Referral Process Enhancement: Innovative Approaches and Best Practices.

OBJECTIVE: This study aimed to enhance the efficiency of the referral system at the Sultan Qaboos Comprehensive Cancer Care and Research Centre (SQCCCRC) in Muscat, Oman by reducing the average time for new patients' acceptance and the delay between patient acceptance and their first appointment. METHODS: A one-group pretest-posttest quasi-experimental project was conducted from Quarter 2 of 2022 to Quarter 2 of 2023. Data collected during the pretest and posttest phases were compared to evaluate the impact of interventions on the average days for patient acceptance and the time to first appointment after acceptance. The intervention involved developing a comprehensive referral system incorporating technology development, improved accessibility, orientation materials, internal training, policy formulation, criteria definition, and tailoring acceptance criteria to specialty programs. Awareness campaigns were also conducted to educate patients about the referral process and available transportation options. The project followed the FOCUS PDCA (Find, Organize, Clarify, Understand, Select, Plan, Do, Check, Act) approach for implementation. RESULT: Significant improvements were observed in the oncology referral process, with the average days for patient acceptance decreasing from 4.3 days to 1.3 days post-implementation. Statistical analysis confirmed the significance of this change (F-value = 46.25, p < .0001). Similarly, the average days to first visit appointment after acceptance decreased from 8.6 days to 4.0 days, with statistical support (F-value = 6.29, p < .0). CONCLUSION: This study represents a significant advancement in optimizing the oncology referral process. When considered in conjunction with previous research findings, it underscores the importance of ongoing efforts to enhance efficiency in patient referrals.

Improving Care Continuity in Oncology Settings: A Lean Management Approach to Minimize Discharges Without Follow-Up Appointments.

OBJECTIVE: This study aimed to reduce the number of patients discharged without scheduled follow-up appointments by implementing lean management principles. METHODS: Conducted at the Sultan Qaboos Comprehensive Cancer Center in Muscat, Oman, the research utilized a one-group pretest-posttest quasi-experimental design to evaluate the impact of lean management interventions on the rate of patient discharges without follow-up appointments. Strategies such as the Kaizen principle, Gemba Walks, cross-functional collaboration, standard work procedures, and waste reduction were employed to enhance operational efficiency. RESULTS: Spanning from Quarter 3 of 2022 to Quarter 2 of 2023, the study demonstrated a significant decrease in the percentage of patients discharged without planned follow-up appointments. The rate dropped from 9% in September 2022 to 0% in March 2023, with statistically significant differences observed (X2= 65.05, p value=<.0001). CONCLUSION: By effectively implementing lean management principles, this research successfully enhanced care continuity for oncology patients after being discharged.

Reducing the Risk of Fall among Oncology Patients using Failure Modes and Effects Analysis.

OBJECTIVE: This project aimed to mitigate the risk of falls among oncology patients using Failure Modes and Effects Analysis (FMEA) in the outpatient setting.



Methods: The project was conducted within outpatient settings, specifically encompassing outpatient clinics, daycare, radiology and radiotherapy, and rehabilitation at the SQCCCRC. The project employed an observational analytical design to assess the fall risk assessment procedure in outpatient settings. The project integrated a 7-step procedure for conducting an FMEA methodology, including defining the system or process, identifying potential failure mode, evaluating the effects of each failure mode, Assigning severity, likelihood, and detection of occurrence ratings, and identifying and implement corrective actions. In addition, Risk Priority Numbers (RPNs) were used to identify the impact of the interventions in reducing the risk of patient fall assessment and management.



Result: In the patient fall screening process, interventions yielded substantial reductions in RPNs for failure modes like "Wrong assessment" (57% decrease) and "Complex risk assessment scale" (63% decrease), addressing knowledge gaps and simplifying risk assessment. Similarly, the "Missed fall assessment" failure mode saw an impressive 80% reduction in RPN, rectifying unclear processes and knowledge gaps. In the Fall risk precaution measures process, interventions led to noteworthy RPN reductions, such as 80% for "Unclear fall precaution measures-responsibilities" and 57% for "Missed bracelets for high risk," demonstrating successful risk mitigation. Moreover, interventions in the Patient Education process achieved significant RPN reductions (57% and 55%) for "No/improper education" and "Unuse of educational material and resources," enhancing staff education and patient awareness. The total reduction in RPNs was 62% in all failure modes in the fall assessment and management process.



