A closer look at the international health regulations capacities in Lebanon: a mixed method study.

BACKGROUND: Lebanon ratified the International Health Regulations (IHR) (2005) in 2007, and since then, it has been facing complex political deadlocks, financial deterioration, and infectious disease emergencies. We aimed to understand the IHR capacities' scores of Lebanon in comparison to other countries, the IHR milestones and activities in Lebanon, the challenges of maintaining the IHR capacities, the refugee crisis's impact on the development of these capacities; and the possible recommendations to support the IHR performance in Lebanon. METHODS: We used a mixed-method design. The study combined the use of secondary data analysis of the 2020 State Party Self-Assessment Annual Report (SPAR) submissions and qualitative design using semi-structured interviews with key informants. Semi-structured interviews were conducted with nine key informants. The analysis of the data generated was based on inductive thematic analysis. RESULTS: According to SPAR, Lebanon had levels of 4 out of 5 (≤ 80%) in 2020 in the prevention, detection, response, enabling functions, and operational readiness capacities, pertaining that the country was functionally capable of dealing with various events at the national and subnational levels. Lebanon scored more than its neighboring countries, Syria, and Jordan, which have similar contexts of economic crises, emergencies, and refugee waves. Despite this high level of commitment to meeting IHR capacities, the qualitative findings demonstrated several gaps in IHR performance as resource shortage, governance, and political challenges. The study also showed contradictory results regarding the impact of refugees on IHR capacities. Some key informants agreed that the Syrian crisis had a positive impact, while others suggested the opposite. Whether refugees interfere with IHR development is still an area that needs further investigation. CONCLUSION: The study shows that urgent interventions are needed to strengthen the implementation of the IHR capacities in Lebanon. The study recommends 1) reconsidering the weight given to IHR capacities; 2) promoting governance to strengthen IHR compliance; 3) strengthening the multisectoral coordination mechanisms; 4) reinforcing risk communication strategies constantly; 5) mobilizing and advancing human resources at the central and sub-national levels; 6) ensuring sustainable financing; 7) integrating refugees and displaced persons in IHR framework and its assessment tools; 8) acknowledging risk mapping as a pre-requisite to a successful response; and 9) strengthening research on IHR capacities in Lebanon.

Baseline Assessment of Health Research Systems in Saudi Arabia: Harnessing Efforts and Mobilizing Actions.

Major transformations are taking place in the Kingdom of Saudi Arabia (KSA) to achieve the 2030 vision for the health sector. A key component in strengthening the health system is a strong research governance strategy that can support the decision-making process by providing timely and accurate evidence that reflects local context and needs. This paper sought to better understand governance structures and policies for health research systems and support clusters so that they function effectively. This paper outlines the findings of an in-depth baseline assessment of existing health research efforts, activities, and plans of eight research clusters in the KSA and identifies key gaps and strengths in health research governance and capabilities. A cross-sectional design was used to survey research clusters in KSA. A six-part survey was developed to better understand the research clusters' health research governance and capacities. The survey was sent to all KSA clusters and was completed in a group setting during meetings. Findings clearly show strong efforts to support research governance initiatives in health clusters in KSA. While some clusters are more advanced than others, there are plenty of opportunities to share knowledge and combine efforts to help achieve the goals set out for KSA health transformation. This baseline assessment also reflects the first attempt of its kind to understand the KSA experience and provide much-needed lessons on country-wide efforts to support the health system given the trickling effect of this sector on all others, enhancing and advancing national growth.

Staying ahead of the curve: avigating changes and maintaining gains in patient safety culture - a mixed-methods study.

