Journal of

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Background: Pre hospital emergency medical service (EMS) as the first line of emergency care and treatment in the out- of -hospital has a considerable importance in the health care system. Planning on finding about strengths and weaknesses and improve the quality of EMS by exploring the problems of this section has considerable important.This study aimed to explore the challenges of pre hospital emergency medical service in Mashhad.

Materials and methods: A qualitative study was done with 14 personnel working in EMS sites in Mashhad using purposeful sampling. Data was collected by semi structured interview and analyzed using conventional content analysis approach according to Graneheim and Lund man 2004 with ATLAS.ti  software.

Results: Three general themes were identified including 1) "challenges in Human resources"( Individual characteristics of human resources and personnel's dissatisfaction 2) "challenges in organization" (Structural challenges, lake of equipment and human resource limitation 3) "socio-cultural challenges"(Environmental-social challenges and cultural challenges) were determined.

Conclusion: personnel's dissatisfaction, structural challenges, human resource limitation, lake of equipment   and Environmental-social challenges were the most important challenges in pre-hospital emergency system. Organizational independence , create organizational rows, regulation of laws and administrative regulations reform in relation to the range of services offered by emergency personnel, attention to the facilities and cooperation And the participation of other organizations, such as media and traffic to enhance pre-hospital emergency services at the community level can be effective in reducing the challenges in hospital emergency system.

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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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Introduction: Since incorrect selection of  a manager might lead to incorrect choices of other members, organizations need to consider this important issue  and use well-sought mechanisms for managers’ selection process. Accordingly, this study aims to rank the key factors associated with the selection of operational managers in Tehran University of Medical Sciences.
 
Materials and Methods: This research employed a logical and systematic trend to develop and rank the indicators using fuzzy TOPSIS method. In order for prioritization of key indicators of qualification of operational-level;  after reviewing the literature and using experts’ viewpoints , the dimensions of performance have been selected and using, the SMART technique the key criteria were weighted. A validated and reliable questionnaire was used for data collection.
 
Results: Fifty individuals participated in this study. 37 (74%) and 13 (26%) were male and female respectively. The mean and standard deviation of age of participants were 41.68 and 7.06 years. Literature reviews and related studies indicated 48 indices  for choosing qualified managers. Among these, according to the  expert’s opinion in management science and managers, 36 indices were selected as key indicators. Based on the FTOPSIS analysis, indicators of higher education in the field of management, compliance time, power of expression, adornment and belief in law and order achieved coefficients as 0.205, 0.204, 0.203, 0.202 and 0.197, rank first to fifth.
 
Conclusion: According to the results management related education and expertise in technical aspects of organizational management control  were at the top of ranking . Results of this study can help  medical universities and health service organizations to develop guidelines for selecting their managers.

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Background: Hospital managers' success depends not only on internal of the hospital environment, but also on the external. Considering the importance of the social responsibility of hospitals as an external organizational issue, this study aimed to assess the importance of social responsibility and the implementation status of hospitals.
Materials and Methods: This analytical descriptive study was conducted in Kermanshah educational hospitals in 2016. The study population consisted of management team of each hospital in middle and first-line level, of which 150 were selected using census sampling method. The data gathering tool was a researcher-made questionnaire. Validity and reliability of the instrument was confirmed. Data analysis was performed using SPSS20 software, descriptive and inferential statistics.
Results: The mean score of importance and status of social responsibility implementation were high (86.20 ± 9.98) and moderate (60.62 ± 12.41), respectively. Among the domains, the highest and the least attention were paid to environment (11.65 ± 88.30) and suppliers (13.47 ± 81.48) domains, respectively. The highest level of accountability in patients was (68.87 ± 26/14) and the least was found in organizational processes (14.47 ± 42.02). There was a significant statistically difference in social status according to organizational status and employment type (p <0.05).
Conclusion: The results revealed that the rate of social responsibility of hospitals was moderate. It seems that providing a systematic assessment of managers performance and authorities, functional feedback and using the successful experiences of organizations in the field of social responsibility are necessary.
 

