Journal of

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Background: Accreditation is an appropriate strategy for improving the quality, safety and effectiveness of hospital services. Iran national hospital accreditation was initiated as a government and mandatory program in 2012. This study aimed to identify the prerequisites of hospital accreditation implementation in Tehran province hospitals.
 
Materials and Methods: This qualitative study was performed using semi-structured interviews with 72 managers in different level from 15 university, private, military, social security and charity hospitals in 2016. Hospitals were selected purposefully through Tehran province hospitals. Content analysis was used in order to data analysis.
 
Results: Pilot testing of standards before announcing to hospitals for implementation, education and training of hospital managers and employees on accreditation standards, providing required resources, allocating enough time for implementing the standards and providing incentives for implementing standards are the main hospital accreditation prerequisites. Absence of these prerequisites in accreditation implementation resulted in huge challenges for hospital managers and employees.
 
Conclusion: Providing the accreditation prerequisites for hospitals facilitates implementation of hospital accreditation in hospitals which in turn results in quality improvement, safety and hospital services effectiveness.

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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: microbial contamination of hospital wards is one of the most important factors in the transmission of hospital infections among inpatients in hospital units.
This study aimed to analyze the error in the diagnosis of microbial contamination in the hospital's intensive care unit and its root causes analysis in 2015.
 
Materials and Methods: This study was conducted in three stages. The first stage conducted as a case report. The second stage was designed to identify the factors affecting the occurrence of error by Root Causes Analysis and conducting an interview and panel. Third stage was provided using self-made questionnaire and Delphi technique to obtain appropriate strategies to identified errors. In order to data analysis SPSS software was utilized.
 
Results: The main causes of hospital infections were organizational and managerial causes, task related causes, laboratory-related causes, causes associated with training, causes associated with work teams and causes related to working conditions in the intensive care unit. The study findings extracted from the Delphi technique revealed that simple actions such as hand wash and disposable appliances usage are significantly effective in hospital infection prevention.
 
Conclusion: One of the most important ways of preventing and controlling hospital infections is investigating the root causes of these infections. Also, personnel training regarding effective methods to nosocomial infections’ care and control and patient safety culture should be considered by managers.

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Background:Human reliability assessment consists ofusing quantitative and qualitative methods to predict human contribution to the occurrence of error;so, using reliability assessment techniques is necessary to prevent and limit the consequences of errors in sensitive work environments.Healthcare considers as the high-risk areas.With due attention to the high rates of cesarean section in Iran, this study aimed at evaluating human reliability during this operation.
Materials and Methods:This was a qualitative-descriptive study which was performed as a cross-sectional one using the EMEA technique. At first, the process of operation was divided in to tasks and sub-tasks using the method of hierarchical task analysis. Then, according to the EMEA instructions, the work sheet was completed for all personnel in the operating room.
Results: A total of 126 errors, including 40 errors (31.75%) related to circular nurse activities, 34 errors (26.98%) related to anesthesia activities, 33 errors (26.19%) related to scrub nurse activities and 19 errors (15.08%) related to the activities of the surgeon, were identified.In general, skill-based errors (51.59%)  and judgment-based errors (1.59%) were the highest and the lowest amount, respectively.
Conclusion:According to the study results, among three working groups, skill-based errors forcircularand scrub nurses and anesthesiology expert with the most frequency, and knowledge-based errorsfor surgeon tasks, with the highest frequency should be considered as priorities tocontrol errors.

