Prevalence and predictors of burnout among nurses during the COVID-19 pandemic: A survey in teaching hospitals.

BACKGROUND: Occupational burnout is one of the most important consequences of the coronavirus disease pandemic, associated with psychological well-being, quality of care, and intention to leave the nursing profession. This is a major health problem with serious adverse consequences not only for nurses but also for patients and healthcare systems. OBJECTIVE: To assess burnout and its associated factors in nurses who worked in teaching hospitals during the COVID-19 pandemic in Iran. METHODS: A cross-sectional study was conducted on nurses of two COVID-19 referral hospitals in Tehran, Iran. Data were collected using the sociodemographic form and Maslach burnout inventory-human service survey (MBI-HSS) questionnaire. Data were evaluated using SPSS software version 26. RESULTS: A total of 264 participants, 52.7% (n = 139) were males and the mean of them age was 34.41±9.71 years. Almost 50% of nurses experienced burnout, in each dimension. Emotional exhaustion was associated significantly with job retention intention (P = 0.01) and depersonalization was significantly associated with gender (P = 0.02), age (P = 0.01), educational level (P = 0.004), work shifts (P = 0.006), and job retention intention (P = 0.02). In addition, personal accomplishment score was significantly associated with age (P = 0.002), marital status (P = 0.03), educational level (P = 0.03), work shift (P = 0.04) and job retention intention (P = 0.01). CONCLUSION: The burnout rate in the COVID-19 era is high among nurses associated with improper care. Psychosocial support is needed to improve mental well-being among health care workers during unpredictable conditions like pandemics.

Post-discharge follow-up system in psychiatric patients: A case study of Farabi Hospital in Isfahan.

BACKGROUND: Mental illness is one of the most common problems in human societies and the continuation of care and post-discharge follow-up. This study was conducted to define a post-discharge follow-up framework for Farabi Hospital in Isfahan. MATERIAL AND METHODS: This was a multistage study, including, interviews literature review, and focus group discussions. Participants included 18 purposefully selected nurses, physicians, and managers, directly involved in the discharge process of Farabi Hospital in Isfahan. The interviews were semi-structured. Data were organized using MAXQDA10 software. The initial framework was set through the extraction of semantic main and secondary codes. The framework was finalized through three several focus group discussion sessions. RESULTS: Results included of 17 sub-categories and seven main categories as "education," organizational arrangement," "team-building," "patient and family participation and trust," "engaging some supportive institutions of community," "process management" and "information management." CONCLUSIONS: To implement a post-discharge follow-up system for psychiatric patients in Farabi Hospital of Isfahan must be concentrated to patient and family education, team building, organizational arrangements, participation, and trust of patients and family, while engaging community health centers and notice to information and management and process management.

Assessment and Reduction of Human Error using SHERPA Technique in Chemotherapy Department of a Large Military Hospital.

Background: Medical errors are numerous in medical activities. Considering the sensitivity and importance of the medical group's professions, the emergence of an apparently simple error can cause the death of an individual or even a group of individuals. The present study aims the evaluation and reduction of human error using a system human error reduction and prediction approach System Human Error Reduction and Prediction Approach (SHERPA) in the nurses of Baqiyatallah hospital's chemotherapy ward in 2019. Materials and Methods: A cross-sectional study was conducted in the chemotherapy ward using the SHERPA technique. Then, the duties were determined in detail using Hierarchical Task Analysis (HTA). The errors were identified using the SHERPA checklist, and the risk outcomes and intensities were finally evaluated. Results: Based on the study findings, there are 109 possible errors for 48 sub-duties. The most frequent errors fall in the functional area (54%) and the least frequent errors pertain to the area of selection (3%). Conclusions: In order to reduce the errors and increase the quality of the services and safety of the patients, errors can be identified by using the SHERPA technique; after identifying these errors, using this technique, it is possible to prevent the recurrence of the identified errors by careful planning. Considering the fact that the most frequent error was found in the functional domain, modern protocols can be codified in this area, and standards can be observed for putting the problems of this section atop of the priority list and reducing the errors and increasing safety of the patients.

Providing a model for financing the treatment costs during biological crises using the fiscal space development approach.