Conclusion: Overall, FMEA is a valuable strategy for reducing fall risks among oncology patients, but its success depends on addressing these limitations and ensuring the thorough execution and maintenance of the identified corrective actions.

Examining Nurse and Patient Factors Before and After Implementing an Oncology Acuity Tool: A Mixed Methods Study.

Background and Purpose: To evaluate the nurse documentation compliance, pressure injury compliance, and fall prevention compliance before and after implementing an oncology acuity tool (OAT) at a specialized cancer center in Jordan. Methods: A mixed methods design was used. A qualitative approach was employed using a semistructured interview with 15 nurses selected by purposive sampling. In contrast, the quantitative approach included pre- and postdata obtained to identify the role of adopting the OAT in improving nursing documentation and applying fall and pressure injury-prevention precaution measures. Results: The thematic analysis developed seven themes, including oncology acuity score (OAS) and assignment processes, OAS and patient outcomes, OAS and nurse outcomes, limitations of the OAT, driving forces, restraining forces, and recommendations or suggestions. The results showed significant improvements in nursing documentation (p =.0385), application of pressure injury (p ≤ .00001), and falling precaution measures (p ≤ .00001). Conclusion: Nurse assignment, nursing compliance, and patients' and nurses' outcomes improved after utilizing the OAT.

Decision-Making Preferences among Advanced Cancer Patients in a Palliative Setting in Jordan.

Understanding patients' decision-making preferences is crucial for enhancing patients' outcomes. The current study aims to identify Jordanian advanced cancer patients' preferred decision-making and to explore the associated variables of the passive decision-making preference. We used a cross-sectional survey design. Patients with advanced cancer referred to the palliative care clinic at a tertiary cancer center were recruited. We measured patients' decision-making preferences using the Control Preference Scale. Patients' satisfaction with decision-making was assessed with the Satisfaction with Decision Scale. Cohen's kappa statistic was used to assess the agreement between decision-control preferences and actual decision-making, and the bivariate analysis with 95% CI and the univariate and multivariate logistic regression were used to examine the association and predictors of the demographical and clinical characteristics of the participants and the participants' decision-control preferences, respectively. A total of 200 patients completed the survey. The patients' median age was 49.8 years, and 115 (57.5%) were female. Of them, 81 (40.5%) preferred passive decision control, and 70 (35%) and 49 (24.5%) preferred shared and active decision control, respectively. Less educated participants, females, and Muslim patients were found to have a statistically significant association with passive decision-control preferences. Univariate logistic regression analysis showed that, being a male (p = 0.003), highly educated (p = 0.018), and a Christian (p = 0.006) were statistically significant correlates of active decision-control preferences. Meanwhile, the multivariate logistic regression analysis showed that being a male or a Christian were the only statistically significant predictors of active participants' decision-control preferences. Around 168 (84%) of participants were satisfied with the way decisions were made, 164 (82%) of patients were satisfied with the actual decisions made, and 143 (71.5%) were satisfied with the shared information. The agreement level between decision-making preferences and actual decision practices was significant (ⱪ coefficient = 0.69; 95% CI = 0.59 to 0.79). The study's results demonstrate that a passive decision-control preference was prominent among patients with advanced cancer in Jordan. Further studies are needed to evaluate decision-control preference for additional variables, such as patients' psychosocial and spiritual factors, communication, and information sharing preferences, throughout the cancer trajectory so as to inform policies and improve practice.

Validation of the Arabic Version of the Edmonton Symptom Assessment System.

Quality cancer care is a team effort. In addition, patients' symptoms change over the course of treatment. As such, the Edmonton Symptom Assessment System (ESAS) is a simple tool designed to quickly monitor symptom change. Here, we present the results from a two-phase study aimed at validating the Arabic version of the ESAS (ESAS-A). Phase one involved the creation of two versions of the ESAS with both reverse and forward translations by bilingual, native Arabic speakers as well as evaluation by an expert panel. The reconciled version was then administered to 20 patients as a pilot from which to create the final version, which was then used with 244 patients. Phase two for the ESAS-involved an ESAS-based validation of 244 adults aged 18 years and older who were diagnosed with advanced cancer; then, further validation was completed in conjunction with two other symptom survey tools, the EORTC-Pal 15 and the HADS. The ESAS-A items possessed good internal consistency with an average Cronbach's alpha of 0.84, ranging from 0.82 to 0.85. Moreover, the results of ESAS-A showed good agreement with those of EORTC QLQ- 15 PAL (r = 0.36 to 0.69) and HADS (r = 0.60 and 0.57) regarding anxiety and depression. We found the ESAS-A to be responsive to symptom change and a median time to completion of 3.73 min. The results of our study demonstrate that the ESAS-A is a reliable, valid, and feasible tool for the purposes of monitoring symptom change over the course of cancer treatment.

