Journal of

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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.

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Introduction: Root cause analysis is one of the most important tools in disaster management that aims to identify the real causes of an issue and find ways to eliminate them. Surgery is one of the areas in which the possibility of clinical error is significant. Therefore, the study aims to explain the weaknesses and challenges of root cause analysis in surgical events and identify the experience of staff around the technology.
Materials and methods: This qualitative study was conducted through interviews in 2021. Twenty members of the root cause analysis team working in teaching hospitals affiliated to Iran University of Medical Sciences were interviewed. After conducting the interviews, MAXQDA software version 10 was used to analyze the thematic content and extract concepts related to the research objectives.
Results: The majority of participants were female, head nurse, aged 30 to 40, work experience of 11 to 15, and employed in Hasheminejad Hospital. The most important weaknesses identified for root cause analysis included the lack of proper implementation of the root cause analysis process and the lack of participation of individuals, hospitals and universities in this process.
Conclusion: Health managers and policymakers should address the weaknesses of root cause analysis by explaining the necessity of the process, root cause analysis immediately after each clinical event, evaluating the effectiveness of root cause analysis, and providing adequate feedback from the authorities. Upstream therapy, creating a culture of root cause analysis, providing the necessary facilities to perform these analyzes, providing clear instructions to encourage and punish employees.

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Introduction: Health tourism is a new form of tourism industry that aims to maintain recovery and regain physical and mental health and has grown in recent years. Therefore, the present study was conducted to investigate the factors affecting the marketing of health tourism in hospitals affiliated to Iran University of Medical Sciences.
Methods: The present study is descriptive-analytical and was conducted on 270 individuals at some point in 2021. The study population consisted of all heads, managers, matrons, quality managers and heads of international patients of public and private hospitals affiliated to Iran University of Medical Sciences. The data collection tool was a researcher-made questionnaire. Data were analyzed by using SPSS software version 23.
Results: The results of study showed a significant difference between the components of price, place, promotion and people in the two types of hospitals (P-value <0.05). While no significant difference was observed between other components (product, physical evidence and process) (P-value <0.05).
Conclusion: Providing the needs of medical tourists will increase their satisfaction. Therefore, paying attention to the effective factors in marketing and trying to solve the shortcomings of this field can be very effective in attracting health tourists and turning Iran into a medical tourist destination.

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Background
Satisfaction with the salary and other payments and the way they are distributed are of the most important and effective dimensions of human resources management. The purpose of this study was to determine the level of employee satisfaction with the performance-based payment plan in 2021 across hospitals.
Materials & Methods
This was a cross-sectional study conducted in 2021 on 280 employees of teaching hospitals affiliated to Iran University of Medical Sciences. Data were collected by a questionnaire and analyzed by non-parametric tests and Spearman correlation in SPSS.
Results
The mean of total satisfaction in the staff was 2.95 ± 0.55 (out of 5). Among the various categories in the field of satisfaction, the highest mean of satisfaction was related to the physical conditions of the workplace with 3.3 ± 0.64 (out of 5) and the least was related to the payment system with 2.56 ± 0/86. The mean performance of all employees was 63.72 ± 8.82. (out of 100). In this regard, the mean score of staff attendance was 74.22 ± 6.97, job type was 30.97 ± 15.78 and the average quality coefficient of performance was 85.98 ± 11.12. According to the Spearman correlation test, there was a significant correlation between mean total satisfaction and attendance score (r = 0.19), job type score (r = 0.32) and performance quality coefficient (r = 0.21) (p-value <0.05).
Conclusion
The mean of employee satisfaction with the performance-based payment scheme was estimated to be moderate. It seems that health policy makers need to work and plan to improve payment and increase the motivation of healthcare staff.

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Background and purpose: Assessing job satisfaction within any organization is essential due to its impact on productivity and overall effectiveness. This study aimed to evaluate the validity and reliability of the Persian version of Spector's Job Satisfaction Questionnaire among employees of emergency medical centers.
Methods: This descriptive-analytical study was conducted among 270 employees of emergency medical centers in Ahvaz between February 2021 and June 2021. Data collection was performed using a census method and Spector's Job Satisfaction Questionnaire. Face validity, content validity, and translation accuracy of the questionnaire were reviewed by experts. Convergent and divergent validity and reliability were assessed using factor loadings, average variance extracted (AVE), reciprocal factor loadings, Cronbach's alpha, and composite reliability in SMART-PLS 3 software.
Results: The face validity, content validity, and translation accuracy of the questionnaire were confirmed by experts to suit the Iranian context. All item factor loadings and the AVE index for all constructs exceeded 0.4. The AVE index for the entire questionnaire was 0.523. Examination of reciprocal factor loadings confirmed divergent validity. Cronbach's alpha and composite reliability indices for all constructs were above 0.7. The Cronbach's alpha coefficient and composite reliability for the entire questionnaire were 0.83 and 0.88, respectively.
Conclusion: The validity and reliability of this questionnaire, as adjusted for the Iranian population, were confirmed to be high. Therefore, this questionnaire can be effectively used to evaluate job satisfaction among employees in various organizations, particularly in healthcare organizations and centers.

