Evaluating the Performance of Managers of Tehran University of Medical Sciences ’ Obstetrics and Gynecology Hospitals from the Viewpoint of Personnel

Today, various methods are used in order to assess the health care system which is one of the Governance Leadership Direction (GLD) standards of the Joint Commission International (JCI) of America. This study aimed to evaluate the performance of managers of Tehran University of Medical Sciences’ Obstetrics and Gynecology Hospitals from the viewpoint of personnel, based on the JCI Accreditation Model. This study is a descriptive-analytical research and a cross-sectional study in 2014 which has been conducted among the 311 personnel of two hospitals of obstetrics and gynecology of Tehran University of Medical Sciences. Tools for data collection included two questionnaires. The first questionnaire had 27 questions to evaluate the ability to implement the Governance, Leadership, and Direction (GLD) aspects of JCI standards. The second questionnaire was designed to evaluate the performance of managers. The data were analyzed using the SPSS Software version 18 and Mann-Whitney and Kruskal-Wallis statistical tests. The results show that in the studied hospitals, the functional performance standards of GLD have a relatively high level (average = 0.50 ± 2.30 from 3) and among its dimensions, the highest score related to monitoring (average of 0.57 ± 2.23) and the least related to leadership (average of 0.530 ± 2.26). There was a Corresponding author. M. Bakhateiyari et al. 210 significant relationship among age, education and employment type of personnel and GLD standards and aspects. Given the relatively good rating of various aspects of management performance in the studied hospitals, it can be upgraded and get closer to the JCI international standards. Meanwhile, emphasizing on leadership seems more urgent.


Introduction
Maintaining and improving the health of people are of the development priorities of each country and the health sector authorities are always trying to take advantage of their available resources, and provide the best and highest quality of health care services to the society [1].In fact, in all countries, providers of health care services, given the available resources, try to provide the highest level of quality of services [2].That's the reason why the quality of services in health-medical organizations is of special importance [3].Meanwhile, the managers of hospitals have some functions related to society and social environment, so they have an integral coexistence with them and pay attention to the expectations of people in order to continue optimal communication between service providers and service requesters, leading to the improved quality of hospital activities [4].
Since improving the quality leads to acquiring competitive advantages for these organizations, this matter has been considered with many research enthusiasts in this field [5].In this regard, a detailed assessment is of particular importance which leads to a structured judgment and quality documentation [6].Also, because of the nature and extent of the services which are presented in the healthcare sector, the occurrence of any mistake, even a small, could be irreparable.Hence, in this section, the performance evaluation and flawless service providing in accordance with the performance standards, are necessary [7].
On the other hand, human nature being of presented activities and services provided in this section, are among other reasons for précised and accurate evaluation of this [8], so that the lack of evaluation of the different aspects of the organizations is considered as one of the symptoms of the organization illness [9].The World Bank study referred to five reasons of customers' satisfaction and how to keep them, fair access to health care, efficiency and effectiveness of health care services, eliminating the existing differences in the process of providing services and high cost of health care services, based on the evaluation of the performance in the health sector and improving the quality.
All these cases require the sensitivity and the necessity to performance evaluation in a methodical and systematic frame to bring quality to them, in addition to responding to problems in hospitals [10].On the other hand, leading organizations in the today world, by understanding the interactions between organizations, quality, quality of human resources and effective management, know their key to success in applying modern and quality methods of management with the benefit of educated humans [11].Therefore, the success rate in achieving organizational goals is directly related to the performance of human resources, especially managers [12].Meanwhile, managers as main decision makers, facing with various issues within and outside the organization, are necessary to play an important and decisive role in the success or failure of the organization [13].
This matter becomes more significant in healthcare organizations, especially hospitals who are dealing with human lives [14].The poor performance of hospitals managers leads to delay in treatment and disease progress or death.Also, the poor performance of the hospital managers in the country causes wasting human and financial resources and ultimately reduced productivity [15].Therefore, it is necessary to periodically evaluate the performance of managers.Meanwhile, due to the salient impact of women's health on society's health and the health of future generations, women's hospitals have a special place among other hospitals and this kind of hospitals as well as other hospitals and health care centers, must be evaluated, especially in terms of the performance of managers, because they serve to one of the largest and most significant populations, namely women, mothers and their newborn babies.Hence, we aimed to hold a research on evaluating the performance of managers of Tehran University of Medical Sciences' Obstetrics and Gynecology Hospitals from the viewpoint of personnel, based on the Accreditation Model (JCI standards).

