0.819 0.805 0.791 0.745 0.869 0.858 0.855 0.622 0.438 0.293 0.504 0.526 0.491 0.273 0.282 0.315 0.363 0.634 TC DMIS RM CI OHMR SPPS OAR 0.455 0.329 0.298 0.378 0.234 0.257 0.280 0.400 0.250 0.257 0.312 0.106 0.170 0.277 0.587 0.461 0.568 0.401 0.235 0.573 0.601 0.717 0.385 0.630 0.642 0.531 0.509 0.502 0.591 0.366 0.350 0.409 0.465 0.504 0.526 0.477 0.171 0.465 0.381 0.240 0.341 0.319 0.557 0.110 0.486 0.531 0.353 0.263 0.192 0.553 0.251 0.377 0.465 0.296 0.270 0.277 0.446 0.282 0.577 0.374 0.269 0.428 0.373 0.477 0.335 0.552 0.567 0.360 0.252 0.327 0.493 0.269 0.538 0.579 0.382 0.310 0.355 0.488 0.427 0.598 0.521 0.276 0.269 0.322 0.784 0.277 0.536 0.748 0.564 0.408 0.450 0.781 0.390 0.605 0.773 0.631 0.438 0.523 0.787 0.441 0.543 0.535 0.504 0.687 0.514 0.815 0.335 0.523 0.596 0.597 0.522 0.489 0.827 0.429 0.507 0.593 0.516 0.501 0.478 0.761 0.580 0.583 0.533 0.482 0.484 0.493 0.424 0.866 0.460 0.516 0.340 0.349 0.500 0.470 0.943 0.601 0.513 0.387 0.474 0.601 0.475 0.869 0.566 0.428 0.282 0.328 0.494 0.515 0.465 0.701 0.706 0.448 0.282 0.359 0.568 0.425 0.804 0.657 0.480 0.469 0.332 208 © 2024 by the authors; licensee Online Academic Press, USA International Journal of Applied Economics, Finance and Accounting 2024, Vol. 19, No. 1, pp. 196-215 Latent variables RM3 RM4 RM5 RM6 CI1 CI2 CI3 CI4 OHMR1 OHMR2 OHMR4 OHMR5 OHMR6 OHMR7 SPPS2 SPPS3 SPPS4 SPPS5 SPPS6 SPPS7 SPPS8 OAR1 OAR2 OAR3 OAR4 OAR5 LDE 0.634 0.441 0.496 0.418 0.563 0.453 0.403 0.545 0.267 0.313 0.353 0.313 0.306 0.364 0.446 0.511 0.526 0.262 0.295 0.502 0.504 0.515 0.404 0.479 0.501 0.571 PPM 0.559 0.538 0.555 0.468 0.644 0.512 0.385 0.500 0.235 0.390 0.080 0.205 0.293 0.403 0.295 0.372 0.276 0.185 0.158 0.336 0.389 0.306 0.217 0.311 0.314 0.418 TC DMIS RM CI OHMR SPPS OAR 0.706 0.388 0.815 0.716 0.531 0.423 0.393 0.527 0.573 0.884 0.543 0.516 0.625 0.603 0.652 0.598 0.913 0.668 0.686 0.602 0.601 0.508 0.577 0.859 0.519 0.619 0.573 0.591 0.760 0.441 0.808 0.873 0.697 0.540 0.502 0.713 0.376 0.616 0.887 0.559 0.475 0.411 0.635 0.489 0.602 0.846 0.676 0.306 0.318 0.661 0.579 0.555 0.861 0.571 0.381 0.457 0.474 0.352 0.496 0.609 0.671 0.247 0.378 0.541 0.273 0.466 0.577 0.695 0.438 0.403 0.491 0.407 0.419 0.443 0.608 0.308 0.490 0.484 0.179 0.411 0.491 0.788 0.535 0.346 0.467 0.156 0.499 0.473 0.825 0.516 0.265 0.577 0.298 0.582 0.544 0.766 0.530 0.370 0.456 0.411 0.443 0.366 0.389 0.854 0.601 0.525 0.340 0.495 0.333 0.384 0.830 0.577 0.638 0.371 0.452 0.443 0.532 0.734 0.665 0.381 0.287 0.386 0.305 0.479 0.654 0.366 0.434 0.349 0.501 0.419 0.487 0.798 0.505 0.511 0.312 0.522 0.389 0.484 0.848 0.593 0.519 0.295 0.517 0.462 0.489 0.738 0.606 0.488 0.623 0.451 0.397 0.361 0.495 0.823 0.504 0.482 0.578 0.451 0.445 0.586 0.792 0.547 0.481 0.410 0.437 0.388 0.557 0.831 0.501 0.457 0.391 0.325 0.412 0.699 0.852 0.533 0.450 0.573 0.422 0.498 0.656 0.860 Table 20. Measurement model quality index. Latent variables LDE PPM TC DMIS RM CI OHMR SPPS OAR Type Exogenous Endogenous Endogenous Endogenous Endogenous Endogenous Endogenous Endogenous Endogenous Average variance extracted (AVE) 0.605 0.675 0.629 0.798 0.692 0.752 0.532 0.605 0.675 Rho de D.G. 0.888 0.935 0.910 0.922 0.930 0.924 0.871 0.916 0.918 The data in Table 21 confirms the discriminant validity of the external model as the square root of AVE for each latent variable surpasses the correlations between them. This underscores the overall validity of our measurement model combined with the established convergent and divergent validity. Additionally, the coefficient of determination R² values exceeding 0.1 as indicated in Table 22 demonstrate the significant structural causality between exogenous and endogenous variables in our model. According to Falk and Nancy (1992) and Croutsche (2002) the structural model holds vital significance. Lastly, the Goodness of Fit Index (GoF) considers the effectiveness of both the structural and measurement models (Michel & Vincenzo, 2005). − This index is calculated as GoF= (√ H 2 × −R2 ). In our case, GoF= (√(0,662x0,521)) = 0,587 which supports the effectiveness of both the structural and measurement models with the usual values of 0.1, 0.25 and 0.36 indicating a moderate fit with our model (see Table 23). Table 21. Discriminant validity. Latent variables LDE PPM TC DMIS RM CI LDE PPM 0.778* 0.377 0.536 0.224 0.339 0.328 0.821* 0.368 0.105 0.393 0.358 TC 0.793* 0.261 0.482 0.644 © 2024 by the authors; licensee Online Academic Press, USA DMIS 0.893* 0.373 0.294 209 RM 0.832* 0.566 CI 0.867* OHMR SPPS (AVE) 0.605 0.675 0.629 0.798 0.692 0.752 International Journal of Applied Economics, Finance and Accounting 2024, Vol. 19, No. 