Challenges of implementation of hospital accreditation in Iran: an exploratory factor analysis.

BACKGROUND: Today, accreditation is considered as the most commonly used health assessment approach. Considering the importance and application of the process of this approach in the hospital, this study aimed to investigate the challenges of implementation of hospital accreditation in Iran using exploratory factor analysis. METHODS: A cross-sectional study design was carried out from July to December 2017, consisting of 200 managers in the seven hospitals accredited by the MOH in Tehran, Iran. Samples were selected through the purposive sampling method, and data were collected using a structured questionnaire in which validity and reliability were confirmed. Likert's five-choice range was used for the rating of items. Exploratory factor analysis was used to categorize the identified challenges and extract the mathematical model on them. RESULTS: Exploratory factor analysis identified six dimensions (implementation, evaluation, content, structural, psychological, and managerial) with 40 items using a 5-point Likert scale. Each dimension accounted for greater than 63.20% of the total variance. The scale had strong content validity (indices = 0.84). Each dimension of Cronbach's alpha ranged from 0.74 to 0.94. Implementation, evaluation, content, structural, psychological, and managerial components also formed the final identified areas. CONCLUSION: The present study showed that there were major challenges in the path to successful deployment of Iranian hospital accreditation, requiring serious action by managers and policymakers in this field.

Pillars of Hospital Preparedness in Radiation Emergency Management.

Human beings have always suffered and have incurred irreparable damages from different disasters. The most logical way to deal with disaster is to be comprehensively prepared. In line with this, the readiness of hospitals in the vicinity of nuclear centers is of great importance, as this could lead to reduced injuries and damage. In this study, we aimed to develop a model by which hospitals could effectively react to nuclear incidents. This is a comparative study using library studies, including examining existing patterns, recommended policies and instructions of WHO and IEAE, and articles and documents of selected countries that have models for radiation disaster management. The primary developed model was discussed in expert panels and, ultimately, with some modifications, was finalized. The findings of the research indicated that the most important factors in the success of crisis management are skill in predicting a crisis and having a preparation plan for necessary measures at the time of an incident. Different countries have developed various approaches toward radiation incident management that are mostly focused on human resources, medical equipment, and physical space. The model plan developed here includes a two-part foundation with seven pillars. Intra- and intersectorial arrangements are considered as the foundation, and the pillars are physical structure, medical equipment, human resources, process and instructions, intra- and intrasectorial coordination, information systems, and organizational structure. Having an appropriate model for coping with radiation incidents is pivotal for hospitals active in areas with nuclear centers. Undoubtedly, existence of an effective and comprehensive model could reduce the consequences of radiation crises.

Design of a Model for Management of Referral System in the Iranian Urban Family Physician Program.

BACKGROUND: The purpose of this research was to identify the main dimensions of management of referral systems in family physician program and then introduce them to policymakers of the country primary health care. METHODS: This descriptive-correlation study was designed in Mazandaran Province, northern Iran (2017). The participants were employees of health centers of Mazandaran and Fars Provinces, Iran. The dimensions influencing on the referral system were identified systematically in the selected countries by using researcher-made questionnaire according to a statistical method called Factor Analysis. The data sufficiency was evaluated by the Bartlett's and Kaiser-Meyer-Olkin's tests. Reliability of test was calculated and confirmed according to Cronbach's Alpha and Combined Reliability tests. Validity of the test was calculated and confirmed based on the average variance extracted (AVE). RESULTS: In confirmatory factor analysis, coefficient of effect of Electronic Health Record on referral system (as the most important dimension), coefficient of Family Physician, coefficient of structure of insurance, coefficient of policymaking in health care system, coefficient of proper stewardship of health system, and basic health care services, were 0.887, 0.877, 0.860, 0.804, 0.568, and 0.522, respectively. CONCLUSION: Six effective dimensions including Electronic Health Record (as the most important dimension), family physician, structure of insurance, policymaking in health care system, proper stewardship of health system, and basic health care services were identified. According to six effective dimensions on management model of the referral system in the Iranian urban family physician program, the health system authorities pay serious attention to the six identified dimensions of the current study to improve the health of the urban community.

Evaluation of Facilitators and Barriers to Implementing Evidence-Based Practice in the Health Services: A Systematic Review.