OBJECTIVES: This study examines how the results of the Hospital Survey on Patient Safety Culture changed between 2012 and 2019 and identifies organisational factors affecting these changes. DESIGN: The study combined the use of quantitative surveys of staff and qualitative interviews with hospital leadership. Secondary data analysis was performed for previous surveys. SETTING: This study was conducted in a tertiary care teaching multisite hospital in Riyadh, Saudi Arabia. PARTICIPANTS: One thousand hospital staff participated in the survey. Thirty-one executive board members and directors and four focus groups of frontliners were qualitatively interviewed. PRIMARY AND SECONDARY OUTCOME MEASURES: Twelve safety culture dimensions were assessed to study the patient safety culture as perceived by the healthcare professionals. An additional semi-structured interview was conducted to identify organisational factors, changes, and barriers affecting the patient safety culture. Furthermore, suggestions to improve patient safety were proposed. RESULTS: Comparing the results revealed a general positive trend in scores from 2012 to 2019. The areas of strength included teamwork within and across units, organisational learning, managerial support, overall perception of safety and feedback and communication about error. Non-punitive response to error, staffing and communication and openness consistently remain the lowest-scoring composites. Interview results revealed that organisational changes may have influenced the answers of the participants on some survey composites. CONCLUSIONS: Patient safety is a moving target with areas for improvement that are continuously identified. Effective quality improvement initiatives can lead to visible changes in the patient safety culture in a hospital, and consistent leadership commitment and support can maintain these improvements.

The use of evidence in decision making by hospital managers in Lebanon: A cross-sectional study.

BACKGROUND: Knowledge synthesis products have emerged as support agents for decision making in clinical practice and policy. However, their use for evidence-informed decision making remains limited in health care management especially in low- and middle-income countries. This study assesses the use of evidence by middle and senior managers in Lebanese hospitals. METHODS: This multihospital cross-sectional study used a self-administered web survey of middle and senior managers. Hospitals were purposively selected, and data were analyzed using descriptive statistics and thematic analysis. RESULTS: Hospital participation rate was 25%, while adjusted managers' response rate was 44.8%. Prevalence of using evidence was 70%, while prevalence of evidence-seeking behavior was 90%. Evidence was mainly used in design of policies, protocols, and procedures; nursing issues; or procurement decisions. Facilitators for evidence-informed decision making included upper management support and organizational culture, whereas limited resources such as funding, time, and training hindered use of evidence. CONCLUSIONS: Findings indicate that utilization of evidence was comparable with that of high-income countries. Training and continuous education were crucial for advancing evidence-informed decision making among hospital managers. However, neither the quality nor the sources of evidence used for decision making were assessed in this study. Future studies should assess the quality and sources of evidence utilized in decision making.

Engagement of health research institutions in knowledge translation in the Eastern Mediterranean Region.

BACKGROUND: Health research institutions in the Eastern Mediterranean Region (EMR) can play an integral role in promoting and supporting Knowledge Translation (KT). Assessing institutions' engagement in KT and bridging the "research- policy" gap is important in designing context-specific strategies to promote KT and informing funding efforts in the region. AIMS: The objective of this study was to explore the engagement of EMR institutions in KT activities. METHODS: A cross-sectional survey of institutions undertaking health research in the 22 EMR countries was undertaken. The survey covered institutional characteristics, institutional planning for research, national planning for health research, and knowledge management, translation and dissemination. RESULTS: 575 institutions were contacted of which 223 (38.3%) responded. Half the sampled institutions reported conducting priority-setting exercises, with 60.2% not following a standardized approach. Less than half institutions reported frequently/ always (40.5%) involving policymakers and stakeholders in setting priorities for research on health. Only 26.5% of respondent institutions reported that they examine the extent to which health policymakers utilize their research results. Moreover, only 23.3% reported measuring the impact of their health research. CONCLUSIONS: There is still misalignment between national health research priorities and actual research production, and KT activities are still rarely undertaken by institutions in the EMR. National governments and international funding agencies are called to support research production and translation in the EMR. Institutions and researchers are also called to produce policy-relevant research and be responsive to the needs and priorities of policy-makers.

Contractual health services performance agreements for responsive health systems: from conception to implementation in the case of Qatar.