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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: The Pabon Laso Model is one of the most important models of evaluating efficiency. Many studies are implemented with this model in Iranian hospitals. This study aimed to review related articles with systemic review and meta-analysis method.
Materials and Methods: The data was gathered using related keywords in databases such as IranMedex, MagIran, IranDoc, Medlib, SID, PubMed, Google Scholar, Elsevier, and Scopus. The articles were searched during 2001 to 2015. Inclusion criteria were determined as articles published in Persian and English, Pointing at least one of three criteria Pabon Lasso model in Iran and access to full-text articles. Exclusion criteria were articles other than hospital performance assessment, and articles which presented as conferences event, case reports, letters to the editor and educational articles. Meta-analysis method was used for calculating Pabon Lasso indices. CMA: 2(Comprehensive Meta-Analysis) was utilized.
Results: 27 articles out of 396 articles were reviewed. The results of 348 hospitals had shown 79.9(22.9%), 76.8(21.7%), 117.8(33.8%), and 74.6(21.4%) of hospitals were in areas one, two, three, and four, respectively. The average of length of stay, bed occupancy, and bed turnover were 3.4 (3-3.7, 95% CI), 63 (41-95,95% CI), and 78.4 (71.8-85.2, 95% CI) per year, respectively.
Conclusion: Study results revealed that only one-third of hospitals were in area three in Pabon Lasso model. The performance status of three fields were average in the length of stay (approximately standard), bed occupancy (upper than standard), and bed turnover (lower than standard).
 

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Background: Accreditation is one of the health sector evaluation methods that used to promote healthcare quality. The study aimed to identifiy the strength and weakness of accreditation surveyors and the impact of their performances.
Materials and Methods: This study is a qualitative research which conducted between hospital accreditation stakeholders in 2016- 2017. Data were gathered using semi-structured interviews and analyzed by a thematic analysis method.
Results: The findings of in strengthen were categorized in 7 themes. The main strengthen was acceptance of accreditation by surveyors, educational approach, reputation, personal effort to develop knowledge and skills, and existence of senior surveyors. Our results for weakness were classified in 8 themes. The main weaknesses were lack of sufficient knowledge, experience, skills and weakness in personal characteristics. Based on the findings, the accreditation surveyors’ performance was evaluated as under-moderate in past two periods of hospital accreditation. The interviewees announced that weakness of surveyors’ performances was one of the main effective factors of low stability of accreditation results.
Conclusion: Recruitment of surveyors based on main competence, education and empowerment of surveyors, and assessing the surveyors can lead to more validity of accreditation results and finally lead to increasing the commitment of hospitals to quality.
 

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Background: Hospitals are the most important and largest institution in each country's health system which health care services are carried out on a large scale. One of the most important processes to improve the quality of health services is accreditation in the country. This study aimed to identify challenges, obstacles and providing solutions in hospital accreditation.
Materials and Methods: This research is a qualitative one which conducted using content analysis approach in the north of the country in 2017.  Twenty-five people consisted of two heads of hospitals, three hospital managers, three matrons, four supervisors, ten nurses, three people responsible for accreditation selected as contributors to the study using a targeted sampling approach. After the interview with Maxqda software, coding was performed and necessary analysis was carried out. In order to obtain data validity, two methods of reviewing the participants and reviewing experts were used.
Results: Analyzed data was categorized in the 98 initial codes, 16 concepts and 5 main categories. The main issues included resource challenges, organizational challenges, technical challenges, negative consequences and solutions.
Conclusion: Pathology helps the organization to focus on problems and by collecting and analyzing data and identifying risky spots, managers and planners will find methods to develop and solve the problem. Particularly, the correct implementation of the accreditation process can lead to comprehensive clinical excellence.
 

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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: The present research aimed to assess the readiness of selected hospitals of Tehran University of Medical Sciences to implement quality improvement programs and clinical audits from the viewpoint of managers.
Materials and Methods: A descriptive-analytic study was conducted in May 2017 in four selected hospitals of Tehran University of Medical Sciences. The study population of this study was 20 managers of selected hospitals who were selected by census sampling method and entered the study. The data gathering tool was a two-part questionnaire whose validity and reliability were confirmed. In this study, we used SPSS software version 23 and statistical tests to analyze the data.
Results: The effectiveness and readiness of hospitals to implement a clinical audit program was equal to 60% in the field of data and information, cardiology and feedback; 55% in resources, design and implementation, clinical audit management, and evidence and standards; 50% in illness and education; and 45% in manpower. Also, with increasing frequency of clinical audits, hospital readiness for quality improvement processes increases.
Conclusion: Due to the effectiveness and low readiness of hospitals in implementing a clinical audit program, especially in the field of human resources (45%), it is necessary that managers and planners of clinical audit programs in hospitals have a precise knowledge of these factors in order to control the organizational environment and help improve the effectiveness of audit programs.
 

