Journal of

Background: Recently, considerable attention has been paid to medical errors in health care system. Taking into account that nurses spend more time with patients in comparison with other staff, they are more prone to human errors. The present research conducted to investigate nurses' errors in delivery emergency ward in a hospital affiliated to Tehran University of Medical Sciences.

Material and Methods: In the present coss-sectional study,at first, task analysis was conducted  to nursing proffession using Hierarchical Task Analysis (HTA) technique by FGD. In next step, the Human Error Probability (HEP) was determined utilizing SPAR-H method and dependences of performance-shaping factors (PSFs) and action and diagnosis activities were identified. Finally, after determinig dependency level, the final diagnosis HEP was calculated and risk assessment level was carried out  using the risks' probability and intensity tables.

Results: According to the results, four groups of studied tasks, the lowest errors were belonged to "working with serum pumping machine'' subtask with the error level of 0.055 and the highest error probability related to '' transfusion of blood products'' subtask with the error rate of 0.78. Moreover, special responsibilities of the wards had the highest level of undesirable risks.

Conclusion: In the present study, the analysis of identified errors reveals due to high work demand, insufficient time and the need for accurate administrative monitoring and providing required arrangements, the main causes of errors can be attributed to high level of stress and complexity in the tasks of delivery emergency ward. 

Background: Quality management as an organizational strategy helps enhance hospital efficiency, effectiveness and productivity. This study aimed to examine the impact of quality management on employees’ job satisfaction at Respiratory Intensive Care unit, Labafijejad Hospital.

Materials and Methods: A participatory action research was used for the intervention in 2013. A quality improvement team was established and operational processes were improved using a quality management model. The quality improvement team identified and standardized working processes, identified quality goals for the processes and improved them until achieved quality goals. Employees’ job satisfaction data was collected before and after the intervention.

Results: The quality management model implementation improved employees’ job satisfaction at the Respiratory Intensive Care unit. Employees’ job satisfaction was increased from 56.6 percent in 2013 to 68.3 percent in 2014. Integrating employees’ needs in quality improvement activities helps sustain the benefits of quality management. As a result, employees’ moral and satisfaction increase.

Conclusions: Implementing an appropriate quality management model appropriately in a supportive environment helps enhance employees’ job satisfaction and morale. Managers' and employees' commitment and involvement in quality improvement activities are required for successful quality management implementation.

Background: Three aspects of health, responsiveness rate and equitable financing introduced as the main goals of health systems. In this study, responsiveness rate was assessed among private and social security hospitals in 2013.

Materials and Methods: The descriptive-analytical study conducted as a cross-sectional one among 10 hospitals in Tehran city (20 percent of total social security and private, 8:2 respectively) in 2013. Study population consisted of all inpatients and outpatients referee to eight private and two social security hospitals and 333 subjects selected to data gathering randomly. The valid and reliable World Health Survey questionnaire was utilized. Data was analyzed by SPSS₁₇ using descriptive statistic, Mann–Whitney and Kruskal–Wallis tests.

Results: In points of view among inpatient and outpatient, the mean score of responsiveness rate were 4.1±0.71 and 3.7±0.60 respectively. These amounts estimated 4.4±0.46 and 3.2±0.82 for inpatient and 3.8±0.58 and 3.5±0.63 for outpatient in private and social security hospitals respectively. Also, the mean score of responsibility rate assessed 4.4 in private hospital which was higher than social security ones (3.2); and this difference was statistically significant (P<0.001).

Conclusion: Responsiveness rate dimensions were evaluated moderate to high among assessed hospitals. These results were enhanced in private hospitals rather than social security ones. It is recommended that hospital managers should pay more attention to client and mechanisms to improve responsiveness rate and providing more services quality. 

Background: Health care systems especially hospitals often encounter several risks which has weaken efficiency and hospitals performance entirely. Resilience engineering (RE) enables to remain high risk systems stable faced to sudden changes or minimizes negative effects of changes.

Materials and Methods: This study considered a new hybrid framework concept regarding the non-value added waiting time and resilience engineering indices as efficiency indices to evaluate private and public hospitals performance. With the intention of evaluating the hospitals performance, a hybrid framework including simulation and MADM methods utilized. Output-oriented Data Envelopment Analysis (DEA) approach used as MADM method.

