Journal of

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Background: Education and evaluation should be designed to educate and evaluate students in the real field or similar to their future work place. This study aimed to improve summative evaluation in internship.
Material & Methods: A quantitative (61 students) and qualitative (15 students) study with health services management students conducted in Tabriz Faculty of Health and Nutrition. OSFE was developed as a summative evaluation method based on students' experiences about final evaluation of clerkship, which ascertained using two FGDs. In the OSFE method students attended in the several stations to do particular skills individually. In each station students' skill has been assessed by a trained examiner using standard checklists. At the end of exam, students' opinion about new method has been asked through qualitative and quantitative methods. Qualitative data analyzed by hand and SPSS software was used to analyze quantitative data.
Results: Findings from FGDs (after OSFE) showed that the majority of students were satisfied about OSFE and they believed that it is a good method to assess students' skills and competencies. Quantitative study also demonstrated that 74% of students believed that OSFE is a good method to evaluate their capabilities and 70% verified that they have been attended in an orientation session about OSFE. Moreover, 58% considered OSFE as an equitable method.
Conclusion: It can be suggested that OSFE could be used as a valuable summative evaluation method for non-medical students' clerkship and practical courses.

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Background: Assessing applied resources in a hospital as a health system will lead to identify organizational problems in this section and subsequently the necessary actions to resolve them. The aim of this study was to determine measurement of inappropriate admission and hospitalization (ISP: Inappropriateness Patient Stay) and associated reasons.

Materials & Methods: One widely used tools to assess appropriate use of hospital recourse is Appropriateness Evaluation Protocol which include objective criteria related to clinical services provided to the patient. Survey of admission and hospitalization in a cross-sectional and prospective study for 246 patients in the Alinasab hospital affiliated insurance organization carried out in Tabriz.

Results: The total of 7 percent of admissions and 6.2 percent of hospitalized were diagnosed inappropriate manner. There was no significant association between inappropriate admissions and other variables. There was significant relationships between Inappropriate bed days with insurance (P=0/041) and duration of hospital stay (P=0/041). However, there were no association between sex, disease diagnosis and hospital days per week with Inappropriate bed days.

Conclusion: The reasons of inappropriate admission and hospitalization in Iran are similar to other countries. Upgrading strategies to referral system performance, creating standard protocols to evaluate criteria for medical personnel and increasing outpatient diagnostic institutions could be reduce inappropriate admissions and stay of patients.

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Background: The hospital is one of the main organizations which offering health care and medical services in a high level allocated sources in the health sectors. Therefore, considering to efficiency costs is great importance. This study aims in considering the efficiency of the hospitals of Medical University in Tabriz, Iran, by using Data Exhaustive Analysis Method.
Materials & Methods: The study inspected and analyzed the technical efficiency and also effective factors on it in selected hospitals by using Data Exhaustive Analysis Method during the 3 period years (1384-1387). In order to conduct this study, the comprehensive Input-oriented Form of Data Exhaustive Analysis Method assuming in the variable return compared with the scale. The variables of the inputs in this study included number of physicians, non-physician staff, and active bed and annual costs of the hospital. The variables of the outputs included the coefficient of the occupied beds, number of admitted patients, and surgeries. To data analyzing, SPSS and data envelopment analysis software were used. It is worth mention that the data in this study were accumulated by using the forms devised by the authors and standardized questionnaire via referring and going to the hospitals.
Results: The findings of data exhaustive analysis method showed that there was %5(TE=0/953) possible capacity augment in the technical efficiency. The findings also suggest that there is a potential frugality in consuming the inputs in order to produce a constant amount of the output. Meanwhile, there is a potential augment of the output by using a constant amount of the input, as well. The findings also represent the effect of the demographic factors and functional factors on the efficiency of the hospitals.
Conclusion: It is suggested that to leave out the surplus staff, decrease the surplus costs of the hospital through replacing the energy consumption and a proper management of energy and other surplus inputs, hire sophisticated managers and applying the graduated field of management in health care and medical services and also hire the managers with high quality degrees, create the data envelopment analysis of enhancing efficiency should be one of the useful way to provide qualified medical services in our society as a comprehensive programming. Based on the findings of the data Exhaustive analysis method, improving the efficiency of the hospitals, health care system and medical section are essential as well.