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Background: Nosocomial Infections (Nis) Are Regarded As The Most Common Complications Of Health Cares. These Infections Affect Patient’s Safety in Developing and Developed Countries. The Aim Of This Study Was To Epidemiology and Determine the Causes of Nosocomial Infectioin Teaching Hospital of Tehran In A Teaching Hospital In Tehran.
Materials and Methods: This Cross-Sectional, Descriptive And Analytical Study Was Designed In 2019 At A Teaching Hospital Affiliated With Iran University Of Medical Sciences. The Nosocomial Infection Registry Data between 2017 and 2018 Was Used. The SPSS24.0 Software Package Was Used To Analyze Data Into Descriptive (Frequency, Percentage, Mean and Standard Deviation( And Analytical) ANOVA) Statistics.
Result: The Most Frequent Type of Infections Were Urinary Tract (39.76%), Ventilator Associated Events (20.92%), Bloodstream (20.71%), Respectively. Skin and Soft Tissue Infections (0.7%) Had The Lowest Prevalence. The Highest Incidence Of Nosocomial Infection Was In The ICU With 200 Patients And The Lowest Incidence Was In The ENT With 23.1 Patients And The Overall Incidence Of Nosocomial Infections Was 84.9 Patients Per 10,000 Patient-Days.

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Background: Medical errors represent a serious problem for intensive care and increase the length of stay and mortality. Tracking of medical errors in hospital have focused on voluntary reporting of errors, but 10 to 20 % of errors are ever reported and, of those, 90-95 percent cause no harm to patients. This study was conducted to recognition and analysis medical errors in Intensive Care Unit by GTT in 2019.   
Materials & Methods: This study was a retrospective descriptive-experimental and was conducted in the Intensive Care Unit of a public hospital in Tehran. In 2019 for 13 weeks,127 records were separately reviewed by two nurses by using the IHI checklist and final confirmation was performed by the physician. The data were analyzed by SPSS 22 software.
 Results. 622 triggers, 277 adverse events related to triggers, 121 adverse events without trigger and totally 398 adverse events were identified in ICU. 93 records from 127 records had adverse events. The incidence rate of adverse events was 73/2%, 3/13 adverse events per pa­tient and the incidence rate was 24/8 adverse events per 100 patients-day. The most frequency of events and harms were respectively related to care, intensive care, surgery and medication modules.
Conclusion. According to the result of patient records reviewing and the high rate of AEs that required intervention and also the result of similar study, we can state this tool is more reliable than other methods to detect AEs, such as voluntary reporting of error.
 

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Background and purpose: Electrocautery is a very important tool in surgery. Electrocautery burn is a common side effect of operation surgeries. Quality management is a useful strategy for improving the quality and safety of hospital services. The objective of this study was to examine the impact of quality management on reducing electrocautery burns.
 
Materials and methods: A participatory action research was conducted in the operating theatre of a hospital in Tehran, Iran, in 2013 and 2014. A quality improvement team was established in the hospital operating theatre. The quality improvement team using an 8-step quality management model, standardized working processes, identified quality goals for the processes and improved them until achieved the quality goals. Data on electrocautery burns was collected before and after the intervention and compared.
 
Results: Electrocautery burn rate was 0.40% in 2012. A wet patient due to sweating or washing during the surgery, in-appropriate patient position, faulty earth well, faulty anti-static mattress and long usage of electrocautery devices were the main reasons of electrocautery burn injuries. Accordingly an action plan was developed and implemented for preventing and reducing electrocautery burns. Consequently, electrocautery burn rate was reduced to 0.21% and 0.02% in 2013 and 2014. Electrocautery burn was significantly reduced by 95% in two years.
 
Conclusion: Electrocautery burns can be easily prevented using the quality management strategy. Implementing an appropriate quality management model appropriately in a supportive environment enhances the safety of hospital services.