Results: The results revealed that RE factors play a significant role in hospitals performance's promotion; also the private hospitals had better performance compared to the public ones.

Conclusions: Study results indicated that teamwork efficiency index compare to other efficiency indices had more effect on hospitals performance. Health system managers should be considered improved performance and efficiency policies and focus more on other RE indices parallel team work index.

Background: The present study performed with the purpose of nursing care quality assessment and its association with process management in Shahid Beheshti hospital of Kashan in 2014.

Materials and Methods: In this applied, cross sectional and correlation study with the purpose of assessing the nursing care quality, 200 hospitalized patients who had more than 48 hours length time selected randomly conducting modified four parts SERVQUAL questionnaire in likert scale. In order to evaluate hospital performance based on process management model (EFQM) Excellence model questionnaire was utilized. Data analyzed using SPSS software version 16 by descriptive statistics and multivariate regression tests at a significance level of less than 0.05.

Results: Data extracted from 200 completed questionnaires analyzed. Respondents included 104 women and 96 men. The mean duration of hospitalization was 6.9 ±12.9 hours and the mean age of patients was 37 ± 12.02 years. Total nursing quality services were more than average and it assessed good (3.8 ± 0.92).Scores of Shahid Beheshi hospital were 215.66 and 217.64 in empowerment and results EFQM dimensions respectively. Multivariate regression coefficient was assessed 0.57.

Conclusions: Based on study results, it is necessary to make use of new management system and professional training to nurses in order to improve nursing quality services in hospitals. 

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. 

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. 

Background: Medical errors and adverse events are the main reasons of many avoidable deaths and imposed expenditures in worldwide health systems. Hence, this study aimed to recognize some challenges, medical errors and adverse events, and to address the appropriate solutions in order to solve them in the Iranian health system.

Materials and Methods: This qualitative study had three main data resources including key informants, national documents and expert panel. Key informants (30 persons) and experts (12 persons) were selected purposefully from macro, meso and micro levels of health system and some other health related organizations. Data were interpreted and analyzed through a mixed (inductive/deductive) thematic framework.

Results: Although, most reasons of medical errors were in relation with weak patient security system and low level security culture in hospitals, other factors like manpower, physical and external agents of hospital environment induced these errors as well. The most considerable solutions to decrease the medical errors comprised identification of medical error reasons in different levels of heath system, errors documentation and generation a consolidated system for recognition and following the errors and their main causes.

Conclusion: Relieveing the reasons of medical errors and adverse events can be a great step to prevent them. In order to eliminate the medical errors and its challenges, it is necessary to develop the consonant programs in national level via conclusive will of organizations, groups and related individuals.

Background: Considering the importance of hand hygiene in nosocomial infections prevention and the low outcomes of performed researches in hand hygiene, this study aimed at assessing the effective factors on hand hygiene using planned behavior model among nursing and midwifery staff in atea hospital of Hamadan in 2015.

Materials and Methods: This study was a descriptive and cross-sectional study in which all nursing and midwifery staff of the Atea hospital selected through census sampling. Hand hygiene behavior was observed and all participants filled out a questionnaire based on Planned Behavior Model. Data was analyzed   using descriptive and inferential statistics.

Results: only 31 participants (21.1%) had hand hygiene behavior higher than average and 123 (79.9%) had lower than average. Hand hygiene was in the lowest rate, 21.3% and 13% after patient contact and prior to action aseptic respectively.  Knowledge (84%) and attitude (90.4%) about hand hygiene was high, but the level of perceived control, (53.35%) was at the low level. Also, there were significant statistical differences between perceived control and hand hygiene between subjective norms and hand hygiene (p<0.05).

Conclusions: The knowledge and attitude to adopt hand hygiene behavior is not enough alone. Along with staff training, it is necessary to have hospital managers and physicians training, providing appropriate context and omitting barriers to have suitable hand hygiene behavior in practice.

