Journal of

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Background: In year 1995, new system administration plan of hospitals (fee for service) was notified. This scheme was implemented in hospitals for 20 years. In the early September 2104, new guidelines of performance-based fee for service plan with the aim of deficiencies in the previous plan was reviewed and implemented in hospitals in Isfahan. This study aimed at investigating reform strategies to improve monitoring performance and infrastructure implementation development of the new scheme of fee guidelines in 2014.

Materials and Methods: This study was a qualitative one based of phenomenology. Depth interviews were used to collect data. Eleven individuals assessed including top and middle managers and professors of Isfahan University of Medical Sciences using content analysis method.

Results: In this study, eight main themes and ten sub-themes extracted including appropriate policy making, health management reform in health system, cultural building in monitoring, proper planning, physicians' motivation, infrastructure improvement, improving training, informatics and constructive interactions between senior managers and hospitals' directors.

Conclusion: With the aim of rationalizing the health system, new instructions and fee for service plan should be considered well to tackle weak points. It seems that coping with these weak spots in new fee for service plan, has feasibility to provide more satisfaction among physicians and staff. To achieve main goal of the project which defined as patients and staff satisfaction, using new reform strategies to facilitate plan implementation, continuing observation and stronger mentoring recommended.

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Background: Hospitals directly affected by disasters and crises which will be provided services facing with crises by well-informed and high performing personnel. This study aimed to determine self-efficacy level in disasters among senior managers of hospitals.

Materials and Methods: This study was a descriptive-analytical and applied one which was conducted in all public and private hospitals affiliated to Tehran University of Medical Sciences in 2015. Study population was all senior managers of hospitals and data was collected by a researcher-developed, valid and reliable questionnaire.  Data analyzed using descriptive and Inferential statistics.

Results: Self-efficacy facing with crisis was assessed on average level (101 out of 130) and high among married men with previous experience in disasters. Also, self-efficacy level reported high among aged and position of ED managers. Nevertheless, there was no significant relationship between self-efficacy and participation in educational course and hospital ICS membership.

Conclusion: Given the relationship of self-efficacy with the aged and prior experience in disasters, these variables should be considered in selecting proper people for these positions. Moreover, having successful experiences dealing with challenges enhances the level of Self-efficacy among managers. Hence, using some techniques such as simulation or providing maneuvers can acquaint managers with the possible conditions facing with disasters. 

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Background: Reduction of errors is necessary to improve the quality of healthcare, promoting communication between the hospital staff and patients, and decreasing the patient's complaints in hospitals. Due to the high probability of error in the operating room (OR), this study aimed to detect the potential errors in the OR of Nemazee hospital using FMEA.
Materials and Methods: This study was a qualitative one which assessed Failure Mode and effects of OR in six steps using FMEA technique. At First, the OR activities were listed, then the failure modes were recognized. Next, the Risk Priority Number (RPN) of each error was calculated according to the indicators of Occurrence (O), Severity (S) and Detectability (D).
 Results: Totally,204 failure modes in 36 activities in five process in surgery ward were recognized.15.7 percent of failure modes classified as high risk factors (RPN ≥ 100). The most and the least distribution of origin factors were related to human and organization and technical errors, respectively.
Conclusion: The majority of errors in OR was set in of human skills category. Besides, the most and the least failure modes were belonged to “patient anesthesia by circular activity number 20, RPN=1795.23)” and “not to oxygenation for patients (the activity number 36, RPN=99.33) respectively. Identification of 36 activities and 204 errors in the 5 processes of Operating Room represents the comprehensiveness of HFMEA method in the identification, classification, evaluation and analysis of the health system errors.  
 

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Background: Necessity of development, quantity and quality improvement needs of medical tourists had been unavoidable based on medical tourism growth with its competitive function. This study aimed to determine satisfaction rate of medical tourists referee to Tabriz hospitals to get treatment services.
Materials and Methods: This descriptive and analytical study was conducted on 82 medical tourists referee to all wards of selected hospitals using convenient sampling method in Tabriz city. Data was collected using a-28 items valid and reliable researcher made questionnaire. Cronbach’s Alpha was calculated 0.708. In order to data analysis, SPSS Software version 23 was utilized. Also, Spearman’s correlation coefficient was used to assess the association between different aspects of patients’ satisfaction.
Results: Satisfaction rate was obtained in five main aspects including cultural problems (51.88%), structural issue (57.50%), insurance payment system (16.04%), information system and communication channels (41.34%) the economic challenges (50.35%). The information system and communication channels had high effect on economic aspects (p<0.001).
Conclusion: It seems necessary that health policy makers and managers pay more attention to foreign medical tourists and faced challenges correction in order to change Tabriz city to a medical tourism center of excellence and improving regional economic development. 