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Background: The success of organizations depnds on their managers’ performance. This study aimed to measure hospital managers’ performance in the city of sari in 2017, Iran.
Materials and Methods: About 294 top, middle and first-line managers working in the hospitals in Sari (including four public, two private and one social security hospital) particaipated in this descriptive and cross-sectional study. A valid and reliable questionnaire was used to assess managers’ performance in eight functions including decision making, planning, organizing, coordinating, leadership, communication, budgeting and control. SPSS software, the 21^st version, was used for data analysis.
Results: The mean score of hospital managers’ performance was 3.87 out of 5.  Managers scored high in organizing (4.12), leadership (4.06), and decision making (3.97) and low in budgeting (3.27), planning (3.83), and coordinating (3.84). Managers’ performance was linked to their age, marital status, education level, and educational background. Those managers who worked in a position related to their educational background had better performance.
Conclusion: Hospital managers rated their performance as good. Measuring managers’ performance, determining their strengths and weaknesses and applying corrective actions are beneficial to the improvement of hospitals’ performance.

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Background: Hospital accreditation is assumed as an effective control mechanism for health systems to improve quality and efficiency. Current study thus, seeks to look into the relationship between hospitals’ accreditation and efficiency
Materials and Methods: In order to measure efficiency, hospital inputs and outputs included the ratio of physician and nurse to bed, mortality and nosocomial infection rate and quality of inpatientservices were used. A sample of 554 hospitalized patients selected using stratified random sampling
method. Data gathering instruments were researcher-developed questionnaire and checklists. DEAP and SPSS software deployed to assess correlation between accreditation rank and technical efficiency
Results: Average hospitals’ technical efficiency score was 0.94 indicating an improvement capacityof %5.1 for hospitals efficiency. The mean quality score was 4.13 out of 5( in the range of 3.9-4.3)There was no correlation between hospitals accreditation rank and their technical efficiency
Conclusion: According to the results, it seems efficiency should be also considered in accreditationmetrics. In addition, for measuring efficiency, performance based inputs and specifically outputs tohave reliable results should be chosen

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Background: One of the hospitals’ goals is providing high quality of health for patients and patient satisfaction is one of the indicators of quality of health care in hospitals in all countries. The present study aimed to evaluate patients’ satisfaction about performance of health transformation plan in teaching hospitals affiliated to southern Khorasan province in 2016.
 
Materials and Methods: This study was a cross-sectional, descriptive-analytic one which 410 patients admitted to seven public hospitals of south Khorasan province were evaluated using a standard questionnaire on patient satisfaction during one month. Data analysis was performed by SPSS₂₂ software using descriptive and inferential statistics.
 
Results: level of 51.5% patients ‘satisfaction was assessed high, 37.1% in a good, 9.9% moderate and 1.6 low level. Regression analysis revealed that average score of satisfaction with education level and economic situation had a significant association (p <0.05) which patients with higher education level and better economic status had less satisfaction. There was no significant relationship between other demographic variables and satisfaction level.
 
Conclusion: According to study results, it can be concluded that the health transformation plan can achieve its goals and success regarding patients’ satisfaction and patient costs reduction due to patients' perspective. In order to increase patients’ satisfaction, paying more attention to welfare and nutrition and evaluating satisfaction in other groups (nurses, physicians and personnel) recommended.
 

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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: 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: Activity-Based Costing Analyzes the Activities Performed in the Service Delivery Process and Accurately Identifies Costs to Improve The Performance and Efficiency of The Delivery Units and Calculates the Cost of Each Activity by Identifying Services and Activities. The Purpose of This Study Was to Calculate the Cost of Radiology Services Based on Activity Based Costing Method In Firooz Abadi Hospital.
 
Materials and Methods: This is a descriptive retrospective study conducted in 2018. Data were collected through interview with Hospital officials, direct observation and from existing documents in hospital. Data entry was done through Excel software and analyzed Based on activity-based costing system in eight steps.
 
Results: Based on the Findings of this Study, Four Types of Imaging Services Were Commonly Found In Firooz Abadi Hospital. From Total Radiology Costs, 79.3% Were Estimated to Be Related to Direct Costs and 20.7% to Indirect Costs. Finally, the Cost Per CT Scan Service Was 725,133 Rials, Mammography 608,054 Rials, Radiology 809,165 Rials and Ultrasound Service 512,692 Rials.
 
Conclusion: Results of the Study Indicated that Direct Costs accounted for most Costs in Radiology Unit, So Improving Performance and Policies in Health System, Particularly in Human Resource Management, Service Consumption Standardization and Staff Training Suggested to Cost Reduction.
 