Measuring Occupational Fatigue among Higher and Middle Management at a Specialized Cancer Center during the COVID-19 Pandemic.

PURPOSE: This study aims to measure the occupational fatigue level and describe the sources and consequences of occupational fatigue among middle and higher management at an international specialized cancer center during the COVID-19 pandemic. METHODS: A mixed-method design was used in this study. A convenience sampling technique was utilized to select the participants from King Hussein Cancer Center, Amman, Jordan. The data was collected through a self-administered questionnaire. This questionnaire included both quantitative and qualitative sections. We utilized Fatigue Risk Assessment and Management in High-Risk Environments (FRAME)-26 items scale for the quantitative section. Two main questions were included in the survey to identify the sources and consequences of occupational fatigue. RESULTS: The results show that the average mean of occupational fatigue was 2.95/5 (SD=0.70). The level of changes in fatigue levels after the COVID-19 pandemic increased by 0.87/3 (SD=1.45). The sources of occupational fatigue could be categorized into five themes: workload, work environment, staffing, psychological, and physical sources. There are four themes categorizing occupational fatigue: social, economic, health, and daily activity and lifestyle. CONCLUSION: This study affords valuable insight into the level, source, and consequences of occupational fatigue among middle and higher management at an international specialized cancer hospital in developing countries. The results indicate that the occupational fatigue level was moderate, and the fatigue level was negatively impacted by the COVID-19 pandemic.

Adopting Lean Management in Quality of Services, Cost Containment, and Time Management.

OBJECTIVES: This study aims to identify the role of adopting lean management in the quality of service, cost containment, and time management and to identify factors affecting lean management adoption, quality of service, cost containment, and time management in oncology settings. METHODS: A cross-sectional design was adopted in this study at the King Hussein Cancer Center (KHCC), a private institution in Amman, Jordan. A convenience sampling technique was used to select 360 participants. A self-administered questionnaire (58 items) was used to collect the data.  Results: The mean value for the quality of services was 3.84±0.56. These values for adoption of lean, time management, and cost containment were 3.82±0.74, 3.73±0.75, and 3.40±0.76 respectively. The results showed that the impacts of lean management adoption on the quality of service, cost containment, and time management were significant (p-value<0.001). The results showed substantial effects of all factors (organizational, departmental, and individual factors) on lean adoption, quality of service, cost containment, and time management (p value<.001). CONCLUSION: Lean management adoption had a significant impact on quality of service, cost containment, and time management in oncology settings.

Laparoscopic Partial Nephrectomy: Off-Clamp Versus on Clamp.

PURPOSE: The aim of this study is to describe our experience in laparoscopic partial nephrectomy and to compare the differences between off-clamp and on-clamp techniques in terms of clinical characteristics and outcomes. METHODS: A retrospective study was utilized. A purposeful sampling method was used to select the patients. The inclusion criteria for kidney tumors were as follows: exophytic, maximum diameter 3 cm, RENAL score 4 or more, solid or cystic, and suspected of malignancy. Around 32 participants were selected. The data were collected from patient files. RESULTS: There were no statistically significant differences between the mean of the off-clamp group and the on-clamp group in terms of tumor size, size of the kidney, and the position of the tumor. The average expected blood loss in the off-clamp group was 150.15 +/- 60.25 mL and in the on-clamp group was 75.25+/- 40.11 mL, with a p-value of less than 0.001. There was no statistically significant difference between the two groups in terms of the most common surgical complications, postoperative drainage, overall operation time, renorrhaphy time, and postoperative bedtime. CONCLUSION: The off-clamp group was shown to have a higher tumor resection duration as well as a higher rate of expected blood loss. The functional result of alterations in the estimated glomerular filtration rate seemed to be better in the off-clamp group. We expect to understand its long-term safety and oncological efficacy better as we continue to use this method.