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Background: Patients' safety is a critical component of health care quality. As health care organizations continually strive to improve, there is important growing recognize of establishing a culture of patients' safety. To establish a safety culture in a healthcare organization, the first step is measuring the current culture. The aim of the study was to measure physicians, nurses and Para clinical personnel perceptions in patient safety culture in Tehran's selected hospitals, and to compare findings with U.S. hospitals.
Materials & Methods: Physicians, nurses, and Para clinical personnel who worked in training hospitals affiliated with Tehran university of medical sciences were asked to complete a self-administrated patients' safety culture survey (n = 145). Data collection was carried by using the Persian version of HSOPS, developed by Agency for Healthcare Research and Quality (AHRQ). Cronbach's alpha and chi-square tests were employed in statistical analyses.
Results: Among the dimensions of patients' safety culture with the highest percentage of positive responses the teamwork within units (67%) was higher, whereas that with the lowest percentage of positive responses was non-punitive response to error (51%). Except to Handoffs and transitions dimension the entire dimension scores were lower than the benchmark scores. The study revealed that more than half of the participants were not reported the errors.
Conclusion: Improving patients' safety culture should be a priority among hospital administrators. Meanwhile, Healthcare staff should be encouraged to report errors without fear of punishment action.

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Background: Accreditation is one of the evaluation systems which have numerous effects on the key indicators in health care system. To develop a suitable accreditation model, a best way could be the benchmark of the powerful and successful accreditation models in all over the world. By considering likely differences in the various countries health systems, this study aims to survey the compatibility of the best accreditation models and standards in Islamic Republic of Iran's health care system.
Materials & Methods: In this study, the expert's perspectives have been ascertained about standards of selected references accreditation models based on standards "importance" and "feasibility" using two rounds Delphi Technique. The experts selected among scientific and academic experts in the areas of accreditation and health services management. They were asked to fill up the Delphi questionnaire and send back it to the researchers in the designated time. Each standard scored in Likert scale from 1 to 9. Standards with mean score of ≤ 3 were rejected, standards with mean score between 4 and 6 send to the second round and standards with mean score ≥ 7 included in the national model.
Results: In the first round, 20 out of 27 questionnaires have been obtained from experts. After data analyses all the standards have been accepted except 31 with mean score between 4 and 6. Remained 31 standards with achieved mean scores in first round, send back to the study experts through the second round. In the second round, 17 out of 20 questionnaires collected and finally 18 standards were rejected.
Conclusion: According to the variety of standards, comprehensive categories and richness of necessary details of standards, the resulted model in this study could be a rich and suitable model for Islamic Republic of Iran. Therefore, using this model could empower evaluation system and improve the quality of health care system.

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Background: This study aimed to survey the relationship between job stress, self- efficiency and coping ability among staff of therapeutic- educational hospitals of Tabriz University of Medical sciences.
Materials & Methods: This cross-sectional study was conducted in 2009 among therapeuticeducational hospitals of based on a two stage random sampling. Initially seven hospitals were selected using a simple random method and then 288 persons from the therapeutic and administrative staff were chosen as the sample to be studied using a classified random method. Data were collected using 4 questionnaires titled personal information, self-efficiency, Tores Theorell's job stress scale and Schwarzer's self efficacy and Coping Inventory for Stressful Situation CISS-21 ( Dutch's coping). Data were analyzed Using SPSS software version 11.5 and also Chi-Squared test, T -test, One-Way Anova , Regression analysis and Pearson correlation coefficient.
Results: All the demographic variables including age, gender, marital status, working hours and work experience had a significant relationship with job stress. Pearson correlation test indicated a negative correlation between job stress and self- efficiency, working hours, age and work experience (P<0.001). Additionally there was a positive correlation between self- efficiency and working hours and age and coping ability with work experience ( p< 0.05).
Conclusion: Considering the importance of staff`s mental health issue it is suggested that background factors such as high work load ,dignity level and social value and social supportive programs are taken into close consideration staff`s needs related to these issues are fully satisfied so that better health services are provided.

