جستجوی مقالات مرتبط با کلیدواژه « بیمارستان های دولتی » در نشریات گروه « پزشکی »

 The quality of work life is a sign of an organizational culture based on which employees feel self-sufficiency and self-esteem. Considering that such a study has not been conducted among the operating room staff, the present study aimed to determine the quality of work life among the operating room staff of selected hospitals in Tehran in 2021.

 The current research is a descriptive-cross-sectional study. Sampling was done as a cluster and the samples were selected from the operating room staff of selected government hospitals in Tehran in 2021. In total, 231 participants answered questions related to demographic information and Walton's quality of work life questionnaire (35 options) in the form of self-report. The data were analyzed with the help of descriptive and inferential statistical methods in SPSS-24 software at a significance level of 0.05.

 The participants age averaged (standard deviation) at 31.69 (6.35). The mean (standard deviation) of the quality of work life of operating room workers was 96.04 (18.28), so that 23.8% had low levels of work life quality, 73.2% had average and 3% had high work life quality. The overall work life environment and safe and healthy work environment revealed the lowest and highest scores, respectively.

 It seems that the quality of working life of the operating room staff is not at the optimal level. Therefore, the treatment officials should provide the necessary platforms to improve the quality of work of the operating room staff in different areas, so that the staff can serve with more motivation.

Designing a payment system for healthcare workers- doctors and nurses, in particular- in the hospitals is more intricate than that for other organizations. Beyond the legal compliance, the unique features of the medical professions and nursing work environment should be considered. Due to the lack of adequate researches on payment methods for doctors and nurses in Iran, especially regarding the recent changes in “fee for services” (FFS) payment, the present study aimed to investigate the payment challenges faced by the doctors and nurses in Iranian public hospitals.

Challenges were identified by interviews, and prioritized by adopting the MARCOS method. The study population included the hospital managers, healthcare payment method experts, and doctors and nurses in the public hospitals. Targeted sampling and semi-structured interviews were conducted to collect the data. In the MARCOS method, criteria determination, weighting, and scoring of the challenges were performed by five experts in the field of healthcare payment. Criteria included decreased motivation (25%), reduced productivity (15%), correction cost (40%), and implementation difficulty of the correction (20%). Calculations were performed using Excel software and determining the relevant priorities.

A total of 16 interviews were conducted in this study, with 10 interviews about the academic faculty and hospital managers in Isfahan University of Medical Sciences, three about the nursing experts in Tehran, and three about the Ministry of Health experts. According to MARCOS method calculations, the top 4 challenges in compensating doctors were identified as: low FFS ceiling, lack of job difficulty incentives, the inadequate impact of full-time work, and the progressive taxing. Additionally, the 2 primary challenges in compensating nurses were: irregular payment of FFS, and collective payment of FFS instead of individual payment.

At the time of this study, Iranian public hospitals provided the doctors with individual rights, benefits, and allowances, while it provided the nurses with collective rights, benefits, and overtime pay. Although these compensation methods often posed different challenges, most of the issues were associated with the allowance payments. By prioritizing key challenges, authorities may have developed the necessary solutions for addressing the challenges as well as enhancing the satisfaction of doctors and nurses in Iranian public hospitals.

A good and healthy communication between the physician and patient and the therapeutic staff is the basis of good medical care, and communication skills play an important role in patient's satisfaction and their treatment. The aim of this study was to explore the physicians' communication in public hospitals of Yazd city using phenomenological methods.

This qualitative research was conducted using the phenomenology method from January 2021 to August 2022. The location of the study was 2 hospitals affiliated to Shahid Sadoughi University of Yazd. The statistical population included general practitioners and specialists from the government hospitals of Yazd city. Among these doctors, 12 people who had a working experience of more than 11 years and were willing to cooperate with the researcher were selected as the sample using a selective and purposive method. Data were collected through interviews. Lincoln and Guba criteria were used to assess validity and reliability of the research, and these data were analyzed by NVIVO 11 software.

Results demonstrated that physicians' communication pattern consisted of 11 sub-themes: psychological factors; family factors; lack of skills; information disorders; challenges related to patients, colleagues, and medical profession; hospital environment; social harm; and religious factors. These sub-themes were categorized into five main themes: environmental, individual, communicative, cultural, and professional aspects.