OBJECTIVE: Despite their use worldwide, strategy-based performance management is limited in the Eastern Mediterranean Region. This article explores Qatar's experience, the first from the Region, in implementing contractual agreements between healthcare providers and the regulator-Ministry of Public Health-to align strategy, performance and accountabilities. DESIGN: mixed-methods including tools development and pilot-testing, guided by performance management cycle with a focus on knowledge translation and key principles: feasibility; mandatory participation; participatory approach through Steering Committee. SETTING: All public, private and semi-governmental hospitals and primary healthcare centers. INTERVENTION(S): (i) semi-structured interviews; (ii) review of 4982 indicators; (iii) Delphi technique for selecting indicators with > 80% agreement on importance and > 60% agreement on feasibility; (iv) capacity-building of providers and Ministry staff and 2-month pilot assessed by questionnaire with indicators scoring > 3 considered valid, reliable and feasible; and (v) 1-year grace period assessed by questionnaire. MAIN OUTCOME MEASURE(S): Approach strengths and challenges; Data collection and healthcare quality improvements. RESULTS: Contracts mandate reporting 25 hospital and 15 primary healthcare indicators to the regulator, which delivers confidential benchmarking reports to providers. Scorecards were discussed with the regulator for evidence-informed policymaking. The approach uncovered system-related challenges and learning for public and private sectors: providers commended the participatory approach (82%) and indicated that contracts enabled collecting valid and timely data (64%) and improved healthcare quality (55%). CONCLUSION: This experience provides insights for countries implementing performance management, responsive regulation and public-private partnerships. It suggests that contractual agreements can be useful, despite their mandatory nature, if clear principles are applied early on.

Improving patient safety culture in Saudi Arabia (2012-2015): trending, improvement and benchmarking.

BACKGROUND: Measuring patient safety culture can provide insight into areas for improvement and help monitor changes over time. This study details the findings of a re-assessment of patient safety culture in a multi-site Medical City in Riyadh, Kingdom of Saudi Arabia (KSA). Results were compared to an earlier assessment conducted in 2012 and benchmarked with regional and international studies. Such assessments can provide hospital leadership with insight on how their hospital is performing on patient safety culture composites as a result of quality improvement plans. This paper also explored the association between patient safety culture predictors and patient safety grade, perception of patient safety, frequency of events reported and number of events reported. METHODS: We utilized a customized version of the patient safety culture survey developed by the Agency for Healthcare Research and Quality. The Medical City is a tertiary care teaching facility composed of two sites (total capacity of 904 beds). Data was analyzed using SPSS 24 at a significance level of 0.05. A t-Test was used to compare results from the 2012 survey to that conducted in 2015. Two adopted Generalized Estimating Equations in addition to two linear models were used to assess the association between composites and patient safety culture outcomes. Results were also benchmarked against similar initiatives in Lebanon, Palestine and USA. RESULTS: Areas of strength in 2015 included Teamwork within units, and Organizational Learning-Continuous Improvement; areas requiring improvement included Non-Punitive Response to Error, and Staffing. Comparing results to the 2012 survey revealed improvement on some areas but non-punitive response to error and Staffing remained the lowest scoring composites in 2015. Regression highlighted significant association between managerial support, organizational learning and feedback and improved survey outcomes. Comparison to international benchmarks revealed that the hospital is performing at or better than benchmark on several composites. CONCLUSION: The Medical City has made significant progress on several of the patient safety culture composites despite still having areas requiring additional improvement. Patient safety culture outcomes are evidently linked to better performance on specific composites. While results are comparable with regional and international benchmarks, findings confirm that regular assessment can allow hospitals to better understand and visualize changes in their performance and identify additional areas for improvement.

Pharmacists' views and reported practices in relation to a new generic drug substitution policy in Lebanon: a mixed methods study.