BACKGROUND: Evidence-based practice (EBP) is an ambition for health service administrators. We aimed to systematically review the major relevant articles in case of barriers and facilitators to implementing evidence-based practice in health services. MATERIALS AND METHODS: The type of study was a systematic review. We searched the libraries and online sources such as PubMed, MEDLINE, Wiley, EMBASE, ISI Web of Knowledge, Scopus, Science Direct, Cochrane Library, and Google scholar. We used keywords included "Evidence-Based Practice", "Evidence-Based Management", "Healthcare", "Care Management, Evidence-Based Healthcare Management", "Health Care", Health", "Barrier", "Facilitator", policy and "Evidence-Based Healthcare". RESULTS: In total, 12 studies were included. Several barriers and facilitators were recognized through the included papers, the factors such as organization support and a helpful education system improved skills, knowledge, and confidence to EBP. The outcomes of studies were identified as the employ of the internet as a highest-rated skill for increasing EBP quality. CONCLUSION: Generally, the results showed health service administrators should first identify barriers of EBP then transferred them to facilitators to the implementation of proper and efficient EBP.

Factors affecting patient safety: a qualitative content analysis

Background: Patient safety is one of the main components of good-quality health services. The main objective of this study is to explore the most effective factors relating to patient safety in Iran. Methods: This qualitative study was done using content analysis. Data were collected using semi-structured interviews. Through purposive sampling, 14 participants were selected by experts who were familiar with the patient safety friendly hospital program. Interviews were recorded and then analyzed by framework analysis using MAXQDA software. Results: Of 2,474 initial codes, 10 main themes and 53 sub-themes were identified, including importance of human resources; organization and management; interactions and teamwork; medication; equipment and physical environment; patient-related factors; patient safety and quality improvement; the importance of documentation; assessment and monitoring; medical errors; barriers and challenges. Conclusion: Factors affecting patient safety can be divided into two groups: facilitators and barriers. Hospitals can improve the implementation of patient safety standards, reduce the adverse events and enhance patient safety by strengthening facilitating factors, such as providing human resources, adequate medical equipment and facilities, increasing employee participation in quality improvement programs, improving staff training, communicating with patients and their families, and addressing the existing challenges and barriers

Interaction between stewardship and social health insurances: A comparative and document analysis.

Background: Social health insurances provide protection to access affordable coverage of services and stewardships of health system need to intervene to fulfill these objectives. This study conducted to assess interaction between stewardship and social health insurances. Methods: This qualitative study conducted in two phases as comparative study and document analysis in 2018. Comparative study employed to identify the dimensions and requirements of interaction between stewardship of health systems and social health insurances in countries around the world. In document analysis, all evidence about Iran health financing reviewed. Data extraction forms were used to gather data. Results: There were less interaction between stewardship and social health insurances in revenue collection and risk pooling. Advisory role of stewardship and proposals to coverage of uninsured people and performing risk analysis were some examples of such interaction. In Iran's health system, where stewardship plays a magnificent role in service provision, the basis of interactions are contracts, payment systems and timeline of payments. Conclusion: Mechanisms of interaction in Iran is not clear or does not work properly. Thus, nonstructural merging of social health insurances needs to redefine these mechanisms.

Assessment of Patient Safety Culture in Iranian Academic Hospitals: Strengths and Weaknesses.