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Background: One of the main components of the quality of health services is patient safety. This study aimed to determine safety culture status of psychiatric patients from the viewpoint of the medical staff of Ibn Sina and Hafez hospitals in Shiraz.
 
Materials and Methods: This descriptive-analytic study performed as a cross-sectional one in 2017. The study population included 165 health care personnel of the hospitals which were selected by census sampling. The study tool was a standard questionnaire for the hospital's safety culture. Data were analyzed using descriptive statistics and independent t-test, ANOVA, Pearson correlation coefficient and multivariate linear regression using SPSS version 23 software at a significant level of α = 5%.
 
Results: The average of safety status of the patients calculated 154.62 ± 19.74. The patient safety culture was estimated at an acceptable level (64.1%). The dimensions of personnel affairs (36%) and non-punitive responses to errors (34.7%) were in an unfavorable situation. There was a significant association between the employment status of personnel and patient safety (P<0.05).
 
Conclusion: Despite the acceptable condition of the patient's safety culture, however, the dimensions of the non-responsive response to the mistakes and issues related to the personnel were in an unfavorable situation and require prompt and appropriate actions. It is suggested that hospital authorities to provide the necessary interventions including cultures for reporting of errors, organizing comprehensive training programs, and continuously improving the clinical governance system.
 

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Background: Communication is one of the central concepts and an integral part of the nursing profession. This study aimed to determine the effect of communication skills training of nurses on patient satisfaction with nursing staff services in teaching hospitals affiliated to Shiraz University of Medical Sciences.
 
Materials and Methods: The Comparative study carried out in 2017. The research population included nurses from educational hospitals and patients referring to them. Four hundred patients were selected through convenience sampling method and one hundred trained nurses and one hundred untrained nurses were randomly chosen. The data collection instruments were a standard questionnaire. Data were analyzed in SPSS₂₃ using T-test, ANOVA, Tukey test, and Pearson correlation coefficient at α = 5% level.
 
Results: Mean scores of nurse-patient commination and satisfication of nursing services among patients under care of trained nurses were 93.5 ± 21.08 and 176.24 ± 22.14 and mean score of patients under care of untrained nurses the scors 81.76 ± 18.83 and 166.36 ± 41.10, respectively. A significant direct correlation was found between nursing-patient commination score and patient satisfaction score (P= 0.023, r= 0.681). Patients under the care of trained nurses were more satisfied with nursing services than those served by untrained nurses (P= 0.012). The results revealed that patient satisfaction had a significant relationship with age (P<0.001) and marital status (P₌0.031).
 
Conclusion:  Implementation of communication skills training courses for nurses leads to improved patient satisfaction. Hospital directors are recommended to consider holding regular communication skills training courses for their nursing staff.

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Background: Evidence-based Management (EBMgt) has been developed as a management model to improve the quality of management decisions. Hospital managers’ decisions can have a significant impact on service effectiveness and hospital success. Hence, this study aimed to survey sources of evidence among public hospitals' managers for decision-making in Iran.
 
Materials and Methods: This cross-sectional study was conducted with 183 managers of public hospitals in eight educational centers of the Ministry of Health and Medical Education in 2017. The research tool was an evidence-based management questionnaire with 20 items and 6 main domains. Data analysis was performed using descriptive and inferential tests by SPSS₂₁.
 
Results: One hundred seventy-two (94%) out of 183  participants were male. The mean age and work experience were 45.28 and 19.30 years, respectively. The lowest score was related to "the academic journals" (52.56%), While managers relied heavily on "Ministry of Health programs" (80.98%). The average use of scientific-research evidence, fact and hospital information, political-social development plans, managers’ professional expertise and ethical-moral evidence and values and expectations of all stakeholders were 59.70%, 62.43%, 75.30%, 71.36%, 71.83% and 73.7%, respectively.
 
Conclusion: The study results revealed that hospital managers utilized the scientific-research evidence less than other evidence, which it is a matter of concern; so, managers need to improve their education and research level. Using hexagon of evidence sources, managers can identify the best available evidence for hospital decisions and they make the best decision in the process of evidence-based decision making.
 

