Journal of

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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. 

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Background: Organizational culture has a crucial role in hospitals’ productivity. The success or failure of strategies and plans in organisational change depend on organizational culture. This study aimed to examine the organizational culture of Tehran hospitals in 2014.

Material  and Methods: This descriptive-analytical study was carried out in 18 hospitals (public, private and semi-public hospitals) that were selected out of 114 hospitals of Tehran using quota- randomized sampling method. About 696 employees in diagnostic, curative, administrative and logistic departments participated in the study. Data was collected through a valid and reliable questionnaire and analyzed using SPSS20. Spearman, U Man- Whitney and Kruskal- Wallis statistical tests were applied.

Results: The mean score of organizational culture was 3.62 out of 6 (moderate). There was a significant relationship between organizational culture and the type of hospitals (p=0.002). The mean score of organizational culture was higher in Private and Semi-public ecurity hospitals respectivey. Attention to details and customer orientation dimensions were high in public and semi-public hospitals and private hospitals respectively. The most and the least mean score of organizational culture was related to administrative and support services units. 

Conclusion: Organization culture was evaluated in moderate status in hospitals of Tehran city. Thus, it is recommended  that hospital managers  improve hospitals 'organizational culture  specially in creativity, innovation, integration and teamwork dimensions using organizational engineering culture plans.

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Background: Insurance companies sometimes do not reimburse hospitals completely. Reducing the amount of deduction of bills increases hospital’s income and efficiency. This study compares the deductions imposed by social insurance organization on Imam Khomeini hospital’s bills before and after the implementation of health transformation plan.
 
Material and Methods: Data of this descriptive-descriptive study calculated from the deductions applied to the hospital of outpatient and inpatient bills of social insurance organization in second six months of 2013 (before implementation of health transformation plan) and the same time of 2014 (after implementation of of health transformation plan). This quasi experimental study was conducted using the data. Data was analyzed by SPSS software using paired t test.
 
Results: The bill deductions in the second six months of 2013 compare to the same time in 2014 were 2.9 and 11.1 percent, respectively. Hospital bill deductions increased 282.8 percent after the health transformation plan implementation. The deductions on inpatients and outpatients records increased 6 and 12 times, respectively. Most deduction was imposed on surgical and laboratory bills in 2013 and on radiotherapy, chemotherapy and hoteling bills in 2014.
 
Conclusion: Deductions of hospital bills extremely increased from social insurance organization after implementation of health transformation plan. In order to identify deductions causes, providing related education to staff and physicians and relative process improvement are necessary.

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Background: The Health Promoting Hospitals (HPH) initiative emphasizes on changes in traditional hospitals’ approach in care provision. This study aimed to provide scientific evidence required for successful planning and implementation of the HPH in the country’s educational hospitals.
 
Materials and Methods: In this descriptive-analytical study, opinions of 300 frontline health professionals working in the ten educational hospitals affiliated to the Tabriz University of Medical Sciences were examined using validated tools in 2016. Descriptive data analysis procedures and logistic regression analysis (using Enter method) were applied by SPSS software version 22. The level of significance was considered less than 0.05.
 
Results: The mean scores and SD for applicability of the HPH standards were 66.06±17.51. Gender (OR=3.19 95%CI: 1.33- 8.40), occupation type (OR= 1.50 95% CI: 0.65- 0.70), hospital type (general vs. specialized) (OR= 1.59 95%CI: 1.10- 1.25), number of active beds (OR=3.84 95% CI: 1.56-9.42) and having prior knowledge about the HPH program (OR=2.81 95% CI: 1.31-4.80) were identified as significant predictors of the HPH standards’ feasibility in the studied hospitals.
 
Conclusion: Given that study findings, at least the baseline subjective inclination to adapt the HPH standards in the educational hospitals do not exist through the Iranian health care providers’ points of view. As the first step in progress towards preparation for implementing the HPH standards, planning of tailor-made educational programs for hospitals’ staff in Iran is recommended.
 

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Background:  Need to assess the health system performance, various models and frameworks have been developed by different groups and organizations. This study explores health system performance assessment frameworks using the comparative-analytical study.
 
Materials and Methods: This is a comparative-descriptive study conducted using descriptive-prescriptive method based on comprehensive comparative analysis. The scope of research includes health system frameworks. The study results compared and interpreted based on identified factors in comparative tables.
 
Results:  Overall, 11 frameworks out of 16 ones described, analyzed and compared to each other. Some of the frameworks in addition to providing insight about the health system have focus on assessment of health system performance. Each framework follows especial goals which focus on importance the health systems assessment.
 
Conclusion: During the time, health system frameworks have changed and developed according to the health systems changes. Developed Frameworks in recent years are more comprehensive than others which have been presented at first. Utilizing these frameworks in order to identify health system goals, assess based on responsibility (organizational actions or outside the organizations) and ways to reach them can be effective. Using the developed frameworks based on their domains and objectives can be considered in health system performance.
 

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Background: One of the main concerns of managers is work deviant behaviors of employees. Workplace deviance is voluntary behavior that violates significant norms and in so doing threatens the well-being of an organization, its members or both. The study aimed to explore the relationship between emotional intelligence and organizational citizenship behavior with work deviant behaviors.
 
Materials and Methods: This study was a cross-sectional descriptive analytical one. This study was conducted on 290 employees (administrative workers and nurses) working in four selected hospitals in Tehran city including Shahid Motahati, Shahid Rajaii, Hazrat-E-Rasol, and Dr. Shariati. Sampling method was stratified random sampling method. Data collection instruments were three questionnaires including Schutte’s emotional intelligence, Padsakof organizational citizenship behavior, Bennett and Robinson’s work deviant behavior. Validity and reliability of the questionnaires has already been verified in studies before. Data analysis was performed using independent T-test, ANOVA, Tukey and parametric Pearson's Correlation Coefficient.
 
Results: Among demographic and organizational variables, There was a significant relationship between age and work deviant behavior (P=0.012). Reverse significant statistical relationship between emotional intelligence, organizational citizenship behavior and courtesy with work deviant behavior was observed (P=0.0001).
 
Conclusion: The study results revealed that personnel with higher emotional intelligence will have a more positive attitude and more allegiance and commitment toward the organization; therefore they will show more organizational citizenship behavior and less inclined to abuse in the workplace.
 

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Background: Information technology application in health care is increasing. The aim of  this study, is to introduce a scientific model for designing an electronic system for managing patient transfer.
Materials and Methods: This study is an exploratory qualitative study. At first a review of literature was carried out for identifying clinical, managerial and process indicators necessary for patient transfer. Then 30 experts, who had vast experiences on patient transfer, were selected using purposive sampling approach and their informational needs were extracted using focus group discussion and semi-structured interviews. Then clinical indicators extracted from literature review and informational needs collected from interviews were distributed among 51 experts in the form of Delphi questionnaires. Process indicators were also distributed among 35 experts to summarize all necessary indicators for designing patient transfer system. At the final step an expert panel approved the model.
Results: Thirty eight process indicators and 249 clinical and managerial components were finalized for designing the system. The process indicators were used for designing “monitoring and reports sections” of the system. The clinical indicators were used for designing “main sections” of the system including request for patient transfer, automatic algorithm for selecting destination hospital, information flow cycle, communicating clinical data and documentation. Final model also includes user interfaces relevant to responsibility of the user.
Conclusion: The proposed model, which contains necessary indicators for patient transfer, can communicate clinical information among hospitals and by providing proper infrastructure, will be able to improve patient transfer process.