A mixed methods study protocol for developing a public governance model for Iranian hospitals: design, justification and methodological framework

BACKGROUND: The public hospital preparedness is essential for epidemic disaster like COVID-19 pandemic. This study was conducted to present a hospital management preparedness model of Iran's public hospitals for the epidemic. MATERIALS AND METHODS: The method of this study was an exploratory sequential mix method study (qualitative–quantitative). In this study, qualitative and quantitative methods were used in four stages. (1) Interviews with hospital managers to identify hospital management experiences during the COVID-19 epidemic and categorize the results in themes and subthemes, (2) assessing the performance of public hospitals in managing the coronavirus epidemic in a quantitative method, (3) present the initial hospital management model for a public hospital in epidemic conditions using an expert panel, and (4) validation of the model using the Delphi method. RESULTS: Experiences of hospital managers and specialists were categorized into eight themes: information gathering and environmental analysis, general and operational planning, provision of equipment and physical and financial resources, training and empowerment of human resources, a compilation of instructions and job descriptions, review and ensuring maximum readiness, monitoring and follow-up of service provision and existing problems, evaluation and feedback of performance problems and level of preparation and 51 sub-themes. The quantitative study indicated that all the investigated indicators had a significant decrease in the first month and an increase in the epidemic's continuation. The results were categorized in nine themes and 59 sub-themes, and finally, the model was validated in one round by the Delphi method. CONCLUSION: In Iran, managers have valuable experiences in COVID-19 epidemy management, but these experiences are scattered and not organized. In this study, by a qualitative–quantitative, a model was presented that contains essential points obtained from the experience of hospital managers and experts in actual disaster conditions and is appropriate and fits hospital structure and infrastructure of the health system in Iran.

BACKGROUND:There is a growing global movement toward quality and safety in healthcare and quality improvement (QI) in general surgery. The first step in any QI initiative is identifying the challenges and barriers to achieve such goals and then to define appropriate actions. This study aims to provide an overview of the QI challenges in Iranian hospitals’ surgery-related processes and suggest applied solutions accordingly.METHODS:This is a sequential (qual-quant) mixed-method study from November 2019 to January 2020, involving 21 face-to-face interviews with hospital managers, quality officers, and surgery-related clinicians and staff, followed by a Delphi consensus-seeking stage to finalize solutions. MAXQDA software was applied for organizing the concepts, and thematic content analysis was used for analyzing the data as an inductive approach to extract the emerging themes and sub-themes.RESULTS:The managerial problems were classified into four groups of (I) defects and delays in completing patient medical records, (II) irregularity and the lack of transparency in the direction of processes in the hospital, (III) inappropriate and unrealistic operating scheduling, and (IV) poor safety considerations. The proposed solutions included imposing stricter regulations for competing for medical records, such as reduction of payments, development of guiding brochures or protocols for patients on their arrival, assigning a certain number of experienced nurses and surgeons for schedule management, rewarding the report of medical and surgical error cases, and developing a regular monitoring program for the proper implementation of surgical safety guidelines.CONCLUSION:There are various managerial barriers that hamper QI in hospitals’ surgery-related processes. Implementing simple but agreed solutions can lead to saving patients’ lives, reduction of the unnecessary use of resources, and enhance of patient and staff satisfaction.

Background: This study aimed to explore service quality in Iranian hospitals by a systematic review and meta-analysis of the existing literature.Methods: The literature search in the international (PubMed, Scopus, and the ISI) and Iranian (SID, Iranmedex, and Magiran) scientific databases was conducted to identify studies (published in English and Persian) used the service quality gap (SERVQUAL) model to examine service quality in Iranian hospitals between 2000 and 2016. The databases were searched using a combination of the following keywords: "hospital service quality", or "healthcare service quality", and "SERVQUAL model", or "gap model", and "Iran". A random-effects meta-analysis model was used to investigate the quality of hospital care in Iran.Results: A total of 13 articles with 4,217 patients were included in the study. Results indicate that there are negative gap values between patients' expectations and perceptions in six SERVQUAL dimensions namely. tangibility, reliability, responsiveness, assurance, empathy, and access. The overall mean score of patients’ expectations and perceptions of quality of hospital care in Iran were estimated 4.59 and 3.69, respectively (i.e., quality score gap= -0.9). The highest and lowest quality score gap values were related to the reliability and responsiveness dimensions, correspondingly.Conclusion: The study found that expectations of patients from hospital care have not been met in Iran. Thus, improving service quality in Iranian hospitals warrants further attention by health professionals, health policy-makers, and hospital managers.