BACKGROUND: Governments in both developed and developing countries have adopted generic drug substitution policies to decrease pharmaceutical expenditures and improve access to medicine. In August 2015, the Ministry of Public Health (MOPH) in Lebanon introduced generic drug substitution and a unified medical prescription form as policy instruments to promote generic drug use. The objective of this exploratory study was to examine the attitudes of community pharmacists and the reported practices in relation to the implementation of the new generic drug substitution policy. METHODS: We used a cross-sectional mixed methods approach composed of self-administered questionnaires and semi-structured interviews. The study population consisted of community pharmacists in Lebanon. We randomly approached one pharmacy personnel from each selected community pharmacy. We conducted descriptive analyses to assess responses to questionnaire and regression analyses to understand associations between responses and respondent demographics. We analyzed qualitative data thematically. RESULTS: Out of 204 invited community pharmacies, 153 pharmacies participated (75% response rate). The majority of respondents (64%) were in favor of generic drug substitution; however, less than half (40%) indicated they have substituted brand drugs for generic equivalents. Moreover, 57% indicated that the existing pricing system discourages them from performing generic drug substitution. Most respondents indicated that physicians are overusing the "non-substitutable" option (84%) and that there are technical problems with processing the new prescription form (78%). Less than half (47%) reported that the MOPH is performing regular audits on the forms collected by the pharmacy. While 45% of the respondents indicated that consumers have accepted most of the generic substitutions, 21% perceived the increase in generic drug dispensing to be significant. Findings suggested a potentially significant association between being informed about generic drugs and respondents' support of the policy. Suggested strategies to address implementation challenges included strengthening stewardship function of MOPH, securing full commitment of health care providers, conducting educational and awareness campaigns about generic drugs and generic drug substitution, and aligning incentive systems of the key stakeholders. CONCLUSIONS: The majority of community pharmacists were supportive of generic drug substitution in general but not of the current implementation of the policy in Lebanon. Findings revealed implementation challenges at the provider, patient, and system level which are hindering attainment of the policy objectives. The key lessons derived from this study can be used for continuous improvement of the policy and its implementation.

Exploring the relationship between work environment, job satisfaction, and intent to stay of Jordanian nurses in underserved areas.

AIMS: The aims of this study are to (1) examine the relationships between work environment, job satisfaction and intention to stay at work; and (2) explore the predicting factors of intention to stay at work among nurses in underserved areas. BACKGROUND: Developing and fostering creative work environment are paramount especially in underserved areas, where the work conditions present many challenges. METHODS: A descriptive correlational design was utilized to collect data from 330 hospital nurses who worked in two underserved governorates in Jordan. A set of instruments were used to measure the variables of the study. RESULTS: The results showed a strong positive association between job satisfaction and work environment. The results of logistic regression indicated receiving housing, job satisfaction, and work environment were the predicting variables of the level of intention to stay at work. CONCLUSION: It is critical to improve work conditions and create a culture of supportive work environment in underserved area.

Constraints to applying systems thinking concepts in health systems: A regional perspective from surveying stakeholders in Eastern Mediterranean countries.

BACKGROUND: Systems Thinking (ST) has recently been promoted as an important approach to health systems strengthening. However, ST is not common practice, particularly in Low- and Middle-Income Countries (LMICs). This paper seeks to explore the barriers that may hinder its application in the Eastern Mediterranean Region (EMR) and possible strategies to mitigate them. METHODS: A survey consisting of open-ended questions was conducted with a purposive sample of health policy-makers such as senior officials from the Ministry of Health (MoH), researchers, and other stakeholders such as civil society groups and professional associations from ten countries in the region. A total of 62 respondents participated in the study. Thematic analysis was conducted. RESULTS: There was strong recognition of the relevance and usefulness of ST to health systems policy-making and research, although misconceptions about what ST means were also identified. Experience with applying ST was very limited. Approaches to designing health policies in the EMR were perceived as reactive and fragmented (66%). Commonly perceived constraints to application of ST were: a perceived notion of its costliness combined with lack of the necessary funding to operationalize it (53%), competing political interests and lack of government accountability (50%), lack of awareness about relevance and value (47%), limited capacity to apply it (45%), and difficulty in coordinating and managing stakeholders (39%). CONCLUSION: While several strategies have been proposed to mitigate most of these constraints, they emphasized the importance of political endorsement and adoption of ST at the leadership level, together with building the necessary capacity to apply it and apply the learning in research and practice.