Establishing a proper relationship between the patient and physician is the essential component of a high quality medical care. Improving this relationship will cause patient's more commitment to the treatment, more satisfaction with the medical team, and less medical errors and complaints.

Spiritual cu lture, including moral values and norms, along with the responsibility of medical staff, has an effective role in improving and restoring patients' health. The purpose of this study is to examine the effect of spiritual culture on s ocial responsibility with the mediating role of social capital in public hospitals in Tehran .

Methods :

This study is applied in terms of purpose and descriptive survey - based in terms of data collection method. The statistical population of the study includ es the staff of hospitals affiliated to Tehran University of Medical Sciences. Using Cochran's formula, 384 available samples were selected. In order to collect information, three standard questionnaires including Carol’s Social Responsibility Questionnair e, Nahapit and Goshal’s Organizational Social Capital Questionnaire and a researcher - made questionnaire of spiritual culture were used. In order to evaluate the reliability of the questionnaires, Cronbach's alpha was used. Delphi method was also used to ev aluate the validity of the content. For this purpose, the questionnaires were approved by relevant experts. Data analysis was performed through a questionnaire in two descriptive and inferential sections (Kolmogorov - Smirnov test, Pearson correlation test, multiple regression test). In this study, all the ethical considerations were observed and the authors reported no conflict of interests .

Based on the results of factor analysis, the factor loadings of the components were greater than 0.4 and the ir significance values were higher than 1.96, which is confirmed. The mean variance extracted should also be greater than 0.4. Based on the results, they were all higher than 0.4, which indicates significance. Based on the obtained t - statistics, all the th ree hypotheses were accepted at p value of 99% .

The findings showed that spiritual culture has a positive, significant and direct relationship with social responsibility with the mediating role of social capital. Culture plays an important role in competing with competitors and striving to achieve spiritual goals. Spiritual culture increases the responsibility to perform duties and in a way pays a ttention to the social values and the cultural ethics of the society and social responsibility. Ther efore, hospitals are suggested to create a suitable platform for effective programs such as education to strengthen the spiritual culture of the employees . Please cite this article as: Mousavi - Kashi Z, Movafagh A, Mohsenikabir Z. The Effect of Spiritual Culture o

Sustainable innovation is recognized as one of the influencing factors in the performance of the health sector because the dynamic and complex nature of the health care industry requires innovative methods and solutions to achieve sustainability. The aim of this study is to determine factors influenced by and influencing sustainable innovation in public hospitals in Tehran.

The present applied research was conducted in two stages according to mixed methods research (qualitative and quantitative). In the first stage, in order to extract the factors influencing sustainable innovation in public hospitals, 11 people were selected from among the experts of public hospitals in Tehran by the snowball sampling method, and in-depth interviews were conducted with them. In the second stage, through a questionnaire and the fuzzy dimatel method using Excel software, the internal relationship between these factors and the influenced and influencing factors was determined.

72 codes were extracted from the interviews and categorized into 17 factors. Out of 17 factors, 8 factors were influencing ones and 9 factors were influenced ones. According to the results of the research, the manager's familiarity with current knowledge was the most influencing factor and the observance of stability was the most influenced factor in all aspects of the hospital.

Considering the benefits of sustainable innovation, it is recommended that hospital officials should provide a suitable platform for the development of sustainable innovation in hospitals with practical and up-to-date training and human resource development and the use of systems that create transparency in hospitals.

In the present era, the implementation of open innovation process is necessary for any organization, and hospitals as the main medical centers are no exception. In fact, hospitals, as health operational units, are always directly exposed to changes in the field of health services. Therefore, the present study has investigated the factors affecting open innovation in public hospitals in Guilan province.

From the point of view of purpose, this research is an applied study and in terms of data collection, it is in the category of descriptive research, which was conducted cross-sectionally in 1400. The statistical population of the study was 1600 senior managers and staff of public hospitals in Guilan province. For sampling, a non-randomized judgmental sampling method was used to access community members (senior managers and employees with at least a bachelor's degree). 250 questionnaires were used to perform the test. Data collection tools are standard questionnaires. The reliability of the questionnaire was confirmed through Cronbach's alpha, and the validity of the questionnaires was confirmed through the face and content validity, convergent and divergent validity. The structural equation modeling method has been used to test the research hypotheses. The software used in this research is SPSS 26 and Smart PLS3.