1, pp. 196-215 Latent variables OHMR SPPS OAR Note: LDE PPM TC DMIS RM CI OHMR SPPS (AVE) 0.191 0.314 0.351 0.144 0.136 0.141 0.484 0.403 0.384 0.142 0.187 0.357 0.440 0.370 0.345 0.523 0.249 0.244 0.729* 0.351 0.260 0.782* 0.518 0.532 0.605 0.832 * * Square root of AVE. Table 22. R² and adjusted R² results. Latent variables LDE PPM TC DMIS RM CI OHMR SPPS Average Type R² Adjusted R² Exogenous Endogenous Endogenous Endogenous Endogenous Endogenous Endogenous Endogenous 0.377 0.329 0.224 0.682 0.689 0.614 0.639 0.430 0.521 0.377 0.329 0.224 0.662 0.668 0.598 0.624 0.406 Table 23. Goodness of fit. Fit assessment metrics Absolute Relative External model Internal model GoF GoF (bootstrap) Standard error 0.587 0.856 0.988 0.866 0.603 0.804 0.976 0.824 0.047 0.049 0.044 0.026 Critical ratio (CR) 0.587 0.856 0.988 0.866 The survey results validate the measurement and structural models enabling us to test the hypotheses formulated in this paper (see Table 7) concerning the causal relationships in our proposed model. We begin by examining our overarching hypothesis which addresses the impact of implementing an IMS combined with information systems security on healthcare organizational performance in the Rabat-Kenitra-Sale region. Concurrently, we test 15 derived hypotheses corresponding to specific causal relationships presented in Table 24 . Our analysis using the PLS approach to structural equations confirms 11 of the 15 derived hypotheses illustrating the intricate interactions among various variables within Moroccan healthcare organizations' internal and external environments. Table 24. Hypothesis testing. 1* 2* Note: Derived hypothesis no H1 H2 H3 H4 H5 H6 H7 H8 H9 H10 H11 H12 H13 H14 H15 Independent variable (cause) LDE LDE LDE PPM PPM TC TC DMIS DMIS RM RM RM CI CI CI Dependent variable (effect) PPM TC DMIS RM CI RM CI RM CI OHMR SPPS OAR OHMR SPPS OAR Student's T Pvalue Effect size f² Validity of hypotheses 53.89 74.47 37.22 21.81 197.36 23.34 52.92 28.24 19.67 0.341 0.949 19.70 30.11 -0.339 0.101 0.000 0.000 0.000 0.034 0.045 0.024 0.000 0.007 0.049 0.734 0.347 0.048 0.004 0.735 0.919 0.605 11.55 0.288 0.105 0.097 0.121 0.622 0.177 0.089 0.002 0.019 0.023 0.197 0.002 0.000 Valid Valid Valid Valid Valid Valid Valid Valid Valid Invalid Invalid Valid Valid Invalid Invalid 1* Quality, safety, environment, and information system security practices. 2* Healthcare organizational performance criteria. The hypotheses in quality, safety, environment and information systems security practices demonstrate that all 9 global hypotheses proposed are valid. In the case of hypotheses connecting variables from the quality-safety-environment and information systems security practices to variables in the healthcare 210 © 2024 by the authors; licensee Online Academic Press, USA International Journal of Applied Economics, Finance and Accounting 2024, Vol. 19, No. 1, pp. 196-215 organizational performance criteria, 2 out of the 6 derived global hypotheses linking the two constructs are supported. Our model comprises one exogenous variable and 8 endogenous variables; each endogenous variable is expressed by one or more variables plus an error term (see Table 25). Table 25. Effect sizes between different causal links. 1* 2* Note: Derivation hypothesis no H1 H2 H3 H4 H5 H6 H7 H8 H9 H10 H11 H12 H13 H14 H15 Independent variable (cause) LDE LDE LDE PPM PPM TC TC DMIS DMIS RM RM RM CI CI CI Dependent variable (effect) PPM TC DMIS RM CI RM CI RM CI OHMR SPPS OAR OHMR SPPS OAR Correlation coefficient (R) 0.614 0.732 0.473 0.627 0.598 0.694 0.802 0.611 0.542 0.705 0.609 0.587 0.663 0.499 0.494 Structural coefficient (β) 0.614 0.732 0.473 0.247 0.190 0.283 0.619 0.290 0.187 0.055 0.167 0.243 0.430 -0.052 0.017 Effect size f2 Effect 0.605 1.155 0.288 0.105 0.087 0.121 0.622 0.177 0.099 0.002 0.019 0.023 0.197 0.0025 0.0002 Large effect Large effect Large effect Small effect Small effect Medium effect Strong effect Medium effect Small effect No effect No effect Small effect Medium effect No effect No effect 1* Quality, safety, environment, and information system security practices. 