BACKGROUND: Expanding fiscal space for health can be defined as providing additional budgetary resources for health, which is highly important during biological crises. This study aimed to provide a model for financing the treatment costs during biological crises using the development of the fiscal space approach. METHODS: This study employed a descriptive mixed-method design, consisting of three stages. In the first stage, a systematic review of relevant literature was conducted using multiple databases, including Scopus, PubMed, and Google Scholar. A total of 45 studies that met the inclusion criteria were selected. In the second stage, a panel of 14 experts identified five primary and 32 secondary strategies using an open questionnaire. Any additional strategies not identified during the literature review were added if a consensus was reached by experts. In the final stage, the Best Worst Method (BWM) was used to prioritize the identified strategies and sub-strategies based on their feasibility, effectiveness, quick yield, and fairness. RESULTS: Five strategies and fifty sub-strategies were identified. The most important strategies were the increase in health sector-specific resources (0.3889), increase in efficiency of health expenditures (0.2778), structural reforms (0.1111), health sector-specific grants and foreign aid (0.1667), and conducive macroeconomic conditions (0.05556). The most important sub-strategies were establishing and increasing earmarked taxes for the health sector (0.0140), expanding Universal Health Coverage (UHC) plans (0.0103), attracting the participation of non-governmental organizations (NGOs) and charitable organizations in the health sector (0.0096), integrating basic social insurance funds (0.0934), and tax exemptions for economic activists in the health sector (0.009303) during the crisis. CONCLUSION: This study identified five main strategies and 50 sub-strategies for financing the treatment costs during biological crises. The most important strategies were increasing health sector-specific resources, improving efficiency of health expenditures, and implementing structural reforms. To finance health expenditures, harmful and luxury goods taxes can be increased and allocated to the health sector during crises. UHC plans should be improved and expanded, and the capacity of NGOs and charitable organizations should be better utilized during crises.

Knocking down the expression of the molecular motors, myosin A, C and F genes in Toxoplasma gondii to decrease the parasite virulence.

Toxoplasmosis is a serious parasitic infection and novel therapeutic options are highly demanded to effectively eliminate it. In current study, Toxoplasma gondii myosin A, C and F genes were knocked down using small interference RNA (siRNA) method and the parasite survival and virulence was evaluated in vitro and in vivo. The parasites were transfected with specific siRNA, virtually designed for myosin mRNAs, and co-cultured with human foreskin fibroblasts. The transfection rate and the viability of the transfected parasites were measured using flow cytometry and methyl thiazole tetrazolium (MTT) assays, respectively. Finally, the survival of BALB/c mice infected with siRNAs-transfected T. gondii was assessed. It was demonstrated that a transfection rate of 75.4% existed for siRNAs, resulting in 70% (P = 0.032), 80.6% (P = 0.017) and 85.5% (P = 0.013) gene suppression for myosin A, C and F in affected parasites, respectively, which was subsequently confirmed by Western blot analysis. Moreover, lower parasite viability was observed in those with knocked down myosin C with 80% (P = 0.0001), followed by 86.15% (P = 0.004) for myosin F and 92.3% (P = 0.083) for myosin A. Considerably higher mouse survival (about 40 h) was, also, demonstrated in mice challenged with myosin siRNA-transfected T. gondii, in comparison with control group challenged with wild-type parasites. In conclusion, myosin proteins knock down proposes a promising therapeutic strategy to combat toxoplasmosis.

Informal Payments for Outpatient Health Care: Country-Wide Evidence from Iran.

Background: Reliance heavily on out-of-pocket (OOP) payments, including informal payments (IPs), has undesired effects on financial risk protection and access to care. While a significant share of total health expenditure is spent on outpatient services, there is scant evidence of the patient's amount paid informally in outpatient services. Such evidence is available for inpatient services, showing the high prevalence of informal payments, ranging from 14 to 48% in the whole hospital. This study aimed to investigate the extent of OOP and IPs for outpatient services in Iran. Methods: A secondary data analysis of the 2015 IR Iran's Utilization of Healthcare Services (IrUHS) survey was conducted. A sample of 11,782 individuals with basic health insurance who were visited at least once by a physician in two private and public health care centers was included in this analysis. The percentage of OOP was determined and compared with the defined copayment (30%). The frequency of IPs was determined regarding the number of individuals who paid more than the defined copayments. The Mann-Whitney test also investigated the relationships between OOP percentage and IPs frequency with demographic variables. Results: The share that insured patients in Iran pay for a general practitioner (GP) visit was 38% in public versus 61% in the private sector, while for a specialist practitioner visit, the figures were 80% and 96%, respectively, which is higher than defined copayment (30%). This share was significantly higher in females, urban areas, highly educated people, private service providers, and specialist visits. The frequency of IPs, who paid more than the defined copayments, was 73% for a GP in public versus 86% in the private sector, while for a specialist practitioner visit, these were 90% and 93%, respectively. Conclusion: Informal patient payments for outpatient services are prevalent in Iran. Hence, more interventions are required to eliminate or control the IPs in outpatient services, particularly in the private sector. In this regard, making a well-regulated market, reinforcing the referral system, and developing an equity-oriented essential health services package would be fundamental.

