The challenges of implementation of clinical governance in Iran: a meta-synthesis of qualitative studies.

BACKGROUND: Policy- and decision-makers seek to improve the quality of care in the health sector and therefore aim to improve quality through appropriate policies. Higher quality of care will satisfy service providers and the public, reduce costs, increase productivity, and lead to better organisational performance. Clinical governance is a method through which management can be improved and made more accountable, and leads to the provision of better quality of care. In November 2009, the Iranian Ministry of Health and Medical Education implemented new clinical guidelines to standardise and improve clinical services as well as to increase efficiency and reduce costs. The purpose of this study was to assess the challenges of implementing clinical governance through a meta-synthesis of qualitative studies published in Iran. METHODS: Ten databases, including ISI/Web of Sciences, PubMed/MEDLINE, Embase, PsycINFO, the Cochrane Library, CINAHL, Scopus, Barakatns, MagIran and the Scientific Information Database, were searched between January 2009 and May 2018. The quality of the included studies was assessed using the Critical Appraisal Skills Programme tool. This study was reported according to the Enhancing Transparency in Reporting the Synthesis of Qualitative Research guidelines. Thematic synthesis was used to analyse the data. RESULTS: Ten studies were selected and included based on the inclusion/exclusion criteria. In the first stage, 75 items emerged and were coded, and, following comparison and combination of the codes, 32 codes and 8 themes were finally extracted. These themes included health system structure, management, person-power, cultural factors, information and data, resources, education and evaluation. CONCLUSION: The findings of the study showed that there exist a variety of challenges for the implementation of clinical governance in Iran. To successfully implement a health policy, its infrastructure needs to be created. Using the views and support of stakeholders can ensure that a policy is well implemented. TRIAL REGISTRATION: CRD42017079077 . Dated October 10, 2017.

Quality improvement in hospitals' surgery-related processes: A systematic review.

Background: There is a growing global movement toward quality and safety in healthcare and quality improvement (QI) in general surgery. The fundamentals of QI begin with an understanding of the underlying theoretical framework. This study aims to provide an overview of the existing QI models and frameworks for general surgery. Methods: In this systematic review, published literature from January 2007 until September 2018 were retrieved from PubMed, Scopus, Web of Science and Embase databases, and Google Scholar using the MeSH terms related to QI and surgery. In total, 25 fulltext articles were finally included, and data extraction was based on research objectives. Results: Nine models were identified for QI in general surgery. These models were categorized into two main groups: (i) conceptual models or frameworks designed for QI in industry and applied in surgery, and (ii) those designed specifically for QI in surgery. Identified QI models were more used for improving postoperative processes and pre-hospital trauma care, identifying causes of prolonged periods of stay and lowering LOS index, improving surgical antimicrobial prophylaxis and antibiotics administrating during surgery process, reducing and controlling infections, reducing complications, reducing mortality and morbidity, reducing waiting times and start time delays, reducing variability and improving surgical clinic experience, reducing costs, improving operating room efficiency by removing processes that add no value, and lowering per-capita costs. Conclusion: According to the findings of this study, there are different models and frameworks with different aspects and dimensions for QI in surgery, which is recommended to use either of these models alone or with each other for specific circumstances. The use of these models in surgery is increasing, and it is recommended that these models could be used according to their functions in cases such as reducing the unnecessary use of resources, increasing the satisfaction of patients and their families with health care and improving the efficiency, safety and quality of healthcare in the surgical departments.

Effectiveness of training and educational programs for hospital managers: A systematic review.

BACKGROUND: Developing and strengthening the competencies and skills of health care managers is a key objective in many health systems. Selecting adequate training methods, content, and using appropriate criteria for assessing their impact is fundamental for improving their usefulness and effectiveness. Filling an important gap in knowledge, this review assesses the evidence on the effectiveness of different types of training and educational programmes delivered to hospital managers. METHODS: In this narrative systematic review, the following electronic databases were searched for literature published between January 1st, 1990 and January 31st, 2019. The Joanna Briggs Institute (JBI) checklist was used to evaluate the quality of the included studies. RESULTS: In total, 9 articles were included. Results showed that the main topics covered by training programs for hospital managers were: planning, organization and coordination, control and supervision of hospital staff, teamwork, communication, motivation and leadership, monitoring and evaluation, and quality improvement skills. Training in these skills was found to improve managers' strategic and operational planning abilities, change management and behavioural management methods, and leadership. CONCLUSIONS: The examined training programs had a relatively positive effect on the managerial skills, knowledge and competencies of hospital managers. In general, these capacity-building programs focused on developing three types of skills: technical, interpersonal and conceptual. Training programs focused on developing technical skills among managers were more effective than those focused on developing other types of skills. Increased investment and large-scale planning are needed to develop better the knowledge and competencies of hospital managers.

Quality improvement in the surgery-related processes: Managerial challenges and solutions from hospitals of Iran.

BACKGROUND: There is a growing global movement toward quality and safety in healthcare and quality improvement (QI) in general surgery. The first step in any QI initiative is identifying the challenges and barriers to achieve such goals and then to define appropriate actions. This study aims to provide an overview of the QI challenges in Iranian hospitals' surgery-related processes and suggest applied solutions accordingly. METHODS: This is a sequential (qual-quant) mixed-method study from November 2019 to January 2020, involving 21 face-to-face interviews with hospital managers, quality officers, and surgery-related clinicians and staff, followed by a Delphi consensus-seeking stage to finalize solutions. MAXQDA software was applied for organizing the concepts, and thematic content analysis was used for analyzing the data as an inductive approach to extract the emerging themes and sub-themes. RESULTS: The managerial problems were classified into four groups of (I) defects and delays in completing patient medical records, (II) irregularity and the lack of transparency in the direction of processes in the hospital, (III) inappropriate and unrealistic operating scheduling, and (IV) poor safety considerations. The proposed solutions included imposing stricter regulations for competing for medical records, such as reduction of payments, development of guiding brochures or protocols for patients on their arrival, assigning a certain number of experienced nurses and surgeons for schedule management, rewarding the report of medical and surgical error cases, and developing a regular monitoring program for the proper implementation of surgical safety guidelines. CONCLUSION: There are various managerial barriers that hamper QI in hospitals' surgery-related processes. Implementing simple but agreed solutions can lead to saving patients' lives, reduction of the unnecessary use of resources, and enhance of patient and staff satisfaction.

A Description of the Temporal Pattern of Out-of-Pocket Expenditure Related to Iranian Healthcare Services during 1995-2014.

BACKGROUND: Out-of-pocket (OOP) expenditure directly impacts on poverty and household welfare, especially when there is a decline in healthcare financing. This study was aimed to describe the temporal pattern of OOP expenditures related to Iranian healthcare services during 1995-2014. METHODS: For describing the trend of OOP spending in Iran, the database of the World Bank was mined for the period under study. Further, the trend analysis has been complemented by an exhaustive and comprehensive review of the extant literature. RESULTS: From 1995 to 2014, out-of-pocket decreased from 53.59% to 47.8% of the total health expenditure, probably because of the different health reforms implemented throughout the years. However, out-of-pocket expenditure in Iran remains higher than the world average (roughly 3 times higher). CONCLUSION: It is an onus of the Iranian government to make serious attempts in order to reduce out-of-pocket expenditure, as well as to protect particularly poor and vulnerable subjects against catastrophic health expenditure. In order to ensure an equitable and affordable access to the healthcare system, decision- and policy-makers in Iran should implement a review of health care costs, insurance tariffs, and healthcare services packages covered by insurance organizations as well as introduce a progressive tax-based financing scheme as soon as possible.