PurposeThe purpose of this paper is to explore the ethnically diverse workplace in Irish hospitals by examining the perspectives of foreign- and Irish-born professionals and their managers.Design/methodology/approachSemi-structured qualitative interviews with 30 health professionals (foreign- and Irish-born) and with hospital managers (Irish-born). All interviews were transcribed and analysed using thematic analysis.FindingsThe managers and professionals interviewed mostly perceived ethnically diverse workplaces as an asset. Health professionals also identified a number of challenges, including internal divisions based on ethnicity, language and communication problems and cultural differences. However, in general, discrimination on the basis of ethnicity was not highlighted by interviewees.Research limitations/implicationsWhile the qualitative design of the study allowed for an in-depth exploration of experiences in ethnically diverse workplaces in selected Irish hospitals, the relatively small sample size poses some limitations. The study brings to light the need for larger-scale survey-based research on the ethnically diverse workplace in Irish hospitals, which includes Irish- and foreign-born health professionals in the sample.Originality/valueThe study includes a variety of perspectives on experiences in ethnically diverse workplaces in Irish hospitals, including foreign-born health professionals, their Irish-born colleagues and hospital managers.

Hospital management by health services management graduates: the change paradigm in Iran

Outsourcing is used as a strategy to improve efficiency, quality, and satisfaction of beneficiaries in hospitals. This study aimed to determine the reasons for outsourcing, outsourced services, achieved objectives, and outsourcing challenges. This qualitative study was conducted through 58 face-to-face semi-structured interviews with chief executive officers (CEOs), chief financial officers (CFOs), and contracting experts (CEs) in 42 public hospitals in Tehran, Iran. Purposive and snowball sampling techniques were used. Interviews were recorded digitally and transcribed verbatim. Data analysis was performed based on an inductive-deductive approach via MAXQDA-10. The Participants included 26 CEOs, 15 CFOs, and 17 CEs. The most important reasons for outsourcing were divided into four main categories including financial resources and funding, customers, management, and factors related to the hospitals. Accessing to up-to-date knowledge and technology, improving service quality and accountability, focusing on strategic points, reducing workload, and increasing patient satisfaction turned out to be the positive outcomes of outsourcing. Weakness in laws and regulations, monitoring and assessment of an outsourced unit, creating dependency and changing organizational culture, as well as human resource issues were introduced as the main pitfalls and challenges of outsourcing. Based on the results, it was suggested that the hospital managers must attempt to outsource services by realistic analysis of the organization's current status. They should specify the reasons and objectives of outsourcing and make decisions based on outsourcing potentials. By taking the current challenges of outsourcing in Iranian hospitals into account, the authorities can make the most efficient decisions with regard to outsourcing.

Introduction: Influenza virus is one of the deadliest viruses that has threatened the human population over the years. Every year, organizations and hospitals must be prepared to deal with the disease and treat people with the flu and be able to manage the disease in the hospital. The aim of this study was to identify hospital management strategies for human influenza in Yazd province, central part of Iran. Methods: This study was a qualitative study with inductive conventional approach. A total of 14 main hospitals in Yazd province were surveyed in 2021. The study population included heads and managers of hospitals, nurses, educational and clinical supervisors, metrons, officials of the quality improvement office and the infection Control Committee. Participants were selected using snowball sampling method. Semi structured interviews were used to collect data. The sample size in this study was up to information saturation. Content analysis method was used to analyze the data. Results: Using the opinions and views of 38 managers and officials of selected hospitals in Yazd province, data saturation was obtained. The most important tasks of the hospital management in terms of influenza control and management were divided into 5 areas (field measures, support, training, awareness, protection and measures in the field of human resources). The major challenges regarding the influenza control and management were classified into 3 areas: hospital (health), macro (university, provincial, national and Ministry of Health guidelines) and community level. Finally, the most important solutions and suggestions were categorized in these 3 key areas. Conclusion: Based on the categorized challenges and problems, as well as the classification of the most important strategies and suggestions, useful action can be taken to the control and management of influenza, both at the hospital level and in the community, in Iranian hospitals especially in Yazd province.