Introduction: Medication process to patients is one of the most important tasks of nurses and doing in correct way can play a significant role in patient safety. This issue is the most significant part of quality care which consisted of patient safety as the impotant element. Medication errors are the main threatening factors of patients' safety. This study aimed at assessing the causes of medication errors from the nurses' viewpoints

Materials and Methods: This study was a descriptive-sectional-analytical one which was done in 2013. The study population consisted of 232 nursing staff of Abadan hospitals(Imam khomeini,Taleghani,Shahidbeheshti ,17shahrivar) which were covered by Ahvaz University of Medical Sciences,Oil Company and Social Security Organization ,respectively. Study instrument was a two part questionnaire including demographic - occupational information and causes of medication errors in 28 items in four fields (nurse, ward, nursing management and pharmaceutical causes).Content validity of questionnaire provided by review of related papers and experts'openion and required correction was performed.reliability of questionnaire was estimated 0.91 using Cronbach's alpha method.

Results: the most important causes of medication errors included shortage of nurses in propration to patient(%44),compression of work in ward(%36.2),fatigue due to over work(%35.8),illegible physician oder(%24.5),anxiety and stress due to work(%25),noise in ward(%22.4),nurse dissatisfaction of salary(%29.7) and similarity in medicine shape(%14.7) respectively.

Conclusion: Management causes such as nursing shortage, organizational factors such as compression of work in ward and some factors like nurses' fatigue had the most effect on occurance of medication errors among nurses. Thus, organizational processes reform and hospital organization to improve service quality and patient safety in order to resolve nurses' problems.

Background: Clinical Governance (CG) is a framework which obligates heath care system to responsiveness regarding maintaining and improving health care services' quality. Purpose of this study was to exists challenges in Clinical Governance establishment evaluation based on national assessors' aspect.

Materials and Methods: This qualitative study was conducted with national assessors' participation of Clinical Governance plan in 2014.Data collection was carried out using face to face interviews with assessors  and analyzed  based on content analysis.

Results: Three main themes were categorized including problems related to clinical governance standards, Existing challenges in assessment process and recommendations to improve quality assessment process.

From the assessors' aspects, the main existing challenges were lack of knowledge and adequate skills in some assessors towards CG, lack of sufficient accordance among assessors team, resistance of some universities and health care systems, lack of existing comprehensive guidelines with the purpose of responsiveness in related ambiguity in assessment and direction process among assessors.

Conclusion: Reinforcement of quality improvement culture in hospitals and increasing susceptibility in plan continuation, correct assessors election and ensuring about knowledge in responsibilities, updating assessors' training and putting to use equal indices in improving clinical governance assessment can be a considerable assist to improve assessment process and resolve related problems. 

Background: The subjects' demographic characteristics are factors influencing their viewpoints about healthcare quality and have a positive association with the clients’ satisfaction. This study aimed at investigating the role of demographic variables on medical tourists' viewpoints about service quality of hospitals in Shiraz.

Materials and Methods: This descriptive-analytical and cross-sectional study was conducted on 200 foreign patients who referred to Shiraz hospitals during the first six months of 2013. Data collection tool was a questionnaire consisting of two parts. In the first part, medical tourists' information was collected and in the second part, their expectations and perceptions of services quality were measured using adapted SERVQUAL scale. The validity was checked out by experts and reliability confirmed by Cronbach’s Alpha test for expectations and perceptions separately (90% and 89%).  Finally, data analyzed through SPSS v.16 software using independent t-test and ANOVA.

Result: According to the results, the mean score of the quality gap was estimated -0.26 for people over the age of 50 years, as it was lower than other groups. Also, the lowest total values of this quantity were related to the individuals with low level of literacy and those who stayed less than 7 days for treatment which were estimated -0.32 and -0.36 respectively. In addition, based on statistically significant dimensions, married tourists, people from Oman and those who had received eye surgery had lower gap mean score than the other patients as their total values were estimated -0.42, -0.21 and -0.22, respectively.

Conclusion: In order to develop the medical tourism industry, the demographic characteristics of the subjects should be considered in policy making and service design which can be result in majority satisfaction.

Background:In the healthcare system, teamwork is important to improve the quality of services and provide safe and effective cares. Operation room, as a high-risk environment, requires high levels of teamwork employees to secure performance. This study aimed at assessing the teamwork among surgical teams of hospitals affiliated to Social Security Organizations in Tehran City.