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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: Expenditure in the health sector requires appropriate resources management. This study was conducted to determine the amount of moral hazards associated with the service providers in the medication prescriptions paid by an insurance organization.
Methods: Study population included paid pharmaceutical documents in Tehran province in 2019. 2000 prescriptions for 500 insured people were randomly selected from the database of the organization. Two indicators (the number of suspicious prescriptions based on the incompatibility of a drug with the history of the disease or the drug spectrum of an insured and the number of prescriptions with a financial burden higher than the average usual burden of a normal patient) were matched with transcript data and analyzed with SPSS version 24. An experienced pharmacist was consulted to examine the drug spectrum of all prescriptions.
Results: 5.4% of total prescriptions were incompatible drugs and 6.4% had created extra financial burden. The highest incidence of risks by speciality was related to general practitioners (16 % with a surplus financial burden of 87/500/000 Rials). The highest number and amount of risks in Rials per insured group was related to supervisors (63 % with a surplus financial burden of 26/000/000 Rials). The risk in the military centres’ prescriptions were more than private and governmental centres and it was relatively equal in contracted (48%) and non-contracted (52%) centres.
Conclusion: The abuse in the health service provision is a high risk for  health care managers  in countries that have health insurance programs which their intelligent tracking reduces many of the insurers’ costs and prevent the shortage of vital medicines.

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   Introduction: The concept of patient satisfaction has become very important in the field of healthcare and the major part of this satisfaction is affected by the quality and variety of hospital hotel services.

The main purpose of this study is to analyzing the effect of quality of non-medical services (hoteling) of hospitals on satisfaction considering the mediating role of satisfaction with health services in Shahid Fayyaz Bakhsh, Shahid Hasheminejad and Masih Daneshvari hospitals.
Method: The type of this study is of applied and descriptive-correlational. The statistical population of this study included 48043 recipients of services in the mentioned hospitals. The sampling method is simple relative random judgment and Krejcie and Morgan table was used to determine the sample size.  information collected through a researcher-made questionnaire. In order to analyze the data and test the hypotheses from descriptive and inferential statistics through SPSS22 software and also to check the model fit and confirmatory factor analysis from Lee software. Shannon entropy method was used to measure the importance and weight of the studied variables.
Results: The weight and priority of each of the research variables implied that the views of service recipients in the field of non-medical services of hospitals, services during treatment, cleaning services, welfare services, human resources, buildings and facilities, and patient nutrition were respectively high to low priorities.
Conclusion: Recipients satisfaction of non-medical services was average. Establishing partnership management system and determining their medical priorities and needs might increase their satisfaction .

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Background: Human resources determine the quality of performance of health care organizations and are one of their most important competitive advantages. Also, committing is very important to perform their duties. Therefore, it is necessary to recognize the factors that affect organizational commitment. This study aimed to investigate how organizational transparency could affect organizational trust and commitment from the perspective of hospital staff.
Materials & Methods: The present study is an applied descriptive-analytical study conducted on 640 staff members in teaching hospitals affiliated to Tehran University of Medical Sciences. The instruments used were: Organizational Transparency and Trust developed by Rawlins (2008) and  Organizational Commitment developed by Meyer and Allen (1997). Data were analyzed using SPSS software version 26 and AMOS.
Results: Organizational transparency dimensions (overall transparency, participation, substantial information, and accountability) had a positive indirect effect on organizational commitment dimensions (affective, continuance, and normative commitment). Additionally, secrecy has a negative indirect effect on organizational commitment dimensions. The relationship between organizational transparency and commitment was also statistically significant, which indicates that organizational trust mediated the relationship between organizational transparency and commitment.
Conclusion: Managers might be able to improve transparency and staff participation in decision-making by taking cognizance of the priorities and information that can be disseminated by hospitals. In fact, increasing organizational transparency expands cooperation and leads to enhancing staff’s organizational trust, and ultimately increases their organizational commitment.

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Management is a key pillar in order to achieve the goals of health systems. An efficient structure for identifying, recruiting, training, promoting, monitoring and evaluating the performance of managers is highly likely to help the specialization of management, prevent non-specialized selection processes and possible deviations. Given the managerial level in which they play a role, health managers ought to have the required competencies and characteristics. The leading countries generally thrive to have structures where proper candidates are systematically placed in the position of management and promoted to the higher positions. Therefore, the experiences of these countries should be solicited in line with the local social, political, economic and cultural factors in order to achieve the health system goals.