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Background and purpose:
As people age, physical dysfunction often increases, leading to various challenges and a heightened need for urgent medical services. Elderly individuals are among the primary users of healthcare and pre-hospital emergency services. Their subjective experiences during emergencies are influenced by their need for timely and relevant information regarding emergency procedures and their clinical condition—a need that is also shared by their caregivers. This study aims to elucidate the experiences of elderly individuals who have used pre-hospital emergency services in Shiraz.
Methods:
This qualitative study was conducted in two phases. In Phase 1, semi-structured interviews were conducted with 21 elderly participants using purposeful and snowball sampling until data saturation was achieved. The interview transcripts were analyzed using Colaizzi’s method to extract key themes. In Phase 2, a panel of experts was convened to further discuss the findings and provide recommendations.
Results:
Analysis of the interviews revealed several themes related to the elderly’s experiences with pre-hospital emergency services. These themes were categorized into sub-themes including ambulance condition, performance of technicians, timeliness of emergency response, and issues related to emergency rules and regulations. In Phase 2, the expert panel offered practical solutions to address the identified challenges.
Conclusion:
The findings indicate that elderly patients face significant challenges when accessing pre-hospital emergency services, such as poor ambulance conditions, suboptimal technician performance, delayed emergency response times, and restrictive emergency protocols. The recommendations provided by the expert panel could inform policy development and lead to improvements in the quality of pre-hospital care for the elderly.

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Background and purpose: Accreditation is one of the most widely recognized and reliable methods for evaluating the quality of hospital services. However, its implementation is often accompanied by various challenges for hospitals. This study aimed to identify the challenges associated with accreditation in small and single-specialty hospitals from the perspective of those involved in the process.
Methods: This qualitative descriptive study was conducted with the participation of 30 individuals, including hospital staff, national accreditation evaluators, and experts from the Ministry of Health's Monitoring and Accreditation Office. Data were collected through semi-structured interviews and individual sessions. Content analysis was used to process the data, which was analyzed using Max-QDA software (version 20).
Results: The accreditation challenges of small hospitals were categorized into four main themes: "accreditation process," "human resources," "structural issues," and "financial constraints." For single-specialty hospitals, challenges were grouped into three themes: "accreditation process," "human resources," and "uniformity of accreditation standards." Common challenges for both hospital types included low staff motivation, insufficient training in accreditation procedures, and issues related to evaluators.
Conclusion: In addition to general accreditation challenges, small and single-specialty hospitals face unique obstacles due to their specific conditions and inherent differences from other hospitals. To ensure the successful implementation of accreditation programs in Iran, policymakers should thoroughly examine the identified challenges and incorporate these insights into national hospital accreditation planning and implementation strategies.

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Background and purpose: The complexity and extreme fluctuations in the healthcare environment, along with the occurrence of unforeseen disasters and risks, have increased the likelihood of disruptions in hospital supply chains. Strengthening supply chain resilience is a key strategy to mitigate these challenges and ensure the continued delivery of efficient and effective hospital services during crises. This study aims to conduct a structural analysis of the factors influencing the resilience of the hospital medical equipment supply chain using the Fuzzy MICMAC approach.
Methods: This mixed-method (qualitative-quantitative) study included faculty members knowledgeable in the field, heads of medical equipment departments in universities and hospitals, senior managers from medical equipment manufacturing and importing companies, and healthcare administrators. Data were collected through checklists and semi-structured interviews. Fuzzy matrix completion and MICMAC analysis were used for data processing, performed using Fuzzy MICMAC software.
Results: Among the identified factors, logistics management was found to have the highest impact on the resilience of the hospital medical equipment supply chain. In contrast, factors such as integration and coordination, cooperative relationships, competition, flexibility, human resource management, and risk/crisis management had the lowest direct impact. Environmental conditions, transparency and protection, information-sharing systems, and human resource management were identified as the least affected factors. Economic factors emerged as a highly influential indirect factor, significantly affecting supply chain resilience.
Conclusion: To enhance the resilience of hospital medical equipment supply chains, logistics management and economic factorsmust be prioritized. Additionally, agility and speed, risk/crisis management, competition, and the development of integrated and cooperative relationships play a moderately indirect role and should be considered in strategic planning.

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Background and purpose: Given the interdisciplinary nature and multiple stakeholders involved in electronic prescribing systems, their implementation process encounters numerous complexities. This qualitative study aimed to explore and clarify the challenges associated with electronic prescribing and prescription dispensing systems.
Methods: A qualitative content analysis was conducted in 2021 (Iranian calendar: 1400). Data were collected through semi-structured interviews with 25 key informants from the treatment management sector and affiliated hospitals of Tehran University of Medical Sciences. The collected data were analyzed using conventional content analysis methodology facilitated by MAXQDA 10 software.
Results: Approximately 350 initial codes were identified, which were categorized into four main themes with eight sub-themes: policy preparation (establishing a policy secretariat and achieving political consensus), policy formulation (developing policy content and advocacy), policy implementation (planning and executing policies), and policy evaluation (monitoring and evaluating policies).
Conclusion: Ensuring public health remains the ultimate goal of the healthcare system. Electronic transformation, particularly in establishing electronic health records, can significantly improve healthcare service quality. Integrated policymaking among the various institutions involved, enhancing technical and procedural infrastructure, human resource training, and societal cultural readiness are essential factors for the effective implementation of electronic prescription systems and the enhancement of healthcare quality.