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Background: utilizing control chart in customer satisfaction evaluation is one of the effective tools in making results of customer analysis practical. This study was conducted to design the method of utilizing control chart in monitoring customer satisfaction in health care facilities.This prospective study measured service recipients' satisfaction in a three month period in a public hospital using a questionnaire in likert scale. After gathering initial data they were analyzed using SPSS and Excel soft wares .In order to evaluate customer satisfaction a ten parameter checklist and interview was used. The average and standard deviation of decuple and quintuple subgroups were compared.
Results: In a three month period the average patient satisfaction score was 4.5 in likert 5 score scale.There wasn't a significant statistical difference between 5,10,25 day duration in patient satisfaction. In addition there wasn't significant statistical difference between 5 samples per day and 10 samples per day and all samples in a day. R-X diagram was used for PSS monitoring.
Conclusion: The results of this study showed that the average PSS in 20 and 25 day periods had no significant difference with 3 month PSS and also there wasn't significant statistical difference between average PSS in decuple and quintuple subgroups.

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Abstract Background: Hospitals are the most important health organization and consume major part of health system`s budgets. Downsizing is one of the strategies used for providing suitable services in hospitals. This study was conducted to do a systematic search for hospital downsizing methods and theirs consequences in order to choose suitable method for Iran. Materials & Methods: Related Articles were identified by systematic search on databases such as Medlib, SID, Pub Med, Science Direct and Google Scholar meta search engine using keywords like Downsizing, Hospital Downsizing, Hospital Rightsizing, Hospital Restructuring, Staff Downsizing, Hospital Merger, Hospital Reorganization and Persian equivalents. 379 articles were extracted and refined step by step. Finally, 25 articles were selected according to study`s goals. Results: The identified downsizing methods included reducing the number of employees and hospital beds, outsourcing, merging hospital wards and combination of fore mentioned methods. The most important consequences of using these methods were: cost, revenue, outpatient visits and surgery, length of stay and hospital admission rates, mortality rate, stakeholder satisfaction, workload of employees mental health and absenteeism . Conclusion: study results indicated that different methods of downsizing are used for providing suitable services and decreasing costs in hospitals. Using Merger and outsourcing are suggested among different methods in hospital wards according to current situation of our country.

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Abstract: Background: Today one of the main problems low or middle income families face is financing healthcare costs. This article studies the methods of of financing health care costs among hospitalized diabetic patients in different types of insurances. Materials & Methods: This is a causal-comparative study. The variables consist of comparative (health care costs) and categorical(different insurance types including: Iran health insurance , social security and others) variables. A researcher-made questionnaire was used to collect needed data . The data were analyzed by one-way ANOVA , Duncan`s statistical test test of Danken and T-test. Results: The results indicated a significant statistical differences between all types of insurance assessed by cost variables. Also the significant differences between patient`s out of pocket expenses ratio of direct costs (p<0.01،F=19.37) and their ratio of total costs (F=25.36, p<0.01) were detected in three types of insurances . Patient`s out of pocket of total cost was 59.55%, 50.34% and 32% in Iran health insurance, social security and other types respectively. Conclusion: In spite of all invested deal of efforts to improve health indices and health care services availability ,health care system is still faces main challenges of providing financial resources and protecting against financial burden on families . Developing a public health insurance and improving health insurance coverage would be helpful for providing financial resources of health care system.