Materials and Methods: In this cross-sectional study "Observational Teamwork Assessment for Surgery" checklist was used to evaluate teamwork skill in surgical teams. Sixty surgical teams from two hospitals were assessed. In order to data analysis, descriptive statistics was used to calculate mean and standard deviation of age, work experience and teamwork scores in surgical, nursing and anesthesia sub teams. Two-Way ANOVA test was used to study relationship between scores of three surgical phases, sub teams and behaviors domains.

Results: Mean and standard deviation of age and work experience of participants were 42.81±8.57 and 10.62±6.18 years, respectively. Mean score of teamwork was 3.60±0.51 (out of 6) that showed higher than average team performance level. Among three sub teams, nursing achieved the highest score (3.78±0.44). There was a significant difference between nursing sub team and others (p<0.05).

Conclusion: Although mean score of teamwork was in higher than average level in studied teams, but discrepancies between three sub teams were high and worrisome. Use of educational solutions utilization can be effective to improve teamwork and increase quality of behaviors in operation room. 

  Abstract

  Background and Aim: Especially in the case of Hospital services, quality assesment is an complicated and vague issue. For achieving this goal Multiple Criteria Decision Making methods help us. These studies aims to knowledge and prioritize quality indicators and rank selected inpatient wards in an elected hospital of Tehran university of medical science by using Analytical Hierarchy Process and TOPSIS methods.

  Materials and Methods: This is a descriptive-analytical and cross-sectional research. At the first, with an overview of the research literature and expert opinion, indicators of quality assessment were selected. Then we did prioritization of these indicators with using of expert opinion and AHP method. In the final stage, selected inpatient wards the Hospital were ranked in terms of quality of service using TOPSIS by a sample consist of 300 of inpatients.

  Results: Eight main domains (Responsiveness, Safety and risk management, Tangibles, attention to patient, Health communications, Competency and professionalism, accessibility, Credit and assurance) were selected for quality assessment. Among these indicators, competency had the highest priority and attention to patient had the lowest priority. Also the department of Heart had the highest quality of service and the department of Neurology had the lowest quality.

  Conclusion: According to crucial role of the service quality on patients’ satisfaction, the use of appropriate indicators for quality of services, prioritizing them and also proper assessment of the quality of hospital services can play a major role in health policies.

Background: The growing importance of hospitals in physical and mental health improvement has led to focus on improving service quality; and hospitals have considered it as a major competitive advantage. This study aimed at investigating the role of improving services quality on hospital brand preference in healthcare industry.

Materials and Methods: This applied study was a descriptive one. A sample of 394 patients selected using stratified and convenient sampling from hospitals of Shiraz city. Data gathering using questionnaire; in order to data analysis, LISREL_8.80 and SPSS₁₉ were utilized using confirmatory factor analysis and structural equation modeling techniques. Data analysis was used to confirm the relationships between variables.

Results: Study results indicated that there was a significant positive effect of service quality on patient satisfaction, patient loyalty and brand equity of hospital. Patient satisfaction had positive effect on patient loyalty to the hospital and the loyalty had significant effect on hospital’s brand equity. Finally, the effect of hospital brand equity was confirmed on hospital brand preference.

Conclusion: According to the study results, it can be suggested that hospitals management take some measures for service quality improvement which can be enhanced hospital brand preference among other hospitals, both spreading justly public health in all layers of society as well as increasing profitability.

Keywords: Service quality, Brand Preference, Hospital

Background: Injuries related to failures and errors due to clinical interventions in patient hospitalization period in hospital are the main reasons of mortality and mortality in worldwide. This study tries to identify and description ICU care failures and assessing the causes of risks, Severity, Occurrence and identifying risk probability ratio and risk prioritizing using FMEA method.

Materials and Methods: This study was carried out in order to evaluating existing situation using Failure Mode and Effect Analysis and utilizes volere logic to plan the patient safety management system. This study performed in the intensive care unit of Loghman Hakim hospital in Iran.

