Journal of

---

Introduction: Intensive Care Unit (ICU) in hospitals is one of the most sensitive and costly units which is really important due to safety and health of patients during their stay in these units. Hence, considering the potential risks in this unit, treatment operations for eliminating or decreasing risks are very important. Among these intensive care units, the most important one is the open-heart surgery unit which may have irreparable damages due to vulnerability of these patients in the process of their transfer, care, and discharge. The present study aims to identify the potential risks and offer solutions for eliminating or decreasing them.
Method: In this research, we used Failure Mode and Effect Analysis (FMEA) method, which is a very useful method for evaluating and managing the risks, to prioritize risk factors. Due to some limitations of the method, fuzzy FMEA and fuzzy TOPSIS methods were also used in order to have more precise results and then the results were compared with each other.
Results: The suggested approach was implemented in ICU-OH (open-heart) unit of Kowsar hospital in Semnan. Finally, nineteen factors were recognized as major risk factors. Also, corrective actions were determined for all detected risks that can be pursued according to their priorities.
Conclusions: Factors including not observing hemodynamic signs, not considering patient safety and security, and inability to interpret arterial gas valve abnormalities are the three top risk factors that can be addressed through training and having more control on nurses.

---

Background and Aim: Clinical governance is one of the important frameworks for continuous quality improvement and safety in health care systems. Identifying the axes of this approach according to local conditions is one of the important priorities of the health system. The aim of this study was to identify the views of stakeholders on the axes of clinical governance in primary health care based on family physicians in Mazandaran province.
Methods: The present qualitative study was conducted using the conceptual framework analysis method in 2018-2019. The study population were key policy makers of Ministry of Health, Health deputy of the University, the county health network, family physicians association, family physicians, and the parliament research center. Participants were selected using purposeful and snowball sampling methods. Data were collected through semi-structured interviews and were analyzed and coded using MAXQDA 11 software.
Findings: According to the interviewees' views, the research findings were classified into 4 main dimensions: dimensions of clinical governance, requirements and structures, decision-makers and dimensions of quality and safety assessment. 17 sub-themes including community participation, clinical audit, clinical effectiveness, personnel management, training, information use, risk management, guidelines and procedures, promotion of health indicators, equipment and facilities, referral system, financing, policy makers, effectiveness, efficiency, human aspects of services and justice were identified and extracted.
Conclusion: According to the research findings, to facilitate the implementation of clinical governance, solutions such as the existence of appropriate infrastructure, commitment of managers, supportive culture, sufficient knowledge, monitoring and evaluation, appropriate culture building, facilities and equipment and sufficient financial resources are suggested.

---

Introduction: The present study qualitatively investigated the main components that should be considered for the implementation of the referral system in Bojnord city.
Methods: In this study, data were collected through doing interviews with experts, and finally, the importance of all the extracted components was evaluated using a researcher-made questionnaire. Also, the exploratory factor analysis method was used to classify the components in main sets. Kolmogorov-Smirnov, one-sample t-test, performed in Excel and SPSS software, was used for statistical analysis.
Results: The most frequent noted components by the experts included "empowerment (knowledge, skill, psychological) of human resources involved in the referral system", "paying attention to the motivation of human resources involved in the referral system", and "developing suitable processes for the referral system and re-engineering the processes to meet the conditions". Finally, the main requirements in the referral system of Bojnord city were divided into three categories included organizational and management, manpower, and technology-based requirements.
Conclusion: Briefly, some components may lead to improvement of the referral system, which can be categorized into organizational and management, manpower, and technology-based requirements. Detailed planning to improve the referral system can lead to the improvement of the health system.

---

Background: The development of the health system increases the health level of the society. The present study was carried out with the aim of development of "Health System Development Scale".
Methods: The study was qualitative-quantitative. For qualitative part, a semi-structured interview with 11 experts was conducted in a targeted manner with maximum diversity and the results were analyzed by open, central and selective coding method. For quantitative part, first the validity of the questionnaire was carried out through interviews with 10 experts. Finally, the construct validity was conducted according to the opinion of 220 experts by exploratory factor analysis (with the Kaiser-Meyer-Elkin scale) and confirmatory factor analysis (in the form of divergent, convergent validity and fit indices) using SPSS and Lisrel software. Reliability was also measured by calculating Cronbach's alpha coefficient and composite reliability.
Results: The scale was designed with 40 statements obtained from the findings of the qualitative study. In the quantitative part, the appearance and content validity ratio of the dimensions of the questionnaire was qualitatively confirmed (for all statements between 0.80 and 0.1). Construct validity was done by exploratory and confirmatory factor analysis and convergent validity was between 0.53 and 0.75 and divergent validity was between 0.54 and 1. The internal consistency of the tool was approved with Cronbach's alpha coefficient between 0.75 and 0.86 and composite reliability coefficient was between 0.72 and 0.80.
Conclusion: The validity and reliability of the scale was confirmed. It is suggested to use it to measure the level of development in the health system by experts in this field.