The results of the structural equation modeling test showed that among the external factors, cooperation with partners and the user, among the internal organizational factors, organizational structure, exploratory learning, and organizational culture, and finally among the individual internal factors, organizational motivation affects the open innovation of public hospitals in Guilan province. The impact of trust between partners, technology, personality traits, and knowledge on hospital open innovation has been rejected.

In collaboration with other health care services, universities, and users, hospitals should develop appropriate policies to transition from a closed innovation system to open innovation, and support effective measures in this regard.

There are many ambiguities and contradictions in the economic consequences of outsourcing services in public hospitals. Therefore, the aim of the present study was to systematically review the economic consequences of outsourcing in public hospitals in Iran.

The information required in this systematic review study was collected using relevant keyword searches in the databases of PubMed, ProQuest, Scopus, Web of Knowledge, Google Scholar, SID, and MagIran without time limit. Textual data were analyzed manually by the content analysis method.

Finally, 20 articles were included in the study. Three types of rental outsourcing, managerial, and public-private partnership were reported in the studies. In five studies, the whole hospital was outsourced. None of the studies had a control group. A total of 51 indicators were used, most of which were total revenues, total costs, and personnel costs. The mean study time of the outsourcing effects was 24.2 months. The results of most studies showed the positive effects of outsourcing in economic terms. The most important achievements of outsourcing included reducing costs and increasing profitability, and the most important obstacles included the existence of hidden costs, imposing additional costs on patients, lack of economic stability, and lack of economic evaluation.

The results showed that outsourcing has been economically successful in many wards and services of public hospitals; however, in some cases, outsourcing has led to increased costs. Therefore, more attention should be paid by hospital managers and health policy makers to identify the influencing factors and negative consequences of outsourcing.

Considering that competitive advantage is the basis of strategic management, the purpose of this study is to determine the relationship between electronic human resource management, competitive advantage, and human resource flexibility.

The present applied and descriptive research was done in the 2020. The statistical population of this research was the employees of the Isfahan government hospitals. Using Cochran formula, 341 people were taken as the final sample. The data collection tool in this study was a standard questionnaire whose validity and reliability had been confirmed in previous studies. The data were then analyzed by SPSS and LISREL software.

The results of the tests showed that electronic human resource management with 0/76 impact factor had a positive and significant effect on the competitive advantage, and the one with 0/66 impact factor had a positive and significant effect on flexibility of human resources. Also, human resource flexibility with 0/35 impact factor had a positive and significant impact on competitive advantage.

Considering the mediating role of the human resources flexibility in the relationship between electronic human resources with competitive advantage, we need to invest in the electronic system related sectors to improve strategic decision-making procedures in the field of appropriate investment in human resources and increased competitive advantage.

In management accounting, the budget is cornerstone of management control process and one of the unresolved issues. In this regard, the purpose of this study is to investigate the effects of hospital budgetary control system on budgetary performance considering the mediating role of budgetary perception.

This is a descriptive and correlational research in terms of nature and method. The statistical population of study is the managers of public hospitals in Fars province. 400 questionnaires were distributed among members of statistical population and 103 questionnaires were collected. For statistical analysis, structural equation modeling technique have been used.

Findings showed that with increasing managers' budgetary evaluation, budgetary attitude (0.895) and budgetary motivation (0.280) increases. Also, managers' budgetary performance by increasing budgetary motivation (0.305) and managers' propensity to budgetary slack (0.382), will increase. However, increasing budgetary participation have no effect on managers' budgetary perception in terms of budgetary attitude (-0.085), propensity to budgetary slack (0.208) and budgetary motivation (-0.1). Budgetary feedback also has not the power to influence managers' budgetary perception in terms of budget attitude (-0.220), propensity to budgetary slack (0.271) and budgetary motivation (0.066). In addition, between budgetary evaluation and managers' propensity to budgetary slack (0.139) and also between budgetary attitude and budgetary performance (-0.055) have no significant relationship was observed. The results of the Sobel test also confirmed the mediating role of the budgetary motivation (3.050) in the relationship between budgetary evaluation and budgetary performance.

Hospital managers and policymaker via giving more importance to budget evaluation can improve managers' budgetary motivation and attitude; Also, they can improve the performance of hospital budgets by improving budgetary motivation.