PurposeThe purpose of this paper is to determine accreditation effects on Iranian military hospital health service quality through nurses’ viewpoints.Design/methodology/approachThe paper is a cross-sectional questionnaire-based study. Sampling drew from a hospital nurse census (n=160). Descriptive statistics were used to analyze participant demographics and nurses’ views. Linear regression analysis determined the independent variables’ overall effect on the accreditation quality results dimension (dependent variable).FindingsFrom the nurses’ viewpoints, accreditation effects on services quality mean score was 3.60±0.61. Linear regression analysis showed that leadership and quality management were identified as the most important accreditation quality predictors. The R2 value (0.698) showed that nearly 70 percent of the dependent variable changes were affected by the independent variables.Practical implicationsThis study gives hospital managers a deeper insight into accreditation and its effects on military hospital service quality. Military hospitals benefit from military organization such as hierarchy and command chain, so managers should employ these characteristics to adopt appropriate policies to promote human resource management as a competitive advantage. Furthermore, results will guide public and private hospital managers on how to manage organizational variables that benefit from accreditation.Originality/valueAccreditation was introduced as a hospital quality improvement program. However, implementing accreditation programs should be cost-effective. Hospital managers and employees should feel that accreditation can improve service quality. Nurses had positive viewpoints about accreditation and its effects on military hospital service quality.

Rapid progress in communication and information technology and fierce competition in hospitals to attract and retain customers has led to concept of customer relationship management. Hospitals today possess the most significant factor in health care system and play an important role in people’s health maintenance. CRM’s noticeable improvement in a hospital can include immediate access to patient’s record, prompt response to patient’s appointment and patient’s immediate admission, timely review of complaints, and flexibility in service delivery to patients. Patient’s satisfaction is the ultimate key in maintaining profitability of hospitals. The purpose of this study is to find effective factors and presenting a framework for customer relationship management in hospitals in Iran. Thus, it examines the framework and factors in patient’s satisfaction in hospitals.

Medical waste is of great importance due to its hazardous nature that can cause undesirable effects on humans and the environment. This study focuses on medical waste management in hospitals of Iran. Data were collected based on questionnaires and for self-report of medical waste management. The results along with other information were sent to the ministry of health network system. Results indicated that the mean generation rate of non-hazardous and sharp and infectious and total wastes in Iran were, respectively, 1.84, 1.09 (36.9% of total waste generated) and 2.98 kg/bed/day. Chemical waste generation rate in Iran is 0.02 kg/bed/day (0.68%) that relative to infectious waste and total waste generation rate is much lower which could be due to improper segregation of medical wastes. There is significant differences between private and governmental hospitals, in terms of infectious and sharp waste generation rates (P=0.027). Also there are significant differences between specialized and general hospitals in group of non-hazardous waste (P=0.039), infectious waste (P=0.001) and total waste generation rate (P=0.02). 65.41% of governmental hospitals used autoclave for infectious waste treatment. In the private and governmental hospitals 14.8% and 24.29%, respectively not have any treatment devices and hazardous waste was disposed without treatment.

BackgroundConcerning maternity service, the mother’s quality assessment is central because emotional, cultural, and respectful support is vital during labour and the delivery process. Studies concerning the perceived quality of maternity services from the perspective of mothers have rarely been carried out in Iranian hospital settings. Therefore, this study aimed to measure the gap between the expectations of patients with maternity services and their perceptions of the service and identify associated factors at a maternity hospital in northwest Iran using service quality (SERVQUAL) and health quality (HEALTHQUAL) questionnaires.MethodsThis cross-sectional study consists of 350 randomly selected participants visiting a maternity hospital in Tabriz, Iran between November 2022 and February 2023. Admitted patients responded to two questionnaires adopted from the SERVQUAL and HEALTHQUAL instruments. The questionnaire was provided on hospital admission for expectation and before hospital discharge for perception. The quality gaps between the expectations and perceptions of participants were analyzed. Data were analyzed using SPSS (Version 24) through descriptive analyses, paired t-tests, and multivariate linear regression.ResultsBased on the SERVQUAL questionnaire, the overall score for expectation and perception were 3.69 and 4.15, respectively and the overall gap in service quality was − 0.45. Similarly, according to the HEALTHQUAL questionnaire, the overall score for expectation and perception were 3.66 and 4.53, respectively, and the overall gap in service quality was − 0.87. In addition, the results indicated that the highest gap was observed for the Effectiveness and Assurance dimensions with gap scores of − 1.20 and − 0.69, respectively. Older patients, having an academic education, women who were residents in urban and those who visited for the first time were found to have significantly higher expectations compared with their perceived quality of care (P < 0.005).ConclusionsThe results of the current study confirmed that there is a negative gap between maternity service women’s expectations and their perceptions. These results suggest there is capacity for improvement in the quality of health service delivery from the patient’s perspective. Therefore, hospital managers need to develop several strategies to improve the interpersonal skills of staff and communication, strengthen trust between patients and health providers, and meet the psychological and emotional needs of patients.