The impact of COVID-19 on health care-associated infections in intensive care units in low- and middle-income countries: International Nosocomial Infection Control Consortium (INICC) findings.

BACKGROUND: This study examines the impact of the COVID-19 pandemic on health care-associated infection (HAI) incidence in low- and middle-income countries (LMICs). METHODS: Patients from 7 LMICs were followed up during hospital intensive care unit (ICU) stays from January 2019 to May 2020. HAI rates were calculated using the International Nosocomial Infection Control Consortium (INICC) Surveillance Online System applying the Centers for Disease Control and Prevention's National Healthcare Safety Network (CDC-NHSN) criteria. Pre-COVID-19 rates for 2019 were compared with COVID-19 era rates for 2020 for central line-associated bloodstream infections (CLABSIs), catheter-associated urinary tract infections (CAUTIs), ventilator-associated events (VAEs), mortality, and length of stay (LOS). RESULTS: A total of 7,775 patients were followed up for 49,506 bed days. The 2019 to 2020 rate comparisons were 2.54 and 4.73 CLABSIs per 1,000 central line days (risk ratio [RR] = 1.85, p = .0006), 9.71 and 12.58 VAEs per 1,000 mechanical ventilator days (RR = 1.29, p = .10), and 1.64 and 1.43 CAUTIs per 1,000 urinary catheter days (RR = 1.14; p = .69). Mortality rates were 15.2% and 23.2% for 2019 and 2020 (RR = 1.42; p < .0001), respectively. Mean LOS for 2019 and 2020 were 6.02 and 7.54 days (RR = 1.21, p < .0001), respectively. DISCUSSION: This study documents an increase in HAI rates in 7 LMICs during the first 5 months of the COVID-19 pandemic and highlights the need to reprioritize and return to conventional infection prevention practices.

The Role of Participation in and Effectiveness of Shared Governance Councils in the Nurses' Perception of a Professional Practice Work Environment.

OBJECTIVES: The aims of this study were to identify the differences in nurses' perceptions of their professional practice work environment (PPWE) related to their participation in shared governance (SG) councils and to examine the perception of effectiveness of SG councils among nurses who participate in them. BACKGROUND: Research suggests that adopting SG in nursing can lead to significant, positive outcomes, such as patient and nurse satisfaction and enhanced nurse empowerment, engagement, and a PPWE. METHODS: The study used a cross-sectional design in a Magnet®-designated urban Jordanian cancer care hospital. A convenience sample of 580 direct care nurses was used. The data were collected using self-administered questionnaires, the Council Health (CH) instrument, and the Professional Practice Work Environment Inventory (PPWEI). RESULTS: Results demonstrated a significant difference in the total score of PPWE between the SG council members (4.85) and nonmembers (4.68) (t = 2.906, P = 0.004). The results also indicated small to strong correlations of the total overall council health mean and all domain means of council effectiveness with total overall PPWEI mean and all domain means of PPWE (P < 0.05) among nurses who participated in SG councils. CONCLUSION: Findings support involving more staff in SG councils and that enhancing the SG councils' effectiveness positively affects the PPWE.

Impact of nurses' emotional intelligence on the implementation of a professional practice model in cancer care.

AIM: To examine the impact of emotional intelligence on the effective implementation of a professional practice model in a specialised cancer centre. METHODS: The study used a cross-sectional design with 580 frontline nurses at King Hussein Cancer Center, Jordan. The sample was selected using a convenience sampling technique. Data were collected using two self-administered questionnaires to measure emotional intelligence and professional practice. RESULTS: The overall mean value of emotional intelligence was 5.60 out of 6 (SD=0.78), while the overall mean value for the implementation of the professional practice model was 4.76/5 (SD=0.59). The results showed that the overall mean value of emotional intelligence had a significant positive correlation with the effective implementation of the professional practice model (r=0.580, P<0.001), even after adjusting for the participants' demographics (P<0.001). CONCLUSION: Emotional intelligence can be considered a predictor for the effective implementation of a professional practice model.

Work Stress, Coping Strategies, and Health-Related Quality of Life among Nurses at an International Specialized Cancer Center.