Optimization of Service Process in Emergency Department Using Discrete Event Simulation and Machine Learning Algorithm.

Introduction: Emergency departments are operating with limited resources and high levels of unexpected requests. This study aimed to minimize patients' waiting time and the percentage of units' engagement to improve the emergency department (ED) efficiency. Methods: A comprehensive combination method involving Discrete Event Simulation (DES), Artificial Neural Network (ANN) algorithm, and finally solving the model by use of Genetic Algorithm (GA) was used in this study. After simulating the case and making sure about the validity of the model, experiments were designed to study the effects of change in individuals and equipment on the average time that patients wait, as well as units' engagement in ED. Objective functions determined using Artificial Neural Network algorithm and MATLAB software were used to train it. Finally, after estimating objective functions and adding related constraints to the problem, a fractional Genetic Algorithm was used to solve the model. Results: According to the model optimization result, it was determined that the hospitalization unit, as well as the hospitalization units' doctors, were in an optimized condition, but the triage unit, as well as the fast track units' doctors, should be optimized. After experiments in which the average waiting time in the triage section reached near zero, the average waiting time in the screening section was reduced to 158.97 minutes and also the coefficient of units' engagement in both sections were 69% and 84%, respectively. Conclusions: Using the service optimization method creates a significant improvement in patient's waiting time and stream at emergency departments, which is made possible through appropriate allocation of the human and material resources.

Systematic review of productivity loss among healthcare workers due to Covid-19.

OBJECTIVE: To assess existing evidence on the effects of COVID-19 on healthcare workers (HCWs) using the health-related productivity loss approach. METHODS: A systematic search of online databases including PubMed, Scopus, Ovid, Web of Science, and EMBASE was conducted up to 25 August 2020. Following two screening stages, studies related to the effects of COVID-19 on healthcare workers were included in the study. RESULTS: 82 studies were included in the analysis. The COVID-19 related death rate among HCWs ranged from 0.00-0.7%, while the positive test incidence varied between 0.00 and 24.4%. 39 evidences assessed psychological disorders. A wide range of psychological disorders observed among HCWs: 5.2 to 71.2% in anxiety, 1.00 to 88.3% in stress, 8.27 to 61.67% in insomnia, and 4.5 to 50.4% in depression. CONCLUSIONS: The early evidence suggests that healthcare workers are one of the most vulnerable groups when it comes to positive COVID-19 infection, mortality, and mental illness.

Designing a model for patient relationship management in the general hospitals using the combination of analytic hierarchy process and interpretive structural modeling.

BACKGROUND: Patient relationship management (PRM), in addition to saving costs, increases patient loyalty and creates a satisfactory environment for the patient and the service provider. This study aimed to design a model of PRM in general hospitals using the combination of the analytic hierarchy process and interpretive structural modeling (ISM). METHODS: This was an applied and cross-sectional study conducted in 2020 at three stages. At the first stage, using a systematic review, factors affecting PRM were identified. In the second stage, these factors were prioritized based on the pair-wise comparisons. In the third stage, the interaction levels of the factors were modeled for the general hospitals using ISM through the use of the MICMAC technique and Excel 2007 software. RESULTS: The results showed that "integrated information system," "registration of the patient's essential information," and "right data at the correct time" were the first to third priority in implementing PRM in the general hospitals. In the final model of ISM, three levels of effective factors were extracted, and 10, 4, and 6 factors were identified in the first, second, and third levels, respectively. CONCLUSION: Establishing the PRM strategy in the hospital, in addition to executive and managerial requirements, depends on the existence of an electronic customer relationship management system, and the choice of new technology, as well as the integration of information systems and technology culture, should be given special attention by managers.

Knowledge mapping of hospital accreditation research: a coword analysis.