BACKGROUND: In the relevant literature, the establishment of a patient safety culture (PSC) is a vital step in providing quality service to patients. The goal of this study was to establish a baseline for PSC in Iranian academic hospitals and to determine its strength and weaknesses. METHODS: A survey was distributed in 26 academic hospitals linked to the Iran and Tehran Universities of Medical Sciences, of which 18 participated. The questionnaire, the Hospital Survey on Patient Safety Culture (HSOPSC), was used to collect the data. The questionnaire contained 14 dimensions and 43 items, and the questions were scored using a 5-point Likert scale in which 1 = strongly disagree and 5 = strongly agree.The results were expressed in the percentage of positive responses (%), or the percentage of positive responses (e.g., agree, strongly agree) to positively worded items (e.g., "Hospital units work well together to provide the best care for patients") in relation to the percentage of negative responses (e.g., disagree, strongly disagree) to negatively worded items (e.g., "When an event is reported, it feels like the person is being written up, not the problem"). To score each item, the following formula was applied: % of Positive Responses = [(No. of Agree + No. of Totally Agree) / Total No. of Subjects Responding to the Question)] × 100). For the negatively worded items, the answers were reversed. To score each dimension, a composite mean score of positive responses were estimated. The same methodology was applied to the scoring of the PSC of each hospital. (i.e., the composite mean score of positive responses on 12 dimensions was obtained). Note that the data reported in the tables of this manuscript represent percentages, and for ease of communication, (%) are omitted from the stated tables. In the text, however, we have used percent wherever needed.To categorize the hospitals' safety culture from very weak to very strong, a range of 0.0% to 100% positive responses on the PSC questionnaire was divided by 5 ((100% - 0.0%) / 5 = 20%), and 5 equally spaced intervals were defined (i.e., 0.0%-20.0%, very weak; 21.0%-40.0%, weak; 41.0%-60.0%, intermediate; 61.0%-80.0%, strong; 81.0%-100.0%, very strong).The convenience sampling method was used to select the samples. For the purpose of this research, 35 questionnaires were randomly distributed in each hospital: 15 among nurses and assistant nurses (as the frontline personnel having the most direct contact with patients) and 20 among other clinical and paraclinical personnel as well as other groups (physicians, residents, interns, ward secretaries, laboratory personnel, radiology personnel, and managers). The questionnaires were distributed and collected by the hospitals' head nurses. The data were analyzed using a one-sample and independent t test. RESULTS: The mean score of the hospitals on the PSC ranged from 42.74 to 67.22, 12 of 18 hospitals obtained an "intermediate" ranking position, and 6 obtained a "strong" ranking position on the PSC. The overall mean (SD) score for the entire hospital for PSC was 56.74 (18.41). No significant difference was observed between the Iran and Tehran universities of medical sciences hospitals for the PSC. However, significant differences were observable at the dimension and item levels.A hospital's strengths lie in the "organizational learning-continuous improvement," "teamwork within hospital units," and "hospital management support for patient safety" dimensions. Dimensions including "feedback and communication concerning errors," "communication openness," "staffing," and "nonpunitive response to error" were shown to be weak points of all of the hospitals in this study. CONCLUSIONS: The PSC of the investigated hospitals is not at an ideal level and is in need of serious improvement, particularly in the dimensions of feedback and communication regarding errors, communication openness, staffing, and nonpunitive response to error. The same conditions hold true for other Iranian hospitals (i.e., the Afshar and Sadoughi hospitals in the city of Yazd, Iran), and American hospitals were used for comparison purposes in this paper.

Donor retention in health care in Iran: a factor analysis.

Background: Long-term financial support is essential for the survival of a charitable organization. Health charities need to identify the effective factors influencing donor retention. Methods: In the present study, the items of a questionnaire were derived from both literature review and semi-structured interviews related to donor retention. Using a purposive sampling, 300 academic and executive practitioners were selected. After the follow- up, a total of 243 usable questionnaires were prepared for factor analysis. The questionnaire was validated based on the face and content validity and reliability through Cronbach's α-coefficient. Results: The results of exploratory factor analysis extracted 2 factors for retention: donor factor (variance = 33.841%; Cronbach's α-coefficient = 90.2) and charity factor (variance = 29.038%; Cronbach's α-coefficient = 82.8), respectively. Subsequently, confirmatory factor analysis was applied to support the overall reasonable fit. Conclusions: In this study, it was found that repeated monetary donations are supplied to the charitable organizations when both aspects of donor factor (retention factor and charity factor) for retention are taken into consideration. This model could provide a perspective for making sustainable donations and charitable giving.

Factors affecting the quality of hospital hotel services from the patients and their companions' point of view: A national study in Iran.

BACKGROUND: The hospitality design of a hospital is a complex process that depends on careful planning, systematic thinking, and consideration of various factors. This study aimed to determine the viewpoints of patients and their relatives on factors affecting hospital hotel services in Iran in 2015. The results of this study can be used to design a suitable model for the assessment and improvement of hospitality service quality. MATERIALS AND METHODS: In this cross-sectional descriptive study, 10 hospitals of Iran were included. The subjects of the study included 480 patients and their companions from different internal and surgical wards. Simple random sampling method was performed at the hospitals, where patients were selected through stratified sampling based on hospital wards, and in each ward, through systematic sampling based on the bed numbers. A researcher-made questionnaire was used as the study tool which was developed through reviewing the literature and opinions of experts. Its internal reliability was determined based on Cronbach's alpha coefficient (α =0.85). RESULTS: In reviewing the eleven aspects of hospital hotel services regarding the patients' and their companions' viewpoint, services related to all aspects, whether human, economic, operational, personnel identification, safety, health care services, physical, clinical welfare, cultural, patient guidance, or public welfare services, received mean scores of higher than three (out of five). CONCLUSION: The present study showed that in the patients' and their companions' viewpoint, factors affecting hospital hotel services in the country are very important. The tool used in this study can be a criterion for assessing the status of the hotel services of the country's major hospitals, so accordingly, the assessment and improvement of the existing conditions can be possible.

