Development and impact of the Iranian hospital performance measurement program

Abstract

Background: Iran developed a national hospital performance measurement program (HPMP) which has been implemented annually throughout its hospitals since 1997. However, little is known yet about its development and the impact of the program on hospital performance.This study aims to describe the development and process of implementation of the HPMP, and to explore the impact on hospital performance by looking at the trends of performance scores of all different types of Iranian hospitals.

Methods: This was a mixed method study consisting of longitudinal data and qualitative document analysis. Hospital performance data over the period of 2002 to 2008 was analysed.

Results: Iran instituted a comprehensive HPMP and implemented it in all hospitals since 1997. The program followed a phased development to stimulate performance and quality improvement in hospitals. Overall, the program has had a positive impact on the performance of general and specialized hospitals. The performance of general hospitals did not appear to be associated with their size or affiliated university ranking. However, the rate of performance improvement of general teaching and private hospitals was significantly lower than the average improvement rate of all general hospitals. There was no relationship between teaching status of the specialized hospitals and their level of performance. However, the performance of the governmental specialized hospitals showed a substantial decline over time. Moreover, among specialized hospitals, the bigger sized and those affiliated with higher ranked universities, reported better performance.

Conclusions: Overall, the development and implementation of an obligatory HPMP in Iran has improved the level of performance in general and specialized hospitals. However, there is room for further performance improvement especially in the general teaching, private, and governmental specialized hospitals. Reconsidering the ownership type, funding mechanisms and responsibility for the HPMP may have an impact on the absolute level of performance and improvement capacity of hospitals. In addition, the role and composition of survey teams, mechanism of implementation according to the characteristics of hospitals, and updating standards are important factors to promote performance improvement and hospital accreditation requirements.

Figure 1

The flow chart of the process of a typical hospital evaluation & grading in Iranian Healthcare System, adapted from Aryankhesal (2010) [24]. Figure 1 Shows the flow chart of the process of a typical hospital evaluation and grading (scoring) in the Iranian health care system. According to the regulations, hospital emergency departments (ED) and Critical Domains (CD) are evaluated first and only the rest of the hospital would be evaluated if the ED and CD are awarded at least grade 3. If the ED and CD are qualified, the evaluation and scoring of all parts of the hospital will start. If the whole hospital is qualified, calculation of scores and defining the grade will be conducted by an assessment team. The grade as determined by the assessment team should be approved by the university’s Vice-chancellor for Treatment, university Chancellor, university’s Evaluation & Supervision Council and finally by the MOHME.

Figure 2

A linear mixed-effects model for the general teaching hospitals. The analysis of general teaching hospitals’ performance is shown in Figure 1 (as an example) for the period of 2002 to 2005. The hospitals that are located in the first quadrant (top right), have a higher performance above the average at the baseline. They increased their performance with a higher rate than the average. Quadrant II (top left) represents the hospitals in which their performance was lower than the average performance in the reference year, but the average rate of increase was higher than the overall average. Quadrant III (bottom left) represents the hospitals in which their average performance and the rate of increase both were lower than the overall averages in the reference year. The hospitals in the fourth quadrant (bottom right) showed a higher performance and lower rate of increase than the overall averages.