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Introduction: The operating room is one of the most sophisticated workplaces, consisting of a vast array of electrical, gas and radiation equipment that are more susceptible to accident than other hospital departments. Therefore it is important to observe safety tips in this section. The purpose of this study was to evaluate the standard of safety in operating rooms of hospitals affiliated to Mazandaran University of Medical Sciences in 2019.
Method: This study was a descriptive cross-sectional study. The statistical population consisted of all operating rooms of hospitals affiliated to Mazandaran University of Medical Sciences. The tool used was a checklist that was completed by researchers by observation and interviewing on-site. Safety standards have been evaluated in terms of the physical space of the operating room, fire safety, personnel safety, patient safety, infection control. Data were analyzed by SPSS version 21.
Results: The operating rooms of university-affiliated hospitals were 80.10% secure in overall safety. The patient's safety area, with 83.34%, had the shortest distance from the standards and the infection control safety area, with 74.24%, had the highest distance from the standards. The highest and lowest scores were related to the safety standard related to the operating room of hospitals (2) and (1).
Conclusion: According to the findings, the operating rooms of the studied hospitals are generally in desirable compliance with safety standards. However, it is essential to pay attention to problem areas to increase the safety factor for staff and patients in the operating room, so appropriate remedial measures should be taken to ensure complete safety of the operating room for all components.

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Introduction : A large number of hospitals and medical healthcare centers catch fire every year. Nowadays, one of the most significant challenges that hospital designers and health providers faced with is fire safety. This study conducted to determine a comprehensive model for fire safety in hospitals by reviewing related studies.
 
Method: This study was conducted using a comprehensive review to find a research paper published on fire in hospitals. Electronic databases such as PubMed Scopus google were searched using the proper search strategy. 
 
Results: Overall, 14 studies were obtained. The findings were analyzed qualitatively through thematic synthesis and divided into some main themes: essential sections and divisions of hospitals in the field of fire, emergency exit patterns, materials and construction status, Flammable consumables materials in hospitals, and appropriate firefighting equipment.
 
Conclusion: The dangers of medical equipment and flammable material, the types of firefighting equipment in the hospital building, architectural safety issues regarding the degree of fire resistance of structures, roofs, doors, walls, and emergency exit stairs are crucial points To protect staff and patients in hospitals that should consider simultaneously.

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Background and Purpose: The importance of hospital quality services in order to best utiliz available resources are not unknown to managers. This is especially important in the maternity sector due to the high density of referrals. Implementation of LDR (Labor, Delivery, Recovery) is one of the new approaches to improve delivery services in the country. The purpose of this study was to evaluate the effectiveness of LDR system on quality of delivery services in two selected hospitals of Qom.
Methods and Materials: This is a descriptive-survey study. Data were collected with a cross-sectional approach to compare the quality of service indicators of a hospital with LDR system as a case and a hospital without LDR system as a control group. Data were collected using a standard questionnaire by Poisson sampling and analyzed by SPSS software.
Results: There was no significant difference between the two hospitals except for LDR implementation. There was no significant association between LDR implementation in delivery sector with overall quality of service indicators (3 vs. 2.5) , input, process and output quality indices. However, LDR implementation had a significant effect on some items of these indices (level of significance = 0.05).
Conclusion: According to the research findings, implementation of LDR did not have a significant effect on overall quality of services, but it did affect the subscales of these indices. Therefore, it seems clear that there is a need for proper management policy to control the costs involved in implementing this system.

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

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Background: In Iran, the accreditation system is mainly focused on hospitals and has not yet succeeded in providing standards for independent medical centers such as independent clinics. The present study reports the development of an accreditation framework for independent clinics affiliated with the country's armed forces.
Materials & Methods: This is a mixed (qualitative-quantitative) study. Experts' agreement (30 people) on the results of a systematic review (201 items) was obtained using a questionnaire and through holding three expert panels. The necessity of each item was calculated using the method of content validity ratio and the weight of standards and headings based on the average.
Results: The existing 201 items were converted into 75 standards in 13 headings as final standards with the weight of each item.
Conclusion: This framework can be used as a comparison tool between independent medical centers and it is necessary to train evaluators, and prepare legal and organizational requirements in order to implement it.