PURPOSE: Hospital accreditation has been adopted internationally as a way and solution for healthcare quality improvement in hospitals. The purpose of this study was to review and knowledge mapping of bibliographic data about "Hospital Accreditation" and assess the current quantitative trends. DESIGN/METHODOLOGY/APPROACH: Scientometric methods and knowledge visualization using the coword analysis techniques conducted in three steps based on the data related to the field of hospital accreditation from 1975 to 2018 obtained from the MEDLINE database. Bibliographic data for titles, abstracts and keywords articles were saved in CSV format and MEDLINE templates by applying filters. Data extracted were exported into an Excel spreadsheet and were preprocessed. The authors applied the text mining and visualization using VOSviewer software. FINDINGS: Hospital accreditation studies have been increased rapidly over the past 30 years. 6,661 documents in the field of hospital accreditation had been published from 1975 to 2018. Hospitals or organizations active in the field of hospital accreditation were in the United States, Italy and Canada. The 10 most productive authors identified in the area of hospital accreditation with a higher influence were identified. "The United States", "accreditation", "Joint commission on accreditation" and "quality assurance, healthcare" had, respectively, the highest frequency. The cluster analysis identified and categorized them into four major clusters. Hospital accreditation field had a close relationship with the quality improvement, patient safety, risk and standards. ORIGINALITY/VALUE: Hospital accreditation had focused on the scopes of implementation of accreditation programs, adherence to JCI standards, and focus on safety and quality improvement. Future studies are recommended to be conducted on design interventions and paying attention to all dimensions of hospital accreditation.

Identifying factors affecting hoteling quality in Iranian public hospitals using DEMATEL approach.

INTRODUCTION: The most important goal of a proper health-care system is to provide good health. Today, patients do not consider hospitals as simply a place of rehabilitation; rather, they compare the hospital with a hotel in terms of environment, facilities, services, and quality of accommodation. This study aims to use DEMATEL approach to extract factors affecting the hoteling quality. METHODS: This was a descriptive, cross-sectional study conducted in 2018. The study was carried out in two steps. In the first step, the factors affecting the hoteling quality were extracted, and in the second step, the DEMATEL technique was used to analyze and rank the cause and effect. The study population consists of all experts in the fields of medicine and health care (hospital managers, deputies, and faculty members familiar with accreditation and hoteling), among which twenty experts were selected using purposeful sampling and a questionnaire designed by the researcher consisting of 11 dimensions was distributed among them. The reliability of the questionnaire was calculated using Cronbach's alpha coefficient which was equal to 0.85 while its validity was confirmed using Delphi technique. DEMATEL approach was used for data analysis. RESULTS: The results show that among factors, human factors and economical-financial factors and, among subfactors, maintaining human dignity and quick action in providing emergency services are among the most important factors affecting the hoteling quality. Maintaining human dignity and speed of action in providing emergency services to patients was identified as the most important factor in improving hoteling quality. CONCLUSION: The results of this study can be used to evaluate the quality of accommodations and health facilities, medical equipment, and building quality of hospitals, which can lead to effective actions and improvement of patient satisfaction and the eventual success of health transformation plan.

Patients' and physicians' perspectives and experiences on the quality of medical consultations: a qualitative study.

AIM: Medical consultation is not only one of the most important steps in disease diagnosis and patient treatment, but also every patient's right. The purpose of this review was to explore patients' and physicians' perspectives and experiences of the quality of medical consultations. METHODS: A qualitative interview study was carried out in outpatient clinics. A combination of face-to-face and telephone interviews was used due to the geographical spread of the respondents. Interviews were recorded and transcribed verbatim. Thematic descriptive analysis was used to interpret the data. Eligible physicians (n = 21) and patients (n = 27) were invited to take part in a semistructured interview to explore the views, perceptions, and experiences of patients on various factors affecting the quality of medical consultations. RESULTS: The consultation quality was categorized into three topics: structure quality, process quality, and outcome quality. Data synthesis identified the following major themes for structure quality of consultations: administrative-organizational quality (with eight subthemes), physical environment quality (with six subthemes), and educational quality (with three subthemes). In addition, process quality was categorized into two major themes: examination quality (with nine subthemes) and interpersonal quality (with 13 subthemes). Outcome quality consisted of three major themes: patient satisfaction (with four subthemes), clinical outcomes (with two subthemes), and organizational outcomes (with three subthemes). CONCLUSION: Medical consultation plays a central role in the quality and effectiveness of the received health care. Using the indicators of consultation quality improvement can develop physicians' clinical competence and skills. Furthermore, decision-makers can use them to monitor and evaluate physicians' performance.

