مجله بیمارستان
سال شانزدهم شماره 2 (تابستان 1396)

The quality of services is a comparison of the customer´s perspective (expectations) with what it has received. If the expectations are more than perceptions, the quality of received services is not sufficient based on customer´s view which resulted in his/her dissatisfaction. The present study performed with the purpose of determining the quality of provided and excepted services to outpatients among hospitals affiliated to Tehran University of Medical Sciences.
Material and The present study is a descriptive- analytics and cross sectional one which has been done in 2015. The study population included all outpatients attending hospital clinics affiliated to Tehran University of Medical Sciences.The sample size was calculated 225 participants based on formula. In order to data gathering in quality of provided and expected services, a 22-items standard questionnaire of Servqual was utilized. Data analysis performed by SPSS using paired t-test, Mann-Whitney and Kruskal-Wallis tests.
The study findings represented that there was a negative gap in the quality of services provided. The highest gap was related to accountability (-0.97) and the lowest gap related to tangibles factors (-0.69) .Moreover, regarding to relationship between demographic variables with perceived service quality, there were significant relationship between insurance type with reliability and empathy dimensions and supplementary insurance with tangibles factors and reliability.
Negative gap (higher expectations than perception) in all aspects of quality improvement is required in all dimensions. Especially, it is necessary to adopt some strategies in the accountability dimension. Reforming management processes, reducing waiting times and increasing employee's motivation in order to achieve appropriate accountability are in this kind of strategies.

Decision to stop or continue the treatment after awareness about complications and risks is patient's rights. On the other hand, patient`s discharge against medical advice could threaten patient's health. This study aimed to determine the causes of patient`s discharge against medical advice to prevent negative effects on patients and health costs.
In this study, 342 patients who left hospitals regarding discharge against medical advice were enrolled. Up to 48 hours of leaving hospital, the patients were received telephone contact, and if consented, were asked about the potential causes and whether or not the explanation of nurses or physician about the risks and side effects of discharge against medical advice. Furthermore, causes of discharge against medical advice were categorized as patient, hospital condition and combined causes.
Study findings revealed that 48.5% of patients with personal reasons, 26% because of dissatisfaction with the service and 25.5% due to a combination of causes left the hospital. Most of the patients were in emergency department (p Given to the study results, it seems that planning for providing and maintaining human resources, training staff especially new entrance, monitoring medical team performance and organizing the triage system are essential in patient`s discharge against medical advice.

Regarding to the importance of controlling health care expenditure, necessity for proper distribution of health care resources and appropriate utilization of hospital resources through inappropriate services reduction for patients, this study aimed to assess suitability of brain CT scans, based on American College of Radiologists (ACR) appropriateness criteria in Shahid Beheshti Hospital affiliated to Kashan University of Medical Sciences (KAUMS).
This cross sectional and retrospective study was conducted in internal and surgery triage unites of an academic hospital in KAUMS to determine the appropriateness of brain CT scans. A General physician reviewed 361 medical records of patients through the check list based on ACR appropriateness criteria. Collected data was classified in three areas including appropriate, possibly appropriate and inappropriate. Data was analyzed using SPSS through descriptive statistics such as Index of dispersion and chi-square test.
Study findings revealed that among delivered CT scans, 310 (85.9%) appropriate, 38(10.5%) possibly appropriate and 13(3.6%) were inappropriate. The maximum and the minimum inappropriate brain CT scans rate 4 (4.17 %) were related to patients with Ataxia and zero (0 %) were related to patients with Headache, respectively.
Based on ACR appropriateness criteria, Brain CT scans were not utilized appropriately. In order to depict utilization review of radiology procedure in Iran, Developing a national guideline is necessary. To detect the effective factors regarding formulating targeted intervention, more comprehensive studies in various hospitals, different specialty and radiology modality seems necessary.

Hospitals directly affected by disasters and crises which will be provided services facing with crises by well-informed and high performing personnel. This study aimed to determine self-efficacy level in disasters among senior managers of hospitals.
This study was a descriptive-analytical and applied one which was conducted in all public and private hospitals affiliated to Tehran University of Medical Sciences in 2015. Study population was all senior managers of hospitals and data was collected by a researcher-developed, valid and reliable questionnaire. Data analyzed using descriptive and Inferential statistics.
Self-efficacy facing with crisis was assessed on average level (101 out of 130) and high among married men with previous experience in disasters. Also, self-efficacy level reported high among aged and position of ED managers. Nevertheless, there was no significant relationship between self-efficacy and participation in educational course and hospital ICS membership.
Given the relationship of self-efficacy with the aged and prior experience in disasters, these variables should be considered in selecting proper people for these positions. Moreover, having successful experiences dealing with challenges enhances the level of Self-efficacy among managers. Hence, using some techniques such as simulation or providing maneuvers can acquaint managers with the possible conditions facing with disasters.