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Background and purpose: With the establishment of a comprehensive health information system (SIB system) in the health department of Iran's health system, one of the important programs of this country to improve health care through the integration of health information was keyed. This study analyzed the performance of this program from the point of view of the end users of the system in the health centers of Boyar Ahmad city.
Materials and Methods: This study was a qualitative research that was conducted using semi-structured interviews and focus group meetings with 25 system users, support officials and staff experts at different levels, reviewing relevant documents and also observing users' performance. The snowball sampling method was carried out in a targeted and networked manner. Qualitative content analysis was used to analyze the data. MAXQDA10 software was used to record, organize and manage study data after collection.
Results: The findings of this study showed that the deployment of this system from the users' point of view contains many positive and negative points, which can be categorized in five general axes, data management system, caregivers' performance, care management, quality of care and infrastructure. The most important challenges of the system included technical inefficiencies, operational inefficiencies, the challenge of statistics and reporting, and technical and social infrastructure, and the most important benefits were improving the quality of care, tracking and reporting, facilitating the care process, and improving the performance of caregivers.
Conclusion: From the point of view of users, the Sib system can be considered as a positive experience in improving the quality of health care, but due to the existence of many challenges, it is far from its final goals

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Background and purpose: Supplementary health insurance plays a pivotal role in the health economy and individual payments, enhancing access to health services and improving individual quality of life. This study aims to explore the challenges and strategies for developing supplementary health insurance.
Methods: This systematic review examined research related to the challenges and strategies for the development of supplementary health insurance in various countries, focusing on articles published in the last five years in both domestic and international databases. For each article, a data extraction form was completed, and the data were subsequently classified, summarized, and analyzed.
Results: Seventeen articles met the study's inclusion and exclusion criteria and were analyzed. The main challenges and strategies for developing supplementary health insurance were identified across seven primary themes: premium and financing, electronic infrastructure, quality improvement, moral hazards and adverse selection, cost-effectiveness and efficiency, evidence-based decision-making, and effective awareness and advertising.
Conclusion: Considering the numerous identified challenges and barriers in the development of supplementary health insurance, it is recommended to focus on creating electronic infrastructures and necessary platforms to enhance and develop policies in supplementary health insurance, particularly in the dimensions of service packages, cost-effectiveness, and efficiency

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The provision of virtual health care has currently received ample attention from health systems worldwide, due to the recent conditions and events. Many countries are trying to provide their preliminary visits and a relatively wide range of other care virtually, paving the way towards the introduction of virtual clinics. However, in many countries, this concept has not been clearly defined, and the characteristics that are necessary to use the virtual clinics are still unknown. This perspective has sought to explain the concept of virtual clinics and their characteristics with a brief review of related literature.

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Background and Purpose: Health status is undeniably one of the most critical indicators of social development and progress. Providing healthcare poses a significant challenge for human life, and managing the healthcare supply chain is of strategic importance. The aim of this research is to analyze and compare the results of meta-synthesis with thematic analysis in identifying the risks of the pharmaceutical industry's supply chain.
Methods: This research follows a qualitative approach, utilizing both meta-synthesis and thematic analysis to identify supply chain risks in the pharmaceutical industry. In the first step, a meta-synthesis and systematic review of related studies over the past twenty-three years were conducted, identifying one hundred articles, which were refined to twenty-six key articles for the research. In the next step, risks specific to Iran's pharmaceutical supply chain were identified through thematic analysis and semi-structured interviews with experts, using targeted sampling. Finally, the results from these two approaches were compared and analyzed.
Results: The meta-synthesis approach identified ten general supply chain risks in the global pharmaceutical industry. Similarly, the thematic analysis approach identified ten specific supply chain risks in Iran's pharmaceutical industry. Six risks were common to both approaches: low quality of raw materials, complexity and incompatibility of information systems, supply of foreign currency and financial payments, transportation and insurance issues, increase in the price of raw materials, and unavailability of medicines. These common risks are critical for both the global and Iranian pharmaceutical supply chains.
Conclusion: Stakeholders in Iran's pharmaceutical supply chain (including hospitals) should prioritize managing these six common risks to improve supply chain performance. Additionally, they should focus on the four unique risks identified through thematic analysis specific to Iran's pharmaceutical supply chain, applying appropriate control measures and activities.