A foresight study of factors affecting the health system research and technology.

CONTEXT: The success of the health system research and technology management in the 21st century can play an important role in advancing the country toward becoming a scientific power. AIMS: The study aimed to increase knowledge and identify factors affecting the health system research and technology, as well as to provide solutions for improving the status of health science and technology. MATERIALS AND METHODS: This was an applied and descriptive study conducted in 2018 using cross-impact analysis. The factors affecting the Iranian Health System Research and Technology Management and their influences on each other were identified using an expert panel. The key-driven factors were determined using the MICMAC software. RESULTS: The input, stake, target, resultant, excluded, and regulating factors were identified. The degree of fill rate the matrix was 58.9%. Financial annex of the health scientific map (S = 206), roadmap (S = 206), governmental laws and regulations (S = 198), and sufficient governmental budget allocation (S = 194) earned the highest potential influence scores by 2025. Furthermore, scientific authority (S = 216), international communication (187), university relationship with industries (S = 187), and competitive infrastructure (S = 178) obtained the highest potential dependence scores by 2025. CONCLUSIONS: The success of the Iranian Health System Research and Technology Management by 2025 requires the development of the financial annex of the comprehensive scientific health map, the development of the road map, and the allocation of sufficient governmental budget for health research. Policy-making in health system research and technology management requires more attention to these factors and the dynamics of relationships among factors in the model.

Challenges of Iranian national health scientific map.

CONTEXT: Iranian National Health Scientific Map is a national plan the implementation of which remarkably influences the progress of the country, though it is facing challenges in its implementation phase. AIMS: The present study has been conducted with the main aim of identifying the challenges facing the comprehensive scientific health map of Iran. SETTING AND DESIGN: This is an applied and qualitative study. SUBJECTS AND METHODS: The study was done in 2017 with the content analysis approach among experts of research and technology management. Some 18 people were selected and were deeply interviewed, meanwhile observing the credibility of research. STATISTICAL ANALYSIS USED: Data analysis was performed based on content analysis and using ATLAS.ti software. RESULTS: Data analysis resulted in the identification of 427 codes, 84 subthemes, and 12 themes. Twelve themes were specified including policy-making, management, university autonomy, quantitative development, consideration of science production chain, designing and monitoring of science map, finance, qualitative assessment, human resources, research ethics, as well as allocating attention to the infrastructure and communication. CONCLUSION: The scientific map of health challenges are indicative of the need for modification of the scientific map and adhering to solutions in line with the removal of the identified challenges. Today, paying attention to the solutions capable of meeting such challenges is a must.

Innovation capability in medical sciences universities: A qualitative study of Iran.

BACKGROUND: Innovation is a competitive advantage, with its preservation and continuity dependent on the organizational innovation capability. This study was conducted with the aim of determining the innovation capability dimensions and components in medical sciences universities of Iran. METHODS: The present study is a qualitative study with content analysis approach, undertaken in 2016-2017. The data processing included 10 deep interviews with the experts of the health innovation domain in top management of the three types of the medicine sciences universities of Iran with >5 years of experience. Targeted data sampling was performed using snowball method and continued until the saturation of the data. Data analysis was performed using conventional content analysis method using Maxqda 12 software. RESULTS: Data analysis resulted in the extraction of 28 categories and 8 main themes including communications and interactions, innovation climate, university setting, policy factors (policy-making, rules and regulations), organizational culture, organizational resources, management and leadership, and organizational learning in two university internal and external dimensions. CONCLUSION: To accelerate innovation in medical sciences universities, recognizing the potential of innovation capability is essential.

Effective factors in implementation and development of health promoting hospitals: a systematic review.

One of the requirements for the implementation of Health Promoting Hospitals (HPHs) is comprehensive integration of health promotion (HP) activities and programs in hospital quality management system. Therefore, this systematic review was conducted utilizing a comprehensive European Foundation for Quality Managment (EFQM) model to determine appropriate criteria for the implementation and development of HPH. This systematic review considered the published literature on factors affecting the implementation and development of HPH during 1997-2016. Twenty-three articles were finalized for further investigation. EFQM was used as guidance for the investigation and analysis of studies conducted in relation to HPH. Regarding our results, real need analysis and accurate assessment of needs, attention to infrastructure factors, HPH standardization, promotion of self-care, knowledge enhancement and patient and staff skills training, improvement of quality indicators, continuous participation of HPH committee, designing HP interventions, paying attention to clinical outcome, equity in health, promoting a healthy work environment, continuity and cooperation etc. are among the factors contributing to HPH implementation and development. In case of having high capacity for successful HPH implementation, comprehensive HPH capacity building and resource development are not possible unless they are performed based on one of the framework emphasized by World Health Organization (WHO) such as EFQM.