Methodology
The present descriptive-analytic study was conducted in a 900-people community at two gynecological hospitals of Tehran University of Medical Sciences (Arash Rouintan Hospital and Women's Comprehensive Hospital).Since only two women's hospitals are covered by the mentioned university, both of them were studied.Through calculation based on the Cochran formula, the samples were 311 people.Given that the number of personnel of one hospital (Arash Hospital) was 419 people and the other hospital (Women's Comprehensive Hospital or Mirza Kuchik Khan) was 364 persons, these samples were probationary divided and 171 people from Arash Hospital and 140 people from the Women's Comprehensive Hospital were selected.Data collection tools were two questionnaires.
The first questionnaire included 27 three-optional "applicable, fairly applicable and inapplicable" questions that the ability to implement JCI standards in Governance, Leadership, and Direction (GLD) aspects was measured and then analyzing the data and recognition of standards which are difficult to perform from the perspective of human resources, the second questionnaire was prepared by the researcher from the measurable elements of standards which are applicable.The second questionnaire which was designed to evaluate the performance of managers contains two parts.The first part consisted of 5 questions related to demographic information and the second part with 27 questions included JCI accreditation standards in terms of leadership and direction and in three areas of monitoring (7 questions) leadership (10 questions) and supervision (10 questions).
The questionnaire was designed according the Likert scale with the options of yes (3 points), partly (2 points) and no (1 points).The content validity was used to confirm the validity of the empowerment questionnaire.The reliability was obtained 0.894 through the Cronbach's alpha method.The data were analyzed using the SPSS Software version 18 and Mann-Whitney (effect of hospital and gender on GLD rating and each of its dimensions) and Kruskal-Wallis (varied effects of age, education, work experience and employment status on GLD rating and each of its dimensions) statistical tests.

Results and Findings
Among a total of 311 questionnaires, 279 cases were completed and returned by the personnel of the studied hospitals.241 (86.4%) of the participants personnel were female, 146 people (52.3%) were aged 40 -30 years, 163 people (53.4%) had a bachelor's degree, 85 people (30.5%) had less than 5 years' work experience and 129 people (46.1%) were formally employed in the hospital (Table 1).
As can be seen in Table 2, the standards of the GLD scope, are generally applicable and fairly applicable (94.7%), according to the personnel viewpoints in the studied hospitals.Meanwhile, the supervision dimension by 96.2 percentage of being applicable and fairly applicable, was greater than other two dimensions and other two dimensions aspects, surveillance and leadership, both equally 94%, have been evaluated applicable and fairly applicable.
As can be seen in Table 3, the under study hospitals, in terms of the GLD performance standards are in relatively good level (rate of 0.5 ± 2.30) and among its dimensions, the highest score is related to surveillance (0.57 ± 2.32) and the lowest is related to ;leadership (0.53 ± 2.26).
The results of the Mann-Whitney test showed that the means difference in GLD scope and its dimensions in the two studied hospitals are not statistically significant, this means that the hospital does not affect the GLD score and its dimensions (Table 4).
The results of the Mann-Whitney test showed that the mean differences in GLD scope and its dimensions are not statistically significant for both men and women, this means that gender does not affect the GLD score and its dimensions.
The results of the Kruskal-Wallis test showed that the educational level and employment status of staff affected the GLD standards and dimensions and there was a significant relationship between working experience and mentioned factors in terms of leadership (Table 5).