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Objective: This study was aimed to assess Service Quality (SQ) of maternity care from the perception of pregnant women. Methods and materials: A cross-sectional study was conducted using a sample of 185 pregnant women at the 9th month of pregnancy were selected randomly from 40 health posts and urban health centers in Tabriz, Iran. Service Quality was calculated using: SQ = 10 – (Importance × Performance) based on importance and performance of non-health aspects from the customer’ perspective. Data collection used a researcher-developed questionnaire whose validity and reliability was reviewed and confirmed. Data analyzed using SPSS-17 software. Independent sample T-test and ANOVA were used to investigate relationship between service quality dimensions and categorical variables. Results: From the customers’ perspective the average service quality score was 7.59 of 10. Service quality aspects of “confidentiality” achieved scores at the level of good quality (≥9) and “support group” (3.48) reached low service quality scores. Also, result indicate housewife assess SQ better than worker (p=0.047) and mother who's have planned pregnancy has had greater SQ score (p=0.022). Although, in the linear regression analysis, job status and planned pregnancy were significantly and independently related to SQ score. Conclusion: Findings revealed a significant room for quality improvement in most aspects of provided care, particularly support group and safety from the perception of people who received maternity care.

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Background: Given the importance of quality in health care and meeting the needs of patients, it seems important to measure the quality of services and identify the weaknesses from the patients' perspective. The purpose of this study is to assess the service quality (SQ) of care as perceived by people with Type 2 Diabetes (T2D). Materials & Methods: A cross-sectional study was conducted among 180 people with Type 2 diabetes in diabetes clinic using convenience sampling method in Tabriz, Iran in 2012. Service quality was calculated using: SQ=10 – (Importance ×Performance) based on importance and performance of non-health aspects from the patients' perspective. Validity and reliability of questionnaire was reviewed and confirmed. Independent sample T-test and ANOVA were used to investigate relationship between service quality and categorical variables. Data analyzed bySPSS13 software. Results: The average service quality score was 8.17 of 10. From the participants' perspective, of 12 aspects of service quality, communication and prevention had the highest score for importance. Dignity had the highest score for performance. However, the highest service quality values were for continuity of care, dignity and confidentiality. Conclusion: overall service quality achieved inadequate quality and there is an opportunity to improve quality of care.

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Background: Pay-for-performance (P4P) is a payment model which tries to pay for the measured aspects of performance and encourage health care providers by providing financial incentives in order to achieve pre-defined goals. This research was done to assess the impact of P4P on efficiency of medical laboratory of Imam Reza hoapital in Tabriz in 2013.

Materials & Methods: This interventional research was a before-and-after study. In order to recognize any changes, efficiency indexes of laboratory were measured and compared whole the year. The data were collected manually assessing the related documents. For comparing efficiency before and after intervention, descriptive statistics were used.

Results: Findings showed that costs didn’t differ significantly after the intervention, but revenue was a little increased slightly (14364 to 16874). Laboratory errors were also increased after the intervention. (0 to 17 cases).

Conclusion: Regarding the results of survey , it seems that we can conclude that this bonus payment system can be used in all levels in which care is provided such as primary health care centers, drug stores, diagnostic centers and hospitals through setting pre-defined goals and considering negative point for any staff who makes an error. 

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Background: consideration of hand hygiene can reduce health care infections effectively. Prevalence of poor hand hygiene consideration will lead to enhance morbidity, mortality and costs. This study aimed at assessing hand hygiene process of nurses by clinical audit method in a selected general hospital in Tabriz.

Materials and Methods: this study was an interventional one using clinical audit method which  was conducted during seven months in surgery, internal, child and women units in a selected general hospital in Tabriz in 2013-2014. The study was carried out on nurses in all shifts (morning, evening and night). Study instrument were monitoring performance checklist and hand washing observation. Checklist was developed by WHO and Ministry of Health guideline.

Results: the total number of situation in pre-intervention was 252 which increased to 336 by the interventions implementation. The overall rate of compatibility of hand hygiene process with standards was 59.94% in pre-intervention which promoted to 80.56% after intervention implementation.