Organizational culture has a crucial role in hospitals’ productivity. The success or failure of strategies and plans in organisational change depend on organizational culture. This study aimed to examine the organizational culture of Tehran hospitals in 2014.
Material and This descriptive-analytical study was carried out in 18 hospitals (public, private and semi-public hospitals) that were selected out of 114 hospitals of Tehran using quota- randomized sampling method. About 696 employees in diagnostic, curative, administrative and logistic departments participated in the study. Data was collected through a valid and reliable questionnaire and analyzed using SPSS20. Spearman, U Man- Whitney and Kruskal- Wallis statistical tests were applied.
The mean score of organizational culture was 3.62 out of 6 (moderate). There was a significant relationship between organizational culture and the type of hospitals (p=0.002). The mean score of organizational culture was higher in Private and Semi-public ecurity hospitals respectivey. Attention to details and customer orientation dimensions were high in public and semi-public hospitals and private hospitals respectively. The most and the least mean score of organizational culture was related to administrative and support services units.
Organization culture was evaluated in moderate status in hospitals of Tehran city. Thus, it is recommended that hospital managers improve hospitals 'organizational culture specially in creativity, innovation, integration and teamwork dimensions using organizational engineering culture plans.

Because of the current population policies adopted in Iran followed by increasing the number of births, this study aimed to investigate the current situation of safe delivery and proposed a model based on clinical governance.
This study is a combinatorial-exploratory research (Mixed Method) conducted in four hospitals in Qazvin and Semnan provinces including two stages in 2014. The first stage was the assessment of current situation; clarifying safe delivery, reviewing literatures, providing two checklists, assessment of current situation based on assessment of continuous quality improvement and assurance of the quality and the second stage was presenting the model including codification of safe delivery model in seven axes of clinical governance, the approval of the model on the panel using nominal group technique.
In quality assurance, hospital (4) and hospital (2) obtained the maximum score (1431) and minimum score (1237) respectively. All hospitals in continuous quality assessment, admission in the intensive care unit (P In order to improve the quality of Maternity ward, hospital's accreditation also should be based on the principles of clinical governance. In addition to evaluations based on quality assurance and annual accreditation, assessment using continuous quality improvement methods based on clinical governance is essential. The proposed model includes seven axes of clinical governance.

Accidents are one of the important health problems in the medical community and the third cause of death after cardiovascular disease and cancer in the world, which can cause irreversible damage and lesion, impose heavy costs and depreciation. Therefore, this study aimed to identify epidemiological aspects of the accidents in the first six months in 2012.
This applied, descriptive and analytical study was conducted during the first 6 months of 2012. Study population was 1952 injured who referred to emergency department to selected hospitals of Mazandaran Province. Data collection performed using checklist of Center for Disease Control as well as interviews and observations. Data was analysis through SPSS version 17 using descriptive and interfere (x2 and Regression) tests.
Study results revealed that there was a significant relationship between incidents leading to injury or death among referred to hospitals with age (p=0.03), gender (p=0.04), type of incident (p Regarding to the significant variables such as the type and location of accident, type of transfer the injured to the hospital, age and gender with accidents and death, planning appropriate education of law to youth, providing air bag and safety improvement of all cars, planning relevant road assistance system, accurate monitoring to its implementation, qualitative and quantitative development of medical centers recommended to Policy makers in health issues.

Pre hospital emergency medical service (EMS) as the first line of emergency care and treatment in the out- of -hospital has a considerable importance in the health care system. Planning on finding about strengths and weaknesses and improve the quality of EMS by exploring the problems of this section has considerable important.This study aimed to explore the challenges of pre hospital emergency medical service in Mashhad.
A qualitative study was done with 14 personnel working in EMS sites in Mashhad using purposeful sampling. Data was collected by semi structured interview and analyzed using conventional content analysis approach according to Graneheim and Lund man 2004 with ATLAS.ti software.
Three general themes were identified including 1) "challenges in Human resources"( Individual characteristics of human resources and personnel's dissatisfaction 2) "challenges in organization" (Structural challenges, lake of equipment and human resource limitation 3) "socio-cultural challenges"(Environmental-social challenges and cultural challenges) were determined.
personnel's dissatisfaction, structural challenges, human resource limitation, lake of equipment and Environmental-social challenges were the most important challenges in pre-hospital emergency system. Organizational independence , create organizational rows, regulation of laws and administrative regulations reform in relation to the range of services offered by emergency personnel, attention to the facilities and cooperation And the participation of other organizations, such as media and traffic to enhance pre-hospital emergency services at the community level can be effective in reducing the challenges in hospital emergency system.