2* Healthcare organizational performance criteria. Nonetheless, our research distinguishes itself from these previous approaches in several significant ways. Firstly, we have adopted an integrated and holistic approach by amalgamating quality, safety, environmental, and information security practices into a unified model named quality-safety-environment and information systems security practices. As a result, we provide a more comprehensive perspective on how these practices interact to influence organizational performance. Furthermore, our model encompasses a broader range of healthcare organizational performance criteria, extending beyond patient satisfaction to operational efficiency, healthcare quality, environmental sustainability and information security management by exploring the nature of the real or potential interactions of the different factors resulting from quality management as input and the other factors resulting from the level of performance and satisfaction as output. This innovative approach has been validated by our findings as summarized in Table 26 which lists the direct effects among the six latent variables within the quality-safety-environment and information systems security practices and their interactions with the latent variables within the healthcare organizational performance criteria. These results confirm our overarching research hypothesis which posits that qualitysafety-environment and information systems security practices within healthcare establishments positively impact the healthcare organizational performance criteria of these entities. Furthermore, this underscores the significance of the sustainability of various quality practices within an organization regardless of the nature of its activities influencing its organizational and managerial performance. Table 26. Assessment of direct effects between variables. Latent variables LDE PPM TC DMIS RM CI OHMR SPPS OAR LDE PPM TC DMIS RM CI OHMR SPPS OAR 0.614 0.732 0.473 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.247 0.190 0.000 0.000 0.000 0.000 0.283 0.619 0.000 0.000 0.000 0.290 0.187 0.000 0.000 0.000 0.000 0.055 0.167 0.243 0.430 -0.052 0.017 0.000 0.000 0.000 - All nine hypotheses tested were valid for quality, safety, environment and information systems security practices. Moreover, our analysis revealed that the exogenous variables leadership and executive engagement demonstrated valid indirect links and exhibited strong effects on various variables within the same construct. Notably, it significantly impacted risk management and continuous improvement as outlined in Figure 7. © 2024 by the authors; licensee Online Academic Press, USA 211 International Journal of Applied Economics, Finance and Accounting 2024, Vol. 19, No. 1, pp. 196-215 Furthermore, the distinctive aspect of our research is the strong positive effects that these exogenous variables, leadership and executive engagement also showed on several other important variables. These included optimization of human and material resources, services rendered, patient satisfaction and even the organizational agility and responsiveness variables within the organizational performance criteria of the healthcare establishments involved in our empirical investigation. It is noteworthy that this level of confirmation indicating the far-reaching impact of leadership and executive engagement hasn't been previously derived using a specific model that facilitates the measurement of such an impact as seen in earlier studies (Morgado et al., 2019; Trunfio et al., 2022). This explains why the majority of health organizations surveyed are aware of the importance of mastering the three interfaces in the first row (see Figure 7). It follows the same way the rest of the second and third-row interfaces with different levels of degree of influence with the exception of two interactions appearing between risk management and continuous improvement with optimization of human and material resources, organizational agility and responsiveness on the one hand, and services rendered and patient satisfaction on the other hand, because patient satisfaction is a complex measure influenced by multiple variables such as quality of care, communication, accessibility and other elements. This reinforces the unique contributions of our research in uncovering these significant relationships and their implications for healthcare service quality and organizational performance. According to Table 27, the invalidity of hypotheses regarding the variable risk management about the variables optimization of human and material resources (tStudent = 0,3413, p= 0,7344, β =0,0552, f² = 0,0025) and services rendered and patient satisfaction (tStudent =0,9493, p=0,3475, β =0,1674, f² =0,0196) and continuous improvement about the variables services rendered and patient satisfaction (tStudent = -0,3398 p= 0,7356, β = -0,0529, f² = 0,0025) and organizational agility and responsiveness (tStudent =0,1013, p= 0,9198, β =0,0176, f² = 0,0002) within the healthcare organizational performance criteria of healthcare establishments which means that there is still an effort to be made to remedy