Higher Income for Male Physicians: Findings About Salary Differences Between Male and Female Iranian Physicians

Background: In recent decades, the role of women in the organizations of developed and less developed countries has increased, but little is known about gender gap in salaries of Iranian physicians. Aims: To analyze the gender gap in the salary of physicians working in public health sector of Iran and its predicting factors in 2016. Study Design: Cross sectional study. Methods: Thirty thousand eight hundred and twenty four records about characteristics of study population were extracted from national human resources for health database. Nearest neighborhood matching technique was used to find adjusted differences of salary between male and female physicians. In addition, by using Oaxaca decomposition method, the reasons for the differences were found. Results: The results showed that there was a difference of 117 dollars in monthly salaries of male and female physicians in favor of men. Differences in male and female salaries could be predicted by place of work and residency, type of specialty, type of employment and marital status. Conclusion: Gender gap in physicians' salaries exists in public health sector of Iran. The payment methods of salaries for men and women should be revised in order to remove the inequalities.

Neutrophil-Lymphocyte Ratio in Different Stages of Breast Cancer.

Despite many advances in the treatment of breast cancer, it is still the second most common cause of death in women in the United States. It has been shown that inflammation plays a major role in the treatment of these cancers and inflammatory factors enhance tumor growth, invasion, metastasis, and vascularization. In this study, we would like to analyze peripheral blood neutrophil-lymphocyte ratio (NLR) in breast cancer patients and its correlation with disease staging. This cross-sectional analytic study was conducted in Imam Hospital, affiliated with Tehran University of Medical Sciences; a total of 195 female patients with breast cancer met the inclusion criteria. All of the patients had a complete blood count with leukocyte differential performed before chemotherapy. Medical records including pathology reports were also available. Data for all patients were collected prior to any surgical intervention. Exclusion criteria included clinical evidence of active infection, presence of hematological disorders, acute as well as chronic inflammatory or autoimmune diseases, or prior steroid therapy. Higher platelet count was significantly associated with the higher stage. The stage was not associated with the hemoglobin level. There was no association between the tumor size and age of patients with NLR. There was a significant relationship between NLR and IDC. There was a significant relationship between IDC and NLRs of less than 8.1 and greater than 3.3. There was a significant relationship between NLR and vascular invasion. There was no association between NLR and estrogen receptor and HER2. There was no significant relationship between the PLR and the cancer stage. In this study, NLR showed a significant relation with the disease staging. As the NLR increases the stage increases as well. Therefore, this ratio may be helpful in the preoperative evaluation of patients with breast cancer.

The impact of the customer relationship management on organizational productivity, customer trust and satisfaction by using the structural equation model: A study in the Iranian hospitals.

CONTEXT: One of the challenges in the fiercely competitive space of health organizations is responding to customers and building trust and satisfaction in them in the shortest time, with best quality and highest productivity. Hence the aim of this study is to survey the impact of customer relationship management (CRM) on organizational productivity, customer loyalty, satisfaction and trust in selected hospitals of Isfahan (in Iran). MATERIALS AND METHODS: This study is a correlation descriptive research. Study population was the nurses in selected hospitals of Isfahan and the sampling has been conducted using stratified random method. Data collection tool is a researcher-made questionnaire of CRM and its effects (organizational productivity, customer loyalty, satisfaction and trust) which its validity and reliability has been confirmed by researchers. Structural equation method was used to determine the impact of variables. Data analysis method was structural equation modeling and the software used was SPSS version 16 (IBM, SPSS, 2007 Microsoft Corp., Bristol, UK) and AMOS version 18 (IBM, SPSS, 2010 Microsoft Corp, Bristol, UK). RESULTS: Among the dimensions of CRM, diversification had the highest impact (0.83) and customer acquisition had the lowest (0.57) CRM, had the lowest impact on productivity (0.59) and the highest effect on customer satisfaction (0.83). CONCLUSIONS: For the implementation of CRM, it is necessary that the studied hospitals improve strategies of acquiring information about new customers, attracting new customers and keeping them and communication with patients outside the hospital and improve the system of measuring patient satisfaction and loyalty.