OBJECTIVE: The main objective of this study is to identify work stress, coping strategies, and health-related quality of life and the relationship between them among oncology nurses. METHODS: A cross-sectional design was conducted at King Hussein Cancer Center. A convenience sampling technique was used to select 446 nurses. A self-administered questionnaire was utilized using three scales: the Work Stressor Inventory for Nurses in Oncology, Revised Ways of Coping Checklist, and Research and Development 36-Item for Health Survey. RESULTS: The results showed that the levels of work stress (2.61/5), using coping strategy scale (1.59/4), and health-related quality of life scale (50.54/100) were moderate. The total mean value of the work stress scale had a significant positive correlation with the total mean value of the coping strategy scale (r=0.322*, p < 0.05) and a significant negative correlation with health-related quality of life. Moreover, there is no significant correlation between the total mean value of the coping strategy scale and the health-related quality of life scale (r=0121, p >0.05). Age and years of experience were negatively correlated with health-related quality of life (r=0.217 and 0.182 respectively, p < 0.05). CONCLUSION: Oncology nurses had a moderate level of work stress, coping strategy scale, health-related quality of life scale. Work stress has a significant correlation with using coping strategies and health-related quality of life among oncology nurses. Proper training regarding effective coping strategies is required. More studies are recommended to examine work stress, coping strategy, and health quality of life among oncology nurses.

Using Failure Mode and Effects Analysis in Improving Nursing Blood Sampling at an International Specialized Cancer Center.

BACKGROUND: The process of blood sampling is considered one of the primary and most common nursing invasive procedures carried out daily. Any failure at any point could have a severe negative impact on patient outcomes. PURPOSE: This project aimed to assess and improve the nursing blood sampling process in a specialized cancer center using failure mode and effect analysis (FMEA). METHODS: An observational analytical design of the nursing blood sampling process using FMEA was conducted in King Hussein Cancer Center in Amman, Jordan. Seven steps were conducted, including a review of the blood sampling process, brainstorming potential failures, listing potential effects of each failure mode, assigning a severity rating for each potential effect, assigning a frequency/occurrence rating for each failure mode, assigning a detection rating scale for each failure mode, and calculating the Risk Priority Number (RPN) for each effect. RESULTS: Eight (out of 28) main critical failure modes with more than 200 RPN were identified in the blood sampling process. Accordingly, five themes were developed to guide the corrective actions. These themes included: process and responsibility modifications, resource and information technology utilization, patients and family engagement, safety culture, and education and training after implementation of the corrective actions. This resulted in a 58 % reduction in the RPN of major failure modes. CONCLUSION: Many factors lead to blood sampling errors. A critical focus should be conducted on the preparation phase due to the possible errors that may occur. Proper identification of patients and blood sample tests are the keys to a significant decrease in blood sampling errors.
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Nursing Professional Practice Model: Development, Implementation, and Evaluation at an International Specialized Cancer Center.

Professional practice model (PPM) is one of the initial steps toward nursing excellence and the main requirement to earn Magnet Recognition. This article will describe the process of development, implementation, and evaluation of a PPM for nursing in a specialized cancer center in Jordan.

The role of e-health in improving control and management of COVID 19 outbreak: current perspectives.

E-health could play an important role in the global response to Coronavirus disease 2019 (COVID-19). This paper aims to outline the roles of using e-health in the control and management of COVID-19 based on current perspectives. Many databases and health organizations were searched. The results indicated that there are significant roles of e-health in strengthening the efforts to control and manage this COVID-19 pandemic through improving safe coordination and communication, affording an alternative for education and training, analyzing the data, and providing safe care. Further studies are recommended to evaluate the role of e-health in the control and management of COVID-19.

The impact of obesity on self-esteem and academic achievement among university students.

BACKGROUND: Previous studies showed that obesity was correlated with many negative social and health outcomes including poor academic achievement and low self-esteem. PURPOSE: To determine the prevalence of obesity and to identify the impact of obesity on self-esteem and academic performance among university students. METHOD: The study used a correlational design to achieve the study objectives. It was conducted at the University of Jordan (UJ). The study population was all university students in at UJ. A convenience sampling technique was conducted to select 419 students. A self-administered questionnaire was designed to collect data from the sample. The body of the questionnaire was divided into two sections: a demographic data section, and the second section aimed to measure the students' self-esteem using the Rosenberg Self-Esteem Scale (SES). RESULTS: The response rate in this study was 91.1%. The results showed that 33 students were obese (7.88%), 116 students were overweight (27.68%), 266 students were normal weight (63.48%), and four students were underweight (0.95%). The results showed that there was a significant negative relationship between obesity and self-esteem (total item) (r = -0.231, 0.000*). The results showed that there was a significant negative relationship between obesity and academic achievement (r = -0.131, 0.002). CONCLUSION: There was a significant impact of obesity on the self-esteem and academic performance among university students.