Supply chain management in healthcare sector is of utmost importance due to its effect on individuals’ health status compared to other industries. In the current world economic situation wherein logical thinking should be based on lifetime costs of products ,as well as supply chain sources and processes, it is essential to have an agile supply chain to have a socio-environmental performance creating competitive advantage.
 

This study was a survey with a correlational design considering its methodology and purpose. The statistical population of this study included the staff of public hospitals in Ilam province, Iran; of which, 340 individuals were selected as the participants based on Krejcie and Morgan’s sample size determination table. Moreover, the SPSS Statistics Software and LISREL Software were used to analyze the data in this study.
 

The statistic of the Kaiser-Mayer-Olkin (KMO) index was equal to 0.844 implying sampling adequacy. Moreover, all the factors affecting supply chain agility had a normal distribution and the test statistic was larger than 1.96 for all the factors, suggesting their relationship with supply chain agility. The positive correlation between supply chain agility and competitive advantage was further confirmed based on the research findings.Additionally,the value of the goodness of fit index (GFI=0.96) showed the fit of the model and the test statistic of the model (T=9.60) revealed the significant impact of supply chain agility on creating the competitive advantage.
 

The results of the present study demonstrated that the seven dimensions of computer-based technologies, flexibility, relationships with suppliers, use of modern technologies, collaborative partnerships, sensitivity to market, and responsiveness of demands had effects on supply chain agility in hospitals. Moreover, public hospitals in Ilam Province were endowed with competitive advantage in three dimensions of durability and permanence, retention, and opportunities; however, they lacked competitive advantage in the dimension of individuals’ unique capabilities.

The importance of management's role in any organization is obvious. Selection and appointment of competent managers in healthcare organizations -given the importance of their services- will also have a significant impact on health systems and communities. Therefore, it is necessary to identify and validate key management skills and competencies to design educational programs and identify and employ the best managers.

This descriptive study consisted of two phases. First, a literature review was performed to identify the required competencies and skills for healthcare management and leadership based on which a five point likert-scale qestionnaire was developed. In the second phase, a Delphi technique was used to collect 20 experts' opinions about the extracted criteria in the questionnaire.

Based on the experts' opinions, eight key criteria including: personality traits, values, basic management knowledge, hospital management knowledge, planning skills, organizing skill and resource allocation, leadership skills, monitoring and supervision skills, and 46 sub-criteria were approved.

Management knowledge is one of most important skills for managers; therefore, it is necessary to revise approaches for selecting managers and change the attitude of hospital managers form autocratic management to leadership and Intra-organizational collaboration and coordination.

Occupational stress is highly associated with how organizational management and support work. In our country, organizational management is often private and public and has a different support pattern.The current study was conducted to Comparison of occupational stress level of nurses in public and private hospitals in Qom, 2016.

This descriptive-analytical study was carried out with 320 nurses working in public and private hospitals in Qom using random sampling. The data collection tool was a demographic questionnaire and a The Expanded Nursing Stress Scale (ENSS). The collected data were entered into the SPSS21 software and analyzed by descriptive statistics, t-test and ANOVA.

In this study, 89 (27.81%) males and 233 (72.19%) female with a mean age of 35.52 ± 6.69 years participated. The results of the study showed that the occupational stress level of nurses in public and private hospitals was at a mild level (55 ± 0/34 and 51 ± 0/79). There was no significant difference between the level of occupational stress among nurses in Qom public and private hospitals (p=0.78), however the high levels of occupational stress in private hospitals nurse were significantly higher than public hospitals (p 0.001 <).

Regarding the higher level of occupational stress among nurses in private hospitals in Qom province, it is advisable to periodically monitor occupational stressors to provide effective management functions to reduce the situation in these hospitals.

Given the complexity of the ruling in organizations, currently knowledge management can be considered as a guide for management practices. Complicated conditions have caused sweeping changes in management of organizations, especially in hospitals, which should be responded to these changes. The knowledge-oriented leadership can be a good answer to these. So, the impact of knowledge-oriented leadership on knowledge management practices in public hospitals was the main objective of this research. This study was a descriptive survey, and an applied research by the objective, and according to the research goals that measure the effects of variables, it is a hypothetical-deductive type. Study population consisted of 631 health sectors of public hospitals in Tabriz. In this research, sampling was done by multi stage cluster method and the views of the managers of 169 health departments were used to collect data. Data analysis was conducted by structural equation modeling. Software outputs indicate a positive and significant impact between knowledge-oriented leadership and knowledge management practices. Also, knowledge-oriented leadership has the greatest impact on knowledge application. The results show that practices of creation, storage, transfer and application of knowledge management has strong relation with knowledge-oriented leadership. In other words, attention to existing knowledge will improve the knowledge of hospitals.