Results: Study finding revealed sixteen routine failures and its priorities which the five main issues were documented as error in decision phase for patients admission or in-admission (PRN 1000), error in discharge time of patient from ICU (PRN 1000), insufficient infection control (PRN 1000) and error in clinical ordering and prescriptions (PRN 800).

Conclusion: The main requirements of the patient safety management identified as planning standards and clinical guidelines, developing evidence based admission and non admission indicators, enacting infection control rules and education of anticipating standards places, hand washing and disinfecting instrument and equipments.

Background: Despite the fact that only one-third of chest pains occur due to heart diseases, still physicians have tendency to admit most of these patients to reduce risk of negligence and its consequences.Clinical decision support systems (CDSS) enable physicians to distinguish better cardiac from non-cardiac chest pain. This study reviewed articles which focused on this issue.

Materials and Methods: Google scholar and PubMed database were targeted for search. Out of ninety primary matching articles based on the title, abstract and keywords, 28 full texts were relevant which were included in this study.

Results: Included articles were classified into two categories such as managing hospital resources and increasing the accuracy of diagnosis. Study results in the first categoryshowed decrease in both reception and referral time up to 30% and length of hospital stay up to 26% using CDSS. In the second category, the highest reported accuracy of diagnosis was 97% and the maximum sensitivity and specificity were 100% and 89.43% respectively. Even though, the results of a study revealed that the accuracy of decision support system in diagnosing cardiac chest pain was better than the compared cardiologists.

Conclusion: Considering the role of CDSS in managing hospital resources and improving accuracy of diagnosing cardiac chest pain, it is suggested that emergency wards and cardiac screening centers equipped by these systems.

Background: Because of the current population policies adopted in Iran followed by increasing the number of births, this study aimed to investigate the current situation of safe delivery and proposed a model based on clinical governance.

Materials and Methods: This study is a combinatorial-exploratory research (Mixed Method) conducted in four hospitals in Qazvin and Semnan provinces including two stages in 2014.  The first stage was the assessment of current situation; clarifying safe delivery, reviewing literatures, providing two checklists, assessment of current situation based on assessment of continuous quality improvement and assurance of the quality and the second stage was presenting the model including codification of safe delivery model in seven axes of clinical governance, the approval of the model on the panel using nominal group technique.

Results: In quality assurance, hospital (4) and hospital (2) obtained the maximum score (1431) and minimum score (1237) respectively. All hospitals in continuous quality assessment, admission in the intensive care unit (P < 0.001), mothers with severe consequence of pregnancy (P = 0.004) and 16 cases out of 27 errors had significant statistical difference.

Conclusions: In order to improve the quality of Maternity ward, hospitals' accreditation also should be based on the principles of clinical governance. In addition to evaluations based on quality assurance and annual accreditation, assessment using continuous quality improvement methods based on clinical governance is essential. The proposed model includes seven axes of clinical governance.

Background: The quality of services is a comparison of the customer´s perspective (expectations) with what it has received. If the expectations are more than perceptions, the quality of received services is not sufficient based on customer´s view which resulted in his/her dissatisfaction. The present study performed with the purpose of determining the quality of provided and excepted services to outpatients among hospitals affiliated to Tehran University of Medical Sciences.

Material and Methods: The present study is a descriptive- analytics and cross sectional one which has been done in 2015. The study population included all outpatients attending hospital clinics affiliated to Tehran University of Medical Sciences.The sample size was calculated 225 participants based on formula. In order to data gathering in quality of provided and expected services, a 22-items standard questionnaire of Servqual was utilized. Data analysis performed by SPSS using paired t-test, Mann-Whitney and Kruskal-Wallis tests.

Results: The study findings represented that there was a negative gap in the quality of services provided. The highest gap was related to accountability (-0.97) and the lowest gap related to tangibles factors (-0.69) .Moreover, regarding to  relationship between demographic variables with perceived service quality, there were significant relationship between  insurance type with reliability and empathy dimensions and supplementary insurance with tangibles factors and reliability.

Conclusion: Negative gap (higher expectations than perception) in all aspects of quality improvement is required in all dimensions. Especially, it is necessary to adopt some strategies in the accountability dimension. Reforming management processes, reducing waiting times and increasing employees' motivation in order to achieve appropriate accountability are in this kind of strategies.