the situation. Table 27. Assessment of indirect effects between variables. Latent variables LDE PPM TC DMIS RM CI OHMR SPPS OAR LDE PPM TC DMIS RM CI OHMR SPPS OAR 0.000 0.000 0.000 0.624 0.627 0.542 0.475 0.440 0.000 0.000 0.000 0.000 0.122 0.077 0.095 0.000 0.000 0.000 0.452 0.302 0.277 0.000 0.000 0.102 0.048 0.081 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 - Future research perspectives come to the forefront concerning healthcare service quality and organizational performance based on the research findings presented in this study. This is especially evident in the potential implementation of mapping using an algorithmic process approach to effectively and efficiently manage diverse interactions between interfaces. Further research could also explore the role of readiness for change in enabling the effective implementation of IMS (Britel & Cherkaoui, 2022) as well as the determining factors to improve healthcare governance (Jeyar et al., 2023). 6. Conclusion In this comprehensive study, we embarked on a meticulous exploration of the intricate interplay among quality, safety, environment, information systems security practices and management within Morocco's healthcare sector. Our primary objective has been to make a substantial contribution to the ongoing enhancement of health services in the country by elucidating the dynamic relationships among these pivotal factors and their ramifications on organizational performance. Our study employed a comprehensive framework incorporating quality-safety-environment practices, information systems security and management criteria focussed on 50 healthcare organizations in the RabatSalé-Kénitra region. Utilizing the PLS structural equations method, our analysis confirmed the validation of 11 out of 15 derived hypotheses shedding light on the nuanced connections between these variables. Our findings provided robust support for all nine global hypotheses linking quality, safety, environment and information systems security practices. This underscores the foundational importance of these elements within Morocco's healthcare system. However, the hypotheses linking these variables to organizational health performance criteria depicted a more nuanced scenario with only 2 out of 6 derived global hypotheses verified. Our research shows the essential requirement to enhance Morocco's healthcare service quality considering the COVID-19 pandemic's challenges. The insights gleaned into the dynamics of quality, safety, environment, and information security practices offer a strategic roadmap for improving the organizational performance of 212 © 2024 by the authors; licensee Online Academic Press, USA International Journal of Applied Economics, Finance and Accounting 2024, Vol. 19, No. 1, pp. 196-215 healthcare establishments. This study advocates for the implementation of comprehensive quality management within the IMS of healthcare services in Morocco ensuring sustained improvement and heightened performance. The role of leadership emerges as a key factor influencing the performance of various constructs related to quality, security, environment and information security systems in healthcare organizations across Morocco. A notable gap exists in awareness regarding the crucial interaction between risk management, continuous improvement of services rendered and patient satisfaction. This observation may be attributed to the gradual progression of the Moroccan health system and the unique dynamics of patient behaviour. This research suggests avenues for future exploration. Subsequent studies could delve deeper into the mechanisms and contextual factors influencing the relationships between quality practices and organizational performance criteria in healthcare. This could involve a more granular examination of the impact of leadership, risk management and continuous improvement on healthcare services and patient satisfaction. Such research endeavors can further refine our understanding and inform targeted interventions for the continual enhancement of healthcare service quality in Morocco. This study has certain limitations despite the valuable insights gained. The identified gap in awareness regarding the interaction between risk management and continuous improvement with services rendered and patient satisfaction signals a need for more in-depth exploration. Additionally, the gradual progress of the Moroccan health system may impact the generalizability of our findings. It is essential to acknowledge these limitations to ensure a nuanced interpretation of the study's outcomes. 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