Designing a supply chain performance model for hospitals is one of the fundamental decisions in supply chain management which significantly affect the investment return and the overall performance in the chain. The purpose of this research was to design a model for assessing supply chain performance in hospitals while considering economic, social and environmental dimensions of sustainability.

This qualitative research was conducted using grounded theory. In order to collect data, 14 experts in public hospitals in Yazd province were interviewed. The participants included five hospital managers, four heads of departments, three supplies deputies, and two administrative heads who had at least 8 years of work experience and were familiar with sustainability issues. A combination of purposeful and snowball techniques was used to collect data which were then analyzed using open, axial, and selective coding methods.

After the analysis of the data, 44 sub-codes affecting the sustainability of supply chain in public hospital were identified. The sub-codes were then classified into six main codes: intervening factors, causal factors, phenomenal pivot, performance strategies, background requirements and performance implications. Improving collaborative cooperation in different parts of hospitals, reducing the risk of medical errors, improving the quality of services, and enhancing the professional status of personnel were some of the implications of assessing the sustainable supply chain performance in hospitals.

The proposed model can be used as a tool of prediction and policy making while assessing sustainability of supply chain performance in public hospitals. Planning and policymaking to enhance health and environmental management system can lead to collaborations between departments, reduction in medical errors (i.e., wrong diagnosis or   medication), understanding the specific needs of each patient, the implementation of educational and health care programs, as well as a reduction of environmental pollutants.

Change in the health system is always considered as the main concern of governments which in turn may have many positive and negative effects. The health sector development plan is one of the programs aiming at improving the therapeutic and economic dimensions of families, given priority by the 11th government of Iran, and is expected to improve performance of the medical sciences universities and their affiliated hospitals, in addition to develop their educational, health, research and cultural systems. The aim of this study is to evaluate technical efficiency of 22 public hospitals of Guilan university of medical science before (April 2013 to March 2014) and after (April 2014 to March 2015) implementation of health sector development plan, using data envelopment analysis approach and in accordance with the production of undesirable factors.
Materials and Methods The current research is a descriptive-analytical type and also a cross sectional one. The research population includes 22 public hospitals of Guilan University of Medical Sciences, with enumeration chosen as the sampling method and the data were collected from documents. Finally, the collected data were analyzed based on the coding the DEA weak disposability model in GAMS software. The findings indicate that before implementation of health sector development plan (2013- 2014), 14 hospitals (63%) were efficient, while after its implementation (2014-2015), number of efficient hospitals increased to 16 units (73%). The average of technical efficiency also computed as 0.954 and 0.958, respectively. Although, observing the effects of changes in social systems often requires time lapse, however, one year after the implementation of the health system development plan, the average of performance in public hospitals of Guilan province was improved.
Conflict of interest: non declared

Crises are usually unexpectedly appearing, resulting in hidden and obvious consequences, so managers must always be prepared to deal with them in the right way. Managing crisis is one of the key elements of the success of government hospitals and their development. The present study was conducted to investigate the readiness of public hospitals in Ilam province in the face of natural disasters such as earthquakes. This research in terms of target is applied and in term of method is descriptive-analytical method. The statistical population consisted of all staff of 9 state hospitals in Ilam province with a total of 1968 people. Using the of Cochran sampling, 321 samples were selected. The data gathering tool was a researcher-made questionnaire consisting of 53 questions. Data analysis was done using SPSS and PLS software. Findings: The results of the research indicate that the public hospitals of Ilam province have a mean of 2.86, physical fitness readiness 3.03, communication readiness and social capital 2.97, and the dimension of operational capability 11.3 and overall preparedness of 87.8, 2, with one-way t test, the test statistic for these variables was 1.47 for the attitude and knowledge probability dimension, 1.98 for physical fitness readiness, 1.46 for communication and social capital, and 2.44 for the dimension of operational capability And 63/1 for total readiness.These results show that the level of hospital readiness in the context of physical and operational readiness is higher than the average and readiness level in the attitude and knowledge preparedness, communication readiness and social capital, as well as overall readiness less than the average. Discussion & According to the findings of the data analysis, it can be concluded that the state hospitals of Ilam province are poorly prepared to deal with crises in terms of their attitude and knowledge readiness. From the point of view, operational readiness is at an acceptable level. From the aspect of communicational readiness and social capital, they are less than the optimal and physically fit point. Based on research findings, managers of these hospitals are recommended to work on creating and strengthening these indicators. In this regard, in order to improve the physical and operational space, the development of communication and social capital, in order to maintain and increase the readiness of attitude and knowledge, knowledge Need to expand