Patient safety culture in a large teaching hospital in Riyadh: baseline assessment, comparative analysis and opportunities for improvement.

BACKGROUND: In light of the immense attention given to patient safety, this paper details the findings of a baseline assessment of the patient safety culture in a large hospital in Riyadh and compares results with regional and international studies that utilized the Hospital Survey on Patient Safety Culture. This study also aims to explore the association between patient safety culture predictors and outcomes, considering respondent characteristics and facility size. METHODS: This cross sectional study adopted a customized version of the HSOPSC and targeted hospital staff fitting sampling criteria (physicians, nurses, clinical and non-clinical staff, pharmacy and laboratory staff, dietary and radiology staff, supervisors, and hospital managers). RESULTS: 3000 questionnaires were sent and 2572 were returned (response rate of 85.7%). Areas of strength were Organizational Learning and Continuous Improvement and Teamwork within units whereas areas requiring improvement were hospital non-punitive response to error, staffing, and Communication Openness. The comparative analysis noted several areas requiring improvement when results on survey composites were compared with results from Lebanon, and the United States. Regression analysis showed associations between higher patient safety aggregate score and greater age (46 years and above), longer work experience, having a Baccalaureate degree, and being a physician or other health professional. CONCLUSIONS: Patient safety practices are crucial toward improving overall performance and quality of services in healthcare organizations. Much can be done in the sampled organizations and in the context of KSA in general to improve areas of weakness and further enhance areas of strength.

The impact of accreditation of primary healthcare centers: successes, challenges and policy implications as perceived by healthcare providers and directors in Lebanon.

BACKGROUND: In 2009, the Lebanese Ministry of Public Health (MOPH) launched the Primary Healthcare (PHC) accreditation program to improve quality across the continuum of care. The MOPH, with the support of Accreditation Canada, conducted the accreditation survey in 25 PHC centers in 2012. This paper aims to gain a better understanding of the impact of accreditation on quality of care as perceived by PHC staff members and directors; how accreditation affected staff and patient satisfaction; key enablers, challenges and strategies to improve implementation of accreditation in PHC. METHODS: The study was conducted in 25 PHC centers using a cross-sectional mixed methods approach; all staff members were surveyed using a self-administered questionnaire whereas semi-structured interviews were conducted with directors. RESULTS: The scales measuring Management and Leadership had the highest mean score followed by Accreditation Impact, Human Resource Utilization, and Customer Satisfaction. Regression analysis showed that Strategic Quality Planning, Customer Satisfaction and Staff Involvement were associated with a perception of higher Quality Results. Directors emphasized the benefits of accreditation with regards to documentation, reinforcement of quality standards, strengthened relationships between PHC centers and multiple stakeholders and improved staff and patient satisfaction. Challenges encountered included limited financial resources, poor infrastructure, and staff shortages. CONCLUSIONS: To better respond to population health needs, accreditation is an important first step towards improving the quality of PHC delivery arrangement system. While there is a need to expand the implementation of accreditation to cover all PHC centers in Lebanon, considerations should be given to strengthening their financial arrangements as well.

A national study on nurses' retention in healthcare facilities in underserved areas in Lebanon.