Context: Organizational learning management is the implementation of knowledge policies and the mission of improving work with the help of knowledge and better understanding in the organization and helps employees to continually apply their capabilities to recognize the complexities and develop common mental models.\nAims: The purpose of this study was to identify a variety of variables, including attitudes, beliefs, and facts about nurses' organizational learning management in the field of health.\nSetting and Design: This study was conducted to determine a more accurate plan for improving the activities in the field of health, considering the importance of managing nurses' organizational learning.\nMaterials and Methods: This qualitative study was carried out by thematic analysis method in 2019. The research population consisted of experts from medical universities of Iran. Semi-structured. Sample size in this study was 15 people, including 8 executives and 7 nurses.\nStatistical Analysis Used: In this study, the “latent content” analysis approach was used to analyze the data, which has four steps (coding, classification, finding themes or themes, data integration)\nResults: The findings of the present study showed that the realization of nurses' organizational learning management in hospitals in Iran can be conceptualized in three categories: individual, contextual and organizational factors.\nConclusion: Although the health system makes considerable efforts to learn nurses, it is not responsive to the needs of nurses in the current situation. Therefore, considering the importance of organizational learning for nurses, identifying the effective factors of learning management for achieving these goals seems necessary.

INTRODUCTION:In the Iranian Accreditation System, leadership and management standards have been almost ignored and not paid enough and necessary attention to the structural components and the infrastructures standards in management and leadership sections. Governing body, medical staff, chief executive officer (CEO), and nursing management standards are inadequate and lack accountability. These standards could lead to reform and finally provide the context for accomplishment of an appropriate accreditation program.MATERIALS AND METHODS:This is a descriptive, comparative, and qualitative study. It was done in two phases. The first phase included literature review of the standards of the selected countries followed by comparison of the standards of the board of trustees, medical staff, CEOs, and nursing management standards to develop the primary framework for Iranian hospitals. In phase two, the primary framework was validated true three rounds of Delphi technique.RESULTS:Surveying the accreditation system standards in selected countries included the USA, Egypt, Malaysia, and Iran. It was found that the management and leadership standards were classify as governing body, medical staff, CEOs, and nursing management standards. The result of this study provides a framework for improvement of the Iranian national accreditation program.CONCLUSION:In regarded to the importance of the leadership and management standards in reform and change and promotion of the health services quality, efficiency, and effectiveness, the results of this study showed that the present standards of the Iranian accreditation assessment system and guidelines lack the necessary infrastructures for implementing a successful national accreditation program.

Conflict of interest: none declared.IntroductionEmployees’ job satisfaction and commitment depends upon the leadership style of managers. This study clarifies further the relationships between leadership behaviors of managers and two employees’ work-related attitudes-job satisfaction and organizational at public hospitals in Iran. A better understanding of these issues and their relationships can pinpoint better strategies for recruiting, promotion, and training of future hospital managers and employees, particularly in Iran but perhaps in other societies as well.MethodsThis cross-sectional study was conducted using self-administered questionnaires distributed among 814 hospital employees and managers through a stratified random sampling.Results and discussionThe dominant leadership style of hospital managers was participative style. Hospital employees were moderately satisfied with their jobs and committed to their organization. Salaries, benefits, promotion, contingent rewards, interpersonal relationships and working conditions were the best predictors of job satisfaction among hospitals employees. Leadership, job satisfaction and commitment were closely interrelated. The leadership behavior of managers explained 28% and 20% of the variations in job satisfaction and organizational commitment respectively.ConclusionThis study clarifies the causal relations of job satisfaction and commitment, and highlights the crucial role of leadership in employees’ job satisfaction and commitment. Nevertheless, participative management is not always a good leadership style. Managers should select the best leadership style according to the organizational culture and employees’ organizational maturity.