Conclusion: This study reveals using clinical audit is a method to improve quality of hand hygiene process. 

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Background: Patient transfer requires the wide variety of functions such as collaboration, appropriate communication and coordination between hospitals and the Center for Treatment Guidance and Information (CTGI). This study aimed at determining the influencing factors in the coordination of patient transfer and also explaining the situation of the CTGI in patient transfer process coordination.

Materials and Methods: This study was a qualitative study (phenomenology) conducted using three Focus Group Discussions (FGD) and thirty interviews with participants who were involved in the process of patient transfer in a referring hospital, six patient receiver hospitals and CTGI in Tabriz. Purposive sampling was used to select study participants. Data was analyzed using content analysis.

Results: The effective factors of the patient transfer coordination were categorized in four main themes including weakness in the exchange of clinical information, data constraints, legal protections weakness and guidelines implementation and lack of clinical empowerment in managing patient. Eighteen sub-themes were identified which include legal protections weakness and guidelines implementation in center for treatment guidance as sector problems.

Conclusion: There are some problems in coordination of patient transfer process which is relate to non adherence a specific procedure for admission , ineffective interactions and information exchange. In order to achieve uninterrupted medical treatment, the patient transfer coordination should be improved. The center for treatment guidance and information should be obtained its position as a supervising authority.

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Background: one of the most essential components in patient- physician relationship is the length of visit. Short time visit can affect visit quality and patient- physician relationship. This study aimed at comparing specialists visit length with standards in general hospitals of Qazvin.

Materials and Methods: This cross-sectional study conducted in general hospitals of Qazvin  in 2013. 428 patients were randomly selected to participate who were referred to the outpatient clinics of selected general hospitals. Studied specialties were including Internal Medicine, Surgery, Pediatrics and Obstetrics and Gynecology. In order to data collection, a Checklist including physician and patient related items was used and data analysis performed using SPSS version 19.

Results: The study results revealed the mean score of outpatients' visits length was 4.67±2.43 minutes which had a significant difference from standards (p<0.0001).Higher mean score was relate to  pediatrics (2.55±7.08) and the lower one was internal physicians (1.82±3.93).

Conclusion: In this study, Visit time in developed countries was lower than developing ones. Several factors were identified which affect visit time. Thus, decision makers should use the results to improve outpatients visit quality.

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Background: Type 2 diabetes is a chronic disease which has incremental prevalence regarding to unhealthy lifestyle. Based on the significant gap between received and standard care in patients with type 2 diabetes, this condition occurred high costs to health system. In order to eliminate this gap, this study aimed at measuring the technical quality of perceived care among patients with type 2 diabetes.

Materials and method: A cross-sectional study was carried out among 180 people with two type of diabetes in diabetes clinic using convenience sampling method. A three part questionnaire includes demographic information, disease statue and the technical quality questions was that the validity and reliability of it was approved.  The data were analyzed using SPSS13software.

Results: Total technical quality score was 2.9 which was lower than bench mark 5. The main indices related to diabetic control (HbA_1c, blood pressure, LDL) were acceptable regarding Iranian diabetic guideline and they were controlled well.

Conclusion: According to notable gap between existing standards and perceived care in type 2 diabetic patients, there is a good opportunity to promote quality of services.

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Background: Emergency response of hospitals to deal with disasters is essential to success in providing qualified emergency services. The aim of current study was to evaluate emergency response of hospitals in Karaj against disasters.

Materials and Methods: This study was a cross sectional one which performed among 13 Karaj hospitals in 2013. To collect data, emergency response Checklist WHO (2011) was utilized with 90 questions prepared in 9 domains (Command and control, Communication,  Safety and security, Triage, Surge capacity, Continuity of essential services, Human resources, Logistics and supply management and Post-disaster recovery).  Data analysis carried out using SPSS version 20 with descriptive tests.