BACKGROUND: Nursing shortages and maldistribution are priority issues for healthcare systems around the globe. Such imbalances are often aggravated in underserved areas, especially in developing countries. Despite the centrality of this issue, there is a dearth of studies that examine the retention of nurses in underserved areas in the Middle East Region. This study investigates the characteristic and the factors associated with the retention of nurses working in rural areas in Lebanon. METHODS: This study uses a non-experimental cross-sectional design to survey nurses working in underserved areas of Lebanon. Underserved areas in Lebanon were identified using WHO definition. A total of 103 health facilities (hospitals and primary healthcare centers) located in these areas were identified and all nurses working at these facilities received a copy of the survey questionnaire. The questionnaire included five sections: demographic, work-life, career plan, job satisfaction, and assessment of work environment. Analysis included univariate and bivariate (chi-square, Student's t-test and ANOVA) tests to describe the respondents and examine the significance between nurses' characteristics and their intent to stay. A logistic regression model was constructed to identify factors associated with nurses' intent to stay in underserved areas. RESULTS: A total of 857 nurses from 63 Primary Healthcare (PHC) centers and hospitals responded to the questionnaire (75.5% response rate). Only 35.1% of nurses indicated their intent to stay in their current job over the coming one to three years. Surveyed nurses were most satisfied with relationship with co-workers and least satisfied with extrinsic rewards. Rural nurses working in PHC centers were more satisfied than their hospital counterparts on all aspects of work and had significantly higher intention to stay (62.5% compared to 31.5% in hospitals, P < 0.001). Regression analysis revealed that nurses less likely to report intent to stay were younger, unmarried, with less years of work experience and were not working towards a higher degree. Analysis reveals a directly proportional relationship between nurses' reported job satisfaction and their intent to stay. CONCLUSION: This study reveals poor retention of nurses in rural and underserved areas in Lebanon, especially in the hospital sector. The status quo is disquieting as it reflects an unstable and dissatisfied nursing workforce. Developing targeted retention strategies for younger nurses and those working in hospitals as well as the offering of professional development opportunities and devising an incentive scheme targeting rural nurses is pivotal to enhance nurses' job satisfaction and retention in rural settings.

Intention to stay of nurses in current posts in difficult-to-staff areas of Yemen, Jordan, Lebanon and Qatar: a cross-sectional study.

BACKGROUND: The nursing workforce shortages in difficult-to-staff areas have implications not only for quality of care but also for population health outcomes. An understanding of attrition and of retention is important to inform policies on the nursing workforce. OBJECTIVES: This paper draws on questionnaire survey data from nurses working in difficult-to-staff areas in four countries in the Eastern Mediterranean Region (Yemen, Jordan, Lebanon and Qatar). It aims to identify the specific and common factors associated with nurses' intention to stay in their current post for the coming 1-3 years in three countries with an internally trained nursing workforce and in a fourth where the workforce is externally recruited. METHODS: Nurses working in 'difficult to staff' areas in Yemen, Jordan, Lebanon and Qatar were surveyed. A conceptual model composed of 6 dimensions based on that of the World Health Organization was constructed with 'intent to stay' (Career Decisions) as the main outcome. Regression models were constructed for each of the dimensions in the conceptual model with 'intent to stay' as the dependent variable for each of the study countries. Subsequently, a collective model that combined Lebanon, Jordan and Yemen was constructed to identify common factors that are associated with intent to stay. RESULTS: Factors associated with intent to stay differed for study countries. Marriage was positively associated with intent to stay in Lebanon and Jordan whereas years of experience were positively significant for Lebanon and Yemen. Shorter commuting time was significantly associated with intent to stay in Jordan whereas a preference for village life was significant for Lebanon. Job satisfaction was significantly associated with intent to stay in all study countries. Nurses in Lebanon, Jordan and Qatar who indicated that they would choose nursing if they had the opportunity to choose a career all over again were significantly more likely to intend to stay in their current post. CONCLUSIONS: Studies of nurses working in these areas can help national policymakers and local nursing directors better manage the sparse nursing workforce in these localities and to provide them with appropriate incentives and support to encourage them to stay.

Improving primary healthcare through accreditation: baseline assessment of readiness and challenges in Lebanese context.