The importance of considering patients’ satisfaction with the health system development plan has an effective role in management planning. The purpose of this study was to determine the satisfaction rate of hospitalized patients in Tehran’s public hospitals as a reduction in the rate of payment for patients in the health system reform plan.
This was a descriptive cross-sectional study conducted in the first half of 1394. The research community is the patients of the Tehran State hospital. A multi-stage sampling (500 patients) was performed. The data gathering tool was a researcher made questionnaire whose validity and reliability were confirmed. Data analysis was done by SPSS software version 22 using correlation, factor analysis, and Friedman test.
Based on the findings of the research, it can be concluded that reducing the amount of hospitalized patients to make vitality, reducing illness due to the insignificant costs of treatment, and enhancing equity in health is a positive consequence of the program. As a result, the health system development plan plays an important role in patient satisfaction and has reduced the health concerns of people.

One of the most valuable assets of any organization is its brand because it causes more profit margins, better cooperation channels and other benefits for the organization. The aim of this study was to investigate the factors affecting brand identity of hospitals in a semi- governmental hospital in Tehran/ Iran. In this descriptive-analytic study, 403 hospitalized patients in a semi-governmental hospital were selected by available sampling method in 2016. The data gathering tool was a researcher-made questionnaire based on the Kapferer model (including 30 questions in 6 domains of brand personality, brand physique, brand culture, relationship, self-image and reflection). Data were analyzed using one-sample t-test in SPSS 16 software. The highest mean scores were attributed to the importance of service quality (4.21), known cases (4.15) and easy access (4.02). The least mean scores belonged to patients' mental and psychological needs (2.31), the distinctive character (2.45) and happy and motivated staff (2.63). There was a significant relationship between total mean score (3.51) and brand personality, brand physique and brand culture (P<0.05). Hospitals cannot survive without attention to the patients' demands. Therefore, by implementing any of the factors affecting the hospital brand identity, it is possible to improve the hospital brand status in the minds of the patients as a superior and valuable brand.

Public hospitals play a great role in people’s health maintenance. One of the major concerns of these centers is constant high quality activities alongside allocating resources efficiently. Meanwhile, examining the performance and studying the procedures and design of management accounting are required to achieve this purpose. It is a descriptive-survey research.The statistical population included financial and administrative personnel of public hospitals (n=25) in Gilan province and 138 people were selected through Cochran formula as the sample. The questionnaires were distributed among the sample to test management accounting design, management accounting application, management accounting satisfaction, and hospitals performance. Research hypotheses testing was done by structural equations modeling. The results indicate that there is a positive significant and direct relationship between management accounting design and application, management accounting design and satisfaction as well as management accounting application and organizational performance. Further, management accounting design develops a significant and indirect relationship with organizational performance through management accounting application. According to the properties of Gilan public hospitals a revision of the dimensions of their management accounting system is required with the purpose of undertaking their duties

The transformation of the health system will achieve their main goal time in patient satisfaction, where the new structure in the area of treatment is acceptable. This study aimed to evaluate the satisfaction of women after the delivery of healthcare reform plan to promote labor.
This cross-sectional descriptive study was conducted in the first half of 1394. The study population included patients in public hospitals in Tehran. Multi-stage sampling was performed (200 patients). The data collection tool was a valid and reliable questionnaire, which was approved. Analysis of the data by factor analysis and Friedman test was performed using the SPSS software, version 22.
Based on the results, it can be concluded hat the physical space of the maternity ward and fitness classes for pregnant women to promote the process of pregnancy and labor are the main factors of satisfaction natural packs is the promotion of labor in public hospitals.