Results: mean score of emergency response was 44.17%. The most and the worst dimensions were hospital triage 70.30% and accident reconstruction after the emergency 24.84% respectively.

Conclusions: Based on WHO checklist, only 44.17% of studied hospitals were able to respond disaster events. Planning and providing a systematic framework to deal with disasters is a necessity, and the major role of hospitals should not be ignored in providing services considering its priority in plans and budgets in disasters conditions. 

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Background: Today's Hospitals operate in an inconstant and competitive environment. To have a successful presence in this environment, there is a need to recognize their own strengths and weakness points which can design appropriate strategies towards. The purpose of this study was to assess the internal environment of a hospital based on Weisbord model and analyze its relation with organizational success dimensions.

Materials and Methods: This study was a cross – sectional and applied one. The study instrument consisted of three sections including demographic information, Weisbord Model questionnaire and dimensions of organizational success assessment.124 out of 150 staff of Oil Industry hospital in Gachsaran participated in the study. In order to data analysis, descriptive statistics and Pearson correlation coefficient test were utilized.

Results: The studied hospital had a relative strength at the scoping (3.63) and leadership dimensions score (3.65) and also a relative weakness at the score of rewards (4.64) and communication dimensions (4.11). In terms of organizational success dimensions, speed (3.28) and flexibility (3.83) had better status than innovation (4.12) and cohesion (4.05). There was a positive and significant correlation between all organizational success dimensions and internal environment. In general, hospital success had the strongest relation with communication dimension(r=0.521).

Conclusion: Hospitals are able to take action through accurate recognition of weakness and strengths points and attempting appropriate modification to achieve organizational success in competitive fields. Then, they take steps towards optimization by improving programs.

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Background: Medication administration is an important part of care process. Correct medication administration and its accordance with standards are essential concerning the significant effects on patients’ health. Hence, this study was designed and carried out to determine Medication administration process using “clinical audit”.

Materials and Methods: This study was a cross-sectional one which carried out with “clinical audit” in a hospital of Tabriz city in 2014. This audit conducted in six steps as followed: 1) selecting topic of clinical audit, 2) determining the criteria and standards, 3) assessment of current status, 4) comparing current situation with standards( Standards of Ministry of Health, Medication safety handbook, medication administration curriculum and NHS guideline in medication management), 5) designing and implementing intervention and 6) re-audit. In order to organize process evaluation, a valid instrument used via observation and checklist.

Results: Results of this audit study revealed that 11 out of 25 assessed steps had very low accordance with standards (less than 15%) and the average accordance of total process was 47 percent before intervention. However, the average of standard adherence rate increased to 78 percent after intervention implementation.

Conclusions: The results indicated the effectiveness of educational intervention programs in using kardex instead of medication card on improving medication administration process generally. In spite of the occurred improvement, it is necessary to have an ongoing assessment and intervention in order to quality improvement. 

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Background: Lack of financial resources or their poor organization is one of the service delivery challenges and Fraction of dedicated revenues is significant problem in health centers in financial resources management. Hence, this study conducted to investigate causes of dedicated revenue's fraction and strategies to reduce them.

Materials and Methods: This qualitative study was carried out based on phenomenology approach in East Azerbaijan Province in 2014. Data collection methods were Focus Group Discussion (FGD) and semi-structure interview guide based which continued to saturation. their participants were selected using purposeful sampling method. Data were analyzed using content analysis method.

Results: Based on participants' experiences, six themes were extracted for causes of fraction and strategies to reduce them. These themes included causes and strategies related to fractions per capita, insurance fractions, fractions related to sending documents, registration fractions, clients' deductions and fractions related to incomplete deposit of cash incomes. In general, eighteen causes and twenty three strategies were identified in dedicated revenues fractions.  

                                                                                                                    

Conclusion: The causes of fractions were related to all stages of changing service process to revenue and insurance obligations in health care centers and strategies and identified interventions emphasize on mentioned fields.