The quality of primary healthcare (PHC) has become of high importance. In 2009, the Lebanese Ministry of Public Health launched the PHC accreditation program to expand and improve quality across the continuum of care. This study will explore the readiness of PHC centers in Lebanon to implement the newly developed accreditation standards including challenges and required actions/strategies. Seventy-two centers were sampled, and respondents were asked to complete a 65-item questionnaire adapted from the national PHC accreditation standards and two open-ended questions. Descriptive analysis was conducted to assess responses to each item. Thematic analysis was used to analyze open-ended questions. Scale scores were considerably low, particularly for areas that relate to quality of service delivery. Most respondents (59.8%) indicated not having a strategic plan on the basis of community needs. Close to 70% of respondents indicated that they do not monitor and investigate trends in rates of sentinel events, near misses, and adverse events. Moreover, 76.2% indicated not having a system for incident and accident-reporting, and only 22.3% reported using one. The PHC accreditation in Lebanon can potentially reform this essential health system component. Results provide insights for policymakers and managers to consider in their efforts to improve quality and performance of PHC centers in Lebanon.

The challenges of working in underserved areas: a qualitative exploratory study of views of policy makers and professionals.

BACKGROUND: The inadequate number of health care providers, particularly nurses, in underserved areas is one of the biggest challenges for health policymakers. There is a scarcity of research in Jordan about factors that affect nurse staffing and retention in underserved areas. PURPOSE: To elucidate the views of staff nurses working in underserved areas, directors of health facilities in underserved areas and key informants from the policy and education arena on issues of staffing and retention of nurses in underserved areas. METHODS: An exploratory study using a qualitative approach with semi-structured interviews was utilized to elucidate the views of 22 key informants from the policy and education arena, 11 directors of health centers, and 19 staff nurses on issues that contribute to low staffing and retention of nurses in underserved areas. The five stage 'framework approach' proposed by Bryman et al. (1993) was utilized for data analysis. RESULTS: Nursing shortage in underserved areas in Jordan are exacerbated by a lack of financial incentives, poor transportation and remoteness of these areas, bad working conditions, and lack of health education institutions in these areas, as well as by opportunities for internal and external migration. Young Jordanian male nurses usually grab any opportunity to migrate and work outside the country to improve their financial conditions; whereas, female nurses are more restricted and not encouraged to travel abroad to work. Several strategies are suggested to enhance retention in these areas, such as promoting financial incentives for staff to work there, enhancing the transportation system, and promoting continuous and academic education. CONCLUSION: Nurses' administrators and health care policy makers could utilize the findings of the present study to design and implement comprehensive interventions to enhance retention of staff in underserved areas.

Integrating patient safety standards into the accreditation program: a qualitative study to assess the readiness of Lebanese hospitals to implement into routine practice.

INTRODUCTION: Concerns about quality of care have led to the integration of patient safety standards and goals in national and international accreditation programs. Since 2005, two national hospital accreditation surveys have been conducted in Lebanon. In 2010, the Ministry of Health integrated patient safety standards into the current program. This study is one of the first efforts in Lebanon and the region to assess hospitals' readiness to integrate patient safety standards into routine practice. METHODS: This cross-sectional study sampled 6807 respondents from 68 hospitals in Lebanon. This paper will detail results from the qualitative thematic analysis of the responses on 5 open-ended questions added to the Hospital Survey on Patient Safety Culture. The emerging themes were compared across regions, accreditation status, and hospital size. RESULTS: Lebanese hospitals have made progress by recognizing patient safety as a major strategic goal and priority, but gaps still exist in implementation. Very few hospitals are ready for effective implementation of these standards. Staff education and training are needed. Public awareness about patient safety and integrating these concepts into health educational curricula were cited as important strategies among others for creating a culture of patient safety. Variations in responses across regions, accreditation status, and hospital size were discussed. DISCUSSION AND CONCLUSIONS: Integrating patient safety initiatives into routine practices requires a cultural shift in health-care organizations. Before assessing whether hospitals comply with patient safety standards, it is important to provide them with sufficient training and education on how to successfully implement these standards. Study findings provide valuable lessons for Lebanon and other countries, which are in the process or currently mandating the implementation of patient safety standards and/or accreditation programs.