The health systems' priority setting criteria for selecting health technologies: A systematic review of the current evidence.

BACKGROUND: In the recent years, using health technologies to diagnose and treat diseases has had a considerable and accelerated growth. The proper use of these technologies may considerably help in the diagnosis and treatment of different diseases. On the other hand, unlimited and unrestricted entry of these technologies may result in induced demand by service providers. The aim of this study was to determine the appropriate criteria used in health technologies priority-setting models in the world. METHODS: Using MESH and free text, we sought and retrieved the relevant articles from the most appropriate medical databases (the Cochrane Library, PubMed and Scopus) through three separate search strategies up to March 2015. The inclusion criteria were as follows: 1) Studies with specific criteria; 2) Articles written in English; 3) Those articles conducted in compliance with priority setting of health technologies. Data were analyzed qualitatively using a thematic synthesis technique. RESULTS: After screening the retrieved papers via PRISMA framework, from the 7,012 papers, 40 studies were included in the final phase. Criteria for selecting health technologies (in pre assessment and in the assessment phase) were categorized into six main themes: 1) Health outcomes; 2) Disease and target population; 3) Technology alternatives; 4) Economic aspects; 5) Evidence; 6) and other factors. "Health effects/benefits" had the maximum frequency in health outcomes (8 studies); "disease severity" had the maximum frequency in disease and target population (12 studies); "the number of alternatives" had the maximum frequency in alternatives (2 studies); "cost-effectiveness" had the maximum frequency in economic aspects (15 studies); "quality of evidence" had the maximum frequency in evidence (4 studies); and "issues concerning the health system" had the maximum frequency in other factors (10 studies). CONCLUSION: The results revealed an increase in the number of studies on health technologies priority setting around the world, and emphasized the necessity of application of a multi- criteria approach for appropriate decision making about healthcare technologies in the health systems.

Relationship between personal characteristics of specialist physicians and choice of practice location in Iran.

INTRODUCTION: Uneven geographic distribution of physicians is a major healthcare issue in Iran. This study aimed to explore the relationship between personal characteristics of the recently graduated specialist physicians in Iran and their choice of practice location. METHODS: A cross-sectional study was conducted to extract information with regard to 3825 recently graduated specialist physicians from all medical schools across Iran between 2009 and 2012. The relationship between physicians' personal attributes and their desire to practise in underdeveloped areas was analyzed using χ2 test and logistic regression analysis. RESULTS: Birthplace, sex, exposure to rural practice before residency program, place of residence, and year of graduation were associated with physicians' desire to practise in an underdeveloped area. The logistic regression showed that female physicians were less likely to choose underdeveloped areas to practise as compared with their male counterparts (OR=0.659, 95%CI, 0.557-0.781, p≤0.001). Physicians who lived in underdeveloped areas were nine times more likely to choose underdeveloped areas to practise as compared with those living in other areas (OR=8.966, 95%CI, 4.717-17.041, p≤0.001). Physicians who did not have previous exposure to rural practice were 28% less likely to choose to serve in the underdeveloped areas as compared to those who had such exposure (OR=0.780, 95%CI, 0.661-0.922, p=0.004). Neither physicians' marital status nor their success in the board certification exam was associated with their choice of practice location. CONCLUSIONS: It seems that increasing the enrollment of physicians with a rural background in residency programs may solve the problem of uneven distribution of specialist physicians in Iran. Because female physicians are less willing to work in the underdeveloped areas than male physicians, increasing the number of male student admissions to residency programs, particularly in certain specialties that are more in demand in the underdeveloped areas, could alleviate the problem of uneven distribution of physicians in the short run. Further, programs that support raising the admissions of female students with a rural background into local medical universities along with providing incentives to encourage them to live and work in rural areas should be put on the policy agenda.

A model for priority setting of health technology assessment: the experience of AHP-TOPSIS combination approach.