Impact of Structured Nurse Leader Rounds on Satisfaction With Nursing Care Among Patients With Cancer.

BACKGROUND: The patient satisfaction rate is considered a challenge for nurse leaders, especially among patients with cancer, due to the complexity of the disease, diagnostic procedures, and treatment. AIM: The purpose of this study was to evaluate the impact of structured nurse leader rounds (NLRs) on satisfaction with nursing care among patients with cancer. Moreover, we assessed the relationship among NLRs, patient satisfaction, and demographical variables. METHODS: A two-group posttest design was used in four adult inpatient oncology units in a specialized oncology center. A stratified random sampling technique was utilized to select 169 patients for the experimental group (80 patients) and control group (89 patients). Structured leader rounds were conducted by nurse leaders using a scripted nurse leader tool to standardize the rounds in the experimental group, while the unstructured leader round was conducted in the control group. Patient satisfaction was measured using the Patient Satisfaction with Nursing Care Quality Questionnaire. RESULTS: The findings revealed that there was a significant difference in total score of patients' satisfaction between study groups (t = -9.213, p > .001). Conversely, the structured leader round has a significant impact on the patient's experience with nurse concern and caring (t = -2.054, p = .042). CONCLUSIONS: Adoption of a structured NLR has a significant impact on improving patient satisfaction in an oncology setting where patients receive care from many disciplines, such as surgical, medical, radiotherapy, and radiology. CLINICAL RELEVANCE: Efficient structured NLRs of nursing professionals are important for enhancing the quality of nursing care and patient satisfaction.

Improving Nurses' Hand-off Process on Oncology Setting Using Lean Management Principles

Background: Patients in oncology setting are struggling with the complexed disease, and long and intensive treatment options. This increase the need of patients for more coordination and effective hand-off between health providers including nurses. Aims: The main aim of this project is to improve the effectiveness of hand-off between nurses in the oncology setting using lean management principles. Methods: One group pretest-posttest quasi-experimental design was conducted at King Hussain Cancer Center during quarter two to quarter four in 2017. The project was conducted using the lean tools including root cause analysis, redesigning the hand-off process; using structured tools, and standardization of the hand-off process. Results: The finding of this project showed a significant decreasing in the hand-off duration and the incidence of events related to nursing practice deviation in post-intervention. Moreover, the results showed that the nurse satisfaction score was improved. However, there is a little difference in patient satisfaction results between two quarters for overall satisfaction and per each domain. Conclusion: The project approved that the use of structured tools, safety briefing, and standardized hand-off process play important role in improving the effectiveness of the hand-off process.

The role of electronic medical records in improving the quality of health care services: Comparative study.

PURPOSE: The purpose of this study is to identify the quality of health care services' differences between adopted Electronic Medical Record (EMR) and paper-based record hospitals. Moreover, to identify how the quality of electronic medical records affect the quality of health care services. METHODS: A cross-sectional, descriptive, and comparative design was utilized between two groups in this study. The study was conducted in two public hospitals in Jordan. One hospital which had adopted the EMR system in their works and another hospital that had paper-based record. A convenience sampling technique was used to select 410 health professionals from the selected hospitals (205 participants from each hospital). SERVQUAL and E-S-QUAL questionnaires were adopted to collect the data about the quality of EMR and quality of health care service. Statistical Package for the Social Sciences (SPSS) Version 21 was deployed to analyze the collected data. RESULT: The results indicate that the quality of health care services (expectation and perception) in EMRs adopted hospital is higher than the quality of health care services in the hospital using paper-based record. Quality of EMRs and its domains (efficiency, availability, fulfilment, and privacy) are high in both perception and expectation of health care professionals in EMR-adopted hospitals. Moreover, there is a significant relationship between the whole perception of the quality of electronic medical records and the quality of services, and between each domain of quality of EMRs and total perception of quality of services. CONCLUSION: Adoption of a high quality of EMR has a significant impact on improving the quality of health care services.