Use of health systems evidence by policymakers in eastern Mediterranean countries: views, practices, and contextual influences.

BACKGROUND: Health systems evidence can enhance policymaking and strengthen national health systems. In the Middle East, limited research exists on the use of evidence in the policymaking process. This multi-country study explored policymakers' views and practices regarding the use of health systems evidence in health policymaking in 10 eastern Mediterranean countries, including factors that influence health policymaking and barriers and facilitators to the use of evidence. METHODS: This study utilized a survey adapted and customized from a similar tool developed in Canada. Health policymakers from 10 countries (Algeria, Bahrain, Jordan, Lebanon Oman, Pakistan, Palestine, Sudan, Tunisia, and Yemen) were surveyed. Descriptive and bi-variate analyses were performed for quantitative questions and thematic analysis was done for qualitative questions. RESULTS: A total of 237 policymakers completed the survey (56.3% response rate). Governing parties, limited funding for the health sector and donor organizations exerted a strong influence on policymaking processes. Most (88.5%) policymakers reported requesting evidence and 43.1% reported collaborating with researchers. Overall, 40.1% reported that research evidence is not delivered at the right time. Lack of an explicit budget for evidence-informed health policymaking (55.3%), lack of an administrative structure for supporting evidence-informed health policymaking processes (52.6%), and limited value given to research (35.9%) all limited the use of research evidence. Barriers to the use of evidence included lack of research targeting health policy, lack of funding and investments, and political forces. Facilitators included availability of health research and research institutions, qualified researchers, research funding, and easy access to information. CONCLUSIONS: Health policymakers in several countries recognize the importance of using health systems evidence. Study findings are important in light of changes unfolding in some Arab countries and can help undertake an analysis of underlying transformations and their respective health policy implications including the way evidence will be used in policy decisions.

A multi-faceted approach to promote knowledge translation platforms in eastern Mediterranean countries: climate for evidence-informed policy.

OBJECTIVES: Limited work has been done to promote knowledge translation (KT) in the Eastern Mediterranean Region (EMR). The objectives of this study are to: 1.assess the climate for evidence use in policy; 2.explore views and practices about current processes and weaknesses of health policymaking; 3.identify priorities including short-term requirements for policy briefs; and 4.identify country-specific requirements for establishing KT platforms. METHODS: Senior policymakers, stakeholders and researchers from Algeria, Bahrain, Egypt, Iran, Jordan, Lebanon, Oman, Sudan, Syria, Tunisia, and Yemen participated in this study. Questionnaires were used to assess the climate for use of evidence and identify windows of opportunity and requirements for policy briefs and for establishing KT platforms. Current processes and weaknesses of policymaking were appraised using case study scenarios. Closed-ended questions were analyzed descriptively. Qualitative data was analyzed using thematic analysis. RESULTS: KT activities were not frequently undertaken by policymakers and researchers in EMR countries, research evidence about high priority policy issues was rarely made available, and interaction between policymakers and researchers was limited, and policymakers rarely identified or created places for utilizing research evidence in decision-making processes. Findings emphasized the complexity of policymaking. Donors, political regimes, economic goals and outdated laws were identified as key drivers. Lack of policymakers' abilities to think strategically, constant need to make quick decisions, limited financial resources, and lack of competent and trained human resources were suggested as main weaknesses. CONCLUSION: Despite the complexity of policymaking processes in countries from this region, the absence of a structured process for decision making, and the limited engagement of policymakers and researchers in KT activities, there are windows of opportunity for moving towards more evidence informed policymaking.