Discussion
This study aimed to evaluate the performance of the Women's Hospitals covered by Tehran University of Medical Sciences, according to the JCI international standards in the scopes of governance, leadership and direction (GLD), for the first time in the country.The results showed that according to the personnel viewpoints, these standards are    [18].As previously mentioned, in this study, the GLD standards were measured in three scopes of governance, leadership and direction that finally evaluated in a relatively high level by staff.In fact, it is worthy to say that the under study hospitals, are among single-expertise and country pole university hospitals that have patients from all over the country.Hence, the importance of them causes that (at the time of accreditation), compliance with standards be of great concern.
Also, because of the small being of hospitals and a relatively limited number of referrals and beds, handle relatively good level of compliance with the standards in such hospitals can be relatively easily done.Farzianpour et al. also in their study cited some causes of low accreditation rating in the studied hospitals due to the high volume of referrals and high accreditation rating due to limited expertise and low volume of referrals [19].
Khodayari et al. in their study evaluated the rating of international JCI accreditation standards at desirable level of 68.8%, in the field of cares given to patients in three Shaheed Hashemi Nejad, Shaheed Rajai and Shaheed Motahari Hospitals [20].Ameriuon et al. observed in the evaluation of the Joint Commission International Accreditation Standards in the laboratory of a military hospital that this laboratory at 52 percent, achieved perfect score and at 40%, achieved the relative rating in terms of the Joint Commission International Accreditation Standards and finally, was classified in a desirable level [21].Farzianpour et al. in the study on evaluating the JCI standards in the field of the patient and family rights in Iran's hospitals observed that these standards have been implemented in desirable and satisfying ways from the standpoint of head sections, so that all aspects of the study points were above average [17].
Also, Abbasi and colleagues in investigation of the ACC standards in two selected hospitals of the Social Security Organization And a university hospital, reported 73.5% for standards' average rating [22].The present studies showed that in the midst of GLD dimensions, the leadership scope earned lower point than the two other dimensions.In fact, there is some evidence which suggests that hospitals in the country don't have efficient tools for identifying strengths and weaknesses of management and university hospitals, in particular, have started a continuous improvement and progress in a small number of their leadership processes and this affair can justify the low points in this dimension [23].
Parham et al. in the evaluation of the performance of performance of Shaheed Beheshti Hospital in Qom, based on Organizational Excellence Model, obtained the rating of leadership criterion lower than average, namely 48.42% [24].Khalsei in the study on the performance of leadership in Khorramabad Hospitals, based on self-assessment model, obtained the average ratings of university, social security and private hospitals, 26%, 22% and 31%, respectively [23].McCarthy and colleagues also in their study, classified the various organizations based on points they earned in the self-assessment process, in five categories of beginners, so-so organization, improved ones, reward winners and world level organizations.
By comparing the mean scores of the studied hospitals with McCarthy and others classification, it can be said that all studied hospitals in all aspects of leadership are in the so-so category [25].Calingo and colleagues in their study during 2006-1995, cited that the earned points by America's Health Care Organization based on the Malcolm Baldrige Model, is 38% for the leadership criteria [26].In this study, no significant differences were observed between the studied hospitals in the field of GLD and also its dimensions and in fact, it is worthy to say that given that both the educational hospitals and both gynecologic hospitals are the same in size and have a similar situation as well and this has reduced the differences between the two hospitals that compliance with the performance standards of management can also be not exempted from this rule.
The results of studying the effects of demographic factors of personnel on the score of managerial performance standards (GLD) and its dimensions also affected these factors, age, education level and employment status of personnel and GLD standards and its dimensions and between the working experience and the mentioned factors, except leadership, there is a significant relationship.Also, no significant relationship was found between workers gender and GLD and its dimensions.Farzianpour and colleagues also in the study on the standards of accreditation in the obstetrics and gynecology wards in selected hospitals of Ardabil, observed an indirect relationship between age and work experience with the score of accreditation standards [19].

Conclusion
Since the main purpose of the performance evaluation was based on the JCI international standard Governance Leadership Direction (GLD), we first realized the current state of the organization and determined its strengths and weaknesses and then attempted to strengthen the strengths, eliminate weaknesses and improve the organization status, the findings of this study could determine the strengths and weaknesses of the studied centers and be a guidance for managerial.The results showed that due to the various aspects of organization performance management, it was possible to enhance them to so much more acceptable levels in the terms of standards and in this regard, it seemed more urgent to emphasize on leadership.

Table 1 .
Distribution of personnel completed the questionnaire according to the demographic variables.

Table 2 .
Distribution of the frequency and percentage of the functionality standards of the GLD scope and its dimensions in the women's hospitals covered by Tehran University of Medical Sciences.

Table 3 .
The mean and SD of GLD and each of its dimensions.

Table 4 .
The mean and SD of the results of the Mann-Whitney test for GLD scores and each of its dimensions divided to studied hospitals.

Table 5 .
Results of the statistical analysis of the relationship between demographic variables of the participants in the study and the GLD scope and each of its dimensions.Farzianpor et al. in a study on the standards of quality and patient safety improvement in the Emergency Department of Imam Khomeini Hospital observed that the relevant standards are applicable and fairly applicable with 76.5% rate [17]icable in the studied hospitals.Farzianpour et al. in studies that were separately done on the standards of Patient and Family Education (PFE), Patient and Family Rights (PFR) and Care Of Patient Standards (COPS), found that a vast majority of the international standard have been applicable and only a few have been excluded from the study[16][17].