Dear Editor, Preparing and increasing efficiency in hospitals in disasters need to launch a common protocol named Hospital Emergency Incident Command System (HEICS). HEICS provide more coordination between hospitals and other institutions involved in emergency incidents by utilizing logical management structure, duty descriptions, creating clear reporting channels as well as developing a common and simple nomenclature system. Researches indicated that applying and establishing HEICS is necessity for Iranian hospitals and it can be helpful for use in both emergency and non-emergency situations, such as moving the facilities dispensing medications to hospital staff, or planning for a large hospital or community event. Developing training program on HEICS for hospital managers as well as establishing it seems necessary regarding our country’s condition. In this paper we point out establishing HEICS have to be in agenda for policy maker’s managers in Iranian health system and affiliated hospitals. Critical incidents are sudden, unanticipated events or situations that require quick decisions. Experiences from all around the world show that confusion and chaos are the most common issues which are confronted in hospitals when there is a serious crisis (1). Clearly a timely and effective management system with accurate organization and proactive plans and activities could minimize negative consequences of such incidents and maximize efficiency of emergency services (2-4). Incident command system (ICS) is currently the most common system of incident management in the world, gaining more recognition due to its successful outcomes (2, 4). In ICS, the incident commander, is responsible for directing other peoples to be well organized and involved. ICS is founded on some basic principles, which ensure using resources effectively, and on the other hand, reduce disturbances in decision making and doing proper operations, by responsible organizations (5). In other words, successful response to crisis requires coordination among all hospital wards and units as well as collaboration with pre-hospital emergency forces (such as EMS, Red Crescent agency), police, firefighting in order to make sure communication lines are established. Although certain level of flexibility needed to respond to variety of crisis (6). Instead of ICS, preparing and increasing efficiency in hospitals in such circumstances, a common protocol named Hospital Emergency Incident Command System (HEICS) has been proposed which is extracted from basis ICS (2). HEICS was created in the late 1980s as an important foundation for the 5815 registered hospitals in the United States in their efforts to prepare for and respond to various types of disasters (7). In fact, HEICS is an incident management system composed of some specific roles in the form of an organizational table. Each of these roles has a specific mission during crisis situation, and there is a list of individual job description which guide appointed person in the crisis situation carefully. Actually HEICS allows providing as much responsibilities as required at any time, and it means more effectiveness and lower cost. Thus HEICS has capability of adapting with different kinds of incidents and crisis in any scale (8-10). HEICS provide more coordination between hospitals and other institutions involved in emergency incidents by utilizing logical management structure, duty descriptions, creating clear reporting channels as well as developing a common and simple nomenclature system (2, 4, 11). HEICS provides a commanding system which doesn’t rely on specific people, but it is flexible (6). Significant and effective features in HEICS, especially in its third version (1998) have made it one of the most common and most comprehensive hospital management systems. In developing the fourth edition of HEICS, the value and importance of using an incident management system to assist as well with daily operations, preplanned events, and non-emergency situations became apparent. Thus, the HEICS was created as a system for use in both emergency and non-emergency situations, such as moving the facility, dispensing medications to hospital staff, or planning for a large hospital or community event (7). Developing training program on HEICS for hospital managers as well as establishing it seems necessary regarding our country’s condition. In spite of the necessity of establishing such a system, many developing countries still do not have to establish this system. According Yarmohammadian and his colleagues, barriers for HEICS establishment in Iranian hospitals are classified into two categories: internal and external. Internal barriers are related to health care sector and external barriers are referred to out of health care sector. Some of internal barriers include high cost implementation, lack of motivation in the hospital managers and staff, lack of common language, lack of competitive atmosphere for progress and excellence, involvement of administrative managers in daily activities, lack of empowerment, lack of feeling the need for crisis management, and lack of knowledge in managers. External barriers include lack of authorities support and non-commitment of managers, lack of qualified managers, absence of statutory requirements, too many decision maker authorities, lack of administrative culture for crisis management, poor communication and coordination in crisis team, constant change in regulations, and lack of emergency incident command system in the country (12). According to these barriers some solutions are: using other people’s experience and preparation of training packages related to unexpected disasters, support of department of ministry of health and considering extra and specific budget for it, concept building in different dimensions, creating interest in personnel, appointing qualified managers, training and informing managers in all levels in order to create shared language among them and culture-making, designing instructions and legal bylaws for hospitals and legal requirements, elimination of daily and limited concerns of managers and removing complex administrative processes, inclusion of emergency incident management in managers’ job description and regarding it in evaluation of hospital managers, preparation of indexes and standards related to implementation of circular by managers and selection of managers, job description and monitoring of managers, establishment of regular committee for managers so that they can have planning and implementation of this system in macro level and creating a single organization in the whole community (12-14). It is concluded that, since this system is one of the necessary needs of hospitals, it is recommended that such barriers should be eliminated and responsible entities including Ministry of Health and Medical Education (MoHME) and affiliated hospitals provide codified and ordered plans for establishment of this system. MoHME through approving and notifying rules and regulations can be established such valuable and proactive system for affiliated hospitals as well as private ones.