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Background:  Development of the tourism sector and health tourism specifically can improve the Non-Oil GDP. In this regard, in accordance with the policies of the Ministry of Health and Medical Education, international patient department establishment has been facilitatated health tourism development in the affiliated hospitals. This study aimed to evaluate the performance of international patient department  and its effect on the attraction of medical tourists among hospitals affiliated to Medical Sciences Universities in Tehran City.
Matrials and Methods: This analytical cross-sectional study was designed and conducted in 2017. Study population consisted of all hospitals affilliated to  Tehran University of Medical Sciences (TUMS), Iran University of Medical Sciences (IUMS) and Shahid Beheshti University of Medical Sciences (SBMU). In this study,  hospital entrance criteria was certified by the Health Tourism Department of MOHME. Data was collected using the health tourism assessment checklist which approved by the MOHME. SPSS version 24 utilized to data analysis using descriptive and Inferential statistics.
Results: The study results revealed that  the overall performance of international patient department was evaluated at a desirable level (87.5 score) in hospitals of Tehran city.  Hospitals had the highest rank of hoteling indices (95/100), in compliance with the regulations and functional indicators gained 87.03 and 82.2 score, respectively.  Also, data analysis highlighted that there was no significant difference between hospitals of TUMS, IUMS and SBMU. The establishment of international patient department had no effect on health tourists attraction.
Conclusion: Considering the purpose and mission of international patient department to facilitate the provision of quality and satisfactory services in health tourists, management and oversight mechanisms for the standards implementation such as patient admission, follow up in the origin country and development of hospital marketing policies in order to attract international patients and increase hospital incomes are recommended.

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Background: Brand loyalty is one of the most important factors in maintaining and success of huge organizations such as hospitals. This study aimed to survey the factors that affect the patients’ loyalty to hospital brands in teaching hospitals affiliated to Shiraz University of Medical Sciences (SUMS).
 
Materials and Methods: This cross-sectional descriptive-analytic study conducted in 2017. The study population consisted of 385 clearance patients who were admitted to educational hospitals in Shiraz using stratified sampling method in February 2017 to March 2018. Information was collected using a researcher-made questionnaire and data analyzed by descriptive statistics, T-test, ANOVA, and multiple regressions using SPSS version 23 at a significant level of α = 5%.
 
Results: Patients’ satisfaction (β=0.333, P<0.001), trust in brand (β=0.265, P=0.007), and commitment (β=0.181, P=0.011) had a direct and positive effect on the patients’ loyalty to the hospital brand.
 
Conclusion: According to this study results, hospital managers should pay an attempt to inform the patients about their treatment procedure, follow up the patients’ health after discharge, and increase the communication between personnel and patients. These could contribute to better image and experience for patients resulting in loyalty to the hospital brand.
 

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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: The hospitals' reliance on insurer organizations' resources is increasing due to the growing number of insured persons. However, a relatively large share of these revenues cannot be collected for various reasons and is considered as hospital deductions from revenue. Hence, this study aimed to investigate the causes of hospital deductions from revenue and strategies to reduce them in hospitals affiliated to Iran University of Medical Sciences.
Materials and Methods: This qualitative study was conducted based on the phenomenological approach in 2017. Data was collected through semi-structured interviews consisting 17 finance experts in hospitals. Data analysis was performed using MAXQDA version10 and analytical framework of Gale et al. (2013).
Results: Based on the framework analysis, two themes were identified as the underlying causes of hospital revenue deduction including direct causes and root causes of revenue deduction. Also, in order to reduce revenue deduction strategies, eight themes were recognized including interaction with insurance organizations;  analysis, assessment, and feedback on revenue deficit; coordination and empowerment of employees; proper organization of human resources; strengthening regulatory system, motivational strategies; good planning  and creating an organizational structure.
Conclusion: The revenue deductions occur in all stages of converting services into income and the most important factor is lack of staff awareness and incentive to control deductions. Contributions of all process owners in the hospital and insurers and in particular the commitment of hospital’s senior managers are necessary to control the deductions.
 

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Background: Organizational culture is one of the important predictor of organizational effectiveness, and a key factor success of the organization as a competitive advantage. Todays, a continuous assessment of organizational culture status is considered essential; therefore, this study aimed to identify and measure organizational culture of the Ministry of Health and Medical Education.
Materials and Methods: This descriptive-analytical study was conducted on the headquarters of the Ministry of Health and Medical Education in 2018. The study population consisted of all employees of the Ministry of Health and Medical Education (N=2200), 327 personals were selected through Cochran formula and stratified sampling method. The data collection instrument was a researcher-made questionnaire whose validity and reliability were confirmed (Cronbach's alpha =86.5%). In order to data analysis SPSS₂₄ using descriptive and inferential statistics tests were utilized.
Results: The mean score of total organizational culture was 3.30 ± 0.70 from 5 which was higher than the theoretical average. Also, there was also a significant difference in partnership dimension in terms of employment type and in participation dimensions, accountability to the upstream institutions as well as total organizational culture score in terms of deputy. There was a direct statistical association between dimensions of organizational culture.
Conclusion: According to study results, strong organizational culture will lead to improved performance in the organization and alignment of individuals and activities. Given the importance of specific role of culture in each organization, plans success and change strategies, human resources managers should take appropriate actions to improve internal and external communication and increase teamwork and accountability. 
 