BACKGROUND: In recent times, the use of health technologies in the diagnosis and treatment of diseases experienced considerable and accelerated growth. The goal of the present study was to describe the designated pilot MCDM (Multiple Criteria Decision Making) model for priority setting of health technology assessment in Iran. METHODS: Relevant articles were sought and retrieved from the most appropriate medical databases, including the Cochrane Library, PubMed and Scopus via three separate search strategies, using MESH and free text until March, 2015. Retrieved criteria were questioned from health technology assessment experts in two rounds and the relative weight for valid criteria was finally obtained from paired wise comparison method. After extraction of relative weights based on the aforementioned procedure, TOPSIS (The Technique for Order of Preference by Similarity to Ideal Solution) priority setting model was designed. The stated model was applied for assessing three technologies (adenosine, tissue plasminogen activator and mechanical thrombectomy) which were available for projects call of Iranian health technology assessment department in order to determine applicability of the model for practical purpose. RESULTS: Nine criteria, including efficiency/effectiveness, safety, population size, vulnerable population size, availability of alternative technologies, cost effectiveness in other countries, budget impact, financial protection, quality of evidence, were extracted by the Iranian health technology assessment experts. The relative weights of these criteria were as follows 0.12, 0.2, 0.06, 0.08, 0.08, 0.13, 0.08, 0.09, and 0.15, respectively. Finally TOPSIS pilot model was designed by three health technologies and nine criteria relative weights. Results showed that, the applicability of the stated model was suitable and as the pilot testing, tissue plasminogen activator was the first priority, adenosine was second and mechanical thrombectomy was third for performing health technology assessment by the Iranian ministry of health and medical education. CONCLUSION: According to the results of this study, this model with nine effective criteria and their relative weights and in combination with TOPSIS approach could be used with suitable applicability by health technology assessment department in deputy of curative affairs and food and drug organization for determination of research priorities in health technology assessment.

The evaluation of time performance in the emergency response center to provide pre-hospital emergency services in Kermanshah.

This study evaluated the time performance in the emergency response center to provide pre-hospital emergency services in Kermanshah. This study was a descriptive retrospective cross-sectional study. In this study 500 cases of patients from Shahrivar (September) 2012 to the end of Shahrivar (September) 2013 were selected and studied by the non-probability quota method. The measuring tool included a preset cases record sheet and sampling method was completing the cases record sheet by referring to the patients' cases. Data were analyzed using SPSS version 18 and the concepts of descriptive and inferential statistics (Kruskal-Wallis test, benchmark Eta (Eta), Games-Howell post hoc test). The results showed that the interval mean between receiving the mission to reaching the scene, between reaching the scene to moving from the scene, and between moving from the scene to a health center was 7.28, 16.73 and 7.28 minutes. The overall mean of time performance from the scene to the health center was 11.34 minutes. Any intervention in order to speed up service delivery, reduce response times, ambulance equipment and facilities required for accuracy, validity and reliability of the data recorded in the emergency dispatch department, Continuing Education of ambulance staffs, the use of manpower with higher specialize levels such as nurses, supply the job satisfaction, and increase the coordination with other departments that are somehow involved in this process can provide the ground for reducing the loss and disability resulting from traffic accidents.

Investigating the Financial Performance of Universities of Medical Science and Health Services in Iran, Using Data Envelopment Analysis.

BACKGROUND: Universities of Medical Science and Health Services (UMSHSs) are among the main organizations in Iran's health-care section. Improving their efficiency in financial resource management through creating an appropri-ate coordination between consumption and resources is strategically vital. Investigating the financial performance as well as ranking the Iranian UMSHSs is the research objective. METHODS: The study is of descriptive and applied type. The study population includes the UMSHSs of Iran (n=42) among which 24 UMSHSs are selected. DEA is used with the aim to model and assess the financial performance in-cluding 4 inputs and 3 outputs. Also, linear regression is applied to determine the effectiveness of the applied indices as well as the level of the financial performance. Data are obtained from the Budgeting Center in the Ministry of Health and Medical Education, during 2010 mainly through forms designed based on the available balance sheets. RESULTS: The average score of financial performance assessment for UMSHSs based on the DEA of input-oriented data is 0.74, assuming a constant scale of DEA-CRS. Thus, approximately 25% of the studied UMSHSs have maxi-mum relative performance and totally, there is about a 30% capacity to increase the financial performance in these UMSHSs. CONCLUSION: Most Iranian UMSHSs do not have high financial performance. This can be due to problems in financial resource management especially in asset combining. Therefore, compilation and execution of a comprehensive pro-gram for organizational change and agility with the aim to create a kind of optimized combination of resources and assets is strongly recommended.