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Background: This study aimed to explore the process of establishing a non-governmental and nonprofit  hospital, as a corporate infantry, and a model for the establishment of autonomous and corporate hospitals.
Materials and Methods: This was a qualitative case study. The data were collected by interviewing the founders of Moheb Mehr Hospital, staff and some university officials and charity organizations. The data analysis was conducted based on grounded theory principles and data were coded in three stages of open, axial and selective coding.
Results: The primary factors behind the establishment of Moheb Hospital were the low level of physicians' fees and the physicians’ dual practice in the public and private sectors. The existence of unused spaces at Hashemi-Nejad Hospital and the possibility of contracting supplementary insurance were the secondary factors. The reaction included welcoming from hospital physicians and opposition from the government and the Ministry of Health. A good patient access was created due to the lower charges, in comparison to the private sector, and having contract with the supplementary insurance. The negative comments from the government and the Ministry were gradually adjusted.
Conclusion: The decentralization initiatives of the public sector in hospitals should be considered as a bottom-up process. Instead of turning government hospitals into independent or corporate, it is better to re-establish them in an autonomous or corporate form. Also, before any decentralization action, financial and managerial stability must be created in the organizations. Morevoer, employee benefits must be preserved. Instead of receiving government funding, it is better to use the capacity of the endowment and receive bank loans.
 

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Background: Estimation of cost functions is an appropriate tool for optimal resource allocation in hospitals. The present study aimed at estimating cost function for hospitals affiliated to Shiraz University of Medical Sciences.
                                    
Materials & Methods: In the current cross-sectional study, inputs, costs and resources data for 28 hospitals were gathered from hospital statistics and information system. Required data were collected monthly for two years (2015-2016). Then, The Cobb-Douglas cost function was estimated using panel data analysis. STATA 14 was used for data analysis.
 
Results: Estimates showed that hospitals' cost elasticity concerning the inpatient and outpatient admission were 0.555 and 0.058 for large hospitals, and 0.769 and 0.099 for small hospitals (P<0.01). Among hospitals inputs, the cost of a physician with coefficient 0.175 in large hospitals and 0.481 in small hospitals (P<0.01) was most cost driver. In studied hospitals, average cost (36,406,480 Rial) was higher than marginal cost (26,548,020). Moreover, scale economies index were in small, large, and all hospitals were 0.868, 0.613 and 0.729, respectively. The number of active bed, length of stay and teaching activity had a positive effect on hospitals cost (P<0.01).
 
Conclusion: According to the findings, to control costs, the hospital should manage most cost drivers, such as physicians and pharmaceutical costs. Moreover, According to the average and final cost and scale economies index, hospitals should expand their service provisions with current inputs and resources in order to reach the optimum point of output.

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Background: One of the fundamental changes in the health system of Iran in recent years is the "health system reform plan", that the effects of which should be examined from various dimensions. The purpose of this study is to determining the effect of health system reform plan on health indicators in population covered by Ahvaz University of Medical Sciences.
 
Materials & Methods: In this descriptive-analytical study, the data of the selected health indicators of Ahvaz University of Medical Sciences in the period before and after the health care system reform plan (from 2012 to 2018) was collected, described and analyzed with SPSS.
 
Results: The highest rate of change in mortality indices was between 2013 and 2015, orderly in U5MR, IMR & NMR, With the mean difference 13.282, 10.825 & 7.955 (P=0.001, P=0.002 & P=0.004). The highest rate of change in Care Coverage for Children Under-five, is between 2014 and 2015 with mean difference of 11.335 and about the Antenatal Care Coverage, between 2014 and 2017, with mean difference 10.050 (orderly p=0.002 & p>0.001). MMR was not significant.
 
Conclusion: The time trend analysis on health indicators confirms that the changes in the early years of the reform plan have been a lot, then it has slow down. Most of the change in health indicators is related to years of 2015 and 2016. The findings indicate that the latest health reform plan in Iran has improved the mortality indices (Reduce in NMR, IMR & U5MR), Care Coverage for Children Under-five and Antenatal Care Coverage (6+). Health reform plan has not affected on MMR.

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Background: Hospital, as the largest and most important health system unit, has the highest costs. Governments cannot finance all of the costs of this sector, so reforms are inevitable. In this regard, researchers have explained the underlying factors in financing policy and its commanding.
Materials & Methods: This study is a descriptive study done by qualitatively and quantitatively method in 2019. The statistical population included experts from the health sector, the capital market, and the Social Security Organization. A purposive sampling method was used. Data collection tools were receipts and a semi-structured questionnaire for interviews. MAXQDA 11 software was used to analyze the interviews, and the Delphi technique was used for validation. Walt Gilson and Kingdon models were used for policy analysis and commanding.
 Results: Underlying factors in policy-making and commanding the financing of hospitals from the capital market are macro-factors (governance and legal, political, social, and economic factors) and micro-factors (stewardship, financing, and technical factors). The financing problem stream of hospitals, the policy flow that includes public-private partnership models, and the political flow that began with sanctions open a window of opportunity to finance hospitals through the capital market.
 Conclusion: Upstream documents and development plans allow the privatization of governmental organizations; therefore, in addition to government budgets and dedicated revenues, hospitals can use private-sector financing strategies. In the meantime, easy and inexpensive financing, transparency, and accountability are the capital market characteristics that introduce it as an appropriate strategy. 

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Introduction: Identifying the challenges of Quality Improvement Offices (QIOs) not only helps in planning the quality of hospital services and in trying to provide a suitable solution to solve the problems of these offices but also plays an important role in strengthening the offices and increasing the quality of clinical and non-clinical services of hospitals. This study aimed to investigate the challenges of quality improvement offices in hospitals and provide appropriate solutions.
Methods: The present qualitative research was conducted using semi-structured interviews with 40 managers and hospital boards, matrons, quality improvement experts of hospitals and accreditation offices experts of medical universities in Tehran. Content analysis method was used to analyze the data obtained from the interviews. Then, the collected data were analyzed and classified by MAXQDA10 software.
Results: By analyzing the interviews in the field of challenges and solutions, the extracted codes were classified into four areas of management, standards, evaluation and staff. The most codes were related to management with 5 themes and 21 sub-themes. In addition, most of the solutions were related to the field of management.
Conclusion: The findings of the study showed that most of the challenges and solutions were in the field of management. Focusing on this field could be helpful in improving the quality of offices performance.

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Introduction: Branding is one of the most important needs of any organization to survive and improve the quality of provided products and services.

Today, branding is also being increasingly used by health organizations and has become one of the important elements for improving the quality of services provided by hospitals as the main body of health services. In the present study, the factors affecting the customer-based brand equity were investigated in selected hospitals.

Materials and Methods: This is a descriptive-analytical and cross-sectional study. Using stratified random sampling method, 350 patients were selected from private hospitals in Tehran and Kerman in 2020. Data were collected through a questionnaire and the Stata software V.14 was used for data analysis.

Results: The average customer-based brand equity was higher in women, those with a degree lower than diploma, and in surgical treatment group. Different dimensions of hospital brand value including perceived quality (average), patient loyalty (average), brand image (good) and service brand value (very good) were evaluated and average customer-based brand equity received 76.38 points out of 100 and was at a high level.
Conclusion: Hospital brand value has an important effect on hospital marketing. Hospitals can take steps to attract and retain patients and can create a competitive advantage over others. The results showed the positive effect of perceived quality, patient loyalty, brand image and service brand value on customer-based brand equity.

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Background and Aim: Burnout is one of the most important factors that reduces the productivity of personnel. Therefore, this study aimed to determine the relationship between human resources management functions and job burnout from the perspective of managers and staff of deputy of Health in Iran University of Medical Sciences.
Materials and Methods: Subjects of this cross-sectional study consisted of 657 managers and staff members of deputy of Health in Iran University of Medical Sciences that 242 individuals were selected according to Morgan's table as the study population. Research data were collected using two questionnaires of burnout and human resources management functions.
Results: 174 (70.7%) participants in the study were women, with mean age and work experience of 41.3 and 15.8 respectively and a standard deviation of 7.35 years. 78.9% of married people and 69.1% of the participants were dissatisfied with the status of their salaries. The dimensions of consequential evaluation, transparent job description and comprehensive training with averages of 4.17, 4.12 and 4.03 out of 7 had the highest score among the various dimensions of human resources functions. Different dimensions of burnout showed that the highest mean was related to feelings of personal inadequacy and depersonalization (4.72). The results of the Pearson correlation test showed that there was a statistically significant relationship between human resources management functions and burnout with a correlation coefficient of -0.439 (P <0.05).
Conclusion: Job burnout can be